Bringing psychological treatment to the psychiatric ward : Affecting patients, staff, and the milieu

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