Week 5

It has been a long time since I've posted, simply because I've been so busy. Things have really picked up at my internship, and I am doing quite a lot there. Next week I get to administer a

neuropsychological assessment called the WAIS on a practice subject, so I've been teaching myself how to do that. I have been attending peer supervision meetings, scoring batteries of inventories (including the CORE, DAS, DES and Risk Assessments among many others), continuing work on the dissociation project, and I have been scheduled to observe some upcoming therapy sessions. Next week I'll also be taking the bus to a community counseling center that is affiliated with the NHS a few towns over. It offers services to those with more "moderate" issues, compared to Psychological Therapies which is more intense. It will probably take me close to an hour by local bus, so I am hoping I'll be able to stay there for a while and learn about what they do!

What is also nice is that now there is a clinical psychology trainee in the office with me 4 days a week. She was away on holiday climbing Mount Kilimanjaro, but is back now! She's from Ireland but has lived here now for a few years for University, so it's interesting to get her opinion on various aspects of the psychological field. We have had some really intellectually stimulation conversations. Although our opinions differ sometimes, it just provides me with another view. She also lived in Pennsylvania for 2 years, so she's been able to share her own reflections on our health care system. I really appreciate that. She has also been using some Irish slang and common phrases which has been fantastic. I may be able to tell a compliment from an insult by the time I go to Ireland!

I have also continued to attend the exercise group for some of the patients. Although the atmosphere is really informal and only focuses on exercise, it's a good experience just to have interaction with people in that setting. The class takes place on Wednesdays, so it's a nice mid-week break. Though come Thursday morning, I dread the 1.5 mile uphill-both-ways walk! 

Yesterday, which was Friday, I came home to find a package waiting for me from my friend Tucker! I opened it up to find a lovely letter and incredible cynotype of a killdeer on the beach back home. It is now displayed on the top shelf of my desk so I can see it all the time! The birds here are so different than the ones back home. There are seagulls everywhere, which I find strange...even in Old Town in Edinburgh! It seems so far from their natural place! One of my favorite birds to see here are the magpies. They are almost always on the lawn of the hospital. Anyway, I really love mail. I hope everyone I sent postcards to have received them by now! I wanted to write more this week, but I did not have much extra time!  

Since last night was Friday, we went to a pub that was located on the lawn outside of this castle. It was a really tiny place. Most of the pub seemed to be focused on the Wimbledon match on the one TV in the building. We sat outside in the beer garden, until the midges were too much and we retreated back inside. As I have mentioned before, I do not like beer, so instead I've made a point of sampling ciders from around Scotland. The one I picked was SO sweet it did not even taste like cider...more like a fizzy fruit juice. It was yummy though, which I'm glad, because I paid 3 quid for it!

Unfortunately the castle was closed due to the time we were there, so we just had a wander around the outside of the walls. The town of Dirlton, which took its name for the castle that resides there, is a sleepy little village. Aside from the people at the two restaurants and a few kids playing on a swingset, there really was not anyone in sight. 

We were also lucky to catch this amazing sunset. Since we were just going to the pub, I did not bring my real camera, but I am sorry because my iphone did not do the orange of the sun justice. We joked and said it is the color of Irn Bru, the famous Scottish soft drink! It's a citrus soda that is incredibly sweet, but it outsells both Coke and Pepsi here in Scotland. The only reason I have not tried it yet, is because I do not think I could drink a whole bottle alone.

 I'm going to post a separate entry of my day in Edinburgh!

Reflection: 13th of June

My supervisor is awesome.
The rest of the staff at the hospital is awesome.
I love the work I am doing.

But PHONES are not awesome and I feel like just abandoning it and going back to being phone-less. It was less stressful that way. Seriously. People keep telling me different things (like people who are paid to provide service support) and I keep spending money and nothing is working. I have been pretty calm these last few weeks considering I just moved halfway across the world, but it is THIS that is making me frustrated.

Anyway, about my day:
I am getting to help create a new therapy group for victims of childhood trauma. This one is going to be a women's group (over 18) that combines psychoeducation and more traditional group therapy. In the past they have run 18 week sessions using a compressed form of this 32 week model that is supposed to reflect evidence based research. I think the book is called The Trauma Therapy Group: A Guide for Practitioners. This is second-hand information, but I've been told that evidenced based research is severely lacking from the trauma field, as it is difficult to get funding for treatments that are NOT Cognitive Behavioral Therapy, basically, which is shown to not be working in the long run for trauma survivors. The theory that the facilitators are planning on working from is CBASP, which I mentioned before is considered a "cognitive analytic" theory. Really interesting, been doing some more reading about it. Anyway, I am basically compiling these information packets tomorrow to be distributed to group members, just things for them to read and start normalizing their reactions to their experiences. Apparently last time they ran a group with a similar model, they jumped right into working, bringing up the themes of neglect, isolation and fear almost immediately.

SO my job is going to be to read through the book aforementioned, whatever book it actually is, and look at that 32 week model. Then I'll look at the previous 18 week model that was used by the NHS. Then I will go through the collection of handouts used in psychoeducation groups (like lectures) about childhood trauma, and try to integrate all of it into something cohesive, informative, and able to promote healing. The three facilitators already have a general guidelines of what they want to discuss and how they want to structure it, but I am to synthesize the information more, it seems. I think I'll have a better idea once I do the reading!

After work tomorrow, from which I will be leaving about an hour early, I'm catching the bus to Edinburgh to spend the night at a hostel. In the morning, I'll be going to a number of sites in the Borders and then hopping into England to spend the afternoon at Alnwick Castle. So I will not be posting tomorrow, but hopefully Saturday night or Sunday I'll be able to share some good stories!

Assessments

Basically, getting a phone has been extremely confusing. As I mentioned yesterday, I purchased a phone from Tesco for 30 pounds. So that is approximately 50 US dollars. After setting it up and

Tree lined walk to the hospital

trying to get it to work (which is not very easy, especially when switching from an Iphone) I decided to top-it-up for about 10quid so I can use the data when I go to Edinburgh and then England this weekend. What they didn't tell me is that you cannot use a USA registered credit card to do any top ups. This goes for both for paying online and over the phone! So that means each time I need a top-up, or anyone else who uses the phone, they would have to buy a voucher. I wish I would have known this when I purchased the phone so that I could have gotten a voucher at the same time. Welp. Guess I know what I'm doing after work tomorrow!

In other news, had an interesting day at work, too! But in a good way! I was allowed to start scoring some psychological assessments. It is all very Clinical Psychology.

CORE

First there is the CORE, which is supposed to measure how the client has been feeling in the past week in the areas of subjective well-being, problems/symptoms, life functioning and risk/harm. This assessment is usually done at the start of therapy and at the end to measure therapeutic outcomes.

DASS: Depression Anxiety and Stress Scale

The final assessment I was able to scale today was a DASS, or Depression, Anxiety and Stress Scale. This was probably the most straightforward self-report of the bunch. You just had to calculate the total scores and simple scores for each of those targets (D, A, and S) and then interpret it using a "severity scale." So that was fine.

The hospital on this rainy morning

DES: Dissociative Experiences Scale

Finally there is the DES which is the Dissociative Experiences Scale. These questions to relate to the client's experiences in daily life with dissociation. A high score may be a flag to further investigate Dissociative Identity Disorder in the client. When we think of DID in the states, we generally think of multiple personality disorder and the extreme case of Sybil -something we have always thought to be very rare. Apparently not so here. Most of the cases involving complex childhood trauma I have been told have some connection to dissociation (though nowhere near as severe and dramatic as the Sybil story). I find this all confusing just because it really goes against what I have previously learned. I am curious whether this is an issue here and we don't see it because of our most common treatment module: CBT? Though CBT is still popular here, CBASP, or Cognitive Behavioral Analysis System of Psychotherapy is used for the complex trauma cases (the ones that I'm told experience dissociation the most). From what I've read, this theory involves a great deal of interpersonal transference, which is what psychodynamic theory revolves around. I am just wondering whether there is a connection between the lack of diagnoses of dissociative disorders, since psychoanalytic therapies are seldom found in the states due to insufficient insurance reimbursement guarantees. Maybe out of the CBT mindset we would acknowledge more dissociative traits in clients? I don't know. Just a thought!

Anyway, the DES test is rated on a Likert scale from "Never" to "Always." Here are some samples:

"Some people have the experience of driving or riding in a car or bus or subway and suddenly realizing that they don't remember what has happened during all or part of the trip."

"Some people find that they become so involved in a fantasy or daydream that it feels as though it were really happening to them" 

This was in the interpersonal therapy book I
was reading today! All textbooks should have
Harry Potter references!

After that, I sat in on a teams meeting coincidentally about exactly what I was planning on doing with some of my time here. Apparently a few weeks ago, before I arrived, the NHS administered a survey to the staff asking questions about what they think is working well in the system, what is not working so well, and what can be done to change those issues. This is EXACTLY what I was intending on doing. I have a copy of all of the responses. What is interesting is that very few people from the Psychological Therapies team answered it because they did not want to point fingers at other aspects of the overall care team! Being new to the team, I basically just sat back and listened to all of the different comments. We broke into two different task groups during the three hour period, so I was able to hear the concerns and solution proposals of a wide array of mental health professionals. It was really beneficial! Not sure what tomorrow has in store for me (except a trip to Tesco) but we shall see!

A Scottish Day, Aye

Somehow I arrived just at the start of a rare stretch of summer in Scotland. Since I arrived over a week ago, I have even been sunburned twice (who gets sunburned in Scotland? Me, apparently). When walking to the hospital this morning it seemed that another blue sky would be waiting for me to enjoy at the end of the day.

But I was wrong!
I witnessed my first rainfall since getting here over a week ago. Lucky me I had a "brelly" in my bag!

I am training to run neuropsychological assessments at the hospital. Though I probably won't be here long enough to actually administer them myself, I am going to be able to sit in on assessments and help with the scoring. There is one test I would not have necessarily classified it as a neurospsych test before reading up on it. I would have called it more of a "cognition" test, but I guess that means my vocabulary is off. It makes more sense after reading about it, but I wish I would have taken that Tests and Assessments class already! The assessment I have been focusing on this week is the WAIS- IV or the Wechsler Adult Intelligence Scale. It was designed and first released in the 1950s. I had a moment of panic seeing the boxes of this test and thinking to myself "YOU HAVE GOT TO BE KIDDING ME THEY'RE NOT STILL USING THESE, RIGHT?!"

And then I let out a huge sigh of relief when I realized there were 3 backpacks full of more testing materials. There was a new version released in 2008, so this is the one I am ACTUALLY learning with. I still have my qualms with intelligence scales but I enjoyed playing with the stimuli from the one from the '50s. As you can see from the picture, some of the visual-spatial tests were pretty creepy, or at least in my opinion. Did I mention the clock in the trainees office doesn't work? It ticks and the poor little arms try to move, but they're perpetually stuck at 8:45. With the clock and the rain and being alone in there today... what a setting!

Normally there are a lot of people around but almost everyone had gone to appointments at other sites today. I had finished my work pretty efficiently, and as it was a light load to begin with, I left a bit early. From there, I walked to Tesco because I decided it is probably time that I buy a phone. I got a little pay-as-you-go phone for 30quid, which is kind of expensive, but I'm going to give it to my sister to take with her on her study abroad program in the fall. Now I just have to figure out how to finish setting it up. It's confusing. But again, no straightforward answers from anyone about anything so hopefully I'll figure it out OK on my own.

Oh aside from the rain, the other Scottish thing! I had Haggis today! Well, vegetarian haggis, which is apparently what most people eat. I guess most of the country realized eating organs cooked in a stomach is probably not the healthiest option. So I've got the rain and haggis today. I wonder what tomorrow will bring!

Reflection 10th of June

Just throwing this out there - on the map in the right side of the screen, I have plotted all the spots I have been thus far. I hope by the end of this trip to have pin points all over it!

So, this is where I work:

Mondays are nice because there are other students there. There are four of us total, but the other three only do one day a week at the hospital. I enjoy talking to the other students because they have yet another perspective of the field. We went to lunch today in town as well. It is nice to have that social aspect with others around my age, since I am not really getting that anywhere else. One girl is a Counseling PhD, so we were comparing our program requirements today. As doctoral students, they are required to do 450hours of one-on-one therapy before they are allowed to practice independently and graduate. Their programs are three years compared to our 5-7 years. I thought that was interesting. 450 hours in a placement did not seem like so much at first compared to the 900hours minimum that we get before graduation from our masters program. However, their hours do not include paperwork, trainings, supervisions, agency meetings or events, or any of that. Just 450 hours of delivering therapy.

On Wednesday, I am going to an organizational meeting in which we are going to talk about what things are working and what things are not in the NHS. The other students are going as well, so it should be an enlightening experience for all of us. We are all still kind of outsiders looking in. I am looking forward to being in on these discussions. Then on the 24th, I am going to the Royal Infirmary for a really big NHS meeting. That is an all day event, though I am not really sure what information it will cover. I'm expecting an email about that soon.

In further news, my trip for Friday-Saturday is all booked and paid for. Looking at the itinerary for the tour to Alnwick, I saw that coach might pass right by Haddington on the A1. I decided to just email the tour and ask if it is possible to get off when passing Haddington to save some time and money on the commute home, and they replied that they will do that. I just have to remind them the day of. So that is nice! I feel like the same question in some parts of the USA may warrant a more negative response.

I will admit I am having a bit of anxiety about the internship and not getting to do enough. I have things to do, but I am used to a much bigger work load. I wish my FBI check would come back soon so I can start doing more clinical stuff. I'm pretty fed up with the system we have in the States where we have to do a separate fingerprint check and request for everything we do. It's such a waste of precious resources (like TIME) in my opinion. I just think it would be a shame if I miss out on certain opportunities while I am here due to this formality. Just not sure what else to do, as it is all out of my control. I am trying to make the best of it, but I don't want to feel like I am wasting the precious time I have here. I have two months left from today. I know it's going to fly.

Reflection: 6th of June

It is another beautiful sunny day! I was able to meet with my supervisor about the progression of the internship. I am unfortunately still waiting on the FBI check (in much frustration) so I have not been able to have contact with any confidential information yet. Once that comes in, I can really begin analyzing and quantifying data as well as observe group and individual sessions. Some of the groups I am interested in sitting in on are "Strive and Thrive," "Mindfulness", and "Stress and Anxiety."

Some of the research I will be doing is on dissociation. In the United States, dissociation usually relates to a really severe and chronic symptom of a mental health disorder. Diagnoses such as Dissociative Identity Disorder are extremely controversial. The definition of dissociation here is very Freudian; it is basically what we refer to in our vocabulary as the defense mechanism "repression." My supervisor works with trauma victims and she has found that dissociation (in this sense) is frequently present in this population. I guess I am starting to see the places where the psychodynamic views come in, even if it is not necessarily one of the main treatment modules here - it is in the way cases are conceptualized. I am looking forward to getting into research again!

I have some more reading to do tonight. My supervisor loaned me a book about Rosslynlee Hospital, a former asylum. I imagine there is some interesting history in there! Tomorrow is Friday, and then I think Saturday I will be going to Edinburgh. We have had beautiful weather since I have been here, so I hope it lasts through the weekend! Here are some pictures from my walk to and from the hospital today:

Foggy morning, but I remembered to take a picture of the town phone box 

I love these stone walls

Windows in the hospital

What a view!

Stopped in a cafe on my walk home for some coffee. This cafe is actually a craft and art gallery downstairs. It is called "Petter Potter Gallery." I pass it every day on my walk. 

Out the window of the cafe

Reminds me of a postcard

Reflection: 5th of June

This is the back entrance to one of the buildings I have been
working in. As you can see, it's quite old, but I like that!

Everyone at my internship is so helpful and friendly so far. The whole atmosphere is so much more easy going and relaxed than what I am used to in the states. This is true for both the paid and unpaid jobs I have had! There are no time cards, you do not get punished or reprimanded for being late but if you are it's just natural that you make up the time, and there is a real sense of respect among all of the people. I honestly cannot even tell who is in a position of power just because everyone has such good work ethic and is so responsible for themselves and what they do. Since my first couple weeks I am getting oriented at the hospital and independently exploring, I have had a lot of downtime. I enjoy this as it gives me time to really soak in the whole experience. The conversations I have had with the staff are so insightful. I have been in an office with everyone ranging from therapists, to community psychiatric nurses, to physiotherapists. It has been so interesting discussing elements of the health systems with them. They are equally as curious about our system and how it works. They particularly have a lot of questions about what the Obamacare plan will mean for mental health. This is something I need to look into more to understand, as to be honest, I really do not know how it is going to alter the mental health system. But while these conversations are so interesting, I do not want to detract from peoples' work or have them feel like they must occupy me, so I have been doing reading. I read a few chapters today in a book about Emotional Intelligence, one about Schizophrenia and how it is approached in different countries (including the UK and the USA so that was interesting for my research), and I brought home a book on Positive Psychology to keep with me for a bit.

I was sort of thinking of trying to start my own little research project while I am here, and make up some forms to gather data. If I can get approval, I think I want to survey the mental health care professionals on what their understandings are of the National Health System, how they feel the NHS is meeting the needs of Scotland's people, and what shortcomings/failings they see within the system. Similarly, I would like to hear from the consumers' perspectives on how they feel the system is working for them, what can be improved, and what the process was like when they decided to seek treatment. I would like to bring the same survey back to the States if I can, and look at the comparisons. I think I am starting to gain a clearer understanding of the big picture here, but having first-hand anonymous reflections may be more telling.

Walking to work this morning, it was so cloudy and foggy. I was wondering if my lucky spell of uncharacteristically-nice Scottish weather was over. However, it cleared up again in the late morning and afternoon, revealing a blue sky. Everyone is complaining how summer is here, and how it is too hot for them. It is only about 50 degrees, and I currently have two pairs of socks on. I do not think our definitions of "hot" are the same...and central air does not even exist in Scotland!

Also, if anyone is interested  this article was recommended to me today. It is basically a statement on the theory that diagnosing may not actually be helpful for those receiving mental health care. This topic comes up a great deal at school and is very controversial in America's mental health system. As you can see, we are not the only ones discussing this. It is very though provoking!

Psychiatrists under fire in mental health care battle

Day Two

Today was a low key day at the internship in terms of work for me to do, however, I loved this because it meant I could talk to many people! From 9:30am-12:30pm I attended a training about assessing clients who are "at risk."

This means determining whether they are at a risk of hurting themselves or others. It was a really interesting session to be a part of because their system is so different than ours. I am trying to pickup on the rules and requirements given to mental health professionals by the NHS. It is a very collaborative system, so therefore their confidentiality and ethic laws are different. Even the responsibilities and roles of each person in the "team" are different than ours. I am still trying to learn all the terminology and understand how all the pieces fit together. Everyone has been really nice so far though! I cannot wait until I can start doing clinical work. 

Some impressions about the system - it is much more team oriented. Everyone has the opportunity to receive mental health care, however it is a long process to get into therapy if you want to go through NHS (which is free). However, you do have the option to seek private care. The staff of NHS, particularly in the Psychological Therapies department where I am situated,

Old building, Old keys. But I accessorized mine!

is really mixed. There is a clinical psychologist, a few other doctoral level psychologists, psychiatrists, masters level therapists who are trained in specific therapy models, nurse therapists (which I still don't completely understand), social workers, occupational therapists (who seem to do social work type things) and physiotherapists. Everyone works together and collaborates on cases depending on the needs of the patient - even the general practitioner who does all the referrals has rights to access the information. Very different than here. The staff likes this because they are able to understand each case from a multiprofessional perspective. From what I understand though, each organization within the NHS uses a different database to store info, so there are some issues with everyone having access to all of the documentation. This is something that is being worked on now, however.

I also started reading up on some popular psychological/therapeutic literature for Scotland. Some of the popular theories used here are Cognitive Behavioral Therapy (big surprise), Interpersonal Therapy (ITP), Cognitive Behavioral Analysis Systems of Psychotherapy (CBASP), Cognitive Analytic Therapy (CAT) and Psychodynamic Therapy. I started reading a book on IPT today as I'll be sitting in on one of the therapist's sessions who is a specialist in this technique. I also read an introduction to CBASP because I really was not familiar with that at all. I am curious as to how these therapies are delivered!

 Since towards the end I did not have much left to do, I was encouraged to just to go outside and enjoy the sun. They are so much more relaxed here - there isn't such thing as a time clock in the hospital! I LOVE the fact that coffee/tea is offered after almost every greeting. The coffee here is almost never instant either...someone ground up coffee beans and made me a cup today! At the house, it's always from a french press. I'm afraid by the end of the summer I'll be spoiled by these luxuries!

I am not sure what tomorrow will have in store at the internship, but hopefully I can continue to talk to some of the other staff and form a better understanding of NHS. 

Swans again on the walk home!

Internship: Day 1

Just returned from my first day at the internship! I was SO nervous last night and this morning, fearful of whether I would make it there on time or if I would get completely lost in town, if I would like the people I am working with/for and whether they would like me, whether all of this is worth it. As of this moment, I am feeling hopeful.

Nungate Bridge, which I take to the hospital

I DID get a little bit turned around this morning on my walk to the hospital. But luckily I know myself well enough that I thought this might be a likely occurrence and I left the house a half an hour earlier than I needed to. I ended up needing an extra 10 minutes to get myself back on track, so I got there pretty early. Many of the roads in Haddington look the same, and you have to take a lot of gennets between streets to avoid taking twisty roundabout ways to get anywhere. I think it should take me about 30 minutes each way, but maybe shorter if I get brave and start exploring shortcuts, It is a really pleasant and scenic walk!

View from a bench in the park

When I first got to the hospital I was not sure exactly where to go. I knew I was looking for the Psychological Therapies building, but all of them looked the same! I'll try to remember to take a picture tomorrow. It is a very old hospital, all separate stone structures, but it was redone inside many years ago to house the psychological services for East Lothian. One can tell that the inside looks like an old hospital ward, however, there have not been beds there for years. According to my supervisor, the hospital buildings are "like the inside of the Tardis - it's bigger on the inside, and the hallways seem to keep going and going forever." This was a nice reference to start the day, and I found it very accurate! There used to be a short term psychiatric unit there but that was moved into Edinburgh. I guess the most equivalent type of place in America that I can compare it to is a health agency - not a typical "hospital." People come in for individual, family, and group therapy, and the therapists also travel to other locations around the Lothian towns. Inside the Haddington hospital are housed a clinical psychologist (my supervisor), Masters level therapists (who in Europe are trained in one type of therapy such as CBT), nurse therapists (still unclear on their role exactly), art therapists, and social workers (in a different building).

First thing, my supervisor gave me a lift to the Midlothian office center, where we were to attend a meeting. The health care system in the UK is socialized, the government split up the Lothian areas (I'm in east Lothian) and provides care through the National Health Service. The meeting included the mental health service providers for all of the Lothian areas. It was really interesting listening to all of the conversations, as the terminology is very different! There is apparently a lot happening in Scottish politics that will be changing some things in the system, so I have been told it is a good time to be around. Another girl started volunteering today, but she will only be here on Mondays. It was nice to have someone else about my age there. Everyone was very nice!

After the meeting we went back to the hospital, we took a tour, met the rest of the staff, and talked some about the differences between the Scottish system and the USA system. I can already tell there are many aspects of the system I will have questions about. Hopefully many of them will be answered by spending time with various professionals. At about 1pm, my supervisor took the other trainee and I out to lunch as a "welcome treat." It was so nice. She also made us cupcakes! After lunch we went back again to the hospital, talked a bit more, and then decided to call it a day. Going to try to get there between 9am and 9:30am tomorrow as well. I have a lot of assessment tools and vocabulary to orient myself with!

By the time I left, it was HOT. I think I brought summer with me. I decided to make the walk home leisurely, and enjoy some of the sights, including St. Mary's Church which you can see below. I think I am going to take it easy the rest of the night. Not sure what the plan is!