Trans-diagnostic Short-term Psychotherapy for Psychiatric Inpatients

The most severely ill psychiatric patients are treated on inpatient wards. On most Swedish inpatient wards, psychological treatment is not routinely offered. At the same time, research show that psychological treatment often adds a clinically significant effect to routine care. However, it is a great challenge to handle the diagnostically complex picture present in this context. Often, diagnoses are unclear or preliminary, or there are many co-morbid conditions to be treated simultaneously. Available treatment protocols are often developed for an outpatient population, and for a specific diagnostic group. This, combined with cultural and organizational challenges inherent to the inpatient context, makes the implementation of psychological treatment for these patients a great challenge. Factors such as form of care (voluntary or mandatory), the patient's motivation, and other unforeseen events add to the fact that the length of any given episode of inpatient care is difficult to estimate. This is also a fact that a psychological treatment model must adapt to.

There seems to be a need for developing psychological treatment models in a way that makes them suitable for the special challenges that psychiatric inpatient care present. Looking at the existing research so far, combined with clinical experience, transdiagnostic applicability and flexibility in terms of time frame, context and level of functioning in the individual patient seem to be key factors for a potentially successful model. One way of developing such a model is to individually tailor each treatment, with the support of a few well establish principles. Some form of clinical functional analysis is fundamental for most treatment models based on cognitive behavior therapy (CBT), which is in general the form of therapy that has the broadest evidence base for the most common psychiatric conditions. Functional analysis is idiographic in nature, and takes the individual patient's problems as its starting point, no matter the diagnosis. It is a tool that, at least in theory, is applicable to all behavior. This means that even complex psychopathology such as psychosis or suicidality is potentially amenable to analysis and change.

The challenge with using psychological treatment in an inpatient context is to identify and treat some part of a complex condition, in a way that is possible to combine with other forms of care given on the ward. Functional analysis is a flexible tool in this respect. For example, it would be possible to formulate a meaningful plan for behavioral activation or limited exposure, in the context of a complex psychiatric condition such as schizophrenia.

Besides functional analysis as a basic tool, there are interventions from various therapy models that have been shown effective in an inpatient context. One CBT-based treatment model that has been investigated in an inpatient context with promising results is Acceptance & Commitment Therapy (ACT). In short, ACT aims to promote psychological flexibility in relation to disturbing experiences, for example symptoms of a psychiatric disorder. One of the central processes that ACT targets are so called values. Values are defined as freely chosen concepts that are connected to patterns of action that give a sense of meaning, and that are able to coordinate behavior over time. One example of such a concept might be being a present parent. This is connected to a pattern of various behaviors, with each one giving the person a sense of meaning, because they are connected to an overarching quality of action. Values, in this respect, are different from concrete and reachable goals. Values are not reachable but point to a direction for action more generally.

Generally, some form of maintenance plan is also central for change in psychotherapy to last over time. One method for constructing a maintenance plan is to summarize central principles in a form that the patient can take with them when treatment is completed.