A Practicum in Private Practice for Graduate Students in Psychiatric Nursing Suzanne Leg0
Clinical placements in psychotherapy for graduate students in psychiatric nursing are getting diflkuit to find because of bureaucracy, liability issues, competition, and safety and convenience concerns in urban areas. One solution is to design a placement in private practice.
Copyright 0 1992 by W.B. Saunders Company
I
T WAS LABOR DAY weekend, that last peaceful oasis before the mayhem of university Septembers. I could go to the beach with a serene countenance. All my graduate students taking individual therapy this fall had clinical placements. All the letters were written, all the phone calls made. or so I thought. On the day before we were to leave for the beach, I received a message on my answering machine. A colleague “at the front lines” in a single room occupancy (SRO) hotel had announced to her team that day that the new student would arrive next week, attend the team meeting, and have her first session with her new patient right after the team meeting. Her boss, a nursing director of the huge organization of which this SRO hotel is a small cog, was visiting that morning and rose to object. The proper forms had not been filed! Upon receiving this phone message I was flabbergasted. I had filled out all the details at the same time I filled out the forms for a summer school student placed at the same hotel! After six phone calls I located the nurse in charge of student placements. She told me angrily that I had indeed filled out the forms, but they were written on summer school forms and not fall forms. “But can’t you or your secretary simply copy the form?” I asked helplessly. “No,” she said and added, “and do you know what else we need?” “No,” I replied believing I’d failed the quiz. “The students’ malpractice insurance, health clearance, and current license.” I said, “OK, can she start Thursday as planned?” No, because she
had to get cleared by hospital security and issued a hospital identification badge, even though she would never be near the hospital! Over the weekend, I spent a lot of time thinking about the problems I’d had for the past 3 years finding placements for my students at our urban university. I remembered another incident that occurred the previous May. The semester had ended, and I made an appointment to visit a very large SRO complex where a student had seen a patient and a group all year. I met with the director who had started the residence for people who would otherwise be homeless. I took my husband along. As a sociologist who has studied and written about mental patients for 20 years, I knew he would be interested in seeing this facility, an outgrowth of the community mental health movement. What we saw was strikingly similar to scenes we had both observed in many state hospitals. Patients were sitting in or pacing around the halls and small lounge, smoking, begging for cigarettes, and hallucinating. There was one difference. These patients were receiving almost no professional supervision. One registered nurse with no advanced
From the Columbia University School of Nursing, Graduate Program in Psychiatric Mental Health Nursing, New York, NY and private practice, New York, NY, Pittsburgh, PA, and Kent, OH. Address reprint requests to Suzanne Lego, R.N., Ph.D., C.S., FUN., 334 Sycamore Rd. Edgewotih, Sewickley. PA 15143. Copyright 0 1992 by W.B. Saunders Company 0883-9417/92l0604-0002$3,00ool0
Archives of Psychiatric Nursing, Vol. VI, No. 4 (August), 1992: pp. 21 l-214
211
212
degrees was the only professional on site. Medicines were distributed daily by a nonprofessional staff member in a front office where he and the nurse hung out. When I talked with the director he said they could not accommodate a new graduate student in the fall to replace the one who left. The reason? The departing student had “upset” her patient during the year she saw her, especially when she graduated and moved to another city, terminating her sessions with the patient. “Our staff is protective of our patients. We don’t like to see them disturbed. ” Is it better that they hallucinate in peace? As we left, my husband, who served in the early 1970s on the National Interdisciplinary Committee on Community Mental Health, said, “Nothing has changed in 20 years. Patients didn’t get treatment then, and they still don’t get treatment.” He considers “treatment” to be ongoing psychotherapy. He calls drug treatment a form of “social restraint. ” On another occasion I asked a nurse colleague if we could place a graduate student somewhere in her huge outreach system for an experience in group psychotherapy. She consulted with her staff and came back with a “no,” saying their patients were long term and could not handle the terminations inherent in student placements. I assured her I had supervised groups like this for 25 years. The patients could handle a turnover of students and would profit from this experience. She replied that their patients already had groups. These I knew were “jazz groups” and so forth. The concept of group psychotherapy for long-term patients was unfamiliar to these young mental health professionals. Another example of the difficulty in placing graduate nursing students for psychotherapy experiences occurred the previous spring. A student was seeing a chronic schizophrenic with obsessive thoughts and cocaine abuse. The setting was a day hospital. I was in frequent contact with the student between her weekly supervision sessions because of the complicated nature of this case. In fact, when I was away in Hawaii I called this student daily to check on the patient and help her with any problems. That spring, the psychiatrist in charge of the day hospital told the student she had to terminate her sessions with the patient. He believed the patient was too upset because she had burned her arm with a cigarette. I went to see him with the
SUZANNE
LEG0
student. He explained that although he understood the concept of therapeutic regression, he believed the patient was better off without therapy. I reassured him that I had been supervising students for 25 years and was constantly available to the student. He seemed uncertain. Was it that a nurse was telling a doctor to relax, that she was on top of the situation, or was fear of liability an issue? A week later he told the student the therapy was over, and she was not permitted to terminate properly with this unfortunate patient. This fall, he refused a student because they “had a bad experience last year.” Competition with students in other disciplines also presents problems in student placement. This, coupled with a narrow viewpoint about which patients are “suitable” for psychotherapy, results in a small group of patients sought after by psychiatric residents, social work students, psychology interns, and our graduate students. In rare cases, psychiatric nurses are still not seen as suitable psychotherapists, adding to the problem. In urban areas an additional problem is that students are fearful about travel from one part of the city to another. Public transportation is considered dangerous, and parking is both hazardous and expensive. Inconvenience is another problem. Most of our graduate students work full time and attend school part time. Time is precious. Travel to clinical placements takes hours. In the 199Os, students are less likely to inconvenience themselves than in past decades when they were more compliant. Universities, always competitive for qualified graduate students in psychiatric nursing, attempt to make their programs as convenient as possible. One outgrowth of the biological-versuspsychotherapy approach to long-term patients is the advent of the “case management” role for psychiatric nurses. This means that master’s_prepared nurses working in the community spend most of their time steering patients through the elaborate labyrinth of health and environmental care they need. They take them to clinic appointments (or arrange for them to be taken) and to social security, welfare officers, and the like. In their opinion, someone must help these long-term patients to survive in the world. While I agree, I seriously question whether this need be a masters-prepared nurse. The problem is that the baby has been thrown out with the bath water. Nurses have lost
A PRACTICUM
213
IN PRIVATE PRACTICE
sight of psychotherapy as a treatment modality. I suspect this is because agencies do not support such “old-fashioned” ideas as therapy for longterm patients, especially when drugs keep them so calm, and also because graduate programs have for the most part succumbed to this predominant thinking. So we see that there are many reasons we have problems with student placements for psychotherapy. These include bureaucracy, liability issues, competition, safety and convenience concerns, and most important the notion on the part of young inexperienced mental health professionals and paraprofessionals that long-term mental patients need only be medicated, offered jazz and health groups, and for the most part left to their own devices. They should not under any circumstances be upset! In truth, this notion is supported by a society geared toward the avoidance of anything that is upsetting. A colleague once told me that on the adolescent oncology unit, at her hospital, parents are given marijuana to smoke until their children die, to ease the pain of this experience. The problems of widows given prescriptive tranquilizers to ease their grief, only to become addicted as time goes on, has been written about recently. PRIVATE PRACTICE AS A CLINICAL PLACEMENT
One solution to the problem of finding clinical placements for graduate students learning psychotherapy is to place them in private practice. This kind of placement is not for every student. However, for the very mature, confident student who is committed to the private practice of psychotherapy as a career, this may be a good alternative to general placement. Before designing this placement, I thought about the responsibilities and activities of the psychotherapist in private practice. I decided these include (1) clinical work with patients, (2) attending supervision, (3) participating in personal psychotherapy, (4) attending conferences, (5) writing papers for publication, and (6) presenting papers at conferences. The experience I designed includes all six activities. Clinical Work With Patients
One student currently in the practicum, Marian, told all her friends and associates that she was available to see patients free of charge twice a week for the next 6 months. She told the patients
that when she graduated in December she would continue with any patient who wished to continue at a low fee. Patients were referred by friends and classmates as well as myself. Those who live near her home are seen there. Those near the university are seen in my office. At present she sees seven patients twice a week. She plans to start a group as soon as she has seven clients who are strangers to one another. (Some new patients were referred by current patients and cannot be in a group together.) Supervision
The students attend supervision with me once a week. They share the supervision hour with other advanced students who plan to do therapy full time when they graduate. Supervision is conducted using audio tapes of therapy with patients. Personal Psychotherapy
Because the clinical work is long-term psychodynamic psychotherapy, I believe it is important for the student therapists to be in therapy themselves (Lego, 1984). In Marian’s case this involves analysis twice a week and group therapy once a week. Attending
Conferences
Students are encouraged to attend conferences and to report back to classmates about these. In the New York area there is a rich supply of nursing as well as psychological and psychoanalytic meetings. Writing for Publication
Students are expected to write papers and submit them for publication. I edit these and return them to the students for revision until they are ready for submission. Marian has submitted a paper on her work with the cocaine-using obsessive patient she worked with last year. Presenting
Papers at Conferences
Students are also expected to submit abstracts or papers for presentation at conferences. The two students in the private practice practicum were asked as part of their experience to organize an intercollegiate psychiatric nursing conference. This first conference was held in October, 1990 at Columbia. Papers were given by students from Yale University and Adelphi University as well as
SUZANNE
214
Columbia University. This has become an annual event with the universities rotating as hosts. It is my belief that these six activities socialize graduate students to the role of the professional nurse in private practice. As we all know, a profession and its disciplines can only grow and prosper if we have new young professionals who are encouraged to contribute to this growth. I believe that an advanced clinical practicum in private prac-
LEG0
tice solves the problem of inadequate sources for clinical placement and provides an atmosphere and arena for this kind of professional growth and role development. REFERENCES Lego,
S. (1984).
Designing a private practice. In S. Lego (Ed.), The American Handbook of Psychiatric Nursing (pp. 167-176). Philadelphia: Lippincott.
Clinical placements in psychotherapy for graduate students in psychiatric nursing are getting diflkuit to find because of bureaucracy, liability issues, competition, and safety and convenience concerns in urban areas. One solution is to design a placement in private practice.
Copyright 0 1992 by W.B. Saunders Company
I
T WAS LABOR DAY weekend, that last peaceful oasis before the mayhem of university Septembers. I could go to the beach with a serene countenance. All my graduate students taking individual therapy this fall had clinical placements. All the letters were written, all the phone calls made. or so I thought. On the day before we were to leave for the beach, I received a message on my answering machine. A colleague “at the front lines” in a single room occupancy (SRO) hotel had announced to her team that day that the new student would arrive next week, attend the team meeting, and have her first session with her new patient right after the team meeting. Her boss, a nursing director of the huge organization of which this SRO hotel is a small cog, was visiting that morning and rose to object. The proper forms had not been filed! Upon receiving this phone message I was flabbergasted. I had filled out all the details at the same time I filled out the forms for a summer school student placed at the same hotel! After six phone calls I located the nurse in charge of student placements. She told me angrily that I had indeed filled out the forms, but they were written on summer school forms and not fall forms. “But can’t you or your secretary simply copy the form?” I asked helplessly. “No,” she said and added, “and do you know what else we need?” “No,” I replied believing I’d failed the quiz. “The students’ malpractice insurance, health clearance, and current license.” I said, “OK, can she start Thursday as planned?” No, because she
had to get cleared by hospital security and issued a hospital identification badge, even though she would never be near the hospital! Over the weekend, I spent a lot of time thinking about the problems I’d had for the past 3 years finding placements for my students at our urban university. I remembered another incident that occurred the previous May. The semester had ended, and I made an appointment to visit a very large SRO complex where a student had seen a patient and a group all year. I met with the director who had started the residence for people who would otherwise be homeless. I took my husband along. As a sociologist who has studied and written about mental patients for 20 years, I knew he would be interested in seeing this facility, an outgrowth of the community mental health movement. What we saw was strikingly similar to scenes we had both observed in many state hospitals. Patients were sitting in or pacing around the halls and small lounge, smoking, begging for cigarettes, and hallucinating. There was one difference. These patients were receiving almost no professional supervision. One registered nurse with no advanced
From the Columbia University School of Nursing, Graduate Program in Psychiatric Mental Health Nursing, New York, NY and private practice, New York, NY, Pittsburgh, PA, and Kent, OH. Address reprint requests to Suzanne Lego, R.N., Ph.D., C.S., FUN., 334 Sycamore Rd. Edgewotih, Sewickley. PA 15143. Copyright 0 1992 by W.B. Saunders Company 0883-9417/92l0604-0002$3,00ool0
Archives of Psychiatric Nursing, Vol. VI, No. 4 (August), 1992: pp. 21 l-214
211
212
degrees was the only professional on site. Medicines were distributed daily by a nonprofessional staff member in a front office where he and the nurse hung out. When I talked with the director he said they could not accommodate a new graduate student in the fall to replace the one who left. The reason? The departing student had “upset” her patient during the year she saw her, especially when she graduated and moved to another city, terminating her sessions with the patient. “Our staff is protective of our patients. We don’t like to see them disturbed. ” Is it better that they hallucinate in peace? As we left, my husband, who served in the early 1970s on the National Interdisciplinary Committee on Community Mental Health, said, “Nothing has changed in 20 years. Patients didn’t get treatment then, and they still don’t get treatment.” He considers “treatment” to be ongoing psychotherapy. He calls drug treatment a form of “social restraint. ” On another occasion I asked a nurse colleague if we could place a graduate student somewhere in her huge outreach system for an experience in group psychotherapy. She consulted with her staff and came back with a “no,” saying their patients were long term and could not handle the terminations inherent in student placements. I assured her I had supervised groups like this for 25 years. The patients could handle a turnover of students and would profit from this experience. She replied that their patients already had groups. These I knew were “jazz groups” and so forth. The concept of group psychotherapy for long-term patients was unfamiliar to these young mental health professionals. Another example of the difficulty in placing graduate nursing students for psychotherapy experiences occurred the previous spring. A student was seeing a chronic schizophrenic with obsessive thoughts and cocaine abuse. The setting was a day hospital. I was in frequent contact with the student between her weekly supervision sessions because of the complicated nature of this case. In fact, when I was away in Hawaii I called this student daily to check on the patient and help her with any problems. That spring, the psychiatrist in charge of the day hospital told the student she had to terminate her sessions with the patient. He believed the patient was too upset because she had burned her arm with a cigarette. I went to see him with the
SUZANNE
LEG0
student. He explained that although he understood the concept of therapeutic regression, he believed the patient was better off without therapy. I reassured him that I had been supervising students for 25 years and was constantly available to the student. He seemed uncertain. Was it that a nurse was telling a doctor to relax, that she was on top of the situation, or was fear of liability an issue? A week later he told the student the therapy was over, and she was not permitted to terminate properly with this unfortunate patient. This fall, he refused a student because they “had a bad experience last year.” Competition with students in other disciplines also presents problems in student placement. This, coupled with a narrow viewpoint about which patients are “suitable” for psychotherapy, results in a small group of patients sought after by psychiatric residents, social work students, psychology interns, and our graduate students. In rare cases, psychiatric nurses are still not seen as suitable psychotherapists, adding to the problem. In urban areas an additional problem is that students are fearful about travel from one part of the city to another. Public transportation is considered dangerous, and parking is both hazardous and expensive. Inconvenience is another problem. Most of our graduate students work full time and attend school part time. Time is precious. Travel to clinical placements takes hours. In the 199Os, students are less likely to inconvenience themselves than in past decades when they were more compliant. Universities, always competitive for qualified graduate students in psychiatric nursing, attempt to make their programs as convenient as possible. One outgrowth of the biological-versuspsychotherapy approach to long-term patients is the advent of the “case management” role for psychiatric nurses. This means that master’s_prepared nurses working in the community spend most of their time steering patients through the elaborate labyrinth of health and environmental care they need. They take them to clinic appointments (or arrange for them to be taken) and to social security, welfare officers, and the like. In their opinion, someone must help these long-term patients to survive in the world. While I agree, I seriously question whether this need be a masters-prepared nurse. The problem is that the baby has been thrown out with the bath water. Nurses have lost
A PRACTICUM
213
IN PRIVATE PRACTICE
sight of psychotherapy as a treatment modality. I suspect this is because agencies do not support such “old-fashioned” ideas as therapy for longterm patients, especially when drugs keep them so calm, and also because graduate programs have for the most part succumbed to this predominant thinking. So we see that there are many reasons we have problems with student placements for psychotherapy. These include bureaucracy, liability issues, competition, safety and convenience concerns, and most important the notion on the part of young inexperienced mental health professionals and paraprofessionals that long-term mental patients need only be medicated, offered jazz and health groups, and for the most part left to their own devices. They should not under any circumstances be upset! In truth, this notion is supported by a society geared toward the avoidance of anything that is upsetting. A colleague once told me that on the adolescent oncology unit, at her hospital, parents are given marijuana to smoke until their children die, to ease the pain of this experience. The problems of widows given prescriptive tranquilizers to ease their grief, only to become addicted as time goes on, has been written about recently. PRIVATE PRACTICE AS A CLINICAL PLACEMENT
One solution to the problem of finding clinical placements for graduate students learning psychotherapy is to place them in private practice. This kind of placement is not for every student. However, for the very mature, confident student who is committed to the private practice of psychotherapy as a career, this may be a good alternative to general placement. Before designing this placement, I thought about the responsibilities and activities of the psychotherapist in private practice. I decided these include (1) clinical work with patients, (2) attending supervision, (3) participating in personal psychotherapy, (4) attending conferences, (5) writing papers for publication, and (6) presenting papers at conferences. The experience I designed includes all six activities. Clinical Work With Patients
One student currently in the practicum, Marian, told all her friends and associates that she was available to see patients free of charge twice a week for the next 6 months. She told the patients
that when she graduated in December she would continue with any patient who wished to continue at a low fee. Patients were referred by friends and classmates as well as myself. Those who live near her home are seen there. Those near the university are seen in my office. At present she sees seven patients twice a week. She plans to start a group as soon as she has seven clients who are strangers to one another. (Some new patients were referred by current patients and cannot be in a group together.) Supervision
The students attend supervision with me once a week. They share the supervision hour with other advanced students who plan to do therapy full time when they graduate. Supervision is conducted using audio tapes of therapy with patients. Personal Psychotherapy
Because the clinical work is long-term psychodynamic psychotherapy, I believe it is important for the student therapists to be in therapy themselves (Lego, 1984). In Marian’s case this involves analysis twice a week and group therapy once a week. Attending
Conferences
Students are encouraged to attend conferences and to report back to classmates about these. In the New York area there is a rich supply of nursing as well as psychological and psychoanalytic meetings. Writing for Publication
Students are expected to write papers and submit them for publication. I edit these and return them to the students for revision until they are ready for submission. Marian has submitted a paper on her work with the cocaine-using obsessive patient she worked with last year. Presenting
Papers at Conferences
Students are also expected to submit abstracts or papers for presentation at conferences. The two students in the private practice practicum were asked as part of their experience to organize an intercollegiate psychiatric nursing conference. This first conference was held in October, 1990 at Columbia. Papers were given by students from Yale University and Adelphi University as well as
SUZANNE
214
Columbia University. This has become an annual event with the universities rotating as hosts. It is my belief that these six activities socialize graduate students to the role of the professional nurse in private practice. As we all know, a profession and its disciplines can only grow and prosper if we have new young professionals who are encouraged to contribute to this growth. I believe that an advanced clinical practicum in private prac-
LEG0
tice solves the problem of inadequate sources for clinical placement and provides an atmosphere and arena for this kind of professional growth and role development. REFERENCES Lego,
S. (1984).
Designing a private practice. In S. Lego (Ed.), The American Handbook of Psychiatric Nursing (pp. 167-176). Philadelphia: Lippincott.
