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How Psychotherapy Looks at the Walker Unit

There is a growing number of evidence-based psychotherapies directed to treating psychopathology in adolescents (Gálvez-Lara et al., 2018). Evidence for psychotherapy has been gathered almost exclusively from studies of young people experiencing mild to moderately severe problems, with treatment being highly structured, short term and typically delivered in the community (Bettmann & Jasperson, 2009). It is uncertain whether findings gathered from such studies generalise to the inpatient setting. While the Walker Unit programme aims to deliver structured therapies such as dialectical behaviour therapy (DBT) and cognitive behavioural therapy (CBT), the severity of the psychiatric illness and the complexity of their relational and developmental issues means that young people may not have the capacity to engage with such treatment. Therapy usually needs to be delivered in a more flexible manner, tailored to the young person’s particular difficulties and capacities.

Allocation of Therapist

Psychotherapy is delivered by allied health clinicians or psychiatry registrars alongside other therapeutic and rehabilitative components of the programme. In addition to a severe psychiatric illness, most young people admitted to the programme have experienced relational and attachment difficulties. Many have a history of complex trauma. There is thoughtful deliberation of the young person’s needs, and their cognitive and verbal capacity to engage in psychotherapy. Additionally, consideration is given to the different approaches and therapeutic modalities which are used depending upon the therapist’s orientation, training and strengths. Case examples are presented in Box 10.1 to illustrate these principles.

Box 10.1 Examples of Allocation to Individual Psychotherapy

Holly, a 15-year-old female, presented to the Walker Unit with a history of recurrent suicidal/self-harm behaviour, complex trauma, interpersonal difficulties, severe emotional dysregulation and eating issues. Holly had numerous acute inpatient admissions and interventions in the community with limited progress, often disengaging from clinicians. While deemed to have the capacity to engage she was largely disengaged and non-verbal in sessions. Given Holly’s cognitive capacity and potential to engage verbally, she was assigned to a therapist with experience in dialectical behaviour therapy and working with young people with trauma.

Damien, a 17-year-old male, presented to the Walker Unit with obsessive compulsive disorder, autism spectrum disorder, odd posturing and movement, largely non-verbal, engaging in self-harm and at times displaying physically aggressive behaviours towards others. Damien was assigned to a therapist with experience treating obsessive compulsive disorder. However due to his other difficulties, Damien was also initially assigned to work with the speech pathologist to improve his communication skills.

Lily, a 16-year-old female, presented with social anxiety, depression, and attachment issues, a history of trauma and recurrent suicidal behaviour. She had multiple past short-stay inpatient admissions. Lily had fair engagement with past therapists and was motivated to attend the Walker Unit with the aim of resuming her engagement in schooling and the community. Lily was assigned to a therapist with experience in treating anxiety and depression and working with young people with a history of trauma.

Scheduling of Sessions

As in community care, young people have fixed appointment times for therapy. The frequency may be once or twice weekly, determined by need. This is typically decided in collaboration with the young person and accounts for factors such as; the capacity to engage and keep the focus of attention, the need for skill building sessions and time-limiting factors when the young person has increased home leave or is integrating to the home school. For a young person who has substantial difficulty tolerating therapy sessions or has a limited attention span, more frequent, brief sessions are indicated. If a young person refuses to attend a session, the therapist maintains the therapeutic frame by waiting in the therapy room for the allocated time and reflecting on the patient and their needs. The therapist then attempts to prompt the young person to reflect on their non-attendance.

Outside of scheduled sessions, the therapist may be called upon to provide support to the young person, usually in the context of them becoming distressed leading to self-harm or aggressive behaviour. After such an occurrence, the therapist might be involved in the chain analysis of the event. The information gained from the chain analysis can be used to prevent future escalation or help with early de-escalation when the early warning signs are recognised.

Working Within the Multidisciplinary Team

The individual therapist works alongside other members of the patient’s multidisciplinary team including medical, nursing, education and other allied health staff. Clinicians will feedback on the process and content of individual sessions to team members as deemed appropriate and necessary for their treatment. This involves handing over key themes and processes of their internal world, reporting on therapeutic progress as well as other aspects relevant to their treatment such as their safety and interpersonal relationships. The information that is shared is integrated into their treatment by the whole treating team through discussions with the young person and their family, and helps to inform treatment decisions such as leave off the ward.

The therapist may also support other staff to better understand the emotional needs of a patient engaged in challenging behaviour. This can involve facilitating increased understanding regarding what is being communicated via the difficult behaviour and how staff may be able to respond therapeutically. In addition to formal meetings, therapists often find informal opportunities to discuss treatment with other team members. There is a delicate balance between sharing sufficient information with the multidisciplinary team to aid understanding, and maintaining the young person’s confidentiality and right to privacy. The therapist will seek the young person’s consent before disclosing to the multidisciplinary team sensitive material that has arisen in therapy.

Aspects of the Walker Unit that Facilitate Psychotherapy

Protected Environment

There is a high dropout rate amongst adolescent attending outpatient delivered psychotherapy. (Block & Greeno, 2011). In acute inpatient settings, psychotherapy is directed to crisis resolution. Patients admitted to the Walker Unit are provided with a longer admission, which facilitates more intensive treatment. The physical environment and the staffing on the ward allow for greater containment of risk of self-harm and suicide, factors which can severely disrupt treatment delivered in the community. The therapist is able to implement treatment that is potentially destabilising in the short term at the Walker Unit, as the secure environment provides a safety net for when patients respond adversely to issues that arise within their therapy. This may relate to uncovering distressing material, trauma-related work, more in-depth work on underlying emotional issues and entrenched belief systems or even challenging their attitudes and behaviour.

Protected Therapy Space

At the Walker Unit, the young person is provided with a separate therapy space, as their therapist is not involved in undertaking the family work. Given the wider family and systemic issues are part of the young person’s pathology, maintaining this therapeutic boundary helps to foster trust and rapport. This increases the likelihood of the young person engaging with the clinician, being more receptive to discussing issues that may later be dealt with in the family therapy space.

Therapeutic Alliance

The therapeutic relationship, coupled with the therapeutic modality, characteristics of the young person and the therapist is known to make substantial contributions to the effectiveness of individual psychotherapy (Karver et al., 2018). The therapeutic relationship needs to foster a sense of trust, safety, containment and authenticity for the young person (Shirk et al., 2011). Most young people admitted to the Walker Unit have been exposed to multiple treatments with limited success. Some may have experienced breaches of trust in past therapies. While this presents an added challenge, the therapeutic relationship can be used to work through rejection, hostility and ambivalent dependence on the therapist. In the event that a therapeutic rupture takes place, the Walker setting and admission duration facilitates these formal and informal interactions for reparative work to take place.

Flexibility and Creativity

The nature of the Walker Unit treatment programme enables clinicians to be flexible and creative in overcoming barriers to treatment such as low motivation to engage in treatment, mistrust, hopelessness, severe emotional dysregulation, self-harming and aggressive behaviours and cognitive deficits. This can involve different tools of engagement such as playing games, making puzzles, using sensory toys, working on a shared activity, having sessions outside of the therapy room, for example, courtyard, going for a walk around the adjacent parklands. This reduces the expectation for verbal engagement, allows a point of focus in session and works on building tolerance to being in therapy.

The inpatient environment also allows clinicians frequent opportunities to work with issues that arise in the ‘here and now’, work on practising distress tolerance skills, engage in problem solving and chain analysis, which can ultimately teach better long-term coping skills. For example, a young person can be guided in the moment about working through these difficulties when incidents occur on the ward. Young people also work through a chain analysis after incidents have occurred with the therapist to identify underlying vulnerabilities, the situation and their internal world with the aim to reflect on their actions and improve upon this next time they feel distressed.

Challenges to Delivering Psychotherapy at the Walker Unit

Poor Engagement

During individual therapy, the young person is encouraged to engage actively in their treatment. If capable, they may cite goals such as a reduction in symptoms, and achieving a more stable emotional state. However, this is often a very difficult task for young people who have had a large amount of therapeutic input in their lives and experience a sense of failure, hopelessness, and perceive a lack of capability in working towards their recovery. It is common for young people at the Walker Unit to be resistant to exploring difficult themes that emerge in psychotherapy. Owing to the level of treatment resistance and perceived hopelessness, unfortunately the therapy process may at times be directed more by the therapist, rather than being led by the patient. This lack of collaboration and investment in therapy can also mean that the rate of therapeutic progress with the young person is very slow.

Transference

For severely unwell young people, the delicate interaction between individual psychotherapy and other therapeutic elements in an inpatient unit can provide a recipe for developing strong transference reactions (Tsiantis, 1996). At the Walker Unit, the young person’s level of symptomology, relational issues and the intensive nature of treatment can mean that transference themes which are challenging to manage emerge during the long-term admission. Therapists also need to be mindful of strong counter transference reactions towards patients which can compromise therapeutic care. The therapist then aims to use these reactions for therapeutic purposes, for example, responding non-defensively to a young person’s hostility in the face of themes of abandonment and rejection and maintaining a consistent therapeutic framework. Clinicians manage this through regular supervision and therapeutic reflection with other team members to prevent this compromising the therapeutic care.

Multiple Roles

At the Walker Unit, no clinician exclusively interacts with a patient in the psychotherapy modality. Rather, therapists are involved in multiple roles with the young person, such as facilitating group therapies, group walks and outings, participating in community meeting, presenting MDT care plans, informal conversations and activities, at different points in the day. In each role, the clinician is actively engaging in different patterns of interaction with the young person. It can be advantageous in allowing the therapist to observe, engage and gain traction with the young person in their treatment in different settings and situations, particularly if the young person finds a certain aspect of their treatment difficult. The informal therapeutic spaces can also strengthen the relationship and provide opportunities for therapists to act in role-modelling healthy interactions. However, while the therapist will gain more exposure to the young person, the therapist needs to be mindful of respecting the boundaries between therapeutic interactions. While generally therapists will stick to strict codes of non-self-disclosure, often at the Walker Unit, given the lengthy admission, therapists are not able to be as rigid in their therapeutic role. They will carefully navigate these boundaries and may self-disclose personal information on casual topics if this is deemed beneficial for the patient. As clinicians hold a delicate therapeutic relationship with the young person, they need to be mindful of the impact of the different roles on each other and despite the fluidity of the roles attempt to maintain a sense of consistency. If issues arise, it should be specifically addressed with the young person to repair the relationship and discussed with the wider treating team.

Conclusion

Psychotherapy at the Walker Unit calls on finding flexibility and creativity in delivering evidence-based treatments, with an emphasis on working with a protected individual space and within a multidisciplinary team approach to tackle treatment difficulties and engage severely unwell young people. Generally, challenges are encountered in juggling multiple clinical roles, while managing poor engagement and transference reactions that occur in the longer term setting. While these challenges occur, ultimately it is very rewarding and provides a unique opportunity for this intensive treatment to be delivered in a vulnerable population.