Adolescent & Adult Intensive Outpatient Services

APPIC #118328

Overview

Located within Yale-New Haven Psychiatric Hospital’s (YNHPH) Intensive Outpatient Services, this placement provides fellows with the opportunity to receive comprehensive clinical training within multidisciplinary hospital-based intensive outpatient program (IOP) where the emphasis is on developing competencies for conceptualizing and treating acutely ill and demographically diverse patients across the adolescent and adult spectrums. Fellows are taught to apply a range of theoretical orientations, including developmental/psychodynamic and cognitive-behavioral/dialectical behavioral theories, to inform case conceptualization and treatment planning. Clinical activities include serving as the primary clinician for up to seven adolescent and adult IOP patients; co-leading a variety of group therapies; participating in interdisciplinary treatment team meetings; conducting family sessions; providing risk assessment and management, skills coaching, intake interviews, peer consultation, and supervising an advanced psychology graduate student. In addition to these core training activities, fellows also have the opportunity to receive individual psychodynamically-informed psychotherapy training through the hospital's Long-Term Care Clinic.

Placement Options

This track consists of a single twelve-month training experience, of which half-time is in the YNHPH Adolescent Intensive Outpatient Program and half-time is in the YNHPH Adult Intensive Outpatient Program.

Number of Fellows

One doctoral fellow will be selected into the Adolescent & Adult Intensive Outpatient Services Track for the 2017-2018 academic year.

The Setting

The Intensive Outpatient Programs of Yale-New Haven Psychiatric Hospital treat adolescent and adult patients in a group-based setting. These individuals need more intensive intervention than is readily provided in outpatient settings but do not require the level of supervision and support provided by an inpatient program. About two thirds of newly admitted patients are referred to the IOPs for follow up treatment from one of the YNHPH inpatient units and about one third are referred from outpatient community providers.

The Adolescent IOP is an afternoon, after-school program that treats adolescents between the ages of 12 and 18 with a variety of psychiatric diagnoses and presenting problems: disturbances in their mood, thought processes, and behavior; and significant difficulties at home and/or at school. These adolescents are high risk and in an acute state, recently discharged from the hospital and needing a step down in care before participating in outpatient therapy, or, alternatively, they are escalating at home and in need of more than weekly outpatient therapy to prevent hospitalization.

The Adult IOP is divided into four main treatment tracks: a General Psychiatric track for patients with mood, anxiety and/or psychotic disorders; a Dual Diagnosis track for patients with co-occurring psychiatric and substance use disorders; a general DBT track for patients with borderline personality disorder features who struggle with chronic patterns of suicidal or other self-destructive behaviors; and a substance-focused DBT track for patients who struggle with borderline personality disorder features and substance abuse or dependence. The DBT tracks provide comprehensive DBT that is modified for a group-based day hospital setting. The main modifications of these tracks from standard-model outpatient DBT include: conducting diary card review and behavioral analysis in groups; the inclusion of protocols for preventing contagion of crisis behaviors among group participants; patients participating in concurrent outpatient therapy; and targeting problems in the outpatient treatment with the goal of discharging patients into an effective and productive outpatient level of care.

The Internship

Adolescent Intensive Outpatient Program (12 months, half-time): The fellow will spend half of their clinical hours each week at the YNHPH Adolescent Intensive Outpatient Program (IOP) carrying up to three cases. Activities involve: individual and family therapy: co-leading adolescent groups; and participating in interdisciplinary team meetings. The therapeutic groups focus on goal setting, group process, problem solving, social skills development, and identification of feelings. Also, the groups integrate DBT skills training in order to help the adolescents manage dysregulated affect and high risk behaviors. Through supervision and training, fellows gain knowledge of the developmental stages and issues involved in childhood and adolescence. There is a particular emphasis on how trauma and impoverished backgrounds intersect with and affect developmental outcomes. Fellows strengthen their skills in case conceptualization to inform and guide the treatment. Fellows also develop particular expertise in running groups and understanding group processes.

Adult Intensive Outpatient Program (12 months, half-time):
The fellow will serve as a primary clinician for up to four Adult IOP patients in the Dialectical Behavior Therapy for Substance Use Disorders (DBT-SUD) track. Activities involve: co-leading a variety of DBT therapy groups, including skills training, diary card review, behavioral analysis, and skills coaching; telephone skills coaching; weekly consultation team meetings; risk assessment and management; family sessions; consultation to outpatient providers; and orientation and commitment interviews for prospective DBT patients. In addition, the fellow provides DBT-oriented supervision to an advanced psychology graduate students. In the Adult IOP, fellows will develop DBT competencies for working with patients with Borderline Personality Disorder and other co-morbid conditions, such eating disorders, substance use disorders, dissociation, and schizoaffective disorder. The fellows will also develop proficiencies in: applying behavioral strategies and structured protocols, DBT-oriented case management and consultation, dialectical clinical formulation, and observing personal limits in order to maintain wellbeing and avoid burn out. Additional clinical activities include: co-leading cognitive-behavioral, psychodynamic, and topic-focused groups. The latter cover family issues, managing bipolar symptoms, and discharge planning.

Psychological Assessment:
Doctoral fellows conduct psychological assessments during the year. Most diagnostic assessments focus on evaluations of newly admitted patients on the psychiatric inpatient units and patients who have been participating in treatment for longer periods in the intensive outpatient programs. Each assessment involves administering and interpreting a variety of instruments, participating in individual testing supervision, consulting with the treatment team about the implications of test results for the patient's treatment, providing feedback to the patient in consultation with the treatment team, and writing a final report. Doctoral fellows conduct structured diagnostic interviews, traditional full battery assessments, as well as brief forms of personality assessment and neuropsychological screening.

Long Term Care Clinic:
All YNHH doctoral fellows have the option of receiving weekly supervised individual psychotherapy training within the Long Term Care Clinic. The Long Term Care Clinic is an outpatient psychotherapy training clinic operated by the Department of Psychiatry and YNHH. Individual patients are referred to this clinic by the Yale University Health Services, and as such, are typically members of the University community who are seeking insight-oriented psychotherapy for a variety of identified issues, most commonly related to developmental, relationship, mood, and/or anxiety concerns.

Within the LTCC, individual weekly supervision from a psychodynamic perspective is provided to guide the fellow in conceptualizing and implementing treatment from an insight-oriented therapeutic approach most appropriate to the assigned cases. Typically, doctoral fellows see one individual therapy patient in once-a-week psychotherapy for the full duration of their training year.

Evidence-Based Practices

The following evidence-based practices (EBPs) are used in this placement setting. Fellows generally have exposure to most of these EBPs though do not necessarily receive training or supervised experience in all of them. The EBPs include: Dialectical Behavior Therapy, Dialectical Behavior Therapy for Substance Use Disorders, and Cognitive Behavior Therapy.

Psychological Assessment

Doctoral fellows at YNHH conduct a variety of brief and comprehensive psychological and neurocognitive diagnostic testing protocols during the year. Most diagnostic assessments include evaluations of newly admitted patients on the psychiatric inpatient units, patients who have been participating in treatment for longer periods in the intensive outpatient ambulatory services programs, and patients who are receiving care within the hospital acute inpatient and outpatient specialty medical services. Each assessment involves administering and interpreting a variety of instruments, participating in individual testing supervision, consulting with the treatment team about the implications of test results for the patient's treatment, providing feedback to the patient in consultation with the treatment team, and writing a final report. Doctoral fellows conduct structured diagnostic interviews, a minimum of two traditional full battery assessments, as well as brief forms of personality assessment and neuropsychological screening.

Diversity

At Yale-New Haven Hospital diversity and inclusion are important components of its organizational values. The hospital is committed to providing an environment of inclusion that supports the diversity of its patients, visitors, employees, business partners and communities. Serving the Greater New Haven area and surrounding Southern New England region, YNHH admits a diverse population of patients, both diagnostically as well as demographically. Racially, approximately 65 percent of patients admitted to the hospital are Caucasian, 15 percent Black, 15 percent Hispanic and 5 percent Asian. Likewise, nearly 60 percent of patient’s hospital costs are paid for through Medicare or Medicaid. The hospital is committed to providing the highest standard of care to all patients regardless of socioeconomic status, race, ethnicity, language, nationality, sex, gender identity, sexual orientation, religion, geography, disability and age.

Scholarly Activity

Four hours of protected time is provided to allow fellows with the opportunity to design and conduct a scholarly project of their choice. Individual project objectives are coordinated with the primary advisor, and/or another faculty mentor involved in a program of active research. Fellows may design a project with faculty within their primary training placement, or request to be matched with other faculty in the Yale School of Medicine based on their shared interests and faculty availability. The fellow’s scholarly activity can take many forms. In consultation with the faculty advisor, the fellow may choose to engage in an ongoing research project, evaluate a clinical service or program, or help design and implement a new project that will benefit the individuals receiving services within the YNHH system.

Within the Adolescent & Adult track, fellows also have the opportunity to co-review manuscripts for research journals and to assist with the annual Yale NEA-BPD Conference.

Faculty

Seth Axelrod, Ph.D., Primary Advisor
Debra Bond, Ph.D., Clinical Supervisor
Amber Childs, Ph.D., Clinical Supervisor
Christine DeMaio, Ph.D., Secondary Supervisor
Wendy Levy, Ph.D., Assessment Supervisor
Connie Nickou, Ph.D., Clinical Supervisor

Supervision

Fellows have weekly individual supervision with a primary advisor and with secondary clinical supervisors, weekly DBT consultation team meetings, weekly adolescent rounds, and as needed individual or group assessment supervision. Fellows may receive additional individual supervision for optional clinical activities such as with the Long Term Care Clinic or the Refugee Clinic. Formal evaluations are completed that serve as opportunities to review progress on training goals and address progress toward core competency areas.

Seminars and Specialized Training

In addition to the core didactic seminars within the Department of Psychiatry, and general hospital-based seminars, Adolescent & Adult Intensive Outpatient Service fellows also attend the Dialectical Behavior Therapy Summer Seminar (July and August). This seminar covers theory, formulation, and major strategies of Dialectical Behavior Therapy (DBT) as it is applied to treating severe borderline personality disorder in outpatient and day hospital settings. Attendees actively engage the material through discussions of cases and video examples, skills practice, self-monitoring and problem solving exercises, and role play.

Applicant Qualifications

Strong applicants for this placement generally have prior experience working with adults and adolescents, including individuals who struggle with high-risk impulsive behaviors. In addition, strong applicants will have experience conducting evidence based therapies including at least some components of Dialectical Behavior Therapy (i.e., DBT skills groups, consultation team, phone consultation, and/or individual therapy). Fellows who match with this placement typically have a strong interests in treatment and/or scholarship related to adolescent psychopathology or personality pathology and show promise for developing into leadership roles.

Applicants selected for this placement must successfully pass background checks conducted by Yale University and Yale-New Haven Hospital.

For Further Information

For more information about this placement site, please e-mail seth.axelrod@yale.edu.