Training Experiences & Rotation Descriptions

Selecting Clinical Rotations

Fulton State Hospital offers two full time internship positions. Following orientation, the interns will meet with the Training Director to select the major rotation(s) offered in their track and create their yearly schedule. Also at this time, the interns will review their individual evaluations with the Training Director using the Psychology Intern Competency Assessment Form.

At the outset of each rotation, the rotation’s tasks, requirements, and expectations will be reviewed by the rotation supervisor. At that time, the supervisor will develop an individualized training plan with the intern. The training plan includes the goals of the supervisor and rotation as well as the goals of the intern. The training plan may be modified as the rotation progresses to meet each intern’s needs and interests.

Structure of Rotations

The experiential component of the program is organized into:

• two, six-month major rotations (roughly 4 days per week) and
• two, year long minor rotations (roughly 1 day per week).

Major and minor rotation sequences are conducted concurrently throughout the internship year and are structured around a 40-hour work week.

For all rotations interns receive training in innovative, evidenced-based treatment or evaluations and best practices within nationally recognized treatment programs targeting specific populations. Each rotation has specific requirements and expectations, which are discussed more thoroughly below.  

Major Rotations

• New Outlook Program for Behavior and Mood Self-Management – Nixon Forensic Center or Hearnes
• Recovery and Self-Motivation – Nixon Forensic Center
• Sex Offender Rehabilitation and Treatment Services - SORTS
• Social Learning Program – Nixon Forensic Center
• Competency Restoration and Evaluation Rotation  – Nixon Forensic Center

Minor Rotations

• Program Evaluation
• Psychological Assessment

Other Intern Activities

• Intern seminar (weekly)
• Research meeting (weekly)
• Individual supervision (2 hours per week – major and minor)
• Group supervision (2 hours per week – Training Director and Group Supervisor)
• Cultural Competence Council (monthly)

Competency Restoration and Evaluation Rotation

• Jeffrey S. Kline, PhD, Certified Forensic Examiner, Forensic Coordinator
• Jennie Brooks, Psy.D., Certified Forensic Examiner
• Alexis Reddig, Ph.D., Psychologist

The Competency Restoration and Evaluation Rotation offers the intern the opportunity to work with the Hospital’s three forensic examiners in completing evaluations of criminal defendants. The Forensic Examiners are responsible for completing outpatient and inpatient court-ordered mental evaluations. The evaluation process focuses on several legal questions. These questions include the issues of competency to stand trial, mental state at the time of the alleged criminal conduct (or criminal responsibility), risk assessment for sexual and non-sexual violence, sentencing recommendations, and diminished capacity.

The purpose of the Competency Restoration and Evaluation Rotation is to provide an opportunity for the intern to develop the skills necessary to complete court ordered Forensic Evaluations in the future. In order to build that skill set the intern will be exposed to the evaluation process, competency restoration treatment groups, and a forensic treatment program. The forensic program faculty believes that interns need experience not only in completing evaluations, but also experience working with clients who suffer from serious mental illness.

The intern begins the Competency Restoration and Evaluation Rotation with the six-month forensic major rotation. During the forensic major rotation the intern will participate in both evaluations of criminal defendants and in the competency restoration treatment program. The intern will work with a primary supervisor throughout the rotation, but also have opportunities to complete evaluations under the supervision of the other examiners. Interns will receive at least one hour of individual supervision per week and will review hospital records, police reports, and collateral records and then participate in the evaluation interview and testing. As the track progresses, the intern will take on more responsibility for the interview and information gathering process, culminating in the intern performing evaluations from beginning to end. Throughout the training experience the intern will write complete reports of the evaluation results, detailing the psychological and legal issues that are pertinent to the court. Also, the supervisor may co-sign and submit to the Court some of the intern’s completed evaluations. Finally, interns will have the opportunity to witness testimony of the Forensic Examiners in a variety of cases.

During the rotation the intern will also work with the staff of the competency restoration program, including facilitating and co-facilitating competency education groups, providing individual therapy or education, and participating in treatment planning. The intern also will have the opportunity to perform psychological screenings of new patients admitted to this program, which includes interviewing each patient and gathering information to help in determining treatment objectives.

The Competency Restoration and Evaluation Rotation is collegial in nature. We work hard to help the intern develop independence and take on the role of an independent practitioner. We feel strongly that the intern take an active role in their own learning. We expect the intern to help us develop learning objectives, modify the objectives as the rotation proceeds, and communicate with us when the rotation is not meeting her or his needs. Clear and open communication is the best way to make this a successful rotation.

Learning Objectives

• Learn to write clear and relatively concise forensic assessments in a timely fashion that answer relevant legal questions posed by the Court.
• Gain experience with both structured and unstructured psychological assessment within a forensic context. This will include the use of psychological assessment tools such as measures of psychopathology, intellect, and malingering.
• Obtain an understanding of the interaction between the courts and the mental health profession and how psychological data is used in the legal process.
• Develop an advanced understanding of the DSM diagnostic criteria.
• Gain experience with conducting competency restoration groups and documenting client progress in a manner conducive to future competency evaluations.
• Participate in multi-disciplinary treatment team discussions related to forensic treatment and evaluation issues.

Responsibilities

• Participate in forensic interviews and related assessment interviews (2-3 per week)
• Write approximately 10 reports throughout the course of the rotation
• Participate in multidisciplinary treatment team meetings (2-3 hours per week)
• Conduct competency education and restoration groups (4-5 per week)
• Provide individual therapy for IST clients (1-2 per week)
• Complete progress notes and other relevant documentation
• Read of relevant materials, including articles or court decisions
• Receive supervision

New Outlook Program for Behavior and Mood Self-Management

• Jessica Sergio, PhD, Program Coordinator of New Outlook and Internship Training Director, Senior Psychologist
• Brandy Baczwaski, PhD, Program Director (HFC), Senior Psychologist
• Sharon B. Robbins, PhD, Director of Psychology and DBT-Linehan Board of Certification, Certified Clinician™

New Outlook Program for Behavior and Mood Self-Management is a program that combines the use of Dialectical Behavior Therapy (DBT) and Positive Behavior Support. The most common diagnoses for clients in this program are severe personality disorders, mood disorders, diagnoses involving intellectual and developmental delays, and various paraphilias.

Interns who select this rotation will have the opportunity to learn DBT and its application in a forensic, inpatient setting. The intern will be supervised in providing group and individual therapy, as well as client skill development and coaching calls. Interns are expected to work as part of a multidisciplinary treatment team, which includes participation in a DBT consultation team, program meetings, morning report, treatment team meetings, and other living area activities with the clients. Additional training, treatment, or assessment opportunities may be offered to supplement the intern’s learning experience, depending on their specific interests or learning objectives. The intern will meet with the rotation supervisor for at least one hour per week and supervisors are typically on site in the milieu. Depending on level of familiarity with DBT, in vivo supervision may occur.

Interns participating in this rotation will be required to read Cognitive-Behavioral Treatment of Borderline Personality Disorder (Linehan, 1993) and the DBT Skills Training Manual, 2nd Edition (Linehan, 2015). Opportunities are also available for Dialectical Behavior Therapy workshops and trainings provided by Dr. Ronda Reitz.

Hearnes Forensic Center
The Hearnes Forensic Center is a minimum security facility that provides treatment for 24 males with developmental disabilities. The primary treatment coincides with the New Outlook Program such that clients are provided with Dialectical Behavior Therapy and Positive Behavior Support. In addition to this treatment, clients are provided with opportunities to learn skills related to community readiness. This includes health classes that provide education regarding making healthy dietary choices, managing prescribed and over-the-counter medication, and attending to hygiene-related tasks. Clients are provided with many possibilities to develop leisure interests including a variety of music groups, expressive arts, gardening, sports, and games. Clients in the Hearnes Forensic Center are able to demonstrate their community readiness through their utilization of community passes. Those that are approved, may take supervised trips into the community that vary from eating out at a restaurant to attending a Major League Baseball game and anything in between that is of interest to the client. Interns that choose this rotation would develop a wide range of skills including implementing Dialectical Behavior Therapy and Positive Behavior Support, working with individuals with developmental disabilities, and learning about the transition process from a minimum security facility to the community. 

Learning Objectives

• Become familiar with the core principles of Dialectical Behavior Therapy and how it is applied in a forensic, inpatient setting.
• Learn and apply validation strategies in a treatment context.
• Provide group and individual therapy that fits within the DBT framework.
• Participate in multidisciplinary team discussions and activities related to ongoing client care.
• Understand the importance and use of functional behavior assessment in treatment planning.
• Conduct assessments to clarify diagnoses and develop strategies for working with mood-dependent behavior.
• Become familiar with the needs of clients with intellectual and developmental disabilities.

Rotation Requirements

• Ongoing individual therapy (3-4 clients per week)
• After hours skills coaching, as needed
• Group therapy, which includes DBT Skills, Behavioral Chain Analysis, Safe Offender Strategies, Mindfulness, or other relevant treatment groups (3-4 hours per week)
• Individual case management (2-3 clients per week)
• Multidisciplinary treatment team meetings (2-3 hours per week)
• DBT consultation team meeting and program meeting (2-3 hours per week)
• Completion of progress notes, treatment plan review notes, treatment plan updates, and other relevant documentation
• Reading of required materials
• Supervision meetings 

Recovery and Self-Motivation Program

• Kayla Collier, Psy.D.
• Elizabeth Bryant, Psy.D.

In 2012, the Psychiatric Rehabilitation Program (PRP) was completely re-conceptualized and the name was changed to Recovery and Self-Motivation (RSM). The program was fully implemented in maximum security in April 2012 and intermediate security in May 2012. The intern rotation includes providing services in i intermediate security settings. RSM is intended to help clients with primary psychotic disorders such as schizophrenia or major mood disorders that may also have primary or secondary personality disorders (excluding borderline personality disorder).

Treatment begins with the assumption that each person is capable of returning to an independent and productive life in the outside community. Treatment through this program is intended to help client’s develop and affirm that awareness and to identify and learn skills needed to function independently.

After clients are admitted to the program, through formal and informal assessment of their skills, RSM staff assists clients in identifying skills they are using effectively, and skills they need to learn to use more effectively in order to attain their personal recovery goals. When people with mental illness are assisted in developing and achieving personal goals, motivation for active participation in the recovery process is enhanced. Toward that end, RSM incorporates the philosophies, strategies, and methods of a transtheoretical approach that includes three interdependent elements: Illness Management & Recovery (IMR); Motivational Interviewing (MI); and Stages of Change.

"IMR is comprised of a broad set of strategies to help individuals with serious mental illness collaborate with professionals, reduce their susceptibility to their illness, and cope effectively with their symptoms’’ (Mueser, et al, 2002). It is grounded in the philosophy of recovery and wellness. The IMR approach in combination with MI and the transtheoretical model emphasizes the importance of understanding and accepting resistive behavior without intentionally or unintentionally stabilizing it, while providing clients with knowledge and skill needed for personal recovery. IMR is an evidence-based practice and informs many of the treatment methods and influences the treatment strategies in the RSM.

The stress-vulnerability model of Serious Mental Illness (SMI) posits that the course and outcome of major mental illness is determined by the dynamic interplay of biological vulnerability, stress, and coping. IMR is aimed at interrupting the cycle of stress and vulnerability that leads to relapse and poor functioning.

Learning Objectives

• Increase clients’ motivation for change of self-defeating behaviors including aggression.
• Improve clients’ ability to make rational, recovery-supportive, decisions.
• Teach skills needed for success in a recovery lifestyle including effective social skills, aptitudes and skills supportive of stable work such as attendance, task perseveration, and work performance.
• Help clients’ develop awareness and skills important for long-term illness self-management such as hope, purpose, and confidence.

Rotation Requirements

• Ongoing individual therapy (3-4 clients per week)
• Group therapy, (3-4 hours per week)
• Individual case management (2-3 clients per week)
• Multidisciplinary treatment team meetings (2-3 hours per week)
• Completion of progress notes and other relevant documentation
• Reading of required materials
• Supervision
• Initial training emphasizing the principles of RSM

Sex Offender Rehabilitation & Treatment Services

• Lee Ann McVay, PsyD, Program Director
• Kirsten Hunter, Ph.D., Annual Reviewer

The Sex Offender Rehabilitation and Treatment Services (SORTS) program at Fulton State Hospital specifically provides treatment services for those individuals civilly committed as Sexually Violent Predators under the SVP Act, RSMo, Chapter 632.480 and the following. The Statutory definition of an SVP is any person who suffers from a mental abnormality which makes the person more likely than not to engage in predatory acts of sexual violence if not confined in a secure facility and who has pled guilty to a sexually violent offense, been found guilty of a sexually violent offense, or has been committed as a criminal sexual psychopath prior to 8/13/1980. A mental abnormality is defined as a congenital or acquired condition affecting the emotional or volitional capacity which predisposes the person to commit sexually violent offenses in a degree constituting such person a menace to the health and safety of others. Predatory is defined as acts directed towards individuals, including family members, for the primary purpose of victimization.

The SORTS clients are offered a variety of treatment groups including Process Group, Psychoeducational Groups, and Leisure education groups. Process Groups offer the group members the opportunity to complete chain analyses of their sexual offenses, discuss current and past problematic behaviors, and discuss their dynamic risk factors as well as ways to mitigate their risk.

Interns participating in this rotation will be required to read ATSA Practice Guidelines for the Assessment, Treatment, and Management of Male Adult Sexual Offenders (2014), Assessing Risk for Sexual Recidivism, Some Proposal on the Nature of Psychologically Meaningful Risk Factors, Mann, Hanson, & Thornton (2010), and other relevant articles maybe assigned during the rotation.

Interns are also expected to participate in the multidisciplinary treatment team and collaborate with other treatment providers to enhance client care. Individual supervision is provided on a weekly basis.

Learning Objectives

• Become familiar with the sex offender treatment needs of the individuals civilly committed as SVPs at Fulton State Hospital
• Learn and apply the core principles of group therapy and sex offender treatment. This will include concepts such as the Risk Need Responsivity Model, Chain Analysis, and Dynamic Risk Factors.
• Co-facilitate Process Groups and psychoeducational groups with clients in need of sex offender treatment
• Collaborate with other professionals to assist in decision-making and progress evaluation of clients within SORTS
• Provide feedback to treatment teams and clients regarding treatment needs and progress

Rotation Requirements

• Group therapy (6-8 hours per week)
• Case Manage 2-4 clients
• Multidisciplinary treatment team meetings (2 to 3 hours per week)
• Completion of progress notes, group notes, and other relevant documentation
• Reading of required materials and attendance at continued program trainings
• Supervision (1 hour per week)

Social Learning Program

• Robert Johnson, Ph.D.
• Alicia Pardee, Ph.D.
• Rebekah Purvis, Psy.D.

The Social Learning Program (SLP) is available as a major rotation for interns within the high-security unit of Fulton State Hospital (FSH). Interns on the SLP rotation receive supervised experiences in a state-of-the-art, comprehensive psychiatric rehabilitation setting where they function as an active member of an interdisciplinary treatment team. In addition to gaining valuable knowledge of milieu-based services, interns also obtain experience with a range of clinical interventions, including individual and group psychotherapy and clinical case management. Interns also receive training and develop skills in using observational assessment data to assist the treatment team with data driven clinical decision-making processes. While Social Learning Programs are a recognized evidence-based practice, SLPs can also incorporate additional evidence-based and best or promising practices to meet the individual needs and functioning of program residents.  Interns will also have the opportunity to gain firsthand knowledge of recognized evidence-based practices for people with serious mental illness including but not limited to Social Skills Training (Bellack, Mueser, Gingerich, Agresta, 2004; Liberman, Wallace, Blackwell, Eckman, Vaccaro, Kuehnel, 1993); Illness Management and Recovery (Mueser, Gingerich, 2003); and Systematic Problem Solving (D’Zurilla & Goldfried, 1971).

Social Learning at Fulton State Hospital

In 1987, a task force was formed within the forensic psychiatric service at Fulton State Hospital. Its purpose was to address the problem of excessive numbers of individuals with serious mental illness (most with schizophrenia spectrum disorders) who were receiving mainly custodial services, had accumulated extended periods of hospitalization within the Biggs Forensic Center and showed little progress toward being discharged due to being highly symptomatic and aggressive. The task force contacted national experts, visited other hospitals, and conducted an extensive review of the research literature on treatment approaches for the individuals with severe and persistent mental illness. Their review revealed the work of Gordon Paul and Robert Lentz (1977). Paul and Lentz completed a six year randomized control trial comparing traditional hospital care, an equally comprehensive milieu-therapy program (Therapeutic Community) and a Social Learning Program. The results of the trial indicated that the comprehensive SLP, developed by Dr. Gordon Paul and his colleagues, was the most effective approach for improving the level of functioning of individuals who had a significant history of refractory mental health symptoms and institutionalized behavior to the point of enabling them to successfully return to the community. These results were so compelling that the administration at FSH adopted as a primary goal the implementation of a comprehensive social-learning continuum of care that extend into the community within both forensic and adult psychiatric services. Full implementation of the SLP at FSH began in 1988. Subsequent implementation of the SLP has been extended not only to hospitals with the Missouri Department of Mental Health, but also to numerous states across the country as well as internationally.

Program Description

The mission of the Social Learning Programs at Fulton State Hospital is to provide comprehensive psychosocial rehabilitation and recovery-oriented services. The purpose of the program is to teach and support adults with serious mental illness to overcome difficulties and facilitate the process of recovery. Measurable outcomes of the program’s mission and purpose include the ability to safely live and function in a less restrictive setting, reliable performance of activities of daily living, improved social and occupational functioning, and a higher perceived quality of life while respecting a client’s autonomy and self-determination.

The Social Learning Program is a highly structured, milieu-based, inpatient approach to rehabilitation for individuals with the most severe problem behaviors and skills deficits. It consists of a comprehensive integrated network of skills training techniques and supports based on learning theory, individually tailored to client needs and delivered by all staff within the context of a supportive, rehabilitation-oriented foundation. Individual, group, and unit-wide interventions are based on social-learning theory (Paul, Stuve, & Menditto, 1997; Paul & Menditto, 1992). Together these interventions form an extremely positive teaching environment that assists clients in developing adaptive behaviors and skills relevant to successful return to the community (Menditto, 2002). Data collected within the FSH SLP has demonstrated dramatic reductions in aggressive behavior (Beck, Menditto, Baldwin, Angelone, & Maddox, 1991), reductions in inappropriate behavior (Springer, 2008) and significant increases in adaptive behavior (Newbill, Paul, Menditto, Springer, & Mehta, 2011).

Learning Objectives

• Learn the philosophy and application of social learning principles throughout the rotation
• Become familiar with individualized treatment planning
• Aid in client skill development in identified areas of client need
• Provide group and individual therapy to clients within the program
• Participate in multidisciplinary team discussions and activities related to ongoing client care
• Learn the use of observational assessment in ongoing program evaluation and improvement

Rotation Requirements

• Ongoing individual therapy (1-3 clients per week)
• Group therapy, including Small Group, Social Skills, Illness Management and Recovery, Shaping Class, or other relevant core treatment components (5-10 hours per week)
• Individual case management (1-3 clients per week)
• Multidisciplinary treatment team meetings (1-3 hours per week)
• SLP program meetings (1-2 hours per week)
• Completion of progress notes and other relevant documentation
• Reading of required materials
• Supervision
• Initial training emphasizing the principles of the Social Learning Program

Forensic and Treatment Track Minor Rotations

Program Evaluation

• Niels Beck, PhD, Retired Vice Chair, Department of Psychiatry and Neurology, University of Missouri School of Medicine

The Program Evaluation and Research Service at FSH is charged with assisting the executive leadership team with assessing the cost and effectiveness of facility treatment and rehabilitation programs, as well as evaluating and developing new treatment/rehabilitation technologies and related techniques. In this rotation, interns will gain supervised experience in the selection, use, and development of appropriate program evaluation measures and data bases, and in appropriate data collection and analysis techniques.

This is a required, full year rotation for all interns. Interns will devote approximately one half day each week to the completion of a specific program evaluation project during the course of this rotation, working in collaboration with the Program Evaluation supervision order to base the project on an ongoing institutional treatment program where there is a need for evaluation and further development.

At the close of the rotation, interns will prepare reports of their findings and present them to involved treatment teams as well as the internship staff committee. Co-authorship of resulting manuscripts and conference presentations is available for interested individuals.

Learning Objectives and Rotation Requirements

• Become familiar with principles of program evaluation, including identification of programmatic needs, development or selection of appropriate evaluation or adherence instruments, and the application of research findings to program goals
• Collect and statistically analyze relevant data
• Develop program recommendations based on research data
• Communicate findings in a clear and effective manner to program personnel and interested others
• Begin and complete one program evaluation project and present to the ITC and Research Meeting at the conclusion of the rotation

Psychological Assessment

The assessment component of internship training is an opportunity to explore different aspects of psychological assessment. By the end of the internship year, the intern is expected to demonstrate competence in a variety of assessment techniques and report writing. Through a combination of didactics, direct supervision and clinical experience, the intern will explore different aspects of assessment in a diverse environment. The methods we are employing are intended to develop the ability to write independent reports that are ready for placement in the medical record. Referrals will be made from a variety of hospital programs and units in order to provide a diverse training experience.

The assessment rotation is a required, full year rotation for all interns. Interns will receive approximately one half day per week during that time in which to complete 6 psychological assessments. These assessments will cover a variety of domains, including the following:

• Cognitive assessment
• Personality assessment
• Diagnostic assessment
• Risk assessment/malingering
• Sex offender assessment
• Functional behavior assessment

In order to ensure competency in a number of areas, interns are expected to cover at least 4 of these 6 domains across the 6 assessments. Additionally, 2 of the assessments should involve testing in more than 1 domain in order to address more complex and integrative client needs.

Each assessment will be evaluated by the supervisor via the Assessment Rating Form. The intern is expected to complete such reports within a timely manner, and a completed report should be presented to the supervisor within 2 weeks of test administration or data gathering.

The interns should write assessment reports demonstrating competency in a variety of domains. Admission Screening Evaluations cannot be used as one of the 6 assessments. The intern will score cognitive assessments (even if administered by the psychometrician) to insure an adequate understanding of the tests. Objective assessments such as the MMPI-2 and MCMI-III should not be hand scored.

The intern is expected to follow the standards for psychological evaluations established by the Psychology Department via Psychology Department Policies for most reports. When completing Forensic Evaluations, the intern is expected to complete the reports based on the standards in the Forensic Manual, which will be provided to the intern.

Learning Objectives and Rotation Requirements

• Learn and utilize diverse assessment techniques with clients at various phases of the treatment process.
• Integrate test data with observations of client behavior and progress in order to formulate recommendations for treatment planning.
• Complete comprehensive and useful assessment reports in a timely manner.
• Communicate results with other treatment providers and the client.