Alex Keuroghlian, MD, MPH provides an overview of care for transgender and gender diverse communities. He discusses inequities within a gender minority stress framework and proposes culturally responsive clinical practices for building inclusive, affirming and trauma-informed care environments.
The Behavioral Medicine rotations in the Internship in Clinical Psychology are designed to provide a broad range of clinical experiences.
Blake 11 – Inpatient Psychiatric Service
As part of the generalist training component of the internship, BMED interns will complete a six-month rotation for one half day per week on Blake 11, home of the Inpatient Psychiatric Service. You will learn to provide brief psychological interventions for patients hospitalized on the unit for acute psychiatric concerns and will be exposed to a full spectrum of psychiatric diagnoses, including anxiety disorders, major depressive disorders/suicidality, substance use disorders and psychotic disorders. Interns observe and participate in patient rounds and actively collaborate with a multidisciplinary team of psychiatrists, residents, nurses, social workers, occupational therapists, case managers and other unit staff. You will receive individual supervision for cases and attend a weekly group seminar to discuss clinical issues relevant to inpatient psychiatric care. Interns also have opportunities to co-lead groups based on individual interest or to observe electroconvulsive therapy (ECT) sessions and evaluations within the Acute Psychiatry Service (APS).
Dialectical Behavior Therapy
Each intern will participate in the Dialectical Behavior Therapy (DBT) rotation for six months of the internship. This rotation includes co-leading a weekly 90-minute DBT skills group through the outpatient psychiatry department at Mass General for patients with borderline personality disorder and other psychiatric comorbidities. During the rotation, the you will co-lead the DBT group with an expert in DBT and have the opportunity to participate in a weekly DBT team meeting with other expert clinicians and trainees.
Outpatient Psychiatry Department
The Outpatient Psychiatry Department (OPD) rotation is a year-long rotation. Behavioral Medicine (BMED) interns provide evidence-based cognitive-behavioral treatments to individual therapy outpatients. You will have the opportunity to treat a wide range of psychological disorders (e.g., mood disorders, anxiety disorders and adjustment disorders) in patients with and without medical comorbidities. Common medical populations served include cancer patients (and those with survivorship status), neurological problems (such as epilepsy or multiple sclerosis), HIV and endocrine disorders like type-2 diabetes. Interns carry a caseload of approximately 8-10 patients, and they receive high-quality supervision weekly from multiple supervisors (two hours of individual clinical supervision and one hour of small group supervision). You will also have the opportunity to work as part of multidisciplinary team, communicating with patients’ primary care providers, psychiatrists and medical specialists to provide comprehensive, high-quality patient care. Patients can self-refer to the OPD or be referred by their medical providers
Each BMED intern spends one half-day per week at the Mass General Weight Center for six months of the internship year. The Weight Center is a multidisciplinary subspecialty obesity medicine clinic treating patients with obesity or other conditions related to weight. Each Weight Center patient is assessed by a team that includes a physician, dietitian and psychologist, who together formulate a comprehensive, individualized treatment plan. Weight Center treatments for obesity include behavioral weight management intervention, pharmacological treatments and weight loss surgery; for many Weight Center patients, the team psychologist plays an active role in treating eating disorder symptoms or providing behavioral problem-solving, motivational interviewing and sleep hygiene interventions. Under the supervision of Weight Center psychologists, you will conducts psychosocial evaluations of new Weight Center patients, formulate treatment recommendations and carry a caseload of one to three short-term therapy cases at any given time during the rotation, which typically involve treating emotional eating and binge eating disorders, supporting healthy lifestyle changes and reducing distress related to body image. Interns work closely with the other team members to provide coordinated care and receive one hour of formal supervision weekly, with informal supervision contact as needed. There is also a strong didactic component to this rotation, with assigned readings of scientific articles related to a wide range of obesity and obesity treatment topics and weekly discussions of these articles during supervision.
Adolescent and Young Adult (AYA)
BMED interns may have the opportunity to participate in an Adolescent and Young Adult (AYAs; aged 18-39) clinical rotation for six months of the internship. This rotation includes participating in a series of seminars, involving speakers within and outside of MGH/HMS, centered on exploring the biological, social and emotional concerns that make this population unique in their experiences when diagnosed with a chronic medical condition that interferes with important age-specific milestones. This rotation may include some overlap with the Cancer Center Survivorship Program, wherein the intern may help co-facilitate a weekly 90-minute resiliency group for adolescents and young adults who are transitioning off cancer treatment and/or are diagnosed with other chronic medical conditions. Interns interested in expanding their 6-month rotation may also have the opportunity to become involved in ongoing AYA clinical research trials. This includes participating as a study interventionist or group facilitator, participating in biweekly clinical research supervision team meetings as well as biweekly research meetings with other faculty and trainees working with AYA populations. This rotation will provide interns with the opportunity to receive specialized training in working with AYA populations confronted with the demands of managing a chronic medical illness.
Cancer Center Survivorship Program
BMED interns may have the opportunity to participate in a Cancer Center Survivorship Mind-Body Resiliency Program rotation for six months of the internship. This rotation includes co-facilitating a weekly 90-minute resiliency group with Mass General Cancer Center patients who are transitioning off cancer treatment. Resiliency groups are currently being held at Mass General sites in Boston, Waltham and Danvers through the Cancer Center Survivorship Program. During this 6-month rotation, you will formally train in the delivery of the Stress Management and Resiliency Training (SMART) Program, a mind-body program based on principles of relaxation response elicitation, CBT and positive psychology developed through a collaboration between BMED and the Benson-Henry Institute for Mind Body Medicine. Training involves participating in an 8-session resiliency program as a participant and partaking in a 2-day implementation training. You will co-facilitate the resiliency group with BMED faculty Elyse Park, PhD, Lara Traeger, PhD and Giselle Perez, PhD, as well as participate in weekly team supervision meetings.
Interns interested in expanding their 6-month rotation may also have the opportunity to become involved in one of several funded mind-body clinical research trials. This includes learning and implementing the manualized resiliency treatment as a group facilitator and participating in biweekly clinical research supervision team meetings as well as biweekly research meetings with faculty and trainees affiliated with the Cancer Center Survivorship Program. This rotation will provide interns with the opportunity to learn more about ongoing cancer survivorship research projects, contribute to new and ongoing cancer survivorship grant applications and participate in preparing first author and co-author manuscripts for publication and conference submissions.
The Fenway Institute Rotation, Fenway Health
Dr. O’Cleirigh directs the Behavioral Science Team at The Fenway Institute with a primary focus on intervention development to support HIV prevention and treatment and LGBT health disparities. The rotation at The Fenway Institute is available to interns who have an interest in HIV research and/or in LGBT health. The rotation is typically arranged for the intern to spend one full day a week at The Fenway Institute with the potential to increase their time during the second semester of the internship year. The opportunities for interns on the Behavioral Science Team at The Fenway Institute multiple and varied and are typically linked to current research projects in progress or in development. These projects are generally conducted by researchers who have their primary appointment at Harvard Medical School and in the Behavioral Medicine Program at Massachusetts General Hospital. The Directors of the Fenway Institute are Drs. Kenneth Mayer and Judy Bradford who work closely with the Behavioral Sciences Team.
Current behavioral research projects at The Fenway Institute include:
- Project THRIVE+: (PI O’Cleirigh) A multi-site study to (1) test the feasibility and acceptability of a psychosocial intervention to improve engagement in HIV care, HIV medication adherence among MSM living with HIV with trauma histories; (2) examine, in a pilot randomized controlled trial, the impact of the proposed intervention for MSM with trauma history on improvement in engagement in HIV care, adherence to HIV treatment, (primary outcomes) and reductions of sexual transmission risk taking behaviors (secondary outcome); and (3) explore whether intervention related changes in trauma-specific distress, will mediate intervention related changes in increases in engagement in care and ART adherence.
- Algorithm Study: (PI O’Cleirigh) A multi-site study to (1) compare the efficacy of Algorithm Treatment, which includes the generation of a pharmacotherapy prescription recommendation sent to the patient’s medical provider through the electronic medical record, to Enhanced Treatment as Usual for smoking cessation among PLWH smokers engaged in HIV clinical care; (2) characterize provider-, staff-, patient-, and clinic-level facilitators and barriers to integration of Algorithm Treatment; and (3) examine the cost effectiveness for the intervention relative to primary smoking outcomes.
- QUIT Study: (PI O’Cleirigh) A multi-site study to (1) test the efficacy of the cognitive-behavioral-based QUIT intervention plus Nicotine Replacement Therapy in HIV-infected smokers, using a 3-arm RCT; (2) examine the degree to which smoking abstinence is mediated by reductions in symptoms of anxiety and depression; and (3) estimate the cost-effectiveness of the QUIT intervention for smoking cessation among smokers living with HIV with clinically significant symptoms of anxiety/depression.
- National HIV Behavioral Surveillance: (PI O’Cleirigh) A CDC-funded study run in 3 annual, rotating cycles, each of which aims to surveille a population at increased risk for HIV. The cycles include: (1) gay, bisexual, and other men who have sex with men (MSM) [2017,2020]; (2) persons who inject drugs (IDU) [2018, 2021]; and (3) heterosexuals at increased risk for HIV infection (HET) [2019, 2022].
- Project MATTER: (PI Batchelder) A National Institute of Drug Abuse funded randomized controlled pilot study to test the feasibility and acceptability of a text-enhanced cognitive behavioral intervention to address stigma and shame as barriers to HIV self-care among men who have sex with men with active substance use disorders.
- Project INSIGHT: (PI Batchelder) A mixed methods study funded by the Harvard University Center for AIDS Research designed to better understand how intersecting internalized stigmas affect engagement in HIV self-care among men who have sex with men living with HIV and problematic substance use.
- PrEPsteps: (PI Chai) A study funded by the National Institutes of Health to build and test a smartphone-based PrEP adherence system that responds to adherence data collected through a novel digital pill, with a focus on improving PrEP adherence among who have sex with men (MSM) who use stimulants. Consists of focus group discussions to understand how HIV-negative MSM with stimulant use would use a new smartphone intervention, PrEPsteps, that gives people tools to improve their adherence to PrEP (Aim 1), and a 90-day trial in which MSM would use the digital pill as a tool to help with PrEP adherence (Aim 2).
- DigiPrEP: (PI Chai) A Gilead Sciences-funded study to test the use of a digital enabled PrEP (DigiPrEP) to measure PrEP adherence in men who have sex with men (MSM) who use substances other than alcohol. Consists of individual qualitative interviews to understand how MSM would use and respond to digital pills that measure real-time medication ingestion (Aim 1) and a 90-day feasibility and acceptability trial in which MSM would use the digital pill as a tool to help with PrEP adherence (Aim 2).
- MUSIC Study: (PIs Chai/Taylor) A mixed-methods study exploring the effect of a brief music intervention to modulate the experience of pain in individuals living with HIV who misuse opioids. Consists of a one-time individual qualitative interview about participants’ history of pain and its intersection with antiretroviral therapy (ART), as well as a brief music listening session after which participants are asked about changes in their mood.
The opportunities for interns on these projects include participating in treatment and treatment development studies as protocol therapists. This involves learning and implementing novel manualized cognitive behavioral treatments and receiving weekly clinical supervision. The intern also participates in weekly research team meetings and other trainings. The intern will also be expected to participate in preparing manuscripts for publication and preparing conference submissions from study data sets. Opportunities to make co-author and first author contributions are available on most of these projects. The Behavioral Science Team is constantly developing new projects and the opportunity to contribute to new and ongoing grant submissions is expected and forms part of the supervised research mentorship that is provided through the rotation at The Fenway Institute.
Interns who elect this rotation enjoy the experience of working in the more relaxed atmosphere of an LGBT Health Center (the largest Health Center meeting the needs of the LGBT Community in the country). This rotation also provides opportunities to become involved in biomedical research projects, ongoing epidemiological studies, and policy and education initiatives all of which form part of The Fenway Institute’s portfolio.
Aging and HIV
Interns may have the opportunity to co-lead a weekly Aging with HIV group at Mass General. The group is didactic in nature, leveraging existing evidence-based intervention content developed for people living with HIV (e.g., LifeSteps, adjusted cognitive processing therapy content, mindful self-compassion, motivational interviewing and substance use management).
In order to better serve patients, behavioral medicine has psychologists embedded in several hospital clinics and centers, including the Digestive Healthcare Center at Mass General. The majority of behavioral medicine patients seen through the Digestive Healthcare Center are diagnosed with inflammatory bowel disorders (Crohn's Disease and Ulcerative Colitis) or functional gastrointestinal disorders such as Irritable Bowel Syndrome, Gastroparesis, and Cyclical Vomiting Syndrome. Typical referrals include (1) patients having difficulty adjusting to a recently diagnosed chronic GI condition, (2) patients facing challenges around adherence to medication, diet, or lifestyle changes, and (3) patients for whom stress and anxiety management strategies could improve their medical conditions either directly (by reducing episodes) or indirectly (by improving coping). Directly addressing these challenges often yields noticeable benefit after just a few sessions. Opportunities may be available for interns interested in working with this population.
Women and HIV
BMED interns may have the opportunity to participate in the delivery of group interventions for part of the internship, which includes co-facilitating a weekly 90-minute resiliency group with older, HIV-infected women and/or a lifestyle modification program for HIV-infected women at risk for cardiovascular disease. During this rotation, you will formally train in the delivery of the interventions, including the Stress Management and Resiliency Training (SMART) Program, a mind-body program based on principles of relaxation response elicitation, CBT and positive psychology developed through a collaboration between BMED and the Benson-Henry Institute for Mind Body Medicine. Interns will participate in weekly team supervision meetings. This rotation will provide you with the opportunity to learn more about ongoing projects related to women’s health and HIV, contribute to new and ongoing grant applications and participate in preparing first author and co-author manuscripts for publication and conference submissions.
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