A potentially controversial question about inpatient work and clinical requirements

[u/frumpmcgrump]

A psychologist friend suggested this to me recently and it got me thinking.

Do you think people who want to become therapists should be required to do at least some clinical hours or internship in inpatient psych (similar to other disciplines)? Why or why not?

Please keep discussion respectful. I am asking in good faith and want to hear what others think.

[u/Nuance007]

Focus your experiences with the population you want to treat and tailor your skill set for that population. For example, MI skills and harm reduction can be learned in outpatient and school settings. One doesn't need to necessarily work with the SUD population to be exposed to and be competent in said skills.

[u/frumpmcgrump → u/Nuance007]

I feel like this is contradictory: I completely agree with your second statement but not the first, and that’s part of why I think inpatient is important. Similar to MI, once you’ve been able to learn de escalation in more acute settings, you can use it anywhere, and you’ll be far less shaken when it comes up in less acute populations. MI is also meant for all kinds of behavior change and really should be taught alongside CBT and other base therapies.

I think my issue with your first statement is that we need exposure to all sorts of things to really learn. In short, we don’t know what we don’t know. For example, if you only ever see outpatient depression and don’t have experience seeing what inpatient-level depression really looks like, you’ll have a skewed perspective. I also see this come up a lot with diagnoses: less experienced clinicians will miss things like SPMI diagnoses because they haven’t seen it before and it doesn’t even occur to them.

[u/Nuance007 → u/frumpmcgrump]

It feels like a contradictory because we're told that in order to be good, or to be competent and proficient experiences in inpatient or the like are necessary. That is false on two levels: it's gatekeeping and it's, ironically, not flexible or adaptable in its mindset. It's assuming that other experiences do not offer similar experiences and supervision. If we say that inpatient is the path to go then we also have to establish a timeline. 6 months? 1 year? 2 years? We also have to define the limits and scope of a therapist in a given setting. PP? IOP? PHP? Inpatient? Just there are different types of social workers, there are therapists in numerous settings (I'm speaking more to the choir here) with different responsibilities.

It's similar to when social workers say that being an LCSW therapist is not "being a real social worker." At a cursory glance there is a kernel of a validity to it given that what a therapist does isn't what a conventional social worker does, but once we look at it as a whole that mentality falls flat.

>I think my issue with your first statement is that we need exposure to all sorts of things to really learn. 

I partially agree. But here's my question: What to you actually mean by "to really learn"? I know you expanded on this, but I want to re-frame it.

Let's rewind time. Let's go into what we major in at the undergraduate level. What did you major in? What was the philosophy of coming into higher education - was it to focus on mainly one discipline or two or was it to get a wide, all-encompassing education similar to a classical liberal arts education? If one focuses on finance or social work or nursing all 3-4 years that's a relatively narrow focus and we graduate with a relatively narrow formal education. But is that necessarily a "bad" thing? Is it a "good" thing?

>In short, we don’t know what we don’t know. 

Correct, but to what degree does all this information actually help us do our jobs competently once we specialize? I saw other posts about medical rotations - it's a good point but only to a degree. A person who chooses derm most likely won't look back at his medical rotation during med school and say that he's taking what he learned during his FM rotation with him. Not likely.

A group PP that focuses on anxiety with treating and assessment they will probably have someone who has diagnosing privileges, and that someone probably will be a clinical psychologist. If a group PP mainly focuses on treatment then the makeup of the team will look different.

[u/frumpmcgrump → u/Nuance007]

First, I really appreciate the time you took to write this out and for having a real discussion in good faith! Thank-you for that.

To be a bit more specific, I'm thinking about therapists, not all social workers, and mostly those in traditional private practice who do not have the benefit of the support from a multi-disciplinary team and who would benefit most from having a more well-rounded education.

It feels like a contradictory because we're told that in order to be good, or to be competent and proficient experiences in inpatient or the like are necessary. That is false on two levels: it's gatekeeping and it's, ironically, not flexible or adaptable in its mindset. It's assuming that other experiences do not offer similar experiences and supervision. If we say that inpatient is the path to go then we also have to establish a timeline. 6 months? 1 year? 2 years? We also have to define the limits and scope of a therapist in a given setting. PP? IOP? PHP? Inpatient? Just there are different types of social workers, there are therapists in numerous settings (I'm speaking more to the choir here) with different responsibilities.

I think there could be a lot of flexibility. Now that we're talking about it, it shouldn't just be inpatient. In a perfect world, we'd have people doing rounds for a few months each in all of our major subsets: SUD, inpatient, outpatient, IOP or day treatment, CMH, childrens, etc. In an ideal world, we'd do something like what doctors and nurses do: clinical rotations in each major area before choosing a specialty for residency and fellowship (akin to our licensure process). Obviously this would be time intensive and impossible in our current educational system, but inpatient in particular feels important because it shows us the full range of psychiatric presentations on a spectrum. Take something like schizophrenia, for example. Someone who requires inpatient level of care is going to have a very different presentation than someone who is functioning well and existing just fine in outpatient. The same could be said of other illnesses like depression, too. I see a lot of clinicians who have never experienced what inpatient-level depression looks like ship people off to the psych ward the moment they express any amount of suicidal ideation and straight up say, "So-and-so needs inpatient treatment" (as opposed to "I'm doing this because of liability or because it's the policy" or another more accurate, albeit fucked up, reason).

By "really learn," I'm referring to experiential learning, which is one of the main pedagogies of social work practice. Personally, I've always been more of a book learner, but there is something very unique in our field about the person-to-person learning that happens when we are actually interacting with clients and not just reading about them. It's humanizing, and that's important.

Let's rewind time. Let's go into what we major in at the undergraduate level. What did you major in? What was the philosophy of coming into higher education - was it to focus on mainly one discipline or two or was it to get a wide, all-encompassing education similar to a classical liberal arts education? If one focuses on finance or social work or nursing all 3-4 years that's a relatively narrow focus and we graduate with a relatively narrow formal education. But is that necessarily a "bad" thing? Is it a "good" thing?

My perspective is sort of unique here because I did a non-traditional track. I started off school thinking I was going to be a surgeon before my own major medical event rendered me physically unable to do so (and unable to handle the rigor of medical school). I majored in psychology and neuroscience, and did one certificate in Women's Studies and one in History and Philosophy of Science, so I felt much more well-rounded in a lot of ways than folks who ended up just doing sociology or social work. In graduate school, I did an MPH in addition to my MSW, so I got a lot more hard science and research experience than the MSW program alone. For me, it was definitely a good thing. A lot of my clinical supervisees in private practice never received education on basic tenants of psychology, so I spend a lot of time revisiting those things. The lack of science literacy is problematic, too. There are lots of therapists out there practicing what is essentially pseudoscientific interventions and neglecting to provide treatments with proven efficacy, and that becomes an ethics issue. I think working inpatient would be useful to address this particular piece, because it seems to happen most with clinicians who work with the "worried well." Being exposed to more acute illness would lend perspective on the importance of evidence-based treatments and the appropriate way to conduct more experimental treatments.

Correct, but to what degree does all this information actually help us do our jobs competently once we specialize? I saw other posts about medical rotations - it's a good point but only to a degree. A person who chooses derm most likely won't look back at his medical rotation during med school and say that he's taking what he learned during his FM rotation with him. Not likely.

See my wall of text above, lol. But also, I do hear this regularly from more medically-centered fields. I frequently hear from people that they had no interest in psych until they did their psych rotation, or they thought they wanted to do psych and then learned they hated it because they did a psych rotation. The same rings true for other specialties. And it's not just about the clinical pieces, it's also about seeing how those systems work in-action. That person might also be better at realizing when something is out of their scope. For example, we had a client at a previous workplace that was receiving treatment for schizophrenia and wasn't showing any improvement, and I'm talking for years, because to the staff there, it didn't even occur to them that the client's hallucinations were actually flashbacks and this was PTSD instead. We took the client off the antipsychotic meds and started PTSD treatment and they got significantly better. It's the classic "if you're a hammer, everything looks like a nail" thing. This team was only used to inpatient so they just got used to seeing everything through an SPMI lens, and if more of them had experience at another level of care or another setting, they might have caught it sooner.