**VA Palo Alto Health Care System**

**Psychosocial Rehabilitation Emphasis Area Training**

VAPAHCS, which annually provides outpatient mental health services to
nearly 10,000 veterans at eight sites is gradually shifting to a
psychosocial rehabilitation focus. The shift to Psychosocial
Rehabilitation (PSR) practice begins with the realization that people
with chronic and severe mental illness (CSMI) can and do get better.
This recovery vision is the driving force of psychosocial rehabilitation
and is supported by the VHA *Mental Health Program Guidelines* (9/3/99).
Veterans with CSMI "should not be deprived of the opportunity to attain
greater self-determination." VAPAHCS, an affiliated training center for
many disciplines from several universities, offers multiple excellent
opportunities for educating PSR mental health leaders of the future who
will have a commitment to the potential recovery of CSMI individuals,
will promote integration of care, expand systemic education, and lead
progressive change.

PSR strives not only to achieve stability but moves beyond the
maintenance model of symptom control to emphasize functioning in the
community of one\'s own choosing. Social rehabilitation assists
individuals in transcending limits imposed by mental illness and
addressing social barriers such as second class personhood and stigma,
so that the individual can achieve their goals and aspirations. As such,
PSR is both a conceptual framework for understanding mental illness and
a client-centered system of care. . Fellows in the Psychology
Postdoctoral Fellowship Program who obtain training in the PSR emphasis
area will attain general clinical competencies, as well as the
PSR-specific competencies described below.

**[Philosophy & Values]{.underline}**

VAPAHCS offers services to veterans with CSMI based on the primary
principles of psychosocial rehabilitation, as described by the United
States Psychiatric Rehabilitation Association (USPRA) in their "Practice
Guidelines for the Psychiatric Rehabilitation of Persons with Severe and
Persistent Mental Illness in a Managed Care Environment" (9/9/97). These
guidelines were developed in conjunction with a task force convened by
the Joint Commission on the Accreditation of Health Care Organizations
(JCAHCO) and the work of the USPRA Managed Care Committee. Per these
standards, a psychosocial rehabilitation practitioner will:

-   Promote continuity of care

-   Engage with the whole person

-   Foster hope, self-esteem, & empowerment

-   Encourage advocacy, peer support, & self-help

-   Support consumer-identified community goals

-   Promote education, role models, & self-determination

-   Encourage natural social supports & resources

-   Teach life, stress, & symptom management skills

-   Develop partnerships with consumers, families, caregivers, & the
    community

-   Facilitate community-based normative experiences (Social,
    educational, vocational, & leisure)

    **[Curriculum]{.underline}**

    In addition to ensuring the attainment of advanced general clinical
    competencies in psychology, didactic training is offered in the PSR
    emphasis area. The didactic curriculum is based on materials from a
    variety of leaders in the field of PSR such as: USPRA, Boston
    University's Center for Psychiatric Rehabilitation, the National
    Empowerment Center, and various practitioners and researchers of
    evidence based practices. The foundation of the PSR fellowship
    training will be to promote collective learning from academic,
    research, consumer, and community based resources.

    A variety of teaching methods will be utilized; as much as possible,
    teaching will be informal and arise out of specific clinical
    learning opportunities. The full set of teaching modalities
    includes:

    -   Individual and group supervision

    -   Review of videotaped and written materials

    -   Fellow and guest presentations

    -   Core and affiliated faculty didactic sessions

    -   Interprofessional team development exercises

    -   Attendance at professional/consumer conferences

    -   Observation of staff modeling clinical and leadership skills

    -   Co-facilitation of groups and interventions with staff
        clinicians

    -   Role playing especially for communication and engagement skills

    -   Assigned readings to provide basic information and expand on
        teaching topics

    -   Visits and discussions with consumers who will share their
        recovery experiences

    -   Program development and outcome measurement

The curriculum's learning domains will be based on the seven core
competencies of a psychiatric rehabilitation practitioner as defined by
the examination for Certified/Registered Psychiatric Rehabilitation
Practitioner (CPRP) that evolved from the USPRA "Practice Guidelines".
All of the domains are considered essential for training PSR
professionals. Each content area will have an assigned faculty leader
responsible for coordination and teaching methods related to that domain
across all fellowship disciplines. The faculty leader will be
responsible for ensuring that curricular objectives are addressed and
will coordinate training evaluation within the domain.

# 

# CPRP Exam Program Domains 

######### Interpersonal Competencies 

-   Professional Role Competencies

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-   Community Resources

#### Assessment, Planning, and Outcomes

-   Systems Competencies

### Interventions & Evidence Based Practice

-   Diversity

    **[Exposure, Experience, & Expertise]{.underline}**

    By design, training in the PSR emphasis area will provide integrated
    educational opportunities both on-site and with a variety of
    community PSR-focused agencies that serve individuals with CSMI.
    In-services with College of San Mateo's Transition to College
    Program (for individuals with CSMI), the Enterprise Resource Center
    (100% consumer run agency), Palo Alto New Hope Self-Help Center, the
    Contra Costa Recovery Centers, the San Mateo County Community
    Rehabilitation Coalition, and California Association of
    Rehabilitation Services (CASRA) will offer a wealth of educational
    opportunities. Exposure to local and national PSR programs will
    provide a vital contrast to traditional medical model services that
    have been the standard of care for hospital systems.

###### **Interprofessional Domains**

-   Collective planning of PSR practice

-   Training, skills, and roles of each profession on the team

-   Unique skills and role of one's own profession on the team

-   Cooperative leadership in conducting interprofessional team
    activities

-   Effective problem solving and ability to achieve consensual
    decisions

-   Shared expertise for one's own profession and other professions on
    the team

    **[Proposed Education Dissemination Project]{.underline}**

The psychoeducational quarterly system at the immersion site (see
below), the Community Transitions Center (CTC) provides trainees a
natural structure to design a PSR project that will allow them to
develop their PSR skills by exploring options, fostering engagement,
challenging stigma, and connecting with resources. The presentation of
project curriculum developed by the PSR fellows could be offered via
streaming video technology in cooperation with our MIRECC.

In addition, the PSR fellows will develop a seminar for presentation at
the United States Psychosocial Rehabilitation Association (USPRA) annual
conference. The USPRA conference is a meeting of consumers, family,
providers, and researchers dedicated to disseminating PSR information,
concepts, and techniques.

**Rotation Sites:**

**Community Transitions Center (Building 334, MPD)**

**Primary Supervisor: To be determined**

**1. Population using service:** Persons with severe mental illness
(SMI)

**2. Psychology\'s role on site:** Psychology Fellows are part of the
team of providers on site which include the disciplines of nursing,
social work and recreation therapy, who co-facilitate classes with
persons with SMI.

**3. Professions and trainees on site:** Site staff consists of social
workers, nurse, and recreational therapist. Many staff are Certified
Psychiatric Rehabilitation Practitioners. Trainees are the PSR Fellows
from psychology, social work, and nursing.

**4. Nature of clinical services delivered:** CTC provides a classroom
experience where learning is facilitated by interaction with other
veterans and staff. The format is in a group.

Training in the PSR emphasis area will be based on immersion training at
the Community Transitions Center (CTC), VAPAHC' primary PSR program for
veterans with CSMI. CTC is an open-ended outpatient PSR supportive
learning/resource center for veterans with a major Axis I (Schizophrenia
or Schizoaffective) disorder and severe impairment in one or more
aspects of community living. The primary goal of CTC is to help veterans
live satisfying and productive lives in the community of their choice
i.e. self-directed community integration.

The environment at CTC uses a life-time learning education-based model
designed to reinforce the primary values of psychosocial rehabilitation:
*hope, potential for growth regardless of disability, and
self-determination*. CTC recognizes that providers have the power to
change the service delivery environment and include mental health
clients as the experts in living with mental health disabilities. In
addition, the negative side effects of being identified as a psychiatric
patient, such as internalized stigma, lost opportunities,
demoralization, and lack of identity, are openly addressed. The focus at
CTC is on continually providing choices, opportunities, information,
necessary supports, and role models that encourage clients to make their
own choices and strive toward their own goals. Peer counselors,
"recovery coaches", co-facilitators, alumni, and guest speakers are role
models that inspire all.

The CTC immersion will offer the fellows an opportunity to concentrate
their PSR experience. After the extended immersion-training period, the
PSR fellows will remain anchored at CTC but will expand their PSR
knowledge by working with other service providers to support veterans
with CSMI achieve their community goals as well as problem solve
emergent issues. For example the PSR fellows will advocate and consult
with Mental Health outpatient and/or inpatient providers to support
veterans at CTC. The PSR fellows have the opportunity to interface with
various treatment services potentially offered to veterans with CSMI
such as the Mental Health Clinic, Inpatient Psychiatry, Community Care
Program, Mental Health Intensive Case Management, New Horizons Day
Program, and the Compensated Work Therapy program *depending on the
client's needs and goals*.

**Mental Health Clinic, Menlo Park (Outpatient MHC)**

**Supervisor: Gloria Juliana (Gia) Maramba, Ph.D.**

1.  **Client Population:** Male and female veterans of all ages with a
    variety of Axis I and Axis II diagnoses. Population is 80% male,
    with increasing numbers of recently returned veterans

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1.  **Psychology's Role in the Setting:** Psychologists are integral
    members of the treatment staff and work actively with Nursing,
    Psychiatry, and Social Work to inform treatment decisions and share
    responsibility for leading treatment groups and coordinating care.
    Psychologists provide evidence-based individual and group therapy.

2.  **Other Professionals and Trainees in the Setting:** Psychology
    Postdoctoral Fellows, Psychology Practicum Students, Psychiatry,
    Psychiatry Residents, Social Work, and Nursing Staff.

3.  **Nature of Clinical Services Delivered:**

-   Individual and group psychotherapy.

-   Case management.

-   Medication evaluation and follow-up.

-   Liaison/consultation with other programs and staff.

-   "On Duty" ("OD") teams provide triage, evaluation, and admission
    services for clients in acute distress.

4.  **Fellow's Role in the Setting:** Help develop and co-lead
    psychotherapy groups for veterans with SMI diagnoses. Provide case
    management and psychotherapy for individual clients. Potentially
    supervise psychology trainees.

5.  **Amount/Type of Supervision:** Fellows receive one hour of
    individual and one hour of group case consultation/supervision each
    week. The supervisor works from an integrationist perspective,
    focusing on cognitive behavioral and interpersonal processes and how
    they inform and are informed by the therapeutic alliance. Cognitive
    behavioral, interpersonal, and psychodynamic approaches are
    integrated into treatment. Live supervision of individual therapy
    sessions.

6.  **Didactics**: Fellows are invited, but not required, to participate
    in the outpatient psychiatry seminars occasionally offered.

7.  **Pace:** The workload at the MHC is steady but constant; the fellow
    must be able to juggle time required for individual and group
    therapy sessions, and time for collaboration and contact with other
    heath care providers.

The Mental Health Clinic (MHC) is a full-service outpatient clinic that
serves individuals with a wide range of emotional, social, and
psychiatric problems. Clients represent the full Axis I and Axis II
diagnostic range. Client complaints vary from issues associated with
Adjustment Disorder, to managing symptoms and problems in daily living
associated with Depression, Anxiety, and Schizophrenia diagnoses.
Clients with co-morbid substance abuse/dependence diagnoses and medical
problems are common. Clients are referred to the MHC from various
inpatient programs (e.g., psychiatry, addiction treatment, medical),
other outpatient programs (e.g., Behavioral Medicine), community
programs, or self-referral. The MHC also functions as a
crisis-intervention center for patients in acute distress. Clients
treated by OD triage teams (made up of rotating MHC clinicians) can
admitted for inpatient care, referred to outpatient services, or
referred to other community services.

The Mental Health Clinic is currently committed to enhancing
psychotherapy treatment options to match the needs of recently returned
and aging veterans, and reflect the most current literature on
evidence-based treatments, including but not limited to Cognitive
Behavior Therapy, Acceptance and Commitment Therapy, Prolonged Exposure,
and Seeking Safety. Fellows are encouraged to help develop and co-lead
groups for diagnoses such as Depression, Anxiety, Serious Mental
Illness, Substance Use and Post-Traumatic Stress.

Fellows can also expect a heavy emphasis on interdisciplinary team
functioning given the multidisciplinary staff and team approach at the
MHC. Fellows have the opportunity to attend team meetings in which the
team psychiatrist, social worker, clinical nurse specialist, and/or
psychologist discuss treatment planning. Fellows attend a weekly group
case consultation with other psychologists (staff, postdoc, intern,
practicum students) and providers from different training disciplines.
Finally, fellows can participate in "OD" Walk-in Clinic
multidisciplinary triage team or the Orientation brief assessment team
once a week as well.

Weekly individual supervision is devoted to the fellow's clinical
caseload of individual and group therapy clients, focusing primarily on
case conceptualization and the therapeutic process. Supervision can also
cover professional development issues, treatment team functioning, and
program development issues.

**Inpatient Psychiatry (Buildings 2 and 5, PAD)**

**Supervisors: William O. Faustman, Ph.D.**

**Malathy Kuppuswamy, MD**

**Karen Kasch, Ph.D.**

**Debra Stackman, Ph.D.**

1.  **Patient population:** This rotation allows for participation in a
    range of activities with acutely hospitalized patients with severe
    mental illness. Bldg. 2 at PAD contains a 24-bed coed unit (2B2)
    which provides treatment to severely ill women throughout Northern
    California. As such, it is the only inpatient facility for women
    veterans in VISN 21. The unit also provides treatment for male
    veterans. Unit 2B1 is a 20-bed all male unit which provides
    treatment for acutely ill men. Unit 5B3 in building 4 is a 20-bed
    all male unit providing treatment for primarily voluntary
    psychiatric patients.

2.  **Psychology's role in the setting:** Psychology has an active role
    on all 3 units, performing diagnostic work, teaching, clinical
    assessment, psychoeducation, group psychotherapy, and psychiatric
    rehabilitation.

3.  **Other professionals and trainees in the setting:** Units 2B1 and
    2B2 both serve as teaching units for the residency and medical
    student training programs of Stanford University School of Medicine.
    In addition, these units have long provided training for predoctoral
    interns in the VAPA psychology training program. Psychology fellows
    are welcome to participate in the training experiences (e.g.,
    several hours a week of additional didactic training) offered by the
    Stanford psychiatry training program.

4.  **Nature of clinical services delivered:** Inpatient Psychiatry
    provides acute inpatient care for veterans with serious mental
    illness who are in acute crisis and psychosocial rehabilitation
    through groups that focus on recovery and strengths/values
    assessment, skills training, cognitive behavioral therapy, and
    relapse prevention planning.

5.  **Fellow's role in the setting:** The fellow is expected to perform
    a range of clinical duties and specifically seek out patients with
    severe mental illness. Fellows may offer groups with a PSR focus. In
    addition, past fellows have served as a liaison between inpatient
    psychiatry and the CTC program described above (e.g., taking
    veterans to visit CTC prior to their discharge from acute
    psychiatry) as well as outpatient mental health services, including
    the MH Clinic and supported employment. Fellows are also encouraged
    to provide teaching and assist in the training of predoctoral
    interns on the unit, as well as present didactic presentations to
    staff of all disciplines on the unit as part of the implementation
    and dissemination competency.

6.  **Amount/type of supervision:** At least one hour per week of
    individual supervision as well as several more hours per week of
    group supervision (e.g., co-leading unit groups, participating in a
    supervision group).

7.  **Didactics in the setting:** As noted above, fellows are welcome to
    participate in a range of didactics offered by the inpatient
    psychiatric staff and the Psychosocial Rehabilitation Services
    staff. This includes several hours a weeks of lectures on a range of
    topics in severe mental illness.

8.  **Pace:** Inpatient psychiatry is a rapid paced placement. Patients
    typically stay on the units for approximately 10-14 days, so there
    are usually admissions and discharges on a daily basis.

The inpatient psychiatry rotation provides an opportunity to work with
SMI veterans during acute treatment. The current primary supervisor for
these experiences is William Faustman, Ph.D. Veterans treated on units
2B2/2B1 are typically hospitalized following some type of crisis and
often start hospitalization on an involuntary status (e.g., 72 hour hold
for danger to self or others). The fellow may be placed on Unit 2B1 of
2B2 and there is also sufficient flexibility to allow for training on
both units. Unit 2B2 is directed by Malathy Kuppuswamy MD. Dr.
Kuppuswamy has a background in PSR and has a primary interest in the
integration of PSR into inpatient settings. She is available for
supervision and training in both PSR practices and the general practice
of inpatient psychiatry. As noted above, fellows may take on a variety
of roles in their inpatient training experiences. They may act as the
primary provider for veterans who have been hospitalized with severe
mental illness. This treatment can include the introduction of PSR
principals with these veterans. In this work the fellow can serve as a
liaison between inpatient programs and outpatient programs and services
We have found from prior experience that inpatient veterans may show
better outpatient follow-up with services if they already had been
introduced to the services or program prior to discharge from the
hospital. The fellow may accompany the CMI veteran to the program while
still and inpatient, thus providing such an introduction. PSR fellows
may also lead inpatient groups with a focus on recovery and
rehabilitation. The units also allow for extensive training in the
psychopharmacological treatment of veterans with SMI diagnoses.

Dr. Faustman has an extensive background in the assessment and treatment
of veterans with SMI. He has published extensively in the schizophrenia
research literature and has over 20 years of experience in inpatient
treatment settings. Supervision routinely includes the integration of
the research literature in SMI. He has an additional interest in the use
of cognitive behavioral therapy in the treatment of psychotic disorders
such as schizophrenia.

The primary training objective is developing competence in the treatment
of acutely ill veterans with SMI diagnoses. Areas of specific training
focus can include the following:

> 1\) Integration of PSR principals to the acute treatment of veterans
> with SMI diagnoses.
>
> 2\) Assisting veterans in acute crisis to make a transition to an
> outpatient environment which includes significant PSR opportunities
> (e.g., the CTC program, Community Re-Entry group at the outpatient
> MHC, supported employment program).
>
> 3\) Leading and co-leading inpatient groups for veterans with SMI
> diagnoses.
>
> 4\) Obtaining significant learning in the practice of forensic
> psychology with this population (e.g., writing conservatorship
> letters, attending court hearings relating to competence and
> dangerousness, providing testimony in probable cause hearings).
>
> 5\) Performing neuropsychological assessments of veterans with SMI
> diagnoses and using these data to understand potential difficulties
> the veteran may have in the rehabilitation process (e.g., this can
> include reviewing the literature on the relationship between cognition
> and rehabilitation in schizophrenia).

**Psychosocial Rehabilitation Services (Inpatient, Residential, and
Outpatient care,**

**Palo Alto/Menlo Park/San Jose)**

**Supervisors: Susan Mirch-Kretschman, Ph.D.**

> **Daniel Gutkind, Ph.D.**

PSR services is a program funded by VA Central Office in 2005 to create
and implement evidence-based psychosocial rehabilitation services for
persons with severe mental illness and funded in 2006 to expand services
to include co-occurring (dual diagnosis) disorders. SMaRTER Practices
(Staff Materials, Resources, & Training in Evidence-based Recovery) is
the development and training arm of the program. Research is also a
component of the program.

1.  **Patient population:** Persons with serious mental illness (SMI;
    primarily schizophrenia, schizoaffective, bipolar disorder,
    psychosis) and/or co-occurring disorders (SMI and substance abuse)
    who are receiving services on inpatient units, in residential
    programs, or as outpatients.

2.  **Psychology's role:** Opportunities are varied and can accompany a
    variety of intern learning objectives, including exposure to and
    gaining expertise in:

    A.  Creating recovery plans and offering individual and group
        evidence-based practices to implement plan:

    -   CBT/CT for schizophrenia/psychosis/delusions/paranoia

    -   CBT for bipolar disorder

    -   motivational interviewing

    -   Social Skills Training

    -   family psychoeducation

    -   behavioral tailoring for medication adherence

    -   behavioral reinforcement and shaping

    -   SAMHSAs Illness Management & Recovery

    -   Dual Disorders Treatment for co-occurring disorders (SAMHSA)

    B.  Interdisciplinary team and site work: Services delivered across
        inpatient, outpatient, and residential program care

    C.  Consultation with members of treatment team and support services
        such as Supported Employment (another evidence-based practice)
        to ensure continuity of care and also help train staff to
        reinforce and support the evidence-based skills veteran is
        learning (e.g., CBT, SST);

    D.  Staff training; development and implementation of training
        materials based on dissemination research

    E.  Program development

    F.  Research: program implementation and outcomes, staff and veteran
        outcomes, health and mental health disparities based on stigma
        of severe mental illness.

3.  **Other professionals and trainees in the settings:**
    Interdisciplinary teams providing care across settings include:
    medicine, nursing, pharmacy, social work, recreation therapy, and
    county conservators/public guardians. In addition, interactions with
    PSR fellows in the disciplines of psychology (post-doc), social
    work, and nursing, psychology interns from other rotations, medical
    residents, nursing students, and psychology practicum students may
    also be involved.

4.  **Nature of clinical services delivered:** Creation of recovery plan
    that is individualized, person-centered, strengths and functioning
    focused, to include:

-   Setting recovery goals (functioning in desired role in community of
    choice),

-   Strengths and values assessment

-   Identification of obstacles to recovery goal attainment

-   Measurement

-   To create plan, psychologist most often overcome ambivalence and
    internalized stigma and must rely on skills to help overcome these
    (e.g., use of motivational interviewing to explore ambivalence) and
    address various obstacles to goal attainment through delivery of
    individual and group therapy, consisting of the evidence-based
    treatments and recovery practices for person with SMI.

5.  **Intern's role:** Opportunities exist to participate in a variety
    of roles depending on the intern\'s learning plan and interests,
    including:

-   Direct clinical service provider, including continuity of care
    across settings

-   Consultant and trainer

-   Program development and evaluation

-   Advocate for evidence-based practice

-   Staff training and in-servicing

-   Liaison with other services

-   Researcher

> This rotation is rather unique in that the intern may begin treating a
> patient during acute inpatient hospitalization and then follow that
> patient in outpatient care. The PSR intern will generally devote equal
> amounts of time to inpatient and outpatient care during the 18
> hour/week rotation, with perhaps a bit more time spent on inpatient
> care due to the acuteness of the setting. There is possibility of
> tailoring time at settings to learning plan of intern.

6.  **Supervision:** 1-2 hours of individual supervision per week. 1-2
    hour group supervision through joining with postdoctoral PSR
    Psychology Fellows and PSR Services/Smarter Practices staff. Group
    therapy sessions will be periodically observed and supervision
    given. Individual therapy sessions will likely not be observed but
    may be periodically audio-taped for supervision purposes.

7.  **Didactics:** Didactics in recovery practices and treatment
    conceptualization and planning will be offered as will didactics in
    the evidence-based practices mentioned earlier. The schedule for
    didactics will be more intense at the beginning of rotation to
    familiarize intern with recovery practice and the EBPs for working
    with persons with SMI. Other didactics include implementation
    practices, measurement, and stigma. Resource and learning materials
    are available, including manuals, DVDs, and articles.

8.  **Pace:**

> [Inpatient]{.underline} care is fast-paced and patients are admitted
> and discharged on a daily basis. While PSR interns will not be
> individually involved in the care of all veterans in the inpatient
> wards, they will be expected to monitor the disposition of any
> inpatients they have been assigned to follow individually (typically
> 1-2 inpatients at any given time). Progress notes must be written
> after every contact in a timely manner.
>
> [Outpatient]{.underline} pace is less intensive but more time is taken
> for each note, given the requirements of the clinic or setting and
> also the nature of adding in recovery language and techniques to
> templates. Time is planned for these activities, as is time for
> consultation with the outpatient teams (teaching opportunities). Time
> is also factored in for travel to other sites -- so workload may be
> less but the opportunities are diverse and unique. It is the diversity
> of experiences of the PSR rotation that is its primary strength!

This document was last reviewed on 9/29/2008 by Jeanette Hsu.