This chapter begins with the historical context of the nurse’s role as psychotherapist and the resources and challenges inherent in nursing for the development of requisite psychotherapy skills. Using a holistic paradigm, the framework for practice presented here is patient-centered and based on resilience and relationship. Mental health and illness are viewed through a cultural lens. The significant role of adverse life experiences in the development, contribution, and maintenance of mental health problems and psychiatric disorders is highlighted. A hierarchy of treatment aims is introduced on which to base interventions using a phase model for psychotherapy. This framework is based on the neurophysiology of adaptive information processing which posits that most mental health problems and symptoms of psychiatric disorders are due to a disturbance or dysregulation in the integration and connection of neural networks that occur in response to adverse life experiences. A case example is presented to illustrate the how to apply the framework proposed for psychotherapy practice.
The various disciplines licensed to conduct psychotherapy, depending on their respective state licensing boards, include psychiatrists, psychologists, social workers, marriage and family therapists, counselors, and advanced practice psychiatric nurses (
Postgraduate training and ongoing supervision are encouraged for
| Discipline | Education | Orientation/Setting |
|---|---|---|
| Psychiatrist | Biological treatment, acute care, psychopharmacology and specific psychotherapy competencies for psychiatric | |
| Psychologist | Psychotherapy and psychological testing | |
| Master’s level psychologist | Psychotherapy: some modalities, psychological testing | |
| Social worker | Psychotherapy: interpersonal, family, group; community orientation | |
| Marriage and family therapists | Systems and family therapy, marriage counseling; community outpatient orientation | |
| Counselor | Counseling, vocational, and educational testing; outpatient orientation | |
| Advanced practice psychiatric nurse ( | Psychopharmacology and psychotherapy; group and individual, sometimes family |
In 2002, the American Psychiatric Review Committee mandated that all psychiatric residency programs require competency training in psychodynamic therapy (
Many factors in graduate psychiatric nursing education challenge
Another change in nursing education that significantly impacts
A survey of
A significant challenge for graduate nursing education is the difficulty of finding preceptors and clinical sites for psychiatric graduate nursing students to practice psychotherapy. Most settings have social workers who conduct psychotherapy while the
A national survey of 120 academic psychiatric-mental health nursing graduate programs confirmed the scarcity of sites and found a wide range of individual psychotherapy practice hours required for students, ranging from a minimum of 50 to a maximum 440 hours in the programs for which a certain number of requisite hours are required for psychotherapy (Wheeler & Delaney, 2008). For approximately 50% of programs, however, no designated number of psychotherapy practice hours was required, and medication management hours were integrated along with psychotherapy. A more recent survey reveals significant differences in how
Consequently, most graduate psychiatric nurses leave their graduate studies with a less than adequate knowledge base in this area, and often do not feel competent to practice psychotherapy. Faculty teaching students in graduate programs, when asked whether their students had achieved competency on graduation, felt decidedly mixed, with some stating that they did not envision a future role as psychotherapist and others suggested further training and supervision for competency to be achieved.
Working with people in the intimacy of psychotherapy is an honor, and much good can be done, as well as a great deal of harm. At vulnerable times in their lives, people see the psychotherapist as an expert, and this role often is imbued with a great deal of power and credibility. This privilege also comes with an ethical responsibility for the nurse psychotherapist to get as much training, supervision, and experience as possible in graduate studies and throughout her or his professional life. Expertise is a lifelong pursuit, and continuing education is imperative for those who wish to practice competently. Most licensed mental health professionals in other disciplines, which have considerably more psychotherapy practice in their programs than graduate psychiatric nursing programs, agree that it takes at least 10 years to become a skilled psychotherapist.
How then does one begin to learn psychotherapy? Psychotherapy is a learned skill like any other. The learning process begins with studying each component and practicing the technique and then blending it back together again with what you already know as each separate skill is acquired. Remember how you learned to take blood pressure or any other nursing skill? This can only be accomplished through learning discrete steps and practicing competencies in a skill set until that skill becomes automatic. If it seems like hard work at first, it probably means you are doing it well.
| Stages of Learning | Benner’s Model |
|---|---|
| Unconscious incompetency | Novice no experience, governed by rules and regulations |
| Conscious incompetency | Advanced beginner recognizes aspects of situations and makes judgments |
| Conscious competency | Competency/proficiency 2–5 years experience, coordinates complex care and sees situations as wholes, and long-term solutions |
| Unconscious competency | Expert flexible, efficient, and uses intuition |
Benner (1984) offers a model of role acquisition from novice to expert that examines the levels of competency that can be applied for the novice nurse psychotherapist. It is likely that the graduate student who is pursuing a master’s degree or postmaster’s certificate as an
Juxtaposed to Benner’s model is the four stages of learning model, which may help to allay anxiety for those who are beginning to learn psychotherapy (Table 1.2). Although there is some controversy regarding who developed this model, it is thought that learning takes place in four stages:
Unconscious incompetence (i.e., we do not know what we do not know).
Conscious incompetence (i.e., we feel uncomfortable about what we do not know).
Conscious competence (i.e., we begin to acquire the skill and concentrate on what we are doing).
Unconscious competence (i.e., we blend the skills together, and they become habits, allowing use without struggling with the components).
The challenge initially for novices is that they are becoming increasingly aware of being incompetent as progress is made. This is likely to generate anxiety.
The history of the one-to-one nurse–patient relationship and nurses conducting psychotherapy is detailed by Lego (1999) and Beeber (1995). Table 1.3 highlights the important events. The late 1940s were marked by the development of eight programs for the advanced preparation of nurses who cared for psychiatric patients. An extremely important debate took place over the next few decades about the nurse’s role as psychotherapist. This culminated in the 1967 American Nurses Association (
| 1947 | Eight programs established for advanced preparation of nurses to care for psychiatric patients |
| 1952 | Hildegard Peplau establishes the first master’s in clinical nursing and a “Sullivanian” framework for practice for psychotherapy with inpatients and outpatients |
| 1963 | Perspectives in Psychiatric Care first published as a forum for interprofessional psychiatric articles |
| 1967 | American Nurses Association ( |
| 1979 | |
| 2000 | American Nurses Credentialing Center ( |
| 2001 | Family |
| 2003 | |
| 2011 | American Psychiatric Nurses Association ( |
| 2013 | |
| 2014 | Only |
After the issue of whether nurses should do psychotherapy was resolved, the literature examined the unique qualities that nurses might possess as psychotherapists compared with those in other disciplines who practice psychotherapy. Several strengths were cited: nurses have the ability to be patient because they have worked with the chronically ill and have respect for others’ limitations; nurses are realistic and possess excellent observational skills, resourcefulness, innovation, and creativity (Smoyak, 1990); nurses are able to view the patient in a holistic way, understand crisis orientation, and have a knowledge of general health concerns (Lego, 1992); and nurses are familiar with the daily life and experience of the hospitalized patients (Balsam & Balsam, 1974). Nurses usually have had a breadth of life experience and exposure to many different ages, ethnicities, occupations, socioeconomic status, cultures, and personalities. The novice nurse psychotherapist is well served through experience with communicating and connecting with those from diverse backgrounds. Nurses being close to the patient’s everyday experience is crucial for connection and collaboration. This connection is reflected in the public perception of nurses as positive and trustworthy. In 2019 for the 18th year in a row, the Gallup poll found that nurses top the list of most ethical professions, with Americans rating nurses among the most trusted professionals. Eighty-five percent of respondents rated nurses’ honesty and ethics as “very high” or “high” with medical doctors rated third at 65% (Gallup, 2020).
An additional quality that nurses bring to the role of psychotherapist is a pragmatic, problem-solving approach using the nursing process as an overall framework for practice. Usually, the patient has tried many things to feel better, and therapy is often a last resort. The patient’s problems have brought the person into treatment, and if these problems could be solved outside of therapy with friends or family, he or she would have already done so. The problem-solving approach needed in the psychotherapeutic process is the same as in the nursing process. Both involve an assessment, diagnosis, plan, intervention, and evaluation. Nurses are used to collaborating with patients and thinking about what will solve the problem, what the patient’s perspective is, what the person wants, and what the patient’s strengths are. These approaches are derived from a problem-solving, health-oriented, holistic model fundamental to nursing practice and the nurse–patient relationship.
In my experience working with graduate psychiatric nursing students, this problem-solving approach is useful but one that novice nurse psychotherapists often struggle with. Because nurses are used to taking care of people and are action oriented, beginning students often want to rescue the patient and help the patient to feel better. Helping the patient feel better is not the main goal of psychotherapy, and a focus on amelioration of symptoms may even be counterproductive to the process, although feeling better overall most likely will be a by-product of successful therapy. In a well-intended effort to help the person feel better, the nurse may be too directive and offer fix it suggestions, and this is antithetical to promoting empowerment. Letting the psychotherapeutic process unfold takes time, and that has typically not been a part of nursing practice, especially within the current healthcare system.
Nurse psychotherapists have the honor of participating in the healing process, and as nurse theorists Dossey and Keegan (2013) point out, in the nurse–patient relationship, the nurse enters into a shared experience or field of consciousness that promotes the healing potential of others. Through consciousness, intent, and presence, the nurse psychotherapist’s therapeutic use of self facilitates others in their healing. To counter the learned patterns of nursing practice (i.e., busyness, task focused, and control), the nurse psychotherapist needs to cultivate reflection, mindfulness, and patience. According to Dossey and Keegan (2013), qualities essential for nurse healers include expansion of consciousness and continuing one’s own journey toward wholeness and resilience. This can be accomplished through many different venues: nature, relationships, your own therapy, ongoing supervision, meditation, mindfulness, self-awareness exercises, spiritual practices, chanting, prayer, journaling, openness to receiving one’s own healing treatments, and reflective activities such as hiking, walking, and yoga. Research has shown that the regular practice of mindfulness improves empathy, insight, immune function, attention, and emotional regulation (Dahlgaard et al., 2019). These changes correspond to changes in the brain that include increased activity and growth of regulatory and integrative regions which foster resilience.
Mindfulness is a skill that can be learned through practice and discipline and used as a tool in the psychotherapeutic process. The vast literature on the development of mindfulness crosses many disciplines and orientations, from Buddhism to psychoanalysis. Mindfulness is discussed more fully in Chapters 17 and 18. Safran and Muran (2000) state that mindfulness in psychotherapy has three characteristics:
(a) The direction of attention, (b) remembering, and (c) nonjudgmental awareness. The initial direction of attention involves intentionally paying attention to and observing one’s inner experience or actions. This involves cultivating an attitude of intense curiosity about one’s experience. In mindful meditation, the individual can initially cultivate the ability to attend by focusing the attention on an object (e.g., the breath) and then noting whenever his or her attention has wandered and returning it to the intended focus of attention. By noting whatever one’s attention has wandered toward (e.g., a particular thought or feeling) before redirecting one’s attention, the individual develops the ability to observe and investigate his or her experience from a detached perspective rather from being fully immersed in or identified with it. (p. 59)
Peplau (1991) stressed the need for self-awareness in the nurse–patient relationship and stated: “The extent to which each nurse understands her own functioning will determine the extent to which she can come to understand the situation confronting the patient and the way he sees it” (p. x). However, with the rise of psychopharmacology and biological psychiatry, self-awareness has not been a priority. Self-awareness is key to understanding others, and it reduces the likelihood that therapists will act out their own agendas and use patients for gratification or self-esteem needs. For example, one novice nurse psychotherapist was so rewarded emotionally by his work with a particular patient that he went out of his way to meet with her when she needed him and to schedule additional office hours when he would not normally be in the office. The patient responded with gratitude, which enhanced the self-esteem of the nurse who was conscientious and overly responsible for this patient. It was only through supervision that he began to understand how his need for recognition fueled the overly accommodating stance; how his objectivity about the psychotherapeutic process had been compromised; and how this cultivated an unhealthy dependency in the patient.
Peplau (1991) says that there is a tendency for all those doing therapeutic work to generate inferences from limited data and to assume that these data are complete. It is only natural that we would try to fit the problem into our own limited schemata of experiences, but the richness of clinical data belies this belief. Attributing motivation to one simple reason, such as “she’s borderline and manipulative,” is simplistic and may assuage our anxiety but does not account for complex, multifaceted interactions and contributions that are more often the norm than the exception. Symptoms are usually multidetermined and have many different contributing factors.
Overdeterminism refers to the idea that a problem most often has many different causes. The patient may not be able to provide a full description of these contributions and most likely is unaware of the multiple reasons for the current symptom. For example, a young woman with bulimia may have factors that contributed to the development of her problem: a history of sexual abuse, feelings of deprivation and neglect in her family, a recent loss in her family, a genetic predisposition, a fear of weight gain, cultural pressures about weight, an overemphasis on weight in her family, an inability to self-soothe, a hormonal imbalance, the stress of a new job, and a best friend who is also bulimic. The friend with the same problem may have a few of these contributing factors and others, such as conflict in her home with an abusive, alcoholic father; a depressed, unavailable mother; and financial difficulties that contribute to the instability of her home environment and compromise her ability to manage her emotions. There are no simple answers, and two people with the same problem may have developed and maintained their symptoms for different reasons. Many factors, such as genetics, prenatal insults, parent–child interactions, abuse, neglect, school and social environments, family dynamics, and physical illness, have been studied, and all have been found to play a role in the cause of psychiatric disorders and mental health problems.
We all have preconceptions that are brought to every situation. It is not as important to eliminate these as to be aware of what they are and how they may influence our work. The extent of a nurse’s self-knowledge determines the extent to which he or she can understand another person. Neuroimaging studies have confirmed that being aware of another’s mind is related to a person’s ability to monitor his or her own mental state (Siegel, 2012). A person does not have to be a paragon of mental health to help another. Some feel that to be truly empathic, a person should have experienced psychological suffering, which can serve to deepen the work in psychotherapy. Most expert therapists consider personal therapy and supervision essential for the novice psychotherapist to cultivate emotional genuineness, authenticity, and objectivity. Supervision is not therapy, but it does assist the therapist in discussing difficult cases and understanding his or her own blind spots and how personal issues may impact the therapeutic relationship. Ongoing group or individual supervision after graduation is necessary for continued growth and an ethical practice. Expert psychotherapists usually seek supervision and consultation throughout their professional lives. A sample of suggestions for presenting a case that may be covered in supervision is included in Appendix 1.1.
Irvin Yalom cogently makes a case for therapy for the therapist:
Therapists must be familiar with their own dark side and be able to empathize with all human wishes and impulses. A personal therapy experience permits the student therapist to experience many aspects of the therapeutic process from the patient’s seat: the tendency to idealize the therapist, the yearning for dependency, the gratitude toward a caring and attentive listener, and the power granted to the therapist. Young therapists must work through their own neurotic issues, they must learn to accept feedback, discover their own blind spots, and see themselves as others see them; they must appreciate their impact upon others and learn how to provide accurate feedback. (Yalom & Ferguson, 2002, pp. 40–41)
The student of psychotherapy who undergoes his or her own psychotherapy has a model for what the psychotherapeutic process is and understands the power and the process of psychotherapy in an immediate, experiential way that no amount of reading or didactic study can convey. Many expert psychotherapists report that they have experienced various modes of psychotherapy and this has enhanced their own technique as the skills others use are incorporated into their own practice.
In addition to self-awareness, enhancing one’s own resilience through promoting self-care is fundamental in caring for others. Self-care strategies start with exercising regularly, eating healthily, spending time with friends, getting enough sleep, and limiting work hours to avoid exhaustion. When a flight takes off, the airline attendant announces that all adults must put the oxygen mask over their faces first before securing the mask on a child. This is an appropriate metaphor for all caregivers. Much has been written about the trauma inherent in nursing. Various terms have been used to describe this phenomenon, such as burnout, compassion fatigue, and vicarious or secondary traumatization. A 2017 survey of employed
Competencies for Trauma and Resilience for Nursing Education have been developed and include self-resilience competencies for
In contrast to the biomedical model’s goal to cure with symptom relief treatment, the goal in a holistic paradigm is healing (see Figure 1.1). This is an important distinction, because curing is not always possible but healing is (Dossey & Keegan, 2013). The word heal comes from an old Anglo-Saxon word haelen, which means “to become whole, body, mind, and spirit within oneself”; but it can also be defined in a broader context as being in “right relationship” with oneself, others, and our world. Mariano defines healing as “an emergent process … bringing together aspects of one’s self and the body, mind, emotion, spirit, and environment at deeper levels of inner knowing, leading to an integration and balance” (2013, p. 60). Each component is interdependent and interrelated, based on the premise that when there is a change in one part of the system, the change reverberates in all dimensions. For example, minor changes in one’s emotions may potentiate a change in all other spheres as well as in the person’s relationship with others and his or her world. Conversely, a change in the context or relationships with others may create changes in other dimensions (e.g., body, mind, emotion, spirit) of the person. The context or background is the person’s culture as mediated by the person’s family and relationships.
Some of the goals of psychotherapy include the reduction of symptoms, improvement of functioning, relapse prevention, increased empowerment, and achievement of the specific collaborative goals set with the patient. Within the biomedical model, symptoms are often thought to be the cause of the patient’s problem and psychotropic medications are prescribed to target specific symptoms in an effort to eliminate or reduce the symptoms. For example, prescribing a selective serotonin reuptake inhibitor (
In contrast, in a holistic model, symptoms are seen as a form of communication and are useful for understanding the meaning of the dysregulation and disharmony that are occurring for this person at a given time. By eliminating the symptoms with medication, we are essentially “shooting the messenger.” Often therapists find that therapy works best with full access to emotion; that is, if the person’s emotions are damped down by benzodiazepines or other psychotropic medication, psychotherapeutic work may be compromised. For example,
The holistic paradigm is consistent with the mandate for recovery-oriented behavioral care. The Substance Abuse and Mental Health Services Administration (
These elements and gold standards for recovery may feel familiar to
The diagnosis may not tell us very much about the person sitting in front of us. The nurse is often the only person caring for the patient who sees the whole picture. The nurse knows the patient as “a grandmother who lives alone in a walk-up, estranged from her daughter and often terrorized by her own internal demons” while those practicing from a medical model might describe the same person as “an 88-year-old elderly woman with bipolar disorder.” The former is relevant about who the person is while the latter tells us nothing about the uniqueness of that individual. Indeed the nurse practicing from a holistic paradigm respects the complexity of the person, and historically, this has been the foundation for nursing practice.
Relationship has been considered foundational for psychiatric nursing since Peplau’s seminal work in 1952 (D’Antonio, Beeber, Sills, & Naegle, 2014). The healing that takes place in psychotherapy occurs through the relationship between the therapist and the patient. Lego (1992) maintained that psychiatric nurses develop “a relationship designed to change the patient’s interpersonal situation, changing the intrapsychic situation, thus changing the brain chemistry” (p. 148). Forchuk and associates (1998) observed that the nurse–patient relationship is the “active ingredient” in therapeutic change. Raingruber (2003) concurs and says that relationship and nurturing are hallmarks of psychiatric nursing. Dossey and Keegan (2013) say that the healing relationship occurs through the expansion of consciousness, during which a sacred space is created.
Emotional connection promotes interpersonal attunement, attachment, and coregulation of physiological states (Schore, 2019). Emotional connection with the patient through relationship has been found to be important for successful psychotherapy outcomes with 50% of positive outcomes due to therapist, relationship, and expectancy while the specific technique or theory used by the therapist accounts for only 17% of improvement; 33% of the variance is due to extratherapeutic factors such as spontaneous remission, patient, and community factors (Norcross & Lambert, 2019). The ability of the patient to connect through collaboration depends on the therapist’s skills and on the patient’s emotional developmental level, with some patients much better able to join in collaboration than others. Tryon and Winograd (2002) found that the more troubled, resistant, less-motivated patients are those most likely to need help and the least likely to engage and collaborate with therapists. Chronically disempowered patients, especially those who have been severely traumatized in childhood, often are unable to connect with others and use support to reach new solutions. The challenge for the
Caring in the nurse-patient relationship has been identified as essential for practice (Dossey & Keegan, 2013; Morse, Solberg, Neander, Bottorff, & Johnson, 1990; Schoenhofer, 2002; Watson, 2012). Caring encompasses and expands Carl Rogers’s idea of unconditional positive regard that has been adopted by most mental health disciplines as essential to helping relationships (Rogers, 1951). A phenomenological study delineated the characteristics of the
The nurse psychotherapist creates a healing presence of acceptance, patience, kindness, nonjudgmental attitude, understanding, good listening skills, honesty, and empathy. These qualities are the essence of presence (McKivergin, 1997) and allow the nurse psychotherapist to “be with” rather than “doing to” the patient. Bunkers (2009) says, “True presence involves listening to what is important to the other and listening to what the meaning of a situation is in the moment for that person” (p. 22). Scaer (2005), a neurologist specializing in trauma, says that presence involves a personal interaction that contributes to physiological changes in the person. He states, “This healing, empathic presence affects and alters the parts of the brain that process pain, fear, anxiety, and distress” (p. 167). Presence may facilitate healing through mediation of neurotransmitters and hormones that promote optimal autonomic functioning.
The antithesis to empowerment is authority; in this situation, the therapist knows what is best for the person. The process of psychotherapy cultivates dependency because there is unavoidable inequality in the relationship with the patient, who naturally feels disempowered by needing help at a vulnerable time. This reality and the inevitable transference–countertransference responses create dependent feelings in the patient. The psychotherapist’s competence lies in understanding that the patient’s autonomy is always in the foreground of the process. The overall goal for patients is to deepen their understanding of themselves in order for them to make their own decisions. Caring is fundamental to creating an atmosphere conducive to the cultivation of relationship and empowerment.
Both relationship and resilience are overarching pantheoretical concepts that apply to all approaches of psychotherapy and practice settings. The term resilience refers to the ability of an individual, family, or community to cope with adversity and trauma, and adapt to challenges through individual physical, emotional, and spiritual attributes and access to cultural and social resources (adapted from
An elegant yet simple resilience model based on neurophysiology is proposed by Elaine Miller-Karas and deepens our understanding how to help patients access their resources (2015). Miller-Karas says that one’s resilient zone (
If the person becomes too anxious and hyperaroused, resistances or defenses may increase, and the work of therapy will be thwarted, perhaps not consciously, but nevertheless, the person’s brain will not be able to integrate memories or gain insight. Immediate strategies in a session to decrease arousal levels might include deep breathing exercises or imagery. There are also many patients who have suffered significant trauma and are in a chronic state of either hyperarousal or hypoarousal or swing from one physiological state to the other (see Figure 1.3). If the person is chronically hypoaroused, he or she may be unable to access emotions. Strategies for hypoarousal to increase arousal might include focusing on sensations in the body, mindfulness exercises, and self-regulation strategies. Self-regulation refers to one’s ability to manage emotions and behavior and is further discussed in Chapter 2. Psychotherapy helps those with emotional dysregulation to widen and strengthen their
Severe trauma has been found to override constitutional, environmental, genetic, or psychological resilience factors (De Bellis, 2001). Studies have shown that factors that enhance resilience include the presence of supportive relationships and attachments as well as the avoidance of frequent and prolonged stress (Herrman et al., 2011). These factors are not inborn but can be fostered through psychotherapeutic interventions that focus on the strengths of the person, reducing risks, and improving relationships. Chapter 11 further discusses the
Figures 1.2 and 1.3 illustrate a user-friendly model that the
Source: Adapted by Elaine Miller-Karas from an original graphic by Levine/Heller. Reprinted with permission from the Trauma Resource Institute, Claremont, CA.
Understanding, assessing, and managing anxiety is a cornerstone of Peplau’s Interpersonal Relations Model for Nursing (1991). Anxiety is ubiquitous in the psychotherapeutic process, and the skilled
One of the chief aims of the psychotherapist is to help the patient overcome the fears and inhibitions that have led him to react to his normal and healthy feelings as if they were a threat; to help him reappropriate parts of himself that have been dissociated from full awareness, that have motivated avoidances, and that are likely to generate still further areas of vulnerability, deficits in crucial skills in living, and impediments to the very relationships that could in principle be correctives to the debilitating anxiety. (p. 87)
For the most part, people seek psychotherapy because anxiety or the effects of anxiety have in one way or another interfered with functioning. Sometimes, a person is seeking help for the anxiety itself, such as in cases of panic attacks or phobias, but often the presenting issue is related to the results of the person’s efforts to avoid anxiety. For example, a person with borderline personality traits may present with depression as a result of a lost relationship, but the central issue is a vulnerability to abandonment anxiety. It is likely that in the person’s zeal to avoid the feared abandonments, that person inadvertently creates the very situation that he or she is trying so hard to avoid (Figure 1.4). Wachtel (2011) calls this cyclical psychodynamics, which is explained further in Chapter 5.
Inherent in all the theoretical approaches and basic principles discussed in this textbook is the centrality of anxiety as key to the patient’s problems and the management of anxiety as key to solving these problems. In the safety of the therapeutic relationship, patients are encouraged to tolerate the feared experiences, memories, and thoughts. Cozolino (2017) says that a major role for the therapist is to assist the patient in using anxiety as a compass to explore unconscious fears. In deepening his or her understanding of anxiety as a trigger for avoidance or acting out, the person can then approach with curiosity what is feared. Strategies for working with anxiety are central to all therapy approaches. For example, behavioral techniques such as desensitization or flooding may be taught and increase anxiety initially, with the hope of decreasing anxiety later, so the person can face what was fearfully avoided. Cognitive techniques may involve “restructuring” thinking so that the threat that is anxiety-provoking is not considered as dire as originally believed. Psychodynamic techniques use interpretations to deepen the person’s understanding of anxiously avoided thoughts, wishes, and feelings by making the unconscious conscious in order to understand the cause of anxiety.
For those patients with chronic hyperarousal and anxiety disorders, their
However, a caveat is in order. Workbook exercises are only an adjunct to treatment and do not take the place of the real work in therapy, which is co-constructing a narrative and connecting through a therapeutic relationship. A consistent finding is that treatment manuals do not correlate positively with treatment outcome (Moncher & Printz, 1991; Strupp & Anderson, 1997; Truijens, Zühlke van Hulzen, & Vanheule, 2019). This may in part result from the constraints on creativity and flexibility with such a “cookbook” approach that is not context driven. Often, novice psychotherapists feel more comfortable with these structured approaches and with “doing” things; thus, it may help to manage the therapist’s anxiety more than it does the patient’s. In addition to monitoring the patient’s anxiety, the beginning
It is easy to see why therapy in and of itself is highly anxiety provoking. Change, even a positive change such as we hope occurs in psychotherapy, is anxiety provoking. A seminal study by the Menninger Foundation found that patients who had positive outcomes from psychotherapy often reported an increase in anxiety, but they had learned to use anxiety as a signal rather than as a reality that danger was present (Siegel & Rosen, 1962). In the safety of the therapeutic relationship, the person is exposed to what has been avoided; and as the person begins to change toward healthier ways of functioning, increased anxiety is inevitable. It is important for the therapist to keep this in mind and monitor the patient’s anxiety level as the therapeutic process unfolds. If anxiety becomes too unbearable in psychotherapy, there may be acting-out behaviors and increased resistance to change, or the person may leave treatment prematurely.
Anxiety is inherent in any new enterprise, and learning psychotherapy can be particularly anxiety provoking. In psychotherapy, we are trying to make sense of what is going on, and new information is emerging in every minute in our interaction with patients. One way the brain deals with ambiguous situations is to categorize information. This is largely what diagnosing is about—categorizing and labeling patients through a list of behavioral characteristics. The brain tries to fit the person into what is familiar, and this limits our ability to approach the patient with openness and without preconceptions. As anxiety increases, our focus becomes more limited, and it is harder to maintain the openness required to achieve a nonjudgmental, observational stance. Developing self-awareness about one’s own anxiety is essential in empowering the therapist to allow the space needed for the relationship to develop.
To practice psychotherapy, the therapist must have a model on which to base interventions and some idea of what constitutes a mentally healthy person. Freud’s simple idea that the goal of therapy is to be able to work and love remains relevant, because it can be applied generally to all cultures and people. In contrast, Sullivan (1947) thought that self-awareness was key to mental health and said, “One achieves mental health to the extent that one becomes aware of one’s interpersonal relations” (p. 207). A more contemporary idea is offered by Siegel (2012) and is based on a systems perspective. He says that mental health emerges from integration in the brain/body through relationships. Integration is the core of resilience and vitality and reflects coherence of one's own states of mind. “Internal integration allows for vital interpersonal connections that are themselves integrative.” (p. 351) Integration is accomplished through information processing that links disparate parts into a functional whole. The neurophysiological underpinnings of integration are explained further in Chapter 2.
Appropriate perception of reality
Spontaneity
Ability to concentrate and problem solve
Acceptance of oneself and others
Intense emotional experiences
Peak experiences
Nonconformance
Creativeness and ethics
Interpersonal relationships
Independence and autonomy
Identification with humankind
Source: Adapted from Maslow, A. H. (1972). The farther reaches of human nature. New York, NY: Viking.
Maslow delineated the ideal of a mentally healthy person as one who is self-actualized and who has the characteristics summarized in Box 1.1. Maslow’s hierarchy of needs framework for problem solving is useful in conceptualizing the priority of patient needs (Maslow, 1972). Lower-level needs must be met before higher-level needs can be addressed. Meeting physiological needs is essential, with physical and emotional safety and security next (Figure 1.5). Safety in the world and the therapeutic relationship is essential to enable disclosure so that higher-level needs on the continuum, such as love, self-esteem, and self-actualization, can be achieved. This model is not fixed in that an individual may achieve self-actualization and then be faced with a trauma and have a need for physiological safety that would then take priority over self-actualization and needs higher in the hierarchy.
It is apparent from reviewing the characteristics of self-actualization in Box 1.1 that the meaning of mental health is culture bound; Maslow’s self-actualized person, embodying independence, autonomy, individuation, and nonconformance, is largely a Western idea. For example, Eastern cultural values of interdependence, communal integration, and group harmony which does not fit with Western ideas of self-actualization. Some dimensions of this framework may apply to certain cultures but not to others. Cultural relativity is a term that Horowitz (1982) identified as important to consider in any discussion of mental health; behavior that is considered normal or abnormal depends on social and cultural norms.
Culture is an integral part of all relationships. Our cultural context shapes our perceptions, emotions, attributions, judgments, and ideas about ourselves and others (Barrett, 2017). The powerful influence of culture permeates all dimensions of our life in a way that is often unconscious. We are all multicultural in the sense that we belong to many different cultures simultaneously. For example, a young man who recently returned from combat belongs to the military culture, which values winning in battle and requires following orders and acting bravely. He may return to a society that does not value the war he fought and find a clash of values on his return. He may also belong to an Irish cultural heritage that does not sanction overt expression of emotion, and his male gender has another set of cultural expectations about behavior. He may be homosexual and belong to the gay culture, with the expectations and prejudices that accompany this orientation. His Roman Catholic upbringing adds another cultural layer that may contribute to his guilt, conflict, and confusion. It is easy to see how all of these multicultural influences provide the complex context that will impact his ability to resume his life in a healthy, productive way.
To diagnose and treat mental illness effectively, the
The
Recent cross-cultural research reveals that culture not only determines what is considered a psychiatric disorder but that neurobiological mechanisms linked to stress and trauma vary across cultures (Liddell & Jobson, 2016). For example, higher cortisol levels following a stressful event have been found in Chinese children compared with children from the United States (Doan et al., 2017) and in Brazilian older adults compared with Canadian older adults (Souza-Talarico, Plusquellec, Lupien, Fiocco, & Suchecki, 2014). This is important because relationships and culture shape not only our psychology but our biology. Research has also found that people from different cultural backgrounds vary in their interoceptive awareness (awareness of bodily states) (Ma-Kellams, 2014). Our bodily awareness, past experiences, and surroundings create emotions. Thus, emotions are constructed and predicted by the brain in the moment and learned in a relational context with the embedded values and norms of a particular culture (Barrett, 2017). One’s perception about the world is shaped by predictions the brain is making about physical autonomic states; thus, we are deeply interacting with each other on a visceral level. Assisting the patient in labeling and identifying and exploring emotions without preconceived assumptions about what the person is feeling is essential in all psychotherapy.
If the
According to Luhrmann (2000), a cultural anthropologist, there are traditionally two frameworks for understanding mental illness. One framework is the psychodynamic approach, originally based on Freud’s theoretical speculations, but that has evolved into many other frameworks. This model attributes mental illness more or less to environmental and psychosocial problems (i.e., nurture). In contrast, the biophysiological model attributes mental illness to chemical imbalance (i.e., nature). The latter framework attributes mental illness to an imbalance of neurotransmitters in the brain, and the answer lies in correcting these imbalances, largely through medication. This model has revolutionized psychiatry and has been dominant since the 1950s, when phenothiazines were discovered with great excitement for the treatment of those with chronic mental illness or psychosis.
How changes in neurotransmitters produce symptoms has been an intense focus of investigation, beginning in the 1990s with the “decade of the brain.” These studies are based on the underlying premise that mental illness is a “brain disease” and should be treated as any other illness. This idea has been embraced by mental health providers and drug companies, as well as those diagnosed with a psychiatric disorder. However, a seminal research study found that this belief actually increases rather than decreases stigma and that people thought to have a brain disease are treated more harshly (Mehta & Farina, 1997). Perhaps diagnosing a person with a psychiatric disorder as “brain diseased” sets the person apart and further marginalizes the person as an “other.” Stigma toward those with psychiatric disorders can be reduced through deepening our understanding of the effect of the environment on brain functioning. This knowledge may help to change the conversation from what is wrong with this person to what has happened to this person.
Both genetic vulnerability and environmental influences play significant roles in the development of mental illness. The term epigenetics has been coined to describe this interplay, that is, the environment selects, signals, modifies, and regulates gene activity. Heritable differences in gene expression are now thought to be not the result of
The stress diathesis model of psychiatric disorders has evolved from the recognition that genetics (diathesis/nature) and environment (stress/nurture) both contribute to the development of psychiatric disorders (Hankin & Abela, 2005; Smoller, 2016). That is, for a person who has a genetic vulnerability and encounters significant early life stressors such as childhood trauma or neglect, loss, or viruses, the expression of the gene for the development of the psychiatric disorder most likely will be triggered. Evidence suggests that this is a result of changes in
Two psychiatric disorders that are thought to be strongly heritable, schizophrenia and bipolar disorder, are now thought to share epigenetic roots. Significant epigenetic chemicals were found in the genome of 22 pairs of identical twins diagnosed with either schizophrenia or bipolar disorder (National Institute of Mental Health [
Animal and human studies strongly indicate that genetic factors of stress reactivity and greater physiological reactivity to stressful events may predispose one to a psychiatric disorder (Smoller, 2016). Those who have a stronger, more persistent response to stressors tend to withdraw from stressful situations and have internalizing traits. These people may be inhibited and more fearful, thus predisposing the person to anxiety and depressive disorders. Likewise, those whose temperament tends toward externalizing traits may be predisposed to develop psychopathology with symptoms of impulsivity, aggressiveness, and attentional difficulties. Caregivers who are not able to mediate arousal for their offspring with either of these traits are likely to exacerbate difficulties with affect and self-regulation that may lead to psychopathology (Schore, 2019).
Telomeres,
It is now well established that adverse life experiences are associated with a wide range of psychiatric disorders and medical problems (Felitti & Anda, 2010; Hughes et al., 2017; Suglia et al., 2018). Felitti’s (1998) seminal study of the long-term sequelae of adverse childhood experiences (
Approximately 70% of adults world wide experience at least one traumatic event within their lifetime (Kessler, 2017). Exposure using
Children are particularly vulnerable to adverse events due to the plasticity of the developing brain; those who are brought up in a chaotic or non-nurturing environment suffer neurological consequences that are long-lasting and difficult to remediate (Shonkoff & Garner, 2012). Toxic stress and
Toxic stress in early childhood also plays a role in the intergenerational transmission of disparities in health outcome (Braveman & Barclay, 2009). Research supports the long-term negative sequelae related to the neurobiological responses to childhood stress and trauma (Jiang et al., 2019; Heins et al., 2011; Nicholson et al, 2018; Perry, 2001; Schore, 2012; Stien & Kendall, 2006; Van Dam et al., 2012). These effects may then be inherited by subsequent generations: higher maternal
The link between trauma and mental illness is complex and interactive. Numerous studies have found that adults receiving treatment for severe and persistent mental illness, substance abuse, eating disorders, anxiety, and depressive disorders are highly likely to be survivors of trauma, such as childhood sexual abuse, domestic or community violence, combat-related violence, or poverty (Brown et al., 2009; Chu, 2011; Danese et al., 2009; Read, 2010; Stien & Kendall, 2006; Teicher, 2012). The majority of people served by public health mental health and substance abuse service systems have experienced repeated trauma since childhood and have been severely impacted by trauma (Grubaugh et al., 2011).
Racial trauma and the stress that results from danger related to real or perceived experiences of racial discrimination (Comas-Diaz, Hall, & Neville, 2019) – has been identified as a precipitant of
Judith Herman (1992), in her seminal book Trauma and Recovery, states: “Traumatic events are extraordinary, not because they occur rarely, but rather they overwhelm the ordinary human adaptation to life” (p. 33). Findings in the wake of the World Trade Center disaster indicate that many people experienced significant symptoms, such as insomnia, irritability, general anxiety, vigilance, and impaired concentration, but did not qualify for a diagnosis of
van der Kolk (2014) says that while single-incident traumas may sometimes account for those diagnosed with posttraumatic stress disorder (
Adults who encounter everyday hardships are also at risk. A survey of 832 people from a primary care practice found that there were more
Common sense dictates that suffering any emotional or physical illness is disruptive, disturbing, and stressful. Accordingly, those who experience acute or chronic illness have been found to develop post-traumatic stress symptoms, including those admitted to the
Pointedly, the experience of mental illness may in and of itself be regarded as a traumatic experience. For decades, studies have supported this possibility (McGorry et al., 1991; Meyer et al., 1999; Shaw et al., 1997). A diagnosis of
The above research supports Shapiro’s (2001, 2012, 2018) expanded conceptualization of trauma from the Criterion A events for
The Substance Abuse and Mental Health Services Administration (
… experiences that cause intense physical and psychological stress reactions. It can refer to a single event, multiple events, or a set of circumstances that is experienced by an individual as physically and emotionally harmful or threatening and that has lasting adverse effects on the in-dividual’s physical, social, emotional, or spiritual well-being (
The word “trauma” is used in this book to denote this expanded conceptualization inclusive of all events and situations that are experienced by the person as overwhelming and affect brain functioning through the interruption of information processing. This disruption in brain circuitry, regulatory systems, and information processing, results in the disturbing event or situation being stored dysfunctionally, sometimes affecting the person even decades later (Shapiro, 2018). It is a basic tenet of this book that such experiences are the basis of most psychopathology. Trauma is a response – a disconnection from oneself,– not an event (Mate, 2003; Porges, 2019). It is not so much what has happened to the person, but what happens inside the person. Healing trauma involves the reconnection with self and is always possible.
An individual’s response and the long-term sequelae of a disturbing event are highly individualistic and depend on a multitude of factors, such as the person’s age, developmental stage, coping skills, support system, cognitive deficits, preexisting neural physiology, and the nature of the trauma. It is not just the event itself that determines the long- and short-term effects of trauma, but the individual differences that the person brings to the situation. Traumatic experiences disrupt brain functioning as mediated by genetics, social support, age, development, and many other factors. Healthy functioning of the brain is reflected in the optimal integration and coordination of neural networks. Chapter 2 discusses the neurophysiological theory and research that provide the underpinnings for the psychotherapeutic framework for this book.
The adaptive information processing (
Once information processing is interrupted, the memory of the event becomes fragmented. The emotion related to the experience may become disconnected from the words to describe the event and/or the sound and/or physical sensations. Thus, the fragmented memory is not integrated but stored in the brain with each component existing in discrete units that are disconnected or dissociated from each other. The memory is stored largely in implicit or unconscious memory and is experienced as being in the present once triggered. For example, a woman who was raped 40 years ago might be triggered by having sex with her partner and feel as though the rape was happening all over again, or she may be anxious and fearful around certain places or people that remind her of the event and be unaware of why she is anxious and does not connect her current anxiety to the original experience. These reactions are not in her control but come from neural associations deep within memory networks that are not connected with the conscious mind. Consciousness is defined as our subjective experience of being aware and having access to information about the experience (Siegel, 2012). It is understandable that a person who has experienced multiple traumas may not be very conscious or living in the present.
Psychotherapy interventions can be designed to target any or all areas of the dissociated memory or experience—behavior, relationships, beliefs, the body, images, and/or emotions—to facilitate healing and promote neurophysiological harmony (see Figure 1.6). For example, the therapist using a
The treatment hierarchy framework for practice for this textbook based on
The treatment hierarchy illustrates an overarching framework for therapeutic aims that must be ensured before the person can move up the levels in the triangle (see Figure 1.7). The patient’s physiological needs, such as diet, sleep, and exercise, are essential to a healthy emotional life and the work of psychotherapy. Nurses are knowledgeable about what constitutes a healthy lifestyle and this knowledge is invaluable to integrate into psychoeducation with patients in psychotherapy. Overall, resources must be procured and stabilization guaranteed before trauma can be processed, and then a vision can be developed of a possible future. The aim is toward integration of neural networks, of memories, of oneself and relationships, and of the person’s connection in the world. The patient’s ability to process information is variable, with some patients needing more stabilization so that adaptive memory and experiences are created or are reinforced if present, while other patients may be able to process information and quickly move toward integration. Stabilization strengthens and/or widens the person’s
Source: Adapted from Davis, K., & Weiss, L. (2004). Traumatology: A workshop on traumatic stress disorders. Hamden,
Some psychotherapeutic approaches may have more utility than others, depending on the person’s state of need, resources already present, emotional development, past traumas, and support system as well as the expertise of the therapist. The therapist’s thorough and accurate assessment, as discussed in Chapter 3, helps to formulate a plan to assist the person to move upward on the treatment hierarchy to the next stage. Although treatment is discussed as a stage model, it is not static in that there is some fluidity of movement. Frequently, patients take two steps forward and then one backward; that is, often after therapeutic gain, a period of anxiety, confusion, and/or depression follows. This is because emotion is a powerful agent of change and creates disruption (Damasio, 1999). Even a positive change may have a disorganizing effect on the brain and behavior because of the proliferation of synapses that occurs with new learning (Stien & Kendall, 2006). This idea is supported by a developmental principle of all biological systems that “there can be no reorganization without disorganization” (Scott, 1979, p. 233). It is the therapist’s responsibility to assist the person in understanding that the gains being made are often followed by increased sadness and anxiety. Explaining this to the person, keeping the overall plan and therapeutic aims in the foreground, and conveying hope is essential for the process and progress to continue.
Through therapeutic relationship
Bibliotherapy/role play
Case management
Cognitive behavioral therapy
Community resiliency model skills
Dialectical behavioral therapy
Education about
Managing physiological arousal
imagery
Container
Calm place
Mindfulness/meditation
Medication
Stress management/education
Provide safety
Yoga/exercise
Essential to all approaches discussed in this book is providing for safety and increasing resources, if needed, to attain stabilization and a robust
Stabilization strategies assist the person to be better able to make state changes, that is, to change one’s present physiology in order to function more effectively in the moment. Crucial in case management is the ability of the therapist to assess regressive and adaptive shifts in ego functioning and to recognize conflict to help the person to manage anxiety. Although the therapist may understand what is happening for the patient dynamically, this does not need to be interpreted to the person. Accurate assessment of where the person is in the change process is essential. A stage of change model is helpful in determining where the therapist needs to aim interventions. This is especially useful for interventions aimed at behavioral change. Stages of change are discussed in Chapter 9.
Along with behavioral change and shoring up external resources, if needed, internal resources often need to be increased before processing. Internal resources are less tangible than external resources, and include the person’s ability to manage positive and negative emotions. Indicators that the person has sufficient internal resources include the person’s ability to self-soothe, to demonstrate adequate impulse control, to identify stressful triggers, to regulate moods, and to communicate honestly. In general, the patient’s resources and the traumas experienced need to be balanced. For the person who has a history of many adverse life experiences without positive memories or experiences, more resources may be needed to manage the deleterious effect of these experiences on functioning to enhance the
A stabilization checklist is included in Appendix 1.5 to help the clinician determine whether adequate stabilization has been achieved. The person does not need to meet all the criteria on this list before processing and the therapist’s clinical judgment is essential in order to determine appropriate strategies. Sometimes the instability is driven by the trauma and once the traumatic memory has been processed, symptoms will dissipate. Specific strategies designed to widen or strengthen the
After stabilization has been achieved, the person is ready to move to the next stage of processing. As represented toward the top of the treatment hierarchy in Figure 1.7, processing reflects access to all dimensions of memory: behaviors, affect, sensations, cognitions, and beliefs associated with the trauma (Shapiro, 2018). Processing usually involves assisting the person in constructing a narrative through the exploration of the meaning of significant adverse life experiences and traumas that impair functioning. Changes in physical and emotional responses occur as components of the dysfunctional memory are integrated with other, more adaptive networks. In contrast to state changes that occur in stabilization, processing creates trait changes, that is, enduring relationship and personality changes (Shapiro, 2018). The therapist assists the person in processing using the models and techniques discussed throughout this textbook. Some psychotherapy approaches involve components of stabilization as well as processing such as psychodynamic psychotherapy and
Through therapeutic relationship
Psychodynamic psychotherapy
Imaginal or in vivo exposure
Cognitive processing
Somatic processing
Eye movement desensitization and reprocessing
Processing is based on the idea that humans have an inherent information processing system that usually integrates experiences to a physiological adaptive state in which information can be taken in, and learning occurs (Shapiro, 2012, 2018). Memory is stored in neural networks that are linked together and organized around early events with associated emotions, thoughts, images, and sensations. Healthy functioning is reflected in the optimal integration and coordination of these neural networks, and this occurs through processing information. The neurophysiology underlying processing is discussed in Chapters 2 and 7.
Clinically, processing has been achieved once relationships are adaptive, work is productive, self-references are positive, there are no significant affect changes, affect is proportionate to events, and there is congruence among behavior, thoughts, and affect. A processing checklist is included in Appendix 1.6 to assist the therapist in determining whether processing has led to adaptive change. Periods of processing are usually followed by periods of destabilization, and the treatment process often looks more like a spiral alternating with interventions aimed at stabilization and then processing (Figure 1.9). Ongoing assessment and attunement to the person’s therapeutic process are important in order to monitor progress and plan treatment strategies. The psychotherapeutic relationship is the vehicle for therapeutic change with the therapist’s presence serving to stabilize the person and provides the foundation needed to assist the integration of dimensions of memory and all parts of the self at deeper levels of understanding. The therapeutic relationship may also facilitate processing as dimensions of earlier significant relationships through transference are triggered and reworked in the present. Empowerment and autonomy are fostered as the person moves toward envisioning and planning for the future.
Ms. A is a 26-year-old married woman who works as a costume designer and seamstress for a theater company. She has been in psychotherapy numerous times since the age of 13 for past psychiatric diagnoses of major depressive disorder, bipolar II, panic disorder, and anorexia nervosa. She reports numerous psychosomatic complaints including frequent stomachaches, irritable bowel syndrome, acid reflux, headaches, restless legs syndrome, and generalized pain as well as cold chills all over her body. Her reason for seeking treatment was her anxiety and insomnia related to her loud, annoying neighbors at her condo. Ms. A’s early history involved significant attachment problems with both her mother and father abusing drugs, and subsequently Ms. A was taken away from her parents and into custody by her aunt when she was 2,years,old. Ms. A said her aunt favored her own biological daughter and neglected her throughout her childhood. Her adult trauma history included two previous car accidents. On intake, she scored 63 on the Spielberger Trait Anxiety Scale; 22 on the Beck Depression Inventory; and 27 on the Dissociative Experiences Scale. All scores were significant for anxiety, depression, and dissociation, respectively.
Anxiety, Spielberger trait anxiety scale;
Because Ms. A had significant attachment problems by history, discomfort with her body and physical sensations, difficulty self-soothing, some dissociation, difficulty tolerating negative emotions, and inadequate trust of others, her
At termination, Ms. A’s scores on all measures showed significant improvement (see Figure 1.10). Ms. A’s creativity, visual imaging skills, and humor were great assets to her in our work together. Less tangible outcomes than the reported quantitative data were qualitative outcomes, which included an integrative narrative about herself and her aunt that included a recognition of the impact of her past history; greater ability to express herself and advocate for her own needs; better emotional and physical self-regulation; a sense of security about herself and others; and greater access to full expression of emotion. Her somatic complaints greatly decreased and as illustrated in the graph in Figure 1.10, she did not need or seek medical care for her many illnesses during the course of her psychotherapy treatment in contrast to the 6 months prior to therapy when she had sought help from her primary care provider a total of 12 times. She appeared more robust and stronger at termination, stating that she had never felt this good before.
Psychotherapy has been identified as an important competency that all
Adverse experiences have the potential to abort the wholeness of the brain, interfering with information processing, and this disruption and dysregulation, sometimes in tandem with neurobiologically encoded genetic vulnerabilities, are the basis for many mental health problems and psychiatric disorders. Psychotherapy assists in reintegration of neural networks that have become dysregulated or disconnected, enhancing the development of the brain so that continued growth and healing can occur. This framework is based on neurophysiology embedded in a holistic paradigm in that psychotherapy restores the harmony, balance, connection, and integration of neural networks on a cellular level, which is reflected in deeper connections with oneself and others. The neurophysiological basis for this model is discussed in Chapter 2.
In light of Benner’s model, where do you see yourself in relation to your past practice of nursing, and where are you now in your nurse psychotherapy practice?
How does your choice of intervention affect the outcome of treatment?
How can a person be healed and still have a diagnosed psychiatric disorder? How is curing different from healing? How do you know when healing has occurred?
Discuss a time when you and your patient had a different perception of health and illness and what this experience was like for you. How was this worked out then, and what would you do differently now?
Discuss how your self-understanding may affect your work with your patient. How has your own growth changed since you first began to work with others? Include your thoughts about how your prior practice as a nurse can be a help or hindrance to your practice as a psychotherapist.
What factors in your life led you to a nurse psychotherapist’s role?
Discuss relationship and resilience and give a clinical example of each from your past nursing practice.
Describe a patient you have worked with, explain the person’s traumas and resources, and discuss in general the priorities for treatment using the practice treatment hierarchy.
Presenting a case can seem overwhelming, especially with complex patients. The following guidelines are intended to help you organize your thinking, summarize salient information about your patient in a coherent manner, identify areas where the therapy is stuck (resistance), and formulate questions that may offer insight into the process. Identifying information should be disguised.
Demographics: age, race/ethnicity, gender, sexual orientation, education, and occupation.
Family: relationship status, living arrangement, members of immediate family, and extended relevant family members.
Working Diagnosis and Symptoms: dissociation, anxiety, depression, eating disorder, substance abuse, self-injury, and suicide attempts, destructive or violent behavior.
Relevant Medical Problems and Physical Disabilities: diabetes, asthma, chronic pain, birth defects, sensory impairment, impaired mobility, and so on.
Patient’s Coping Mechanisms: both healthy and unhealthy, defenses, and ego functioning.
Treatment History: inpatient, outpatient, how long and intensive, treatment failures and responses.
Current Treatment: inpatient, outpatient, partial individual, group, and family.
Medication(s): current and past history.
What are the reasons the patient came for treatment now?
What are the patient’s goals? How would the person know if the treatment was successful?
When did the current symptoms start?
What other situations may be contributing to the problem now?
Speculate on what experiential contributors from the past might be driving the current symptoms?
Is there a current crisis?
Resources and strengths.
Draw a timeline with the patient of the most disturbing and pleasant events in the person’s life and rate disturbances on a 0 to 10 scale with 10 being the most disturbing. See Chapter 13 for example of timeline.
What’s going well in the therapeutic process, and what is problematic? Have you established a therapeutic alliance? Is the patient’s life stabilized? Is the patient avoiding or working on issues? Undermining the therapy? Flooding with memories or decompensating?
What makes you want to present this patient? What’s unusual, special, difficult, confusing, arousing, frustrating, scary, overwhelming?
What do you experience with this patient that is unusual for you? Do you feel intense emotions, like or dislike, anger, admiration, humiliation, fear, revulsion, sleepy, dizzy, disoriented, a desire to nurture or rescue, and the urge to confront. Do you wish you could get rid of this patient, or are you afraid of losing him or her?
Based on this information and the hierarchy of treatment in your book, what do you think is the most appropriate interventions/treatment for this person now? What are treatment priorities?
Check off, in the column to the left, all activities that you currently do and keep track of how often you do them for 1 week in the columns to the right. Then put a + in the column to the left of those activities you would like to try in the future. Select one with your therapist to try for the following week, and check off how often you do it. Some of these are learned skills that your therapist may teach you. The idea is to gradually build up and integrate more resources into your life.
| Mon | Tues | Wed | Thurs | Fri | Sat | Sun | ||
|---|---|---|---|---|---|---|---|---|
| Practice deep breathing technique | ||||||||
| Practice safe place | ||||||||
| Practice yoga | ||||||||
| Practice meditation/mindfulness | ||||||||
| Practice progressive muscle relaxation | ||||||||
| Exercise for 30 minutes | ||||||||
| Keep a thought diary | ||||||||
| Develop a list of positive attributes of self | ||||||||
| Practice stopping negative self-talk | ||||||||
| Use affirmations to counter mistaken beliefs | ||||||||
| Practice imagery | ||||||||
| Chant or pray or sing | ||||||||
| Engage in soothing activities (warm bath, nature walk, gardening, …) | ||||||||
| Practice real-life desensitization | ||||||||
| Keep a feelings journal | ||||||||
| Identify and rate feelings (0–10) | ||||||||
| Express feelings | ||||||||
| Practice assertive communication | ||||||||
| Develop a list of actual positive memories | ||||||||
| Practice grounding techniques (counting, holding object, stomping feet, …) | ||||||||
| Take a step toward achieving goal(s) | ||||||||
| Keep a dream journal | ||||||||
| Develop a healing ritual for a specific loss | ||||||||
| Implement a contingency contract | ||||||||
| Keep a food diary | ||||||||
| Eliminate caffeine/sugar/stimulants | ||||||||
| Eat only whole unprocessed food (especially fruits & vegetables) | ||||||||
| Color, draw, or paint | ||||||||
| Keep a log about life’s purpose and meaning | ||||||||
| Watch inspiring or funny movies | ||||||||
| Keep alcohol consumption to one or less drinks per day | ||||||||
| Use spiritual beliefs and practices | ||||||||
| Read self-help literature | ||||||||
| Listen to helpful audiotapes | ||||||||
| Reach out to others | ||||||||
| Listen to or play music | ||||||||
| Talk to a nurturing person | ||||||||
| Attend an appropriate group ( | ||||||||
| Pet and/or play with dog or cat | ||||||||
| Sleep 6 to 8 hours at night |
Please fill in two to three goals for the week and check off each day that you meet that goal.
| Goal | Mon | Tues | Wed | Thurs | Fri | Sat | Sun |
|---|---|---|---|---|---|---|---|
Patient: _________________
Address: _________________
Date: _________________
Phone: _________________
Insurance: _________________
Note: At the end of this form is the form for Patient Case Management Needs, which patients can fill out before the session to identify their key areas of need. However, it is still important for the therapist to assess each goal directly, because patients may not be aware of some needs.
Housing Characteristics
Goal Stable and safe living situation.
Notes Unhealthy living situations include short-term shelter, living with a person who abuses substances, an unsafe neighborhood, and a domestic violence situation.
Status If the goal is already met, check here _____ and describe.
If the goal is not met, check here _____ and fill out the Case Management Goal Sheet.
Individual Psychotherapy
Goal Treatment that patient finds helpful.
Notes Try to get every patient into individual psychotherapy. Inquire whether the patient has any preferences (e.g., gender, theoretical orientation).
Status If the goal is already met, check here _____ and describe.
If the goal is not met, check here _____ and fill out the Case Management Goal Sheet.
Psychiatric Medication
Goal Treatment that patient finds helpful for psychiatric symptoms (e.g., depression, sleep problems) or substance abuse (e.g., naltrexone for alcohol cravings).
Notes If the patient has never had a psychopharmacologic evaluation, one is strongly recommended, unless the patient has serious objections; even then, evaluation and information are helpful before making a decision.
Status If the goal is already met, check here _____ and describe.
If the goal is not met, check here _____ and fill out the Case Management Goal Sheet.
Goal Test as soon as possible, unless one was completed in the past 6 months and there have been no high-risk behaviors since then. For a patient at risk for
Notes Assist patient with accessing community resources in your geographic area.
Status If the goal is already met, check here _____ and describe.
If the goal is not met, check here _____ and fill out the Case Management Goal Sheet.
Job, Volunteer Work, and School
Goal At least 10 hours per week of scheduled productive time.
Notes If the patient is unable to meet the goal of 10 hours/week, have the patient hand in a weekly schedule with constructive activities out of the house (e.g., library, gym).
Status If the goal is already met, check here _____ and describe.
If the goal is not met, check here _____ and fill out the Case Management Goal Sheet.
Self-Help Groups and Group Therapy
Goal As many groups as the patient is willing to attend.
Notes Elicit the patient’s preferences, and consider a wide range of options (e.g., dual-diagnosis groups, women’s groups, veterans’ groups). For self-help groups (e.g., Alcoholics Anonymous), give the patient a list of local groups, strongly encourage attendance, and mention that the sessions are free. However, do not insist on self-help groups or convey negative judgment if the patient does not want to attend. If the patient participates in self-help groups, encourage seeking a sponsor.
Status If the goal is already met, check here _____ and describe.
If the goal is not met, check here _____ and fill out the Case Management Goal Sheet.
Day Treatment
Goal As needed and based on the patient’s level of impairment, ability to attend a day program, and schedule.
Notes If possible, locate a specialty day program (e.g., substance abuse,
Status If the goal is already met, check here _____ and describe.
If the goal is not met, check here _____ and fill out the Case Management Goal Sheet.
Detoxification and Inpatient Care
Goal To obtain an appropriate level of care.
Notes Detox is necessary if the patient’s use is so severe that it represents a serious danger (e.g., likelihood of suicide, causing severe health problems, withdrawal requires medical supervision, such as for painkillers or severe daily alcohol use). If the patient is not in acute danger but cannot get off substances, detox may or may not be helpful; many patients are able to stay off substances during the detox but return to their usual living environment and go back to substance use. For such patients, helping set up adequate outpatient supports is usually preferable. Inquiring about patient’s history (e.g., number of past detox episodes and their impact) can be helpful in making a decision.
Psychiatric inpatient care is typically recommended if the patient is a serious suicide or homicide risk* (i.e., not simply ideation, but immediate plan, intent, and inability to contract for safety) or the patient’s psychiatric symptoms are so severe that functioning is impaired (e.g., psychotic symptoms prevent a mother from caring for her child). In some circumstances, the patient may need to be involuntarily committed; seek supervision and legal advice on this topic.
Status If the goal is already met, check here _____ and describe.
If the goal is not met, check here _____ and fill out the Case Management Goal Sheet.
Parenting Skills and Resources for Children
Goal If the patient has children, inquire about parenting skills training and about referrals to help the children obtain treatment, health insurance, and other needs.
Notes You may need to gently inquire to assess whether the patient’s children are being abused or neglected. If so, you are required by law to report it to your local protective service agency. The same rule applies for elder abuse or neglect.
Status If the goal is already met, check here _____ and describe.
If the goal is not met, check here _____ and fill out the Case Management Goal Sheet.
Medical Care
Goals Annual examinations for (a) general health, (b) vision, (c) dentistry, and (d) gynecology (for women), including (e) instruction about adequate birth control and prevention of sexually transmitted diseases.
Notes Other medical care may be needed if the patient has a particular illness.
Status If all five goals are already met, check here _____ and describe.
If any of the five goals is not met or other medical issues need attention, check here _____ and fill out the Case Management Goal Sheet for each.
Financial Assistance (e.g., food stamps, Medicaid)
Goal Health insurance and adequate finances for daily needs.
Notes It is crucial to help the patient obtain health insurance and entitlement benefits (e.g., food stamps, Medicaid), if needed. The patient may need help filling out the forms; the patient may be unable to manage the task alone, because the bureaucracy of these programs can be overwhelming. If much help is needed, you may want to refer the patient to a social worker or other professional skilled in this area. If the patient is a parent, be sure to check whether the children are eligible.
Status If the goal is already met, check here _____ and describe.
If the goal is not met, check here _____ and fill out the Case Management Goal Sheet.
Leisure Time
Goal At least 2 hours per day in safe leisure activities.
Notes Leisure includes socializing with safe people and activities such as hobbies, sports, outings, and movies. Some patients are so overwhelmed with responsibility that they do not find time for themselves. Adequate leisure is necessary for maintaining a healthy lifestyle.
Status If the goal is already met, check here _____ and describe.
If the goal is not met, check here _____ and fill out the Case Management Goal Sheet.
Domestic Violence and Abusive Relationships
Goal Freedom from domestic violence and abusive relationships.
Notes It may be extremely difficult to get the patient to leave a situation of domestic violence. Be sure to consult a supervisor and a domestic violence hotline representative.
Status If the goal is already met, check here _____ and describe.
If the goal is not met, check here _____ and fill out the Case Management Goal Sheet.
Impulses to Harm Self or Others (e.g., suicide, homicide)
Goal Absence of such impulses, or if such impulses are present, a clear and specific safety plan is in place.
Notes Many clients have thoughts of harming self or others; however, to determine whether the client is at serious risk for action and how to manage this risk, see the guidelines developed by the International Society of Study for Dissociative Disorders in Chapter 3.
Status If the goal is already met, check here _____ and describe.
If the goal is not met, check here _____ and fill out the Case Management Goal Sheet.
Alternative Treatments (e.g., acupuncture, meditation)
Goal The client is informed about alternative treatments that may be beneficial.
Notes Clients should be informed that some people in early recovery benefit from acupuncture, meditation, and other nonstandard treatments. Try to identify local referrals for such resources.
Status If the goal is already met, check here _____ and describe.
If the goal is not met, check here _____ and fill out the Case Management Goal Sheet.
Self-Help Books and Materials
Goal The client is offered one or two suggestions for self-help books and other materials, such as audiotapes or Internet sites, that offer education and support.
Notes All clients should be encouraged to use self-help materials outside of sessions as much as possible. For clients who do not like to read, alternative modes (e.g., audiotapes) are suggested. Self-help can address
Status If the goal is already met, check here _____ and describe.
If the goal is not met, check here _____ and fill out the Case Management Goal Sheet.
Additional Goal
Goal
Notes
*For homicide risk or any other intent to physically harm another person, the therapist must follow “duty to warn” legal standards, which usually involve an immediate warning to the specific person the client plans to assault. Always seek supervision and legal advice, and be knowledgeable in advance about how to manage such a situation.
Patient: _________________
Date: _________________
Goal: _________________
Referrals given to patient, date given, and deadline (if any) for each:
Describe patient’s motivation to work on this goal:
Emotional obstacles that may hinder completion (and stategies implemented to help patient overcome these):
Therapist to do:
Follow-up (date and update):
| Do you need help with any of the following? (circle one) | |
|---|---|
| 1. Housing characteristics | Yes/Maybe/No |
| 2. Individual psychotherapy | Yes/Maybe/No |
| 3. Psychiatric medication | Yes/Maybe/No |
| 4. | Yes/Maybe/No |
| 5. Job, volunteer work, and school | Yes/Maybe/No |
| 6. Self-help groups and group therapy | Yes/Maybe/No |
| 7. Day treatment | Yes/Maybe/No |
| 8. Detoxification and inpatient care | Yes/Maybe/No |
| 9. Parenting skills and resources for children | Yes/Maybe/No |
| 10. Medical care | Yes/Maybe/No |
| 11. Financial assistance (e.g., food stamps, Medicaid) | Yes/Maybe/No |
| 12. Leisure time | Yes/Maybe/No |
| 13. Domestic violence and abusive relationships | Yes/Maybe/No |
| 14. Impulses to harm self or others (e.g., suicide, homicide) | Yes/Maybe/No |
| 15. Alternative treatments (e.g., acupuncture, meditation) | Yes/Maybe/No |
| 16. Self-help books and materials | Yes/Maybe/No |
| 17. Additional goal | Yes/Maybe/No |
Permission to photocopy this form is granted to purchasers of this book for personal use only.
Source: Adapted from Najavits, L. M. (2002). Seeking safety: A treatment manual for
Please check all indicators below to help assess whether patient is stabilized and ready to move to Stage II.
| Comfort with own body and physical experience | |
| Patient is able to establish a useful distance from the traumatic event | |
| No current life crisis such as impending litigation or medical problems | |
| Patient accepts diagnosis and has a working knowledge of trauma | |
| Patient’s mood is stable, even if depressed | |
| Patient has at least two or more people to count on | |
| Patient knows and uses self-soothing techniques | |
| Patient gives honest self-reports | |
| Patient’s living situation is stable | |
| Patient is able to communicate | |
| Patient has stable therapeutic relationship and adequate trust of others | |
| Patient has adequate impulse control, no injurious behavior to self or others | |
| Patient stays grounded and oriented x3 when distressed | |
| No major dissociation present | |
| Patient can identify triggers and reports significant symptoms | |
| Patient can set limits and is able to leave dangerous situations if necessary | |
| Patient can tolerate positive and negative affect, and shame | |
| If | |
| Patient can establish “useful distance” from traumatic event |
Please check all indicators below to help assess whether patient has adequately processed trauma and is moving to Stage III, future visioning. The stabilization checklist should already have been achieved.
| No significant affect changes | |
| Self-referencing cognitions are positive in relation to past event | |
| Can dismiss thoughts of trauma at will | |
| Relationships are adaptive | |
| Work is productive | |
| Good quality of decision-making | |
| Creativity begins to emerge | |
| Boundaries improve | |
| Complaints tend to deal with present-day events | |
| Affect is proportionate to current events | |
| Congruence between behavior, thoughts, and affect |
The safe-place exercise described below helps the patient to enhance skills during stabilization as well as to decrease distress after processing. Through the ability to create one’s own safe place, the person is empowered. As with all learning, the more it is practiced, the more readily available it is when needed. Thus, it should be used on a day-to-day basis. If a patient feels there is no place—real or imaginary—that is safe, have the patient focus on one time in his or her life when he or she felt safe or on a person he or she admires who exemplifies positive attributes, such as strength or control. If the person still cannot find a safe place, ask the person to think of a place where he or she feels relaxed or comfortable. Sometimes patients become more distressed when they relax and it may take some time before the person is able to identify a positive resource. Identifying a safe place resource may take several sessions. Ask the person to sit with his or her feet firmly planted on the floor. Sometimes this exercise is conducted with soothing music and/or background nature sounds. Some therapists tape the exercise with their voice to give to the patient to practice at home. The safe-place exercise follows.
Ask the person to identify an image of a safe place that he or she can easily evoke that creates a personal feeling of calm and safety. Use soothing tones to enhance the imagery, asking the person to “see what you see,” “feel what you feel,” “notice the sounds, smells, and colors in your special place.” Once identified, ask the person to focus on the image, feel the emotions, and identify the location of the pleasing physical sensations and where he or she is in the body. “Concentrate on those pleasant sensations in your body and just enjoy as you breathe deeply, relaxing and feeling safe.” After you have slowly deepened his or her experience of this, slowly ask the person to come back and tell you a description of the place. Ask for details so that you can assist the person in accessing this place in the future. Ask how he or she feels and if the experience has been difficult for the person and/or no positive emotions are experienced, explore other resources that might be helpful. If at any time the person indicates that he or she is not feeling safe, the exercise should be stopped immediately.
If successful in accessing a safe place, the person is asked for a single word that fits the picture (i.e., beach, forest …) and then asked to repeat the exercise using the person’s words for the experience along with deep breathing. Then ask the person to repeat on his or her own, bringing up the image, emotions, and body sensations. Reinforce, after this exercise, that his or her safe place can be used as a resource and ask the patient to practice over the next week, once a day.
During the next session, practice again with the person. Then ask the patient to bring up a minor annoyance and notice the negative feelings while guiding the person through the safe place until the negative feelings have dissipated. Then ask the person to bring up a negative disturbing thought once again and to access the safe place but this time on his or her own without your assistance.
Occasionally the safe-place exercise triggers intense negative affect. Patients should be made aware about the possible activation of issues during the safe-place exercise. Reassure the person that even if temporary activation of issues does occur, this is not beyond the limits of expectation, and that it may identify issues that will be addressed in the course of therapy anyway.
This exercise is an important affect management strategy that can be taught to the patient and practiced so that the person can feel in control and develop mastery over his or her emotions. It also assists with self-soothing, decreasing arousal, and reinforcing a sense of safety. The person should already have a safe place. This exercise should be initiated toward the end of the session when the person has intense negative feelings of anxiety, anger, fear, and/or sadness.
The therapist introduces by saying something like: “Did you know that we can put those bad feelings into a container so you won’t feel so overwhelmed when you leave?” The person’s curiosity is usually piqued at this point even if he or she does not believe you. Continue with: “I can help you do this and then you can take out those feelings when you want and deal with them the next time we meet or when you decide it is okay.” Usually the person agrees if for no other reason than he or she is curious and may think you are really strange to suggest such a thing. The therapist continues in a soothing tone: “So, just imagine you have a container; you can close your eyes or not as you wish. It can be made out of anything that you want and be any size you want but be sure it has a tight lid that you can cover or lock because we are going to put all those negative feelings in. Let me know once you have an image in your head.” Once the person says he or she has the image, ask him or her for a few details regarding size and so on. Then ask the patient to “return to the image and imagine all those bad feelings going into the container. Once you have all the bad feelings in the container, lock it up. Let me know when they are in there.” Once the person says they are in the container, ask the person whether there is any percentage that is still not in the container and usually the person will say something like 10% or 20%. At that point, ask the person: “Do you need a bigger container to accommodate all the bad feelings? You can make it as big as you want. See whether you can put the rest of those feelings in the container now. Let me know when the rest of the feelings are all in the container and locked.” If more negative feelings come up, continue with either imaging another container or making the one he or she has bigger. Ask the person what this was like for him or her, checking to see whether he or she is okay.
It is important to do this exercise slowly and use pacing so that the person does not feel rushed. The session can then be ended with the safe-place exercise. Ask the person to practice the container exercise during the week when negative feelings come up. The patient can also practice allowing the feelings to come out if he or she thinks he or she can manage this and journal about these feelings between sessions. Asking the person at the next session: “What was different for you this past week?” and exploring how feelings were or were not manageable are important follow-up steps and help to assess how to increase the effectiveness of this exercise.
Source: Ginger Gilson, from Gilson, G., & Kaplan, S. (2000). The therapeutic interweave in
