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Bringing psychological treatment to the psychiatric ward: Affecting patients, staff, and the milieu
Stockholm University, Faculty of Social Sciences, Department of Psychology.ORCID iD: 0000-0002-9523-9887
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The psychiatric ward is a complex setting. This has to do partly with the severity of the patients’ suffering. Often, they present with such diagnoses as psychosis, self-harm, substance abuse, and suicidality. In fact, they often present with a combination of these. This renders the delivery of effective treatment a challenging task. Partly, the complexity of the ward has to do with aspects of the context itself. Admissions and discharges often happen fast and unexpectedly, staff members are expected to handle various challenging behaviors, they display quite high levels of burnout and work dissatisfaction, and the wards are often staffed by bank staff, leading to a lack of continuity of care. This adds to the challenge of delivering effective treatment. In the typical Swedish ward, treatment consists of medication, nursing, observation, and management of risk behaviors. Psychological treatment is seldom a routine part of inpatient care. However, there are sound arguments for adding psychological treatment in the form of cognitive behavior therapy (CBT) of various modalities. Further, there is promise in psychosocial interventions delivered by the nursing staff after appropriate training, and in providing supervision to the staff.

The aim of the present thesis was to investigate the feasibility and potential efficacy of acceptance and commitment therapy (ACT), a CBT based psychotherapy model, as a broadly applied intervention in the context of psychiatric inpatient care. In three studies, ACT was evaluated as a brief individual psychotherapy intervention, and as a psychologically informed approach to dealing with patients performed by the nursing staff group in a psychiatric ward for psychosis patients.

In study I, an average of two sessions of ACT was delivered to patients (n = 11) with a diagnosis of psychosis. Compared to a control group (n = 10), the risk for rehospitalization during a four-month follow-up period was significantly smaller for patients in the experimental group. There was also a trend toward increased values-based living scores in the experimental group, compared to controls.

Study II evaluated the effects on staff members (n = 20) and patients (n = 9) of a brief ACT training intervention tailored to the staff group, the aim of which was to introduce ACT as a day-to-day approach to dealing with patients. After a total of 12 hours of ACT training, the staff group displayed a slight increase in work-related psychological flexibility, compared to before, while a non-randomized control group (n = 18) displayed a slight decrease. Patients being treated on the ward after the staff training displayed a slight increase in psychological flexibility during ward treatment, while patients being treated before displayed a slight decrease. In both cases, however, the differences were considered quite small (non-significant in statistical terms). Further, the study investigated ACT-consistent behavior changes among staff members following ACT training, using a multiple baseline single-subject design. Results revealed both expected and unexpected patterns of behavior.

In study III, the usefulness of the ACT model was investigated using a qualitative content analysis. Staff members (n = 10) experienced ACT as useful in terms of dealing with patients’ struggles, enriching typical duties, and dealing with their own stress. Difficulties in using the model related to time restraints, complexities of the model itself, and the severity of patients’ illnesses.

In summary, the present thesis adds to the research basis for ACT as a treatment for psychosis, delivered in an inpatient setting. It shows that the introduction of ACT as an add-on to traditional ward treatment in Sweden is for the most part feasible and acceptable. However, the thesis also discusses various challenges in the implementation of psychological treatment in such a complex context as the inpatient ward, both in terms of delivery of the treatment itself and the evaluation of its effectiveness.

Place, publisher, year, edition, pages
Stockholm: Department of Psychology, Stockholm University , 2019. , p. 96
Keywords [en]
Acceptance and Commitment Therapy, behavior therapy, inpatients, inservice training, psychiatry, psychotherapy, brief, qualitative research, randomized controlled trial, schizophrenia spectrum and other psychotic disorders
National Category
Psychology
Research subject
Psychology
Identifiers
URN: urn:nbn:se:su:diva-166908ISBN: 978-91-7797-654-7 (print)ISBN: 978-91-7797-660-8 (electronic)OAI: oai:DiVA.org:su-166908DiVA, id: diva2:1294473
Public defence
2019-05-10, David Magnussonsalen (U31), Frescati Hagväg 8, Stockholm, 13:00 (English)
Opponent
Supervisors
Available from: 2019-04-15 Created: 2019-03-07 Last updated: 2019-03-19Bibliographically approved
List of papers
1. Brief acceptance and commitment therapy for psychotic inpatients: A randomized controlled feasibility trial in Sweden
Open this publication in new window or tab >>Brief acceptance and commitment therapy for psychotic inpatients: A randomized controlled feasibility trial in Sweden
2017 (English)In: Nordic Psychology, ISSN 1901-2276, E-ISSN 1904-0016, Vol. 69, no 2, p. 110-125Article in journal (Refereed) Published
Abstract [en]

Psychiatric inpatient care in Sweden is often described as lacking in content other than medication and mere containment. In an attempt to increase structured psychological content in the ward context, this study aims to investigate whether a brief form of acceptance and commitment therapy (ACT) is a feasible addition to standard care for psychotic inpatients. ACT has previously been administered to psychotic inpatients in the US, and the present study was an attempt at implementing this intervention in Sweden. In this feasibility study, 22 psychotic inpatients were randomized to one of two conditions: treatment as usual (TAU) or TAU plus an average of two ACT sessions. Measures of rehospitalization and values-based living were obtained before treatment, after treatment, and at four-month follow-up. Results indicate that participants in the TAU plus ACT group were rehospitalized at a lower rate than those who only received TAU (9% vs. 40%), though the difference was not statistically significant. Controlling for age, gender, and pretreatment values-based living scores, there was a significantly higher risk for TAU participants to be rehospitalized. There was a trend toward increased values-based living scores in the ACT group. These results suggest that it is feasible to add structured psychotherapeutic interventions to the existing care package at psychiatric inpatient wards in Sweden. However, the findings need to be explored in larger samples.

Keywords
acceptance and commitment therapy, psychosis, acute treatment, inpatient care
National Category
Psychology
Research subject
Psychology
Identifiers
urn:nbn:se:su:diva-141274 (URN)10.1080/19012276.2016.1198271 (DOI)000399576500006 ()
Available from: 2017-04-03 Created: 2017-04-03 Last updated: 2019-03-07Bibliographically approved
2. Implementation of acceptance and commitment therapy training in a psychiatric ward: feasibility, lessons learned and potential effectiveness
Open this publication in new window or tab >>Implementation of acceptance and commitment therapy training in a psychiatric ward: feasibility, lessons learned and potential effectiveness
2017 (English)In: Journal of Psychiatric Intensive Care, ISSN 1742-6464, E-ISSN 1744-2206, Vol. 13, no 2, p. 73-82Article in journal (Refereed) Published
Abstract [en]

Psychiatric inpatient wards are inherently complex milieus. Staff in wards are expected to alleviate severe suffering in patients whilst handling an increasing administrative burden, resulting in less direct contact with patients. Reports from both patients and staff indicate institutional aimlessness and lack of care content beyond medication and containment. As a possible means of improving this situation, this pilot study investigated the feasibility, potential effectiveness and challenges of the implementation of a 12-hour training programme in acceptance and commitment therapy (ACT), a CBT-based psychotherapy model, on staff (n = 20) and patients (n = 9). The context was a psychiatric inpatient ward for psychosis patients. The staff members of a neighbouring unit acted as non-randomised controls. Feasibility of implementation, data collection and acceptance among staff of the intervention seemed acceptable, while data collection among patients was more challenging. Mean change scores suggest marginal positive changes in psychological flexibility for patients and staff post-intervention. Results are discussed in light of methodological and institutional limitations, and clinical experiences.

Keywords
acceptance and commitment therapy, ACT, inpatients, inservice training, psychiatry
National Category
Psychology
Research subject
Psychology
Identifiers
urn:nbn:se:su:diva-146660 (URN)10.20299/jpi.2017.008 (DOI)
Available from: 2017-09-04 Created: 2017-09-04 Last updated: 2019-03-07Bibliographically approved
3. Usefulness of the ACT model for nurses in psychiatric inpatient care: A qualitative content analysis
Open this publication in new window or tab >>Usefulness of the ACT model for nurses in psychiatric inpatient care: A qualitative content analysis
2017 (English)In: Journal of Contextual Behavioral Science, ISSN 2212-1447, Vol. 6, no 2, p. 208-214Article in journal (Refereed) Published
Abstract [en]

Alleviating the suffering of patients treated in psychiatric inpatient wards is a great challenge. Preliminary or multiple diagnoses, inherent complexities of the inpatient milieu and the lack of potentially effective psychological treatment form part of this challenge. The present study explored the usefulness of a transdiagnostic psychological treatment model (Acceptance & Commitment Therapy, ACT) as a means of improving inpatient care from the perspective of psychiatric nurses. Nurses (n = 10) participated in three ACT workshops, a total of 21 h, and were interviewed about the experienced usefulness and difficulties of the ACT model, as a tool for improving everyday ward work. Results, revealed by qualitative content analysis, suggest usefulness in the areas of alleviating patients symptoms, enriching typical ward duties, and handling one's own thoughts and feelings. Difficulties stemmed from lack of time, the model itself and patients' severe illness. Possible adjustments of the ward context are suggested.

Keywords
Acceptance & Commitment Therapy, content analysis, inpatients inservice training, psychiatry
National Category
Psychology Psychiatry
Research subject
Psychology
Identifiers
urn:nbn:se:su:diva-145278 (URN)10.1016/j.jcbs.2017.04.011 (DOI)000404437600012 ()
Available from: 2017-07-25 Created: 2017-07-25 Last updated: 2019-03-07Bibliographically approved

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