ADULT PSYCHOLOGY TRACK
Introduction to the Adult Psychology Track
I. Cognitive Behavioral Concentration
Primary CBT rotations:
-Inpatients (Williams Unit),
-Implementation of CBT in Community Substance Abuse Treatment Programs,
-Behavioral Activation across the Adult Lifespan,
-Motivational Interviewing and CBT for Substance Use Disorders,
-Outpatient Eating Disorders Program (1 intern)
Minor CBT rotation (Health Psychology rotation):
-Pain/Biofeedback Clinic (2-3 interns)
II. Health Psychology Concentration
Primary Health rotations:
-Cancer Behavioral Symptom Management and Support,
-Clinical Behavioral Medicine,
-Behavioral Sleep Medicine Program
Minor Health rotation (Neuropsychology rotation):
-Brain Tumor Clinic (1 intern)
III. Clinical Neuropsychology Concentration
Primary Neuropsychology rotations:
-Bryan Alzheimer’s Disease Research Center,
-Clinical Neuropsychology Service,
-Brain Tumor Center
Minor Neuropsychology rotation (Child Psychology rotation):
The adult psychology program provides interns with supervised assessment, treatment and consultative experience with the broad range of adult patients treated at Duke University Medical Center. Interns work in an apprenticeship-collaborator relationship with senior staff psychologists, becoming functional members of the treatment team and contributing as professionals to the successful operation of the adult psychology service.
The program provides training in three concentration areas:
- Cognitive-Behavioral Psychology,
- Health Psychology, and
Applicants elect only one of the three concentrations. The only Adult intern that rotates on a child rotation is the Neuropsych intern (minor rotation in the ADHD clinic).
Interns who choose to concentrate in the Cognitive-Behavioral Psychology area spend 75% time in this concentration, and 25% time in one or two other areas. Interns who choose to concentrate in the Neuropsychology rotation spend 75% time there, and 25% time in one or two of the other areas. Interns who choose the Health Psychology concentration rotate across three or four different rotations that expose them to a variety of populations and skill areas
I. Cognitive-Behavioral Treatment Concentration (CBT)
(CBT interns will rotate in several CBT clinics with a minor rotation in the Eating Disorders Program and a minor rotation in the Health Psychology-Biofeedback Clinic)
Overview: Training in cognitive behavioral therapies (with an emphasis on Dialectical Behavior Therapy; DBT) is provided within the context of the Cognitive Behavioral Treatment (CBT) Track. Interns in the CBT track conduct assessments and provide consultation and treatment in both inpatient and outpatient settings. Outpatient work is conducted at two physical locations within DUMC – the Civitan Building and the Duke Child & Family Study Center located at the Lakeview at Pavilion East Building. Inpatient work is conducted on Williams Unit, a 20-bed general psychiatric ward located in Duke South Hospital. Interns on the CBT rotation will be trained over the course of the internship year to conduct individualized assessments and provide CBT and DBT for individuals with mood, anxiety, substance use, and personality disorders. Interns train in several CBT clinics to obtain a diversity of experiences. As such, CBT interns have at least two CBT faculty supervisors for their outpatient caseload, in order to increase diversity of training throughout the year. In addition, interns may co-lead a weekly DBT group for patients with borderline personality disorder or other appropriate diagnostic categories. Co-leading a DBT group provides additional training in mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness skills. Furthermore, all interns participating in the CBT rotation attend a weekly DBT consultation team meeting. Rotations are year-long, allowing treatment-resistant patients to be seen throughout the year for longer-term care.
Overall, the program’s primary goals for interns include increased understanding of the cognitive, behavioral, biological and emotional aspects of mood, anxiety, and personality disorders; development of skills in cognitive-behavioral assessment and treatment of these disorders; and successful oral and written communication with other health professionals.
Diversity of Training: Although CBT interns receive training in DBT, the caseload is a mix of multi-diagnostic patients (e.g., BPD) and those with less complicated presentations. The most common diagnoses treated include mood, anxiety, and personality disorders. All interns will receive training in providing CBT and DBT in a general outpatient setting (the Civitan Building). In addition, interns receive specialized training with one or more of the specific and diverse settings and patients listed below.
- Inpatients. Dr. Robins provides training to interns in brief therapy, consultation, and multi-disciplinary collaboration in an inpatient setting. Interns with inpatient responsibilities are members of a multi-disciplinary team, and take primary responsibility for the cognitive-behavioral assessment and therapy aspects of the patient’s care. Interns learn to provide brief, focused individualized interventions such as activity scheduling, cognitive restructuring, behavioral exposure and response prevention, contingency management, and training in distress tolerance skills.
- Implementation of CBT in Community Substance Abuse Treatment Programs. Dr. Rosenthal provides training in implementation of DBT and CBT for dually diagnosed outpatients in a “real world” substance abuse treatment program (SouthLight, Inc.). This work includes group and individual DBT/CBT and an emphasis on dissemination of empirically supported treatments in a largely poor, ethnically diverse community treatment program.
- Computer-Based Interventions. Dr. Rosenthal provides training in the integration of novel computer-based interventions into treatments for patients who may not respond well to usual treatments, such as those with chronic PTSD and/or addiction. This includes learning how to use virtual reality in cue-exposure and cellular phones as learning reminders in augmentation interventions to empirically supported treatments (e.g., prolonged exposure). Through a grant from the Department of Defense, interns supervised by Rosenthal will have opportunities to learn how to use these computer-based interventions with veterans who have both PTSD and addiction.
- Behavioral Activation across the Adult Lifespan. Dr. Smoski provides training in behavioral activation interventions for mood disorders in adults. Interns will learn a values-informed approach to brief interventions focused on goals attainment and avoidance reduction. Special attention and training is given to implementation of interventions with individuals ages 65 and older.
- Motivational Interviewing and CBT for substance use disorders co-morbid with anxiety or mood disorders. Dr. Seel provides training for those interested in assessing and treating disorders such as PTSD, social anxiety, phobias, bipolar, depression and substance use. Dr. Seel uses empirically supported treatments to include prolonged exposure, cognitive processing therapy, cognitive restructuring, acceptance commitment therapy, and behavioral activation. In addition, Dr. Seel is a member of the international Motivational Interviewing Network of Trainers and incorporates motivational interviewing into her training model. Interns supervised by Dr. Seel will have the opportunity to join live “bug-in-the-eye” supervision with 4th year psychiatric residents who are also learning cognitive behavioral therapy and motivational interviewing.
- Outpatient Eating Disorders Program (OEPD). The OEDP is a comprehensive multidisciplinary treatment program for individuals with anorexia nervosa, bulimia nervosa, binge eating disorder, and other eating disorders. Interns who receive training in this program will be involved in a variety of clinical activities including assessments and evaluations, individual, group, and family psychotherapy, and parent training groups. They also participate in a weekly interdisciplinary team meeting, clinical case consultation meeting, and didactic training seminar that introduces them to a variety of therapeutic approaches and issues in the treatment of eating disorders.
- In addition to the above, several CBT interns will have a minor rotation in the Health Psychology– Pain/Biofeedback Clinic. Please see the description for this rotation provided below in II. Health Psychology.
One CBT intern each will receive training in the eating disorders program, implementation of DBT/CBT in a community substance abuse treatment program, motivational interviewing and CBT for substance use, and computer-based interventions. Several interns will receive training in the Inpatient and behavioral activation rotations. After interns are matched to Duke, we then select interns for the different diversity clinical experiences based in large part on their ranking and ratings of preferences for each rotation.
Didactics: The CBT rotation provides didactics and educational opportunities to interns through several different activities. First, the DBT consultation team meeting serves as an educational opportunity through interactions with faculty and post-doctoral level DBT therapists. One hour of each weekly two-hour meeting is devoted to didactic training. Second, during the first month of training, interns will participate in intensive seminars on issues related to starting the clinical internship, including assessing and managing suicidal behavior, assessing and intervening on substance use in the treatment setting, and DBT skills/theoretical principles. Third, all CBT interns will have individual supervision that may include reviewing therapy tapes, live supervision (e.g., “bug-in-the-eye”), co-leading groups with supervisors, and assigned readings. Fourth, interns will participate in several half-day workshops in empirically validated treatments for specific populations, such as interventions for adult ADHD and Motivational Interviewing, provided by Duke faculty members.
Interns have multiple supervisors who will work with them continuously throughout the year, allowing for more- in-depth supervisory relationships and the development of longer-term goals for clinical development.
Professional Development: There are two primary ways that we help nurture interns during the transition from graduate school to life as a clinical psychologist. Early in the internship year, CBT interns choose a CBT faculty mentor for ongoing mentoring throughout the year about issues relevant to their professional growth (e.g., getting a post-doc or faculty position, balancing one's life with career aspirations, etc.). Throughout the year there are monthly scheduled professional development meetings for all CBT interns with CBT faculty and other colleagues. Over the past 10 years we have continually focused on cultivating and enhancing a supportive atmosphere that equally blends service with learning and professional growth. We care about professional development and work carefully to tailor personalized goals that are attainable.
Research Opportunities: CBT interns have 4 hours of weekly protected research time, during which they can choose to work on their dissertation or any other research projects, including studies and manuscripts with CBT faculty. Although research is not a requirement of the rotation, interested interns are encouraged early in the year to explore research options with faculty members. There are many ways to be involved with CBT faculty research projects while on internship. Dr. Rosenthal is currently running treatment studies and lab-based experiments. He is the PI on NIDA and NIMH sponsored grants investigating the use of portable reminders of learning (using mobile phones) as adjunctive interventions, and DoD sponsored research on the use of computer-based interventions for veterans with PTSD and addiction. Additionally, he has various research projects investigating emotional sensitivity and regulation in borderline personality disorder, with a special emphasis on the use of novel technologies (e.g., immersive virtual environments) in laboratory studies of emotion and psychopathology. Dr. Robins’ research currently focuses on mindfulness and emotion regulation and on the psychopathology and treatment of borderline personality disorder. Dr. Smoski conducts NIH-funded studies of emotion regulation and reward processing in depression, including studies of depression in late life. Via collaborations with Duke Integrative Medicine, Dr. Smoski is involved in ongoing studies of mindfulness. If interns would like to be involved in research on eating disorders, there is the opportunity to participate in a weekly research meeting to explore ways to collaborate with Dr. Zucker’s research projects.
Supervision Training: To enhance capabilities as a supervisor, in the first half of the year CBT interns receive didactic training in supervision. During the second half of the year CBT interns supervise Duke graduate students or psychiatry residents early in their CBT training, and progress as a new supervisor is supervised during this time by CBT faculty.
Supervisors: Clive J. Robins, Ph.D., ABPP, BP, M. Zachary Rosenthal, Ph.D., Julie M.S. Seel, Ph.D., Moria Smoski, Ph.D., Laura Weisberg, Ph.D., Nancy Zucker, Ph.D.
II. Health Psychology Concentration
(Health Interns have a primary rotation and several minor rotations among items A-F listed below, based on the track or program they match with--program information is provided to those applicants who interview with us.)
The Health Psychology concentration involves didactic training, patient care and research experiences. Interns are exposed to empirical and theoretical readings from a number of disciplines, and are expected to use that information while working in both inpatient and outpatient settings. In the Health Psychology concentration, interns rotate through the following rotational placements:
A. Pain/Biofeedback Program
This rotation is composed of a clinical and research program devoted to developing better methods to evaluate and treat chronic pain and psychophysiologically-based illnesses. Current research examines the psychosocial influences on reports of pain, distress, and disability among patients with a range of illnesses and among an ethically, gender, and age-based diverse sample. Medical disorders included in the current research and clinical interventions include but are not limited to Sickle Cell Disease, Raynaud’s Disease, Complex Regional Pain Syndrome (CRPS)/ Reflex Sympathetic Dystrophy (RSD), phantom limb pain, and chronic headaches. Psychiatric disorders include but are not limited to depression and anxiety disorders, somatoform disorders, personality disorders, and dissociative disorders. Interns are exposed to evaluation and treatment of common (Tourette’s Disorder, etc.) and unique presentations of psychopathology (Foreign Accent Syndrome, etc.).
This clinical rotation provides in-depth training in the psychometric evaluation of patients with medical disorders as well as patients with primary psychiatric disorders with particular attention to diversity and effective evaluation and treatment of historically disenfranchised populations. Intern get exposure to personality testing (MMPI-2, NEO-PI-R), brief cognitive tests (Letter Memory Test, MMSE), pain specific questionnaires (Short-form McGill Pain Questionnaire, Multidimensional Pain Inventory), and the use of a range of other validated psychometric instruments (State-Trait Anxiety Inventory, Beck Depression Inventory, Symptom Checklist 90-item Revised, Headache Scale for Locus of Control, etc.).
Interns are also instructed in techniques for diagnostic interviewing using semi-structure interviews, the use of the DSM-IV-TR, clinical observation, and consult liaison. Interns work directly with medical and psychiatric professionals to include clinical psychologists, neuropsychologists, psychiatrists, neurosurgeons, hematologists, anesthesiologists, neurologists, nursing staff, primary care physicians, physical and occupational therapists, and physician assistants in outpatient (Pain Clinic, Back and Spine Clinic, Sickle Cell Clinic, etc.) and inpatient settings.
Interns learn to provide clinical interventions in a high volume setting with treatments focused in 3 primary areas: (1) brief psychotherapy and coping skills training; (2) long-term psychotherapy; and, (3) biofeedback. A vast majority of patients with receive short-term psychotherapies or coping skills training (less than 12 weeks). These include crisis and suicide management, stress management, anger management, systematic desensitization techniques as well as problem-focused coping skills training. Interns are also encouraged to identify patients for long-term psychotherapy that they will treat across the duration of their internship experience. Patients include those with primary personality disorders or who require long-term supportive psychotherapy. Interventional approaches include cognitive behavioral interventions, dialectical behavioral therapy, systematic desensitization administered in individual and group settings. Approximately 1 in every 5 patients will be candidates for biofeedback and psychophysiological interventions to include relaxation training, mental imagery, distraction techniques, breathing retraining, relapse prevention, sleep efficacy, and psycho-education.
Interns are trained in supervision via organized didactics provided by faculty members on the internship. Interns are provided opportunities to apply and refine their supervision skills on the rotation. Intern duties include supervising and assisting to manage the clinical activities of practicum students.
Clinical Supervisors: Christopher L. Edwards, Ph.D., Miriam Feliu, PsyD, Katherine Applegate, Ph.D.
Research Supervisor: Christopher L. Edwards, Ph.D.
B. Cancer Behavioral Symptom Management and Support
The rotation in Cancer Behavioral Symptom Management and Support is based on a scientist-practitioner model of training, and is comprised of clinical and research activities that address the psychological, social, behavioral, and symptom management needs of cancer patients including patients undergoing bone marrow transplant. This rotation’s clinical activities are conducted as part of the Duke Cancer Patient Support Program and the Duke Adult Blood and Marrow Transplant Program. The Duke Cancer Patient Support Program provides psychological services to cancer patients and their families in the outpatient and inpatient clinics of the Duke Cancer Institute, a National Cancer Institute-designated comprehensive cancer center. The Duke Adult Blood and Marrow Transplant Program, which is closely associated with the Duke Cancer Institute, is internationally recognized for its novel approaches to treating leukemia, lymphoma, and myeloma through bone marrow and stem cell transplantation. The Duke Cancer Institute and the Duke Blood and Marrow Transplant Program treat patients from a range of ages, ethnic and racial backgrounds, socioeconomic statuses, and from rural and urban settings in North Carolina and the larger region.
Experiences on this rotation aim to increase interns’ knowledge and skills for treating psychological, social, behavioral, and symptom management issues which occur during the cancer experience. Interns in this rotation work closely with the multidisciplinary Cancer Patient Support and Bone Marrow Transplant Teams. These teams include psychologists, psychiatrists, marriage and family therapists, social workers, physicians, nurse practitioners, pharmacists, nutritionists, physical therapists, and patient financial advisors. Interns gain experience in the role of a psychologist on a medical team and learn how to collaborate within and contribute to a multidisciplinary team.
Interns are trained to conduct and interpret psychological assessments and health behavior evaluations for patients, their families, and caregivers. Assessment techniques include behavioral observation, standardized psychological measures, semi-structured interviews, and diagnostic interviews. Interns also perform regular follow-up assessments of post-treatment quality of life for patients undergoing bone marrow transplant. Through training and clinical experiences, interns become skilled at assessing the psychological, relationship, and behavioral health issues that impact individuals and families affected by cancer.
Interns provide psychological services for patients, their families, and caregivers. Clinical experiences include inpatient and outpatient CBT based psychotherapy, manualized behavioral interventions for symptom management, and health behavior interventions. Psychological services are provided in individual, couples, and group settings through face-to-face meetings, phone, and web-based technologies. Interns gain competence in developing treatment plans and choosing appropriate, evidence-based interventions for the range of issues and problems that arise for patients and their families when faced with a serious, life-threatening illness.
Interns participate in weekly individual supervision sessions for psychological assessment and psychotherapy cases. Interns also participate in weekly multidisciplinary team meetings that include all members of the Cancer Patient Support Team. Through this weekly multidisciplinary meeting, interns gain a sophisticated conceptualization of patients. During the rotation, interns attend educational seminars on psychopharmacology and psycho-oncology. A developmental approach is used. Initially interns are given educational materials about cancer and the bone marrow transplant process, and will work closely with a psychologist or other team member to promote understanding of the treatment process and the clinic environment. Then, the intern will be assigned his/her own patients and groups.
Finally, interns have the opportunity to participate in ongoing research activities. Interns are exposed to issues of research design, quality control, and data analysis inherent in the testing of standardized treatment protocols and program evaluation.
Supervisors: Rebecca Shelby, PhD; Tamara Somers, PhD
C. Clinical Behavioral Medicine Program:
This rotation offers psychological services to patients with a variety of medical disorders, with particular emphasis on cardiovascular disease, end-stage pulmonary disease, chronic liver disease, and renal failure. One emphasis in this rotation is the provision of clinical services for patients in need of, or recovering from, solid organ transplantation. We offer a full range of psychological services for transplantation patients, including pre-transplant psychological assessment, inpatient and outpatient psychotherapy, and behavioral treatments for both pre and post-transplant patients. The intern also plays a prominent role in assessment of pre-transplant patients and of living kidney donors, and participates in weekly interdisciplinary meetings for the lung, heart, liver and renal transplant programs. The intern also provides brief psychotherapy for medical inpatients and outpatients. The intern also has the opportunity to participate in ongoing clinical research activities, which currently include studies of stress management in patients engaged in cardiac rehabilitation, diet and exercise in patients with cognitive impairments at risk for dementia, neuropsychological outcomes and cardiac surgery, exercise training for depression, coping skills training for patients with chronic obstructive pulmonary disease and biobehavioral aspects of hypertension and women's health.
Clinical Supervisors: James A. Blumenthal, Ph.D., Benson Hoffman, Ph.D., Krista Ingle, Ph.D., Patrick Smith, Ph.D., Tamara Somers, PhD
Research Supervisor: James A. Blumenthal, Ph.D.
D. Behavioral Sleep Medicine Program:
A rotation in the Duke Insomnia and Sleep Research Program (DISRP) is designed to provide training in the treatment and assessment of sleep disorders. We have an active Behavioral Sleep Medicine clinic wherein we primarily see patients with insomnia, circadian rhythm disorders and/or sleep apnea treatment adherence issues. We also provide full assessments for sleep disorders. We have several ongoing NIH-funded studies that focus on insomnia assessment/diagnosis and behavioral treatment of primary and co-morbid insomnias. Many of the patients we see for both clinic and research studies have multiple co-morbidities, most notably those with co-morbid depression, anxiety disorders and/or medical conditions. Interns will learn about the complex interactions between insomnia and other co-morbidities, and learn to develop case formulations and appropriate treatment plans.
Rotational activities will include training in psychological assessment of sleep disorders and Cognitive Behavior Therapy for insomnia. Some of the assessment tools we use on the unit include: the Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Duke Structured Interview for Sleep Disorders, daily sleep logs, the Epworth Sleepiness scale, Sleep Self-Efficacy Scale, Beck Depression Inventory, the Beck Anxiety Inventory, Dysfunctional Beliefs and Attitudes about Sleep Scale, Penn State Worry Questionnaire, Pre-Sleep Arousal Scale, Fatigue Severity Scale, and the State-Trait Anger Expression Inventory. Assessment training will include training in interpreting the results of overnight sleep studies and actigraphy. Interns will have the opportunity to observe experienced psychologists conduct CBT for insomnia, and will eventually conduct therapy and assessments under supervision. Training experiences also include attending regular didactic meetings on issues relating to sleep disorders and participating in multidisciplinary clinical rounds.
Supervisor: Margaret D. Lineberger, PhD
III. Clinical Neuropsychology Concentration
(Neuropsychology interns rotate in several Neuropsychology Services and have a minor rotation in one other concentration).
The neuropsychology concentration focuses on providing comprehensive training in clinical neuropsychological assessment and intervention with particular emphases in geriatrics and neuro-oncology. The program is designed to allow interns an opportunity to become well familiarized with brain-behavior relationships, syndromal presentations of both acute and protracted neurological conditions across the adult lifespan, and differing approaches to case conceptualization and neuropsychological assessment. Integral to the training is experience in the application of differing psychotherapeutic approaches and how these approaches may modify diagnostic assessment and intervention. In addition to consistent and extensive clinical experience, the concentration offers didactics and exposure to research applications of neuropsychology within a competitive academic medicine setting.
Interns selecting a major concentration in clinical neuropsychology will have rotation sites in three settings: the Memory Disorders Clinic of the Bryan Alzheimer’s Disease Research Center, the Clinical Neuropsychology Service, and the Brain Tumor program.
- Memory Disorders Clinic - The Memory Disorders Clinic rotation extends for 6 months (2.5 day/ week/ 6 months) and incorporates the intern into a team of medical professionals evaluating new patients with dementia and memory complaints.
- Clinical Neuropsychology Service (CNS) - The rotation in the Clinical Neuropsychology Service extends across the entire year (1.5 day / week/ per year), allowing interns broad training within diverse neurological and psychiatric populations seen in an outpatient setting and also permits some limited exposure to neuropsychological interventions to maximize compensation and coping. Included in the rotation is experience in medical neuropsychology through consultation with the hospital inpatient service.
- Brain Tumor Program - A second six-month rotation in the Brain Tumor program (2.5 day/ week/ 6 months) focuses on structural brain lesions and the role of the neuropsychologist in assisting patients and their families adjust to a brain tumor/ cancer diagnosis.
Simultaneously, the interns will complete a minor rotation in the Child Psychology – ADHD Clinic (please see rotational description provided in under the Child Psychology section/ADHD Clinic.
Interns selecting a minor concentration in clinical neuropsychology will have parallel training to the major concentration students, completing six-month rotations in either the Adult Brain Tumor Clinic or the Memory Disorders Clinic to become familiar with test administration, scoring, interpretation, and report writing. Interns taking the minor concentration will also be involved in the same didactics as the major rotation, which allows for additional opportunities for clinical training and scientific interchange.
Mandatory and optional didactics and training opportunities include a weekly neuropsychology seminar series, a monthly neurobehavior case conference (occurs as part of the weekly seminar), weekly neurology rounds, and at least once-monthly psychiatry rounds. Optional hospital-based didactics include rehabilitation rounds, neuropathology rounds (brain cuttings), neurology in-services and lectures, and observation of psychosurgery. Academic didactic opportunities include weekly conferences (e.g. Center for Cognitive Neurosciences), and periodic (monthly, annual) conferences for the Center for Aging and Human Development and the Bryan Alzheimer’s Disease Research Center. Team affiliations are encouraged as appropriate (e.g., Adult Brain Tumor Clinic, Neurological Disorders Clinic, Psychiatry inpatient/outpatient programs).
Goals for the concentration include mastery of test administration, scoring, interpretation, and neuropsychological report writing. In addition, oral communication skills to a variety of physicians and allied health professionals are fostered, thereby enhancing effective interaction as members of a multidisciplinary team. Multifaceted treatments, such as working with other disciplines to provide comprehensive patient care, as well as traditional diagnostic skills are also emphasized. Feedback and therapy with patients and families is also routine. In addition, interns develop an understanding of neurological symptoms, neurobehavioral disorders, and psychiatric conditions that span across adulthood. Exposure to neuropsychology within a medical-research context is an important part of the clinical training experience. Interns with particular interests in this area may elect to do short-term optional rotations (noted above) with a faculty mentor in a well-defined research area.
Supervisor(s): Kathleen A. Welsh-Bohmer, Ph.D., ABPP/CN (Director of Training),
Guy Potter, Ph.D., Renee Raynor, Ph.D