Module 4: Patient-Centered Treatment Plan
4 The Initial Contact and Maintaining the Frame Kathleen Wheeler with Michael J. Rice
The two most important goals of the first session are to initiate a therapeutic alliance and to assess safety. Both are foundational to the treatment hierarchy described in Chapter 1, and they provide the basis for the psychotherapeutic process. The psycho- biological underpinnings of the therapeutic alliance are discussed in Chapter 2, in light of Porges’s research on neuroception. Neuroception takes place without our conscious awareness and tells us whether situations or people are safe, dangerous, or life threat- ening (Porges, 2004). This chapter discusses strategies that enhance and/or allow the person who comes for help to feel safe in relationship in order to do the work of psycho- therapy. It is only in a safe environment that one is able to inhibit defense systems and engage with the therapist. The therapeutic alliance fosters the ventral vagal response or resilient zone so that the emotional safety of the healing environment allows the patient to continue psychotherapy and to benefit from treatment. Safety issues also include assessment of how safe the patient is from himself or herself and from others. The first contact with the patient is described in this chapter along with issues germane to the first session, such as making practical arrangements, setting goals, how to end a session, and what records to keep. Therapeutic communication techniques are reviewed.
The other important dimension to psychotherapy is maintaining the frame of the session. The frame refers to the parameters of the psychotherapeutic relationship and includes maintaining appropriate boundaries and safeguarding the rules of therapy. Maintaining the frame is relevant for all models of psychotherapy and ensures that the patient is in a safe environment for the emotional intensity that often accompanies the therapy process. Although the rules may seem strange and arbitrary to the novice psy- chotherapist, they are of paramount importance in safeguarding the integrity, structure, consistency, and objectivity of the relationship. Attention to the frame of traditional psy- chotherapy facilitates the best possibility of clinical improvement and personal growth. The therapist is responsible for keeping the frame of the sessions.
The frame provides guidelines for the parameters of therapy, such as adherence to a schedule, fees, confidentiality, therapeutic relationship boundaries, and for minor but important issues during sessions, such as whether eating or smoking or interruptions are allowed during sessions, phone calls between sessions, and starting or stopping on time. By being consistent and trustworthy, punctual, unconditionally accepting, keeping commitments, maintaining boundaries while at the same time being caring, warm, and available, the advanced practice psychiatric nurse (APPN) facilitates neural
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integration. This chapter begins with a discussion of boundaries and countertransfer- ence, self-disclosure, fees, and how to deal with patients who are late or who do not show up for sessions. Change is always fraught with anxiety, and understanding vio- lations of the frame as manifestations of anxiety is key to developing communication strategies that meet this challenge.
DEVELOPING A THERAPEUTIC ALLIANCE
The therapeutic alliance is initiated in the first contact with the patient, and the first sev- eral sessions are crucial for laying the foundation for the therapist’s connection with the patient. The therapeutic alliance enables the patient to continue and benefit from treat- ment. Meta-analytic research studies have found that the therapeutic alliance is itself therapeutic and essential for the successful outcome of treatment no matter what model of therapy is used (Norcross & Lambert, 2019). The percentage of improvement in psy- chotherapy patients is a function of various therapeutic factors and includes patient expectancy (i.e., the placebo effect), technique, extratherapeutic change (e.g., friends, family, self-help, group participation, and clergy), and common factors (e.g., therapist empathy, genuineness, warmth, acceptance, encouragement of risk taking, confidential- ity of relationship, and the therapeutic alliance). In other words, what the therapist does is less important than how the therapist does it. Thus, process is more important than the technique, because the latter only accounts for 10% of change in psychotherapy out- come (Norcross & Lambert, 2019).
A challenge for the therapist is to engage the patient so that he or she will continue treatment. A meta-analysis of 669 studies shows that the dropout rate after the initial session is 20%, that is, one out of five patients terminated treatment before meeting the goals of the proposed treatment (Swift, Greenberg, Whipple, & Kominiak, 2012). Another meta-analysis of psychotherapy dropout and the therapeutic alliance indicates a moderately strong relationship between dropout and therapeutic alliance, that is, the weaker the alliance, the more likely the person will be to drop out of treatment (Sharf, Primavera, & Diener, 2010).
The ideal is to develop a basic level of trust and a shared agenda with the patient, which includes the collaborative goals of therapy. Three elements of the therapeutic alli- ance that most theorists agree with are the collaborative nature of the relationship, the warm, emotional bond between the patient and therapist, and the agreement between the therapist and patient on the goals of treatment (Flückiger, Del Re, Wampold, & Horvath, 2019). Competencies that reflect the therapist’s ability to develop a therapeutic alliance include the ability to establish rapport, enable the patient to actively participate in the process, establish a treatment focus, provide a healing environment, and recog- nize and attempt to repair the alliance if needed. Cultivating the therapeutic alliance is an ongoing process throughout the therapy.
Horvath elaborates on the therapeutic alliance:
Developing the alliance takes precedence over technical interventions in the beginning of therapy. Therapists need to be sensitive to the risk that their own estimate of the status of the relationship, particularly in the opening phases of therapeutic work, can be at odds with the patients and such misjudgment may have costly consequences. Thus it seems prudent to actively solicit from patients their perspective on various aspects of the alliance and to negotiate flexibly the goals of treatment and even the content of therapy to secure their active collaboration and engagement. Particularly close attention is war- ranted in the early phases of work with the patient who is diagnosed with relational problems . . . these patients not only find it difficult to engage in an intimate relationship
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such as the one between therapist and patient, but they also are likely to solicit nega- tive or rejecting therapist responses. The value of an open, flexible stance as opposed to relational control or rigid expectations on the part of the therapist is a consistent theme across much of the literature. The therapists who can complement the patient’s relational style and are able to demonstrate a capacity to collaborate (e.g., adopt the patient’s ideas; using the patient’s ideas or expressions) seem to have a better chance of guiding good alliances. On the other hand, therapists who were seen by patients as rigid or cold; were rated as less effective and had poorer alliances. Negative or rejecting transactions seem to have a particularly insidious impact on the alliance, and there are preliminary indica- tions that such hostile therapist responses may be related to the therapist’s own negative introject. (Horvath, 2001, pp. 369–370)
Although numerous tools are available to measure the alliance, most therapists test the waters of the therapeutic alliance without the use of elaborate tools. One way is to ask the patient at the end of the first session: “How do you feel about working with me?” or “How did you feel about talking to me today?” or “How did you feel about coming here today?” Alternatively, the therapist can question the patient at the beginning of the next session: “How did you feel after the last session?” Patients may respond positively, or they may say something negative, such as: “My last therapist always was very involved, and I’m not sure you will be.” It is important to explore all negative feelings that the person brings up. Often, novice psychotherapists are hesi- tant to open up any suggestion of negative feelings with the patient for fear that the person will be more likely to leave treatment. The exact opposite is true; exploring the person’s negative feelings makes it much more likely that the person will stay in treatment (Cozolino, 2017).
Additionally, besides not exploring the patient’s negative feelings or thoughts about the therapist or therapy, ineffective qualities of the therapeutic relationship have been identified and include the use of confrontation; therapist’s comments that are critical, rejecting, or blaming; therapists who assume they know what their patient is feeling or thinking without asking; the therapist’s rigidity to a treatment method without adapt- ing it to the person; the therapist’s perspective on the therapy relationship not the patient’s perspective; and cultural ignorance (Norcross & Lambert, 2019). Thus, balanc- ing fidelity to the treatment protocol with flexibility to the person is essential. The more knowledgeable the therapist about various treatment approaches, the better able the therapist will be in accommodating the approach to the patient rather than allegiance to a particular therapy.
What is most important for the beginning psychotherapist is learning how to develop the therapeutic alliance. Strategies for initiating and maintaining the thera- peutic alliance include asking detailed questions about the patient’s main concern, validating affect, explaining the therapy process as it unfolds, listening empathically without minimizing or offering “fix it” statements, and goal consensus and collabo- ration (Tryon & Winograd, 2011). Matching the therapist’s style to the patient’s needs (i.e., the therapist’s ability to be an “authentic chameleon”) facilitates the alliance (Lazarus, 1993). This requires the therapist to have facility in a range of techniques and a flexible repertoire of relationship styles to suit different patients’ needs and expectations. Essential relationship building skills have been identified by Perraud and colleagues (2006) in order to assess APPN students’ ability and are included in Box 4.1.
A search of the nursing literature on the therapeutic nurse relationship from 2000 to 2019 found almost 2,000 articles on the nurse-patient relationship, so clearly this is an important area for nursing. Core attributes of the therapeutic relationship in advanced psychiatric/mental health nursing have been deconstructed into nine main
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constructs: conveying understanding and empathy, accepting individuality, provid- ing support, being there/being available, being genuine, promoting equality, dem- onstrating respect, maintaining clear boundaries, and having self-awareness (Dziopa & Ahern, 2009).
For some patients, physical safety is an issue, whether real or imagined. For the psychotic patient, fears of fragmentation and annihilation may be the norm (McWilliams, 2011). Even though psychotic patients may be compliant, it does not mean that they trust the therapist; they may adhere only out of fear of retribution if they do not. Clinicians who work with psychotic patients use various strategies to reduce the overwhelming anxiety experienced by these patients. Strategies include sitting farther away from the patient than usual, leaving the door open, taking as few notes as possible, giving information, communicating with emotional honesty and judicious self-disclosure, providing education, normalization of the patient’s expe- rience, asking the person what would make him or her feel safe, assuming a more
Therapist Contributions to the Therapeutic Alliance
Make the development of the alliance the highest priority early in therapy.
Enter a collaborative partnership.
Listen to the patient’s theory of illness and avoid reinterpreting it to match your own theory.
Allow the patient to direct therapeutic choices.
Attend to and address what the patient considers is important and relevant.
Agree on interventions—only use those that you feel confident will work.
Find out what the patient thinks would represent improvement.
Tailor interventions and homework to accomplish goals set by the patient.
Recognize attitudes and behaviors that cause the patients to react negatively and avoid them.
Explore patient hostility when it is directed toward you.
Engage in supervision to explore relational difficulties.
Be in touch with your own experience of the patient.
Respond honestly and sincerely.
Goal Consensus and Collaboration Skills
Use your clinical expertise to help patients clarify problems.
Address topics of importance to patients that fit with why they feel they have these problems.
Be an understanding and sympathetic listener.
Discuss and agree upon goals frequently.
Check on homework if given.
BoX 4.1 Essential Relationship-Building Skills
Source: Modified and adapted from Perraud, S., Delaney, K. R., Carlson-Sabelli, L., Johnson, M. E., Shephard, R., & Paun, O.(2006). Advanced practice psychiatric mental health nursing, finding our core: The therapeutic relationship in the 21st century. Perspectives in Psychiatric Care, 42(4), 215–226. doi:10.1111/j.1744-6163.2006.00097.x
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authoritative role, using simple communications, and creating opportunities for the person to demonstrate personal competency.
ASSESSING SAFETY
Assessing safety is of paramount importance in the initial contact. Every patient should be asked about suicidal or homicidal thoughts in the initial session. Suicide is a leading cause of death in the United States with rates in every state increasing every year since 1999 (Center for Disease Control and Prevention [CDC], 2018). Although the patient with major depressive disorder usually is considered to be at particularly high risk, research has found those with schizophrenia, bipolar disorder, and substance use disorder are also at high risk (Olfson et al., 2016). However, more than half of those who committ suicide do not have a known mental health problem (CDC, 2018). Other significant risk factors include previ- ous attempts, social alienation, a family history of suicide, interpersonal violence, relation- ship difficulties, and recent discharge from psychiatric hospital. Demographic risk factors include males, single, elderly, adolescent and young adults, and Caucasian (Fowler, 2012). The highest risk factor according to the CDC is a relationship problem (2018).
Suicidality can be screened with questionnaires such as the self-report Beck Depression Inventory (BDI), which has a question about suicidality, or a rating scale such as the Columbia-Suicide Severity Rating Scale available at cssrs.columbia.edu/docs/C- SSRS_1_14_09_Baseline.pdf, which has good normative data (Posner et al., 2011). In addi- tion, an assessment tool, the Suicide Assessment Five-step Evaluation and Triage (SAFE-T) developed by Substance Abuse and Mental Health Services Administration (SAMHSA) and derived from the American Psychiatric Association Practice Guidelines, can be down- loaded for free from store.samhsa.gov/product/SMA09-4432 and a free app is available that helps providers integrate suicide prevention strategies into their practice at store.sam- hsa.gov/apps/suicide-safe. The SAFE-T offers comprehensive guidelines that include an assessment of risk factors, protective factors that can be enhanced, and a scale to determine the level of risk and possible interventions. See Box 4.2 for the SAFE-T. If an assessment tool is used, open interview questions should follow up on all positive items.
(continued)
1. RISK FACTORS • Suicidal behavior: history of prior suicide attempts, aborted suicide attempts, or
self-injurious behavior • Current/past psychiatric disorders: especially mood disorders, psychotic disor-
ders, alcohol/substance abuse, ADHD, TBI, PTSD, cluster B personality disorders, conduct disorders (antisocial behavior, aggression, impulsivity)
Comorbidity and recent onset of illness increase risk. • Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, global
insomnia, command hallucinations • Family history: of suicide, attempts, or Axis I psychiatric disorders requiring
hospitalization • Precipitants/stressors/interpersonal: triggering events leading to humiliation,
shame, or despair (e.g. loss of relationship, financial or health status—real or anticipated). Ongoing medical illness (esp. CNS disorders, pain), intoxication. Family turmoil/chaos. History of physical or sexual abuse. Social isolation
• Change in treatment: discharge from psychiatric hospital, provider or treatment change
BoX 4.2 SAFE-T
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ADHD, attention deficit hyperactivity disorder; CNS, central nervous system; ECT, electroconvulsive therapy; PTSD, posttraumatic stress disorder; SAFE-T, Suicide Assessment Five-step Evaluation and Triage; TBI, traumatic brain injury.
2. PRoTECTIVE FACToRS Protective factors, even if present, may not counteract sig- nificant acute risk • Internal: ability to cope with stress, religious beliefs, frustration, frustration tolerance • External: responsibility to children or beloved pets, positive therapeutic relation-
ships, social supports 3. SUICIDE INQUIRY Specific questioning about thoughts, plans, behaviors, intent
• Ideation: frequency, intensity, duration—in the past 48 hours, past month, and worst ever
• Plan: timing, location, lethality, availability, preparatory acts • Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading
gun) vs. nonsuicidal self-injurious actions • Intent: extent to which the patient (1) expects to carry out the plan and
(2) believes the plan/act to be lethal vs. self-injurious. Explore ambivalence: rea- sons to die vs. reasons to live
4. RISK lEVEl/INTERVENTIoN • Assessment of risk level is based on clinical judgment, after completing steps
1 through 3 • Reassess as patient or environmental circumstances change
5. DoCUMENT Risk level and rationale; treatment plan to address/reduce current risk (e.g., medication, setting, psychotherapy, ECT, contact with significant others, con- sultation), firearms instructions, if relevant; follow-up plan. For youths treatment plan should include roles for parent/guardian.
For Youths: ask parent/guardian about evidence of suicidal thoughts, plans, or behaviors, and changes in mood, behaviors, or disposition.
Homicide Inquiry: when indicated, especially in character disordered or paranoid males dealing with loss or humiliation. Inquire in four areas listed above.
BoX 4.2 SAFE-T (continued)
Risk Level Risk/Protective Factor Suicidality Possible Interventions
High Psychiatric diagnoses with severe symptoms or acute precipitating event; protective factors not relevant
Potentially lethal suicide attempt or persistent ideation with strong intent or suicide rehearsal
Admission generally indicated unless a significant change reduces risk. Suicide precautions
Moderate Multiple risk factors, few protective factors
Suicidal ideation with plan, but no intent or behavior
Admission may be necessary depending on risk factors. Develop crisis plan. Give emergency/crisis numbers
Low Modifiable risk factors, strong protective factors
Thoughts of death, no plan, intent, or behavior
Outpatient referral, symptom reduction. Give emergency/crisis numbers
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Research indicates that using both self-report and interview methods may be the best way to ensure accuracy, because some patients are thought to prefer the anonymity of a self-report form and the interviewer may get a negative response even though the patient is suicidal. Several questions can be asked: “Do you ever experience hopelessness or sui- cidal thinking?” “Do you ever think of hurting yourself?” Asking about suicide ideation does not give the person the idea or increase suicide risk. Most people are relieved to be able to discuss openly the painful feelings they have been struggling with in private. If the patient answers in the affirmative, the therapist can ask follow-up questions: “Do you have a plan?” or “How would you carry out a suicide?” This information is pursued because the more specific the plan, the more likely the person is to hurt himself or herself. Asking for specificity helps to determine the seriousness of intent.
Even so-called parasuicidal behaviors, such as cutting and self-mutilation, should be taken seriously. Understanding the person’s underlying motivation for self-harm is important. There is a distinction between those who self-mutilate in an attempt to stay alive and those who attempt suicide and consider death a solution. Parasuicidal behav- iors may reflect a reenactment of abuse dynamics with a physiological basis associated with poor attachment and early abuse (van der Kolk, 2014). Chapter 2 describes the neurophysiology associated with reenactment of early trauma. These reenactments may be experienced as normal because they mirror early experiences. The person with bor- derline personality disorder may want attention in the context of an abandonment crisis and may escalate the threat and self-destruct in a desperate bid for attention. Because these individuals may be suicidal in the context of an abandonment crisis, talking about the loss sometimes may be enough to assuage the suicidal feelings.
The therapist must openly and honestly express concern and engage in problem- solving with the patient so that a written plan can be developed. This collaborative plan should explicitly address the friends and community resources that would be available in an emergency so that the patient can be safe. A safety plan should be developed for all patients who are thought to be at high risk for self-harm. Guidelines developed by the International Society of Study for Dissociative Disorders (ISSD) with respect to suicidal behaviors can be applied to all patients who are at risk for self-harm. These guidelines include developing a safety plan that consists of a hierarchy of alternative behaviors, such as contacting friends, grounding techniques, medications as needed, and calling the therapist and waiting for a return call and/or going to the ED if the patient feels unable to maintain safety (ISSD, 2011). Although a safety plan and atten- tion to protecting the life of the patient are paramount, it is important that the APPN is careful to avoid chronic crisis management as the purpose of the treatment. For exam- ple, one well-intended recent graduate adopted the role of constant savior and asked her patient to call her every morning to ensure her safety. This backfired because the patient ultimately viewed this as a strategy to relieve the therapist’s anxiety and many frantic moments were spent on the part of the APPN attempting to call the patient when she had “forgotten” to call.
From a clinical and legal perspective, a written safety plan or a no-suicide contract, even if signed by the patient, is not a substitute for clinical judgment. Accurate assess- ment is imperative because the typical no-suicide contract may not be effective in a crisis situation, whether the patient is in the hospital or the community (Garvey, Penn, Campbell, Esposito-Smythers, & Spirito, 2009). A safety contract is only as good as the therapeutic alliance. Safety may be especially compromised if the patient is inebriated or psychotic. Although nurses are used to dealing with life and death situations, they usually do not occur in private practice or without others around to help. The therapist is often in just that situation and must make decisions independently. It is safest to err on the side of caution and believe your intuition that tells you the person may hurt himself or herself. Suicidal patients should be hospitalized immediately if the family
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or significant others cannot guarantee safety and the safety plan cannot be adhered to. The clinician must ensure that the patient is safe and may need to personally escort the patient to the ED if needed.
Other safety issues may need consideration, including the anorexic patient who is severely underweight (20% below the expected weight for the patient’s height; Sadock, Sadock, & Ruiz, 2017); substance abuse patients who may overdose or pose a threat to others if inebriated and driving; actively self-mutilating patients; sexually promiscuous patients; and angry patients who want to hurt others. Each of these situations must be the first order of business in any treatment setting. Any acute mood disorder or psy- chosis, out-of-control substance abuse, or eating disorder may need to be treated in an inpatient program before traditional psychotherapy begins. If the patient comes to the session inebriated or high, the session should not be held, and the patient may need to be escorted to a safe place by the therapist, sent home in a taxi, or have a friend or family member called to escort the person home.
The therapist’s safety must also be assessed. Some patients may be threatening, and the best predictor of violence has been found to be previous violent episodes (McWilliams, 2004). Often, intuition can tell you whether the patient may be violent, and it is better to err on the side of safety than to dismiss your feelings. Leaving your office door open and making sure that you are near the door may be warranted when working with hostile, unpredictable people, or it may be prudent to interview patients with a security guard nearby or with a colleague if you are working in a dangerous setting. One patient came to his session with a gun, which he told the APPN about. He was asked to leave the gun at home for future sessions, which he agreed to, and psycho- therapy proceeded as planned.
THE FIRST CONTACT
APPNs work in varied public and private settings, such as inpatient psychiatric units, inpatient medical settings, outpatient community mental health centers and men- tal health clinics, residential care facilities, integrated behavioral care settings, inter- mediate and skilled nursing facilities, juvenile and criminal justice settings, private practice, primary care and medical outpatient settings, home care, managed care, homeless shelters, substance abuse units and programs, emergency or crisis settings, partial hospital settings, medical homes, and in rural, suburban, and urban areas. A 2018 survey reports that APPN practice sites include hospitals, ambulatory sites, com- munity clinics, schools, and criminal justice facilities, as well as federal facilities such as the Veterans Administration (Delaney, Drew, & Rushton, 2019). This survey found that the majority of APPNs deliver a wide variety of mental health services including diagnosis and management of both acute and chronic mental illness, prescribing med- ications and providing psychotherapy to individuals across the lifespan. The unique practice setting determines how the initial contact with the patient unfolds, and the specifics of each cannot all be covered in this chapter. Guidelines and policies for the particular practice setting should be followed. Aspects of the suggestions offered here may be incorporated into specific settings, if applicable. However, the following discus- sion is probably most relevant for therapists in outpatient settings where psychotherapy is practiced.
The initial phone call is most likely from the patient seeking help, but it occasionally may be from a friend, family member, or professional colleague. It is important to speak to the patient directly, even if someone else has made the first phone call. To avoid tele- phone tag, it is helpful to leave a message with several times of the day and a number where you can be reached, as well as requesting that the person leave a message with a
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telephone number and the times when he or she can be reached if he or she has trouble reaching you. It is better to leave your first and last name when returning a call because the person may not want others who live in the house to know that he or she is seeking help. Recording a “Dr. Wheeler called” message on the patient’s answering machine may leave the person in the uncomfortable situation of explaining to others when she or he does not wish to.
During the initial phone call, the therapist is already gathering information and begins the therapeutic alliance. Keeping the initial phone call as brief as possible is advised unless there are special circumstances. Occasionally, someone may ask whether you specialize in a particular problem or have had experience in a certain area, such as eating disorders or trauma. Answer the question factually, and refer the person else- where if that is warranted. Although at first you may not know what your areas of expertise are and feel you have none, it is probably best for you and the patients to start with populations and approaches with which you feel most comfortable. Knowing your own limits is essential, as is not using modalities with which you have little exper- tise, such as hypnosis, guided imagery, eye movement desensitization and reprocessing (EMDR therapy), or expressive therapies, because in incompetent hands, patient regres- sion may be triggered.
If the person launches into a detailed description of the problem over the phone, it is appropriate to say that it would benefit the prospective patient to come in and set a mutually agreeable time for the first session. Most therapists do not ask about insurance or other specifics on the phone unless the patient asks for information regarding insur- ance or asks about fees or unless the therapist’s agency requires that specific informa- tion ahead of the appointment. Others feel that it is important to discuss financial issues before committing to see the patient, because clarification of how the therapy will be paid for saves time for the patient and the therapist. Patients may not understand the terms of their insurance and may need to call the insurance company before setting up an appointment. Issues regarding which providers are covered, the number of ses- sions, copays, parity diagnoses, and preauthorization, may need to be explained first to allow the person to ask appropriate questions. Some APPNs make the phone call to the patient’s insurance to ensure that the terms of reimbursement are clear before agreeing to see the patient. Another decision that needs to be made is whether to charge for the initial consultation. Some therapists do not charge for consultations, and the patient should be told whether you do or do not charge for the first session. Tell the person the times you have available, and end the conversation by giving directions to your office after an agreeable time to meet has been decided.
The patient comes to the first session with expectations, even if the person has never been in psychotherapy before. Some of these expectations are conscious and some are not. Expectations can tell you about the person’s developmental level and what may be going on in the person’s relationships. For example, some patients with magical thinking fully expect to have their problems solved in a few sessions; those with depen- dency needs may expect to be taken care of or to be given advice; those who have been criticized expect to be disapproved of or judged; and those who eroticize relationships may expect the therapist to have sex with them. Sometimes, asking the person how he or she feels about coming to the session can help to elicit some idea of expecta- tions. Asking if the patient has ever known anyone who was in therapy can also give valuable information about expectations. The patient may have known someone who was greatly helped by psychotherapy or may associate treatment with Woody Allen and endless, self-absorbed neurosis. Some therapists elicit this information by giving the patient an intake form, such as the Multimodal Life History Inventory (Lazarus & Lazarus, 1991). This questionnaire contains questions that address patients’ expecta- tions regarding therapy. What do you think therapy is all about? How long do you
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think therapy should last? What personal qualities do you think the ideal therapist should possess?
If your office shares a waiting room, and you have not met the patient before, it is best to ask those in the room “Are you waiting for Kate Wheeler?” Doing so ensures that you will not be divulging the person’s name to all those sitting there. In that way, the person can say yes without a breach of identity disclosure. Even the simple gesture of shaking hands is important to think about. If it is the therapist’s custom to shake hands, and she naturally extends her hand to the patient, the patient may feel uncomfortable. It is better to take the lead from the patient. For patients who extend a hand, by all means shake hands. For a patient who does not offer, following his or her lead may allow the person control and to feel more comfortable. After the patient enters your office, asking what he or she would like to be called is a courtesy that sets a collaborative tone at the very beginning.
The therapist’s office and seating arrangements are considered with respect to keep- ing the patient’s best interests in the foreground. Seating arrangements may be con- strained if you are seeing patients in a clinic setting, but it is usually best not to sit behind a desk because this puts a barrier between you and the patient. However, sitting at the desk with the person on one side of the desk may be conducive to conversation. Ideally chairs are set at approximately 3 to 4 feet away from each other and arranged so that the person is not directly across from you but at a 45-degree angle. In this way, the patient does not feel scrutinized and compelled to make eye contact and can look away if he or she wishes.
It is not appropriate to have your family pictures visibly displayed in the office. They may be comforting to you, but they may be distracting to the person seeking help and do not serve a therapeutic purpose for the patient. A clock can be placed across from the therapist’s chair, so it can be easily seen unobtrusively by the thera- pist, or it can be placed where both the patient and therapist can monitor how much time is left in the session. Phone calls are not taken during sessions, and all phones and beepers are turned off. This is the patient’s time, and it is courteous to ensure that the patient is the center of attention for the entire session. On the rare occasion when you are working with a professional or personal emergency, it is advisable to tell the person at the beginning of the session that you may be interrupted and to apologize. In most instances, a quiet, confidential setting where you will not be interrupted is imperative.
There are several ways to begin the session. “What brings you here?” usually gets the ball rolling, although for a very concrete-thinking patient, the answer may be “the bus.” “What is going on that you are seeking help now?” or “How would you like to start?” may also be an effective way to begin. “How can I help?” may feel patronizing to the patient and implies something less than a collaboration. Small talk for a moment, such as asking if the person had any trouble finding the office, can be appropriate to put the person at ease because the last contact most likely was on the phone when directions were given. When the person is in the office and the APPN is ready to begin, the type of setting will determine how best to proceed.
The intake or first session for the patient may last for the usual 45 to 50 minutes to 1.5 hours, depending on the clinical site. In some settings, a different therapist does the intake, and the patient then may be assigned to another therapist, or sometimes, the same therapist may do the intake and continue with the person in therapy. If you are serving as the intake therapist in a setting in which forms must be completed by the patient, it may expedite the process to leave the forms with the receptionist so that as much information as possible is obtained before your meeting. Much of the infor- mation needs to be gathered initially, and if you do not have a receptionist, perhaps some of the assessment and intake forms can be mailed to the person ahead of time
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before the first session. Some APPNs give the patient forms to take home at the end of the first session and ask the person to bring them back the next week. In that case, the first session is used to gather only preliminary information and assess safety. Many therapists in private practice leave the first session less structured because this allows the person to tell his or her story in an unstructured way, and it can be invaluable in accomplishing one of the most important tasks of the first session: initiating a thera- peutic alliance.
For those who work in settings in which a comprehensive assessment is required in the initial session, Chapter 3 provides guidelines on how to accomplish this while effec- tively initiating a therapeutic alliance. For those who are in settings in which the assess- ment can be conducted over several sessions, Chapter 3 provides excellent resources and screening tools to incorporate to ensure a thorough and accurate assessment. If you are the prescribing advanced practice nurse only, guidelines for assessment on how to combine medication management with or without psychotherapy are discussed in Chapters 14 and 15. No matter what type of setting you are working in and how you proceed, practical arrangements for continuing the work, establishing goals, ending the session, and keeping records must be considered.
Making Practical Arrangements
Practical arrangements must be made regarding the frequency and length of the sessions. Weekly sessions of 45 to 50 minutes are usually scheduled unless there is a significant reason to deviate from this standard plan. The session begins and ends at predetermined times. Meeting less often usually is not as effective and interferes with the momentum of treatment, unless the goal of treatment is maintenance of the status quo or the APPN is prescribing only and another person is conducting the psychotherapy. It may be best to see the patient more often initially if you are concerned about safety or the person is in crisis. However, starting several times a week often is too intense for most people and may be threatening and counterproductive. The number of sessions per week may be increased after a solid therapeutic alliance is formed and the patient wishes to intensify the work for faster resolution.
Some brief and cognitive psychotherapists advocate setting a termination date at the beginning of treatment, because it is thought that if the ending time is known, the goals and work may proceed faster. Toward the end of the time set, there can be renegotia- tion if more time is needed. Guidelines and principles for short-term psychotherapy are further discussed in Chapters 5, and 6. Sometimes, therapists prefer to allow the process to unfold and leave the termination date open-ended unless there is a specified number of sessions that the person is allowed by the insurance company or there are agency constraints. Frequently, what the person initially came to therapy for evolves into some- thing somewhat different as the process unfolds, and goals are revised periodically. For example, one man came into treatment because he felt depressed and unhappy with his work. As this was explored, he began to examine his long-standing dysthymia and how this related to a childhood traumatic experience that had violated his trust and impacted all dimensions of his life. The goals then focused on resolving his early trauma in light of his deepening awareness of its significance.
A Health Insurance Portability and Accountability Act (HIPAA)–type form explain- ing confidentiality and a Therapy Contract delineating the terms of the psycho- therapy should be given to the patient (see Appendices 4.1 and 4.2). A solo practitioner is held to the same HIPAA standards as organizations with respect to HIPAA. Some therapists also have a policy statement, posted in the waiting room, which describes consumer rights, confidentiality, missed sessions, and fees. A sample is available at www.guidetopsychology.com/compol.htm. The Therapy Contract and HIPAA form
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along with the packet of screening and assessment tools should be signed by the patient and brought back to the next session.
Confidentiality is discussed, and whether you will be discussing information about the person to a supervisor or other healthcare providers is disclosed. Permission for these discussions is authorized with a written release of information form, and care is taken to use discretion and reveal only what is necessary for medical care. If a treatment report requesting more sessions is to be sent to an insurance company, the form may be shared with the patient before sending it. In discussing patients with colleagues or in a professional forum such as a conference or paper, use a pseudonym or initial, and dis- guise identifying information to protect the person’s identity. Even though the person’s identity is kept confidential, permission should be obtained from the patient unless the information shared is an amalgam of cases and is not specifically about the patient. Permissions can also be explicitly stated in the initial treatment contract so that addi- tional permissions are not needed. A formal Informed Consent document is required in some states; however, keep in mind that a written document signed by the patient does not demonstrate that informed consent has been obtained because it does not demon- strate the patient’s comprehension. General risks and benefits should be discussed with the person and documented in the patient’s records that such a conversation took place. Informed Consent specifically for nurse psychotherapists has not been addressed by our professional organizations but Ken Pope’s website provides guidelines from other organizations about requirements. See kspope.com/consent/index.php and the sample of a practice contract in Appendix 4.2.
Confidentiality should be respected in all situations. That is, the APPN should not discuss the patient to the person’s family members or spouse. If a family member calls and is concerned and wishes to tell the APPN something about the patient, the APPN can listen but is obligated to explain that therapy is confidential. The patient should also be informed of the family’s concerns and call so that transparency between the therapist and patient is preserved. Of course, if the patient is a minor, this may change depending on the circumstances and the state law. If the APPN sees the patient in a public setting, it is best to not acknowledge the person’s presence unless the patient says hello first. When asked by anyone for information about the patient, it is best to consult with an attorney experienced in mental health law before complying. Confidentiality should never be broken unless the patient is a danger to himself or herself. If you are concerned that the patient is a threat to others, it is important to document your assessment of the patient and to follow through if the risk is high. Every state has statutes about the duty to report when a patient is a risk to others, and it is important to be aware of your state’s laws about how to manage these patients safely. The APPN is legally bound to report patients she or he suspects are abusing children to child protective service agencies, those who abuse the elderly to adult protective service agencies, and those threatening violence to the police. Familiarity with state statutes and services is essential, and the novice APPN should seek legal advice and consultation from the state board and pro- fessional associations before releasing any confidential records or filing a report with any agency.
Practical arrangement and issues relating to ethics, confidentiality, and scope of prac- tice have become more complex with the advent of telepsychiatry for APPNs who wish to use technology to conduct psychotherapy or prescribe medications. For an overview of the use of Skype in tele–mental health, see www.zurinstitute.com/skype_telehealth. html#top. Prescribing and conducting psychotherapy for those who live out of state must be in compliance with the state regulations in which the patient resides and it is prudent to check with the respective state board of nursing before teleconferencing, Skyping, or prescribing. In addition, other issues are important considerations and are included in Box 4.3.
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The rapid advance of Internet-based digital relationships are sparking a revolution in new models of “digital health.” Digital health involves the use of all forms of digital communication used to interact with healthcare patients. These include the use of all forms of emails, texts, instant message services pagers, file transfers, social media plat- forms, and video conferencing. The rapid growth of these forms of digital communi- cation must adhere to regulatory, licensure, and clinical standards of care in order to effectively maintain the frame of treatment. In general, all electronic devices sending receiving or transmitting a patient’s personal health information should meet the crite- ria listed in Table 4.1, Digital Care Security.
TABLE 4.1 DIGITAL CARE SECURITY REQUIREMENTS
1. Active security encryption
2. Allows for remote wiping and/or remote disabling
3. Contains disabled and\or do not install file sharing applications
4. Active firewall protecting from unauthorized access
5. Active enabled security software
6. Periodic updates to security software
7. Downloaded mobile applications (apps) meet HIPAA security and do not allow tracking or user data authorization
8. Is always under the assigned user’s physical control
9. Contains security encryption software that allows sending and receiving health information over public Wi-Fi networks
10. Users must delete all stored health information before discarding or repurposing the mobile device
HIPAA, Health Insurance Portability and Accountability Act.
Source: Centers for Medicare and Medicaid Services. (2018). Medical privacy of protected health information. Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ SE0726FactSheet.pdf
These major security issues are often misunderstood but are mandatory when providing any form of digital care, including telehealth video conferencing. The major difference between the social\public media platforms and professional digital and video confer- encing is the level of protection of the healthcare information afforded the patient. Public social media do not meet the minimum standards and, often acceptance of the terms and agreements state that the company stores information and shares it with business partners. This is an automatic breach of the privacy guidelines and eliminates the potential use of these public video conferencing platforms.
Compliant Videoconferencing
The use of video conferencing has increased dramatically during the COVID19 pan- demic. Federal and state laws, define video conferencing as care provided by a practi- tioner at a remote location using a telecommunications system (Centers for Medicare & Medicaid Services [CMS], 2011). The Drug Enforcement Administration further modified
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the criteria addressing prescribing across state boundaries. The DEA currently requires the criteria listed in Table 4.2.
TABLE 4.2 DRUG ENFORCEMENT AGENCY (DEA) PRESCRIBING CRITERIA VIA REMOTE TELECOMMUNICATIONS
A. The patient is physically located at a DEA registered hospital or clinic with a practitioner in accordance with state law and registered with the DEA in the state the patient resides.
B. The patient is treated by, and in the physical presence of, a DEA-registered practitioner in accordance with state law and registered with the DEA in the state the patient resides.
C. Practitioners must be registered in the primary state where they are physically located and the state in which the patient resides.
D. All records for FDA approved treatment of narcotic and opioid treatment must be kept in accordance with DEA requirements.
Source: Records and Reports of Registrants, 21 C.F.R. §§ 1304.01–1304.55 (2011); Registration of Manufacturers, Distributors, and Dispensers of Controlled Substances, 21 C.F.R. § 1301.12 (2016).
All healthcare professionals using video conferencing must meet the HIPAA secu- rity and CMS security compliance regulations, as previously mentioned. Access to the video conferencing system and software requires a unique identifier (user name) and a unique password. While many video conferencing systems comply with this standard, noncompliant systems often do not meet the Federal Information Processing Standards 140-2, often referred to as CMS (Medicare Rule) 140-2 at www.hhs.gov/hipaa/for-pro- fessionals/faq/2001/is-the-use-of-encryption-mandatory-in-the-security-rule/index.html. This set of regulations that required that all professional healthcare use meets require- ments of the HITECH Act regulations were revised in 2018 and can be found at csrc.nist .gov/csrc/media/publications/fips/140/2/final/documents/fips1402annexa.pdf. Although at first glance, these regulations appear intimidating, they are really quite straightfor- ward. There are four basic rules that are applied, as noted in Table 4.3.
TABLE 4.3 BASIC RULES FOR COMPLIANT VIDEO CONFERENCING
1. Is the device(s) used for the video conferencing compliant with HIPAA security rules?
2. Is the software used for the video conferencing HIPAA compliant?
3. Is the software FIP 140-2 or CMS compliant?
4. Does the software encrypt the transmission of all information?
CMS, Centers for Medicare & Medicaid Services; FIP, Federal Information Processing; HIPAA, Health Insurance Portability and Accountability Act.
Encryption
The 140-2 rules are an encryption standard beyond the commonly used “Advanced Encryption Standard”(AES) found on most devices. The 140-2 regulations require an internal software program that mathematically encrypts the transmission of all protected health information, including patient records, and patient information at one of four levels based on a system defined by the Pentagon. While somewhat
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daunting, a simple check can verify the video conferencing software uses the 140-2 standard which should run within the background of the video conferencing software. Most institutional information technology (IT) departments operate these programs in the background and users are seldom aware of the presence of the security features. The absence of this encryption is one of the major problems associated with noninsti- tutional social media based video conferencing for psychiatric mental health issues. Failure to adhere to these guidelines can result in federal fines ranging from $100 to $1.5 million (Healthcare Compliance, n.d.). See Table 4.4 for a list of resources for digi- tal care standards.
These aforementioned rules are incorporated into all states’ regulations on reimbursement for telecommunication services as CMS sets the standard for all Medicaid services. The baseline standards for CMS, DEA, and other rules are listed in Table 4.5. All practitioners are advised to check with the state regulations on telehealth and what can and cannot be reimbursed within a state as there are some interstate variations (CMS, 2020).
TABLE 4.4 HYPERLINKS FOR DIGITAL CARE STANDARDS
Topic Federal Hyperlink
hIPAA: Emergencies www.hhs.gov/hipaa/for-professionals/faq/ disclosures-in-emergency-situations/ index.html
hIPAA, FERPA and Student health Records
www.hhs.gov/hipaa/for-professionals/faq/ ferpa-and-hipaa/index.html
hhS: Final Guidance www.hhs.gov/hipaa/for-professionals/security/ guidance/final-guidance-risk-analysis/ index.html
health Information Privacy Rights www.hhs.gov/ocr/privacy/index.html
hIPAA: hITECh Act www.gpo.gov/fdsys/pkg/FR-2013-01-25/ pdf/2013-01073.pdf
hIPAA Privacy Rule www.hhs.gov/ocr/privacy/hipaa/ administrative/privacyrule/index.html
hIPAA Security Guidance www.hhs.gov/ocr/privacy/hipaa/administrative/ securityrule/securityruleguidance.html
hIPAA Text Messaging www.hipaajournal.com/does-your- organization-need-a-secure-text- messaging-service-324
Notice of Privacy Practices www.hhs.gov/ocr/privacy/hipaa/model notices.html
PhI: De-identification www.hhs.gov/ocr/privacy/hipaa/understanding/ coveredentities/De-identification/ deidentificationworkshop2010.html
Security Risk Assessments www.healthit.gov/providers-professionals/ security-risk-assessment
Susan White: AQ: Original URL gave page not found error; please confirm update URL is correct
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Topic Federal Hyperlink
Security Final Rule www.hhs.gov/hipaa/for-professionals/security/ laws-regulations/index.html
Security and Electronic Signature Standards
aspe.hhs.gov/report/nrpm-security- and-electronic-signature-standards/ electronic-signature-standard
FERPA, Family Educational Rights and Privacy Act; HHS, Department of Health & Human Services; HIPAA, Health Insurance Portability and Accountability Act; PHI, protected health information.
Source: Healthcare Compliance. (n.d.). HIPAA compliance guide. Retrieved from https://www.hipaaguide.net/ hipaa-compliance-guide/#HIPAA_Resources
A final issue is the use of clinical standards of care. These are outlined in the American Telehealth Association for Videoconferencing. A summary of the guiding principles are listed in Table 4.5 (Richmond et al., 2017).
TABLE 4.5 TELECOMMUNICATION STANDARDS GUIDELINES
1. Professionals are aware of and comply with laws and regulations integrating nationally recognized professional standards.
2. Professionals are aware of and comply with all professional state board regulations and any guiding scope of practice policies.
3. Professionals who use information communication technologies are trained in equipment and software operation and have IT (information technology) support available for technical difficulties.
4. Professionals are performing services within professional standards of care, and the principles of evidence-based practice.
5. Professionals are aware of federal and state regulations for clinical documentation, storage of health data.
6. Professionals ensure the presence of a facilitator (caregiver, family member, or provider) is avail- able before, during, and after the telecommunication session.
7. Professionals are responsible for the patient’s safety. If, during the virtual encounter, the professional observes the patient’s health is compromised, the patient is referred to local healthcare resources.
8. Professionals are aware of administrative telehealth guidelines affecting telecommunication services.
Source: Richmond, T., Peterson, C., Cason, J., Billings, M., Terrell, E. A., Lee, A., . . . Brennan, D. (2017). American Telemedicine Association’s principles for delivering telerehabilitation services. International Journal of Telerehabilitation, 9(2), 63–68. doi:10.5195/IJT.2017.6232
A leader in the development and use of telecommunications is the American Telehealth Association (ATA). The ATA has developed a wide range of practice guidelines and updates them on a periodic basis. The ATA developed these guidelines to establish the baseline for use of all forms of digital and telecommunications and will evolve as the field advances.
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Fees
Fees should be discussed during the first session. Novice nurse psychotherapists often feel conflicted about charging a fee for their services when they do not feel knowledge- able about what they are doing. Fees should reflect the level of education, the degree of expertise, and the going rate in the community for such services. Sometimes, beginning therapists overlook the extensive education and training required to do psychotherapy and the fact that to take care of the patient’s emotional needs, it is necessary to get paid for their professional services. You may decide to offer a certain percentage of your patients a reduced fee, but having a pro bono practice in which you are paid by most of your patients less than others in your area is a recipe for resentment. Each therapist should decide on the basis of her finances whether a certain number of patients can be offered a lower fee and then fill that number of hours with low-fee or sliding-scale patients and refer others who cannot afford the standard fee to a low-cost clinic.
In agency settings, collecting fees is often taken care of by others, and it is not until the therapist is in private practice that collecting fees becomes an issue. In either set- ting, being clear about the fee and when payment is expected is part of the frame and should be discussed in the initial session. If you are in private practice or a setting that requires that you discuss fees with the person during the initial visit, information about the patient’s insurance may need to be obtained by you. Usually, a limited number of sessions are authorized, sometimes after the deductible is met, and an outpatient treat- ment report (OTR) is required after the allotted number of sessions. This should be dis- cussed with the patient, because many therapists believe that the OTR violates patient confidentiality and that the person should know what information will be provided to the insurance company. Sometimes, a creative solution can be worked out if the person already has a high copay with a managed care company that you are not a provider for. For example, seeing the person 30 minutes instead of the usual 45 to 50 minutes and charging one half of your usual fee may allow the person to pay about the same fee as he or she would if using the managed care company. In that way, the person can be seen for a shorter session and reduced fee, and confidentiality is preserved.
If the therapist is on the provider panel for a managed care company, the provider is contracted to charge a particular fee, and the patient pays a specified copay. Most thera- pists require payment at the end of the month for that month or the first session of the next month for the previous month. Other therapists expect payment at the end of each session. The provider submits the balance to the insurance company on a Health Care Financing Administration (HCFA) form and then gets paid by the managed care com- pany or insurance company usually a month or more later. Psychotherapy sessions are given Current Procedural Terminology (CPT) codes that designate the type of service given for billing and documentation for all insurers. These codes were revised as of 2021 in an effort to better reflect the complexity and level of care for patients. See Chapter 23 for how to use these codes for reimbursement.
For those patients who do not have insurance or when the therapist is not a provider on the panel for the insurance they have, the fee may need to be paid by the patient out-of-pocket. In these cases, usually the patient pays the provider directly. The patient then is responsible for submitting the bill to the insurance company so that he or she can get reimbursed. Most therapists prefer this method of payment as it helps to avoid tracking down claims, wasting time on the phone with managed care companies, and trying to get paid for services already rendered. Whatever method you decide to use for payment, it is best to keep when and how you get paid consistent for everyone to avoid confusion for yourself.
Whether you charge for missed sessions is important information to share during the first session. A cursory survey of colleagues reveals that most APPNs in private practice
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do charge for missed sessions; some charge only for those who do not call and do not show up, whereas others charge if they do not receive 24 or 48 hours’ notice and cannot reschedule for later that week. The idea behind charging for missed sessions is that the session time is rented much as a person would pay money for classes even if the person does not attend. The therapist has saved this time for the patient and should not be penalized financially for the patient’s absence. Paying for missed sessions also empha- sizes the importance of psychotherapy. Just as a person should not arbitrarily decide to not take a medication that was prescribed, psychotherapy is a prescribed treatment modality and, as such, is valuable. Some therapists feel that charging for missed ses- sions conveys to the patient the importance and value of their work together.
If the person cancels or does not come because of weather problems or significant ill- ness, many therapists do not charge for the missed session. Most insurance companies do not allow reimbursement for missed sessions. If you are charging, be sure to state the specifics in the contract with the patient, and do not charge the insurance com- pany because this violates the policy of most provider agreements. Many agencies do not have a cancellation policy and do not charge for missed sessions, and this may explain the high number of absences in such settings. Policies about attendance, missed appointments, and fees in the form of a contract should be provided to the patient at intake and should be signed by the patient.
Establishing Goals and Ending the Session
About 10 minutes before the end of the first session, it is a good idea to ask the person whether he or she has any questions. Then give the patient a brief idea without psychi- atric jargon about what you think may be going on and what may help. For example: “From what you have told me, you have suffered several significant losses in the past year, and this could account for the difficulty concentrating, your sadness, and trouble sleeping that you have been having. I think it would be helpful to come and talk about what has been going on for you. I would like you to take some forms home with you to fill out this week, and over the next few sessions, I will be asking you additional ques- tions so I can get to know you better. This will help me to determine what is the best way to help you.” Conveying hope is also important, for example: “As you talk about some of these losses and begin to feel better, I have a hunch your sleeping will improve too.”
The therapist then discusses the goals of treatment by asking the person: “How will you know this therapy worked. What will be different for you?” or “How would you like your life to improve?” or “What would you like your life to be like?” These are all open-ended questions that assist the person in formulating goals. Patients passively receiving suggestions fare far worse than patients who are actively involved in goal setting. Arriving at some consensus on therapy goals at intake helps the therapeutic alli- ance and engagement, which increases the probability that the patient will return after the initial session and will continue treatment. If the patient wants behavioral exercises between therapy sessions and the therapist is psychodynamically oriented, it will be apparent that there is a disagreement about therapy tasks at the outset, and these differ- ences need to be explicitly negotiated. The therapist and patient need to jointly decide goals and reevaluate them together throughout therapy. Reflecting on your understand- ing of what the patient said helps to strengthen the alliance, and the person knows that you are listening and that you are on the same wavelength.
Although establishing goals is important, Gabbard (2017) cautions against the therapist being too wedded to goals, because the patient may begin to feel that the emphasis on attaining goals is the therapist’s agenda and comply to please the thera- pist. Alternatively, the therapist who is too eager to achieve goals may elicit a stubborn resistance by the patient, who wishes to defeat the therapist by not changing. As a wise
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supervisor once told me: “The therapist should not be the most motivated person in the room.” The therapist should not be too eager and respect the patient’s ambivalence. Safran and Muran (2000) concur and place change in a framework of mindfulness. They state, “change merges out of nonjudgmental awareness, rather than through trying to force things to be different” (p. 116). A basic tenet of psychotherapy is to emphasize awareness rather than change.
Keeping Records
Taking notes during a session is a matter of individual preference. Sometimes, novice therapists take verbatim session notes and go over everything with a supervisor so that nothing will be missed that may be important because everything seems potentially important. This can be very distracting and distancing from the person sitting across from you. It is better to listen attentively, perhaps writing occasionally a word or two to pique your memory for constructing process notes that are more elaborate after the session.
It is important to keep two sets of notes:
1. Process notes include what you think is going on in terms of transference and coun- tertransference, topics discussed, questions about your own intuition, issues for discussion during supervision, or verbatim notes, particularly about a difficult or problematic interaction.
2. A more formal record of the treatment progress covers the diagnosis, level of care, history of present illness, review of symptoms, past, family, and social history, exami- nation components, medication reactions, suicidal thoughts, treatment decisions, and a description of the session for that particular session. These notes should be brief and respectful of the person’s confidentiality. See Chapter 23, for an explanation of these components based on the 2013 CPT codes.
The formal progress notes are kept for legal purposes or for review if mandated by a managed care or insurance company for quality auditing, while the process notes do not need to be delivered if there is a legal action or a medical record is requested. Examples of process and progress notes can be found in Appendices 4.3 and 4.4.
THERAPEUTIC COMMUNICATION
Psychotherapy is considered the talking cure, and therapeutic communication skills are the hallmark of good psychotherapy. Nurses have learned communication skills as undergraduates and most likely have been talking to patients for years. However, as with any new role, the novice APPN psychotherapist may be anxious and forget what she or he already knows, and a review of therapeutic communication may be helpful. Therapeutic communication is embedded in the holistic model of nursing, with the overall aim of promoting integration toward the goals of wholeness and healing. This is accomplished by assisting the person in experiencing and expanding thoughts, feelings, and actions that enhance resources and/or processing. Therapeutic communi- cation can be accomplished through the use of open-ended therapeutic communication techniques with the specific aims of promoting self-understanding and self-acceptance and of enhancing strengths. There is a vast literature on humanistic therapies such as Gestalt, patient-centered, and existential approaches to helping people become more connected with their feelings and more comfortable with expressing themselves directly (see Chapter 6). Most therapies encourage the patient to talk nondefensively about his
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or her emotional experiences, and through the ambient environment of a supportive, nurturing relationship, a narrative of the person’s life unfolds.
The elements of psychotherapy as described in Chapter 1—resilience and relationship— provide the parameters for communication. Good communication is all about context and relationship. Therapeutic communication competency is based on the ability to listen non- judgmentally, facilitate the patient to talk openly, and respond appropriately to what the person says. The psychotherapist assists the person in clarifying feelings and meanings and guides the person into areas that may not be fully conscious to enhance coping skills, deepen self-understanding, and improve the ability to make decisions. The patient does most of the talking, and the focus is on the patient’s concerns. One criterion of effective communication is whether what you say enables the patient to speak more freely. If you are talking more than 10% to 20% of the time, it becomes your session, not the patient’s. When you begin to feel concerned about what you are going to say, remember that less is best. During sessions, the therapist typically uses short sentences rather than long-winded explanations. Lengthy explanations have the potential for increasing the anxiety level of patients, especially during the initial session.
Barriers to listening include an emphasis on gathering information or getting the facts, giving information, and the therapist’s bias and judgmental attitudes. For exam- ple, suppose you are listening to someone talk about an abortion with a cavalier attitude and you are pro-life. How would you hear what the person said? Alternatively, suppose you are an atheist, and the patient talks about reading scriptures every day and the solace that this brings him or her. Would you judge the person as being too religious? Everyone has prejudices and attitudes, and it is important for therapists, through super- vision or their own therapy, to be aware of their attitudes and how they may interfere with their work with the different people encountered in practice. A respectful, non- judgmental stance is essential for the development of rapport and connection.
Gabbard (2017) says that therapeutic communication interventions exist on a con- tinuum from expressive to supportive. Those communication techniques that are most expressive are used by psychodynamic therapists to provide understanding and insight for processing while supportive interventions are less emotionally laden. This concep- tualization is useful and applicable to the treatment hierarchy triangle described in Chapter 1. Some interventions, such as focusing, observation, immediacy, and inter- pretation may be emotionally arousing and are more likely to be employed for patients who are higher on the treatment hierarchy triangle, whereas patients needing stabiliza- tion are more likely to require more supportive techniques, such as broad openings, information giving, giving recognition, restating, clarification, and reflection. However, techniques considered more supportive and needed for stabilization are also used for processing, but the expressive techniques higher on the treatment triangle are most often used for processing, not stabilization.
Communication techniques used for processing may trigger implicit neural networks and, without the proper resources, may be experienced as overwhelming, unmanageable feelings. The supportive techniques are more likely to be resource building and less anxiety provoking. Cozolino (2002) speculates that supportive communication optimizes cortical executive functioning as the patient is invited and supported to experience a wide range of emotions. He states, “This simultaneous activation of cognition, emotion, enhanced perspective, and the emotional regulation offered by the relationship may provide an optimal environment for neural change” (p. 53). Figure 4.1 shows the treatment hierarchy triangle as outlined in Chapter 1, with the continuum of therapeutic communication.
It is not important to know the names of these techniques or to memorize each one, but a review and discussion may help the beginning psychotherapist to identify which skills he or she uses now and how to expand this repertoire of communication skills to include others. Each of us must find words that feel genuine so that we do not sound stilted and mechanical. The examples listed in Table 4.6 assist in advancing the
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Interpretation
Immediacy
Focusing
Observation
Reflection
Clarification
Giving recognition
Restating
Suggestion
Information giving
Stabilization
Processing
FIGURE 4.1 Treatment hierarchy and continuum of therapeutic communication.
TABLE 4.6 SELECTED THERAPEUTIC COMMUNICATION TECHNIQUES
Technique Example
Broad opening Where shall we begin?
Information giving
I recommend that you take this medication at bedtime because it may make you feel tired.
Giving recognition
You were able to do well this week with the goals we set last week.
Restating You cannot study and have trouble concentrating.
Suggestion Some people find it helpful to keep a journal of their thoughts during the week.
Clarification Would you tell me more about what you mean by “upset”?
Reflection You are asking me what to do about your wife’s drinking and are very frustrated by the situation.
Exploring How did you feel when your friend said that to you?
Focusing Yes, your relationship with your mother is important, and it may help you understand better what goes on for you in other relationships by discussing this further.
Observation It seems that whenever you begin to talk about your mother, you change the subject.
Immediacy Perhaps you are feeling that I am not giving you what you need here.
Interpretation From what you have told me, it seems that when you get close in a relationship, you become anxious and then protect yourself by finding fault with the other person.
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psychotherapeutic process and are embedded in the context of attending and listen- ing, empathy, and exploration. Selected techniques are discussed as they relate to these processes of therapeutic communication. All techniques are included in the following discussion; however, those higher on the treatment triangle are most likely not used in the initial session.
Attending and listening
The APPN psychotherapist attends and listens by paying close attention to what the patient is saying verbally and nonverbally. Therapists think of the manifest content as what patients are actually saying, whereas the latent content is what they mean by what they say, or the process. This dichotomy has also been referred to as explicit ver- sus implicit communication. Often, a session or a series of sessions has a latent theme in the foreground, such as issues relating to trust, loneliness, abandonment, feelings of helplessness or inadequacy, or anger toward authority or about the carelessness of oth- ers. The therapist listens and hears the central issues and themes. Even though there may be manifest and latent content, the therapist most often does not directly address latent themes with the patient, but hearing and attempting to deepen understanding of the issues that the person is struggling with are relevant no matter what orientation or model of psychotherapy the therapist subscribes to. For example, a patient came to his session railing against authority figures he felt were controlling and unreasonable. This is the manifest content, whereas the latent content may relate to his feeling, perhaps unconsciously, that the therapist is authoritarian and controlling. It does not necessarily mean that the therapist is authoritarian and controlling, but for this person who is in a dependent position at this time, state-dependent neural networks of anger and resent- ment about helplessness or dependency from a past relationship are activated. The emo- tional arousal and novel sensory experience inherent in the psychotherapeutic process trigger implicit memory networks, or transference.
Transference refers to the patient’s thoughts, feelings, and behaviors that are associ- ated with early important relationships with caretakers and significant others and that are felt toward the therapist. Transference reflects state-dependent memories of specific physiological states of consciousness from the past. These neural networks are activated by the therapeutic relationship. Transference is ubiquitous and reflected in the way the patient acts, talks, and feels about the therapist. For example, a patient who is attend- ing sessions regularly on time and is eager to share experiences and feelings most likely has a positive transference, and a person who is late, is reluctant to talk, and sits guard- edly in sessions most likely has a negative transference. These are polarized extremes to illustrate vivid examples of transference, but most transference manifestations are much more subtle, nuanced, and complex.
There may be many different transference constellations and nuances over the course of treatment. The patient most likely is unaware of these feelings as transferential, espe- cially at first, and it is often difficult for the novice therapist to identify them as well. Listening and responding empathically is usually the best strategy for any negative feel- ings that may arise. For example, one patient came to his initial session sullen and with arms crossed and informed the therapist that he did not trust her. Because the therapist had never seen this person before, the therapist first explored his feelings about coming. It is important to ascertain first whether the patient was forced to come, was responded to in a timely way when he called, or has any other reality-based reasons for the sul- lenness. If there seems to be no reality-based reason that needs to be addressed first, the therapist may understand his attitude as transferential. This can provide impor- tant information about the dynamics of this person. The therapist may empathically
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comment: “It may be hard to trust someone whom you do not know, and it makes sense to not trust me until you get to know me better.”
If the transference is positive, it does not need to be addressed with the patient no matter what psychotherapy approach is used. Only if the therapeutic alliance is threat- ened or the transference is negative does the therapist explore with the person his or her feelings. Once the patient feels understood and validated, a negative transference is often dissipated. In some psychotherapy approaches such as psychodynamic, nega- tive transference is addressed as an alliance rupture and that is the primary work in the treatment (Eubanks, Muran, & Safran, 2019) while in other types of psychotherapy such as cognitive behavioral, goals or tasks of treatment may be changed without address- ing the transference. Listening for such themes and providing feedback in the form of a question, if appropriate, deepens the process and enhances self-understanding and empowerment. The therapist assists the patient in his or her healing journey with the humbling knowledge that the therapist’s understanding may or may not be correct and that all observations require verification by the patient in terms of their probability. The therapist is not the authority on the patient’s unconscious; the patient is. These observa- tions are best delivered by emphasizing the therapist’s subjectivity and nondefensive communication through the use of phrases such as “It seems to me . . .” or “I’m thinking that . . .” or “As I see it. . . .”
Body language speaks volumes about the patient, and the astute therapist is obser- vant of how the patient sits, walks, speaks, and moves. The therapist listens to what the person is saying and considers the meaning of the body language. Where and how does the person sit, and what posture does the patient assume? Does the patient leave his or her coat on? The therapist needs to be aware of the patient’s nonverbal behavior and its meaning. Following the patient’s body language and mimicking the person’s posture or breathing may signal the patient’s unconscious that you are on the same wavelength and can deepen your understanding of the person. Students are sometimes hesitant to try this exercise because of concerns that the patient may notice, but informal reports from APPN students have not found this to be true, and shadowing the patient in this way often serves as an insightful exercise for both the novice and the experienced therapist.
The therapist assumes an open, receptive posture without fidgeting and with arms not crossed. Good eye contact without staring is important, although this is somewhat culturally determined; some people from Asian or aboriginal cultures prefer indirect eye contact. A neutral, expectant look is important, because smiling and friendliness may be experienced as a social interaction or as threatening, or it may imply that the therapist is not serious about the person’s problems. Changes in the physiology of the therapist and the patient are important to observe to detect subtle or obvious dissocia- tive shifts of consciousness in the patient (Schore, 2019). The therapist monitors his or her own body language and somatic experiences. These include changes in body posi- tion, shifts in facial expression or eye gaze, breathing, eye closing, yawning, swallow- ing, skin flushing, and tears that well up or flow.
In addition to following the patient’s body language and your own, a rule of thumb for skillful communication is to use the patient’s verbal language and to follow the affect. By following the emotion, the therapist is attentive and listening to the emotions the person is expressing, whether verbal or nonverbal. Sometimes, there are discrep- ancies in what the person says, the manifest content, and how something is said. For example, if a person is recounting a tragic loss in a monotone that belies the serious- ness of the situation, the therapist may point it out to the patient in the form of an observation: “You have had this horrible loss, but you do not look or sound sad about it.” The person may laugh inappropriately when discussing an unloving marriage, and the therapist may offer this comment: “I am thinking that perhaps it is easier to laugh
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when feeling so unloved than to feel sad about your wife’s neglect.” Observations are made in a collaborative attempt at understanding and out of genuine uncertainty, not as objective truth.
Ralph Greenson (1967) discusses the use of language in his seminal text on technique:
My language is simple, clear, and direct. I use words that cannot be misunderstood, that are not vague or evasive. When I am trying to pin down the particular affect the patient might be struggling with, I try to be as specific and exact as possible. I select the word which seems to portray what is going on in the patient, the word which reflects the patient’s situation of the moment. If the patient seems to be experiencing an affect as though she were a child, for example, if the patient seems anxious like a child, I would say, “You seem scared” because that is the childhood word. I would never say, “You seem apprehensive” because that would not fit, that is a grown-up word. Furthermore, “scared” is evocative, it stirs up pictures and associations, while “apprehensive” is drab. I will use words like bashful, shy, or ashamed, if the patient seems to be struggling with feelings of shame from the past. I would not say humili- ation or abasement or meekness. In addition, I also try to gauge the intensity of the affect as accurately as possible. If the patient is very angry, I don’t say: “You seem annoyed” but I would say: “You seem furious.” I use the ordinary and vivid word to express the quantity and quality of the affect I think is going on. I will say things like: You seem irritable, or edgy, or grouchy, or sulky, or grim, or quarrelsome, or furious, to describe different kinds of hostility. How different are the associations to grouchy as compared with hostile? In trying to uncover and clarify the painful affect and the memories associated to that specific affect, the word one uses should be right in time, quality, quantity, and tone. (pp. 108–109)
Following the person’s affect and staying emotionally close to the patient’s expe- rience enhances connection and the therapeutic alliance while assisting the person in labeling his or her emotions. Expanding the patient’s repertoire and emotional vocabu- lary and awareness is largely the work of psychotherapy. There are many nuances of feelings, and the therapist needs to know the language of emotions. For example, when hurt, a person may feel forsaken, crushed, devastated, destroyed, pained, wounded, disgraced, humiliated, anguished, or rejected. Unless the therapist is aware of his or her own nuances of emotion, it is not possible to convey this knowledge to others. Therapists must know themselves as much as the words for emotions, and even experi- enced therapists do not always have a rich vocabulary to describe feelings.
Giving information is customary for nurses and includes psychoeducation. Information giving normalizes the situation, provides hope, helps to set goals, identifies options, helps deal with obstacles, corrects misinformation, provides new perspectives, provides feedback, and helps to reframe the situation. However, therapists must be careful to not overload patients with information and should consider timing. Often, the person needs an empathic response and may not be ready to hear any information. Any infor- mation given should be clear, specific, and concise. Giving information is not giving advice or telling the person what to do. Giving advice is not compatible with promoting empowerment. If helpful comments and suggestions worked, the patient would not be sitting in your office. Moreover, advice that does not work may be blamed on the thera- pist, and even if the advice is successful, it is a reminder of the patient’s inadequacy and can ultimately be demoralizing. A better strategy is to offer the person various options and explore each so that the patient can choose what to do. In my experience in teach- ing psychotherapy to nurses, being nondirective and not offering fix it statements are difficult for novice APPNs, because most nurses are used to telling patients what to do, particularly in inpatient settings.
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Educating the person about the psychotherapy process is an important component of the initial contact and the ongoing sessions. Often, the psychotherapeutic process seems strange to patients, even if they have had previous treatment. For example, it is common practice and therapeutic for therapists to ask questions about how patients feel about them or about coming to see them, but patients may think therapists want reassurance rather than an honest answer. Patients should be told at the outset that they sometimes may not want to come to their sessions and that is okay to not want to come, but that it may mean that important issues are surfacing and that it is important to come anyway and to be honest about how they are feeling. This is important information, particularly for patients who are in treatment for the first time. It is also important to tell patients that psychotherapy is a relationship and that the feelings elicited sometimes are similar to those experienced in past relationships. For example, if a patient has generally felt vulnerable in relationships and distanced from these feelings by avoiding others in the past, this reaction is likely to occur in the relationship with the therapist. Instruct the patient to tell the therapist when she or he begins to feel this way, because the informa- tion is important to the continuing work of psychotherapy. As therapy progresses, there are many opportunities to educate patients about the process of psychotherapy, and they are discussed throughout this textbook.
Giving recognition is a form of attending. It means that the therapist notices what the person has done and validates dimensions that are successful, which helps to build on strengths already in place. This is different from praise, because indiscriminate praise can backfire. Although praise may make the therapist and patient feel better temporar- ily, it can also leave the patient wondering about the therapist’s sincerity and the reality of the person’s strengths. If everything is wonderful, perhaps nothing is wonderful. Being a cheerleader implies that the therapist has judged that certain actions are desir- able, and this does not foster the patient’s empowerment and decision making. A better reply to positive change would be: “How did you feel about being able to say no and set limits on your own behalf?” Another caveat about cheerleading is that the patient may try to please the therapist, often unconsciously; nonetheless, the therapy process is hijacked and turned into what the person senses the therapist wants without advancing the patient’s self-direction and empowerment.
Empathy
Perhaps the most important element of therapeutic communication is empathy. Cozolino (2017) speculates that empathic connectedness stimulates the biochemical changes in the brain that increase brain plasticity and enhance learning. This makes sense in light of Schore’s work (2019), which demonstrates that social interactions early in life result in the stimulation of neurotransmitters and neural growth hormones that shape brain development. Research in mirror neurons provides a scientific explanation for the devel- opment of empathy through attachment relationships. (See Chapter 2.) The attachment arousal of the therapeutic relationship provides the interpersonal context for integra- tion and regulation of neural networks, with empathy serving as the vehicle for this connection. Empathic resonance is a physiological state of consciousness that helps the therapist connect, attune, and coregulate with the patient (Schore, 2019).
Historically, there has been a considerable amount of research on empathy in nurs- ing (LaMonica, Wolf, Madea, & Oberst, 1987; Layton & Wykle, 1990; Määttä, 2006; Morse et al., 1992; Wheeler, Barrett, & Lahey, 1996). Empathy is a complex concept, and three phases have been delineated. In phase 1, empathy reflects the individual’s empathic potential or ability; in phase 2, empathy is expressed; and in phase 3, empathy is received. Research does not support that a high degree of the nurse’s empathy ability results in the patient receiving that empathy. The most accurate measure of empathy for
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patient outcome is phase 3, empathy received (Wheeler, 2003). This is important because therapists may feel very empathic toward patients, but it is conveying this understand- ing to patients and their hearing it as such that count. The most accurate definition for empathy is “a process of understanding whereby the nurse enters the patient’s percep- tual world, the patient perceives this understanding, and confirmation of self occurs as part of this process” (Wheeler, 2003, p. 207). Confirmation of self is reflected in the patient feeling more worthwhile, energetic, confident, hopeful, and comforted. This physiological state results from the attunement and empathic resonance that are culti- vated through empathic communication techniques.
How does the therapist convey empathy and ensure that it is heard by the patient? The therapist’s empathy is only as helpful as it is accurate. For example, one patient came to his session looking very stony faced. The therapist misunderstood the patient’s silence as anger rather than fear and said: “Perhaps you are angry at me because I had to cancel our session last week.” The reality was that the patient was afraid that he had made a big mistake with his girlfriend and that she was going to break up with him. This kind of breach of empathy can be harmful to the therapeutic alliance. A bet- ter response for the therapist would be to observe and ask for clarification: “You look unhappy. What is going on?” To deepen the perception of what others are feeling, it is sometimes useful to ask, “What would someone be feeling who experienced this? What is the implicit communication in this situation?” Empathy is about trying to understand the key elements of what the person’s experiences, behaviors, decisions, values, and feelings are and about communicating these elements back to the person to see whether the perceptions were correct. It is responding to the context or implicit communication, not just to the words. Often, the person is unaware of what his or her feeling is, and it is the therapist’s job to perceive the emotion and to convey the perception to help the person expand awareness (i.e., to make the implicit explicit).
A related concept to empathy but a barrier to effective listening is being overly sym- pathetic. Feeling sorry for the patient can reinforce self-pity, does not help problem- solving, and can weaken the patient because the therapist is not emphasizing strengths. One patient reported fleeing treatment from a therapist because she experienced the former therapist as “too kind.” If the therapist feels too sympathetic toward the patient, it is most likely about the therapist’s feelings, not the patient’s. For example, one student nurse cared for a young woman about her own age who had just lost her father. The student’s own father had died after a protracted illness several years earlier. Unable to hide her sadness, the student began to cry and was less than effective in being present and objective for her patient.
Empathy picks up on implied feelings and can be invaluable in deepening the process. For example, one patient complained about being charged for a session she had missed for which she had not given 24 hours’ notice. The patient said: “All you care about is money. You don’t care that I was sick and couldn’t come!” The therapist answered empathi- cally, reflecting “You feel angry because you believe that you are not cared about?” This response was less threatening than “You feel angry because you think that I do not care about you.” Even though the latter response was not said and was undoubtedly the more empathic statement, this is an example of being empathic by not expressing empa- thy, because the therapist understood that the patient would have been humiliated and would have experienced the latter response as threatening and intrusive. The patient went on to discuss how unfair it was that the therapist could cancel sessions without repercussions, whereas she had to come or would be charged anyway. The power imbal- ance of the relationship revived how she felt in her relationship with her mother, who was cold and controlling. Being able to express her feelings in a supportive relationship allowed her to remain in therapy and feel understood, even though the framework of the therapy contract, which involved paying for missed sessions, remained the same.
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Reflection is a form of empathic validation. It helps to provide direction, shows the patient that the therapist understands the person’s perspective, helps to develop insight into problems, and encourages the patient to continue discussion. “You feel so hopeless . . .” encourages the patient to expand on his hopelessness. The therapist uses the same language as the patient but does so by paraphrasing and summarizing, not by restating what the person has said. Summarizing pulls together the main themes of the patient’s conversation and can be done at the beginning of a conversation, when a conversation is disjointed, when the patient is “stuck,” when the patient needs a new perspective, and at the end of a conversation. For example, the therapist may say, “You seem to feel very angry but feel that you are not supposed to be?”
Contributions from both the therapist and patient influence the degree of empathy the patient perceives from the therapist. In a review of the literature on the therapist-mediat- ing factors, Elliott and associates found that similarity between the therapist and patient, a nonjudgmental attitude on the part of the therapist, attentiveness, openness to discuss- ing any topic including countertransference, ability to regulate and awareness of one’s own emotions, ability to encourage exploration using emotion words, ability to take oth- ers’ perspective, abstract ability, in addition to the therapist’s posture, and vocal quality influenced patient perception of therapist empathy (Elliott, Bohart, Watson, & Greenberg, 2011). Conversely, therapist behaviors seen as less empathic include talking too much, advice giving, interrupting, failing to maintain eye contact, and dismissing the patient’s ideas. Patient contributions include the patient’s self-esteem, less patient pathology, and the patient’s intelligence that all predicted the patient’s perception of the therapist’s empathy. By enhancing self-awareness and continual work on improving communication skills using the therapeutic skill-building exercises described previously, empathy can be enhanced. Box 4.4 identifies skills and techniques that help to enhance empathy.
If the therapist’s empathic statement is correct, the response of the patient is often one of endorsement and opening up further about what is being discussed, some- times with an enthusiastic “That’s exactly how I feel” or at least with a nod and further thoughtful comments about what is being discussed. Empathy advances the conversa- tion. However, if the therapist is off base, the patient may pause, and the conversation may flounder, or the person may try to help the therapist get back on track. For exam- ple, one woman whose husband insisted she see a therapist because she criticized him
BoX 4.4 Skills and Techniques to Increase Positive Reception of Empathic Overtures
Source: Modified and adapted from Perraud, S., Delaney, K. R., Carlson-Sabelli, L., Johnson, M. E., Shephard, R., & Paun, O. (2006). Advanced practice psychiatric mental health nursing, finding our core: The therapeutic relationship in the 21st century. Perspectives in Psychiatric Care, 42(4), 215–226. doi:10.1111/j.1744-6163.2006.00097.x
Accept and appreciate the patient’s world but make sure that your understanding fits with the patient’s ability to tolerate it.
If you suspect that the patient would rather not hear your empathic statements, do not share them.
Add to or carry forward the meaning in the patient’s communication.
Listen beyond the words. Attempt to capture the nuances and implications and reflect back your understanding.
Focus on patients’ feelings, perceptions, meanings, values, assumptions, and their views of the other people and situations.
Be nonjudgemental, attentive, and open to discussing any topic.
Avoid interrupting, talking too much, and advice giving.
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constantly complained, “This is such a waste of time! I wouldn’t be here if my husband didn’t want me to come. He has all the problems. I don’t know what I am doing here!” The therapist responded with what was thought to be a reflective statement: “You are angry that he thinks you have mental health problems.” The patient angrily responded, “No, that is not what I am angry about. I am being forced to come here and am resentful that he is unfairly blaming me for his problems!” The therapist obviously misunder- stood, and after the patient explained further, the conversation focused on her feelings of being dominated in her marriage and how she criticized her husband as a response to her hurt about his disregard of her feelings.
Empathy is an important element of anxiety management in psychotherapy. Because anxiety often occurs when the patient changes, it is an important dimension for the therapist to be aware of, especially when the patient begins to feel anxious after a sig- nificant therapeutic gain. Any new behavior, feeling, or thought increases arousal in the brain and creates some anxiety, even if it is a change for the better. Change does not feel natural in the beginning, and it may take many tries or much time before it becomes integrated into the patient’s brain and way of being. It is helpful for the thera- pist to educate the patient to expect anxiety when change occurs. For example, one patient who had been able to make significant changes in boundaries in her relation- ship with her boyfriend came to her session and commented about how anxious she had felt during the past week for no apparent reason. The therapist made this interpre- tation: “Perhaps the anxiety you are feeling now is not so much about being stuck as about being able to do things differently from before and your newfound ability to say no when it is not something you want to do.” In psychotherapy, there are always two steps forward and one step back. Emotion is a powerful agent of change and causes disruption (Damasio, 1999). It is thought that this is due to a proliferation of synapses which disorganizes the brain (Stien & Kendall, 2004). In any case, an increase in anxiety or depression after a positive change follows the basic biological principle that “there can be no reorganization without disorganization” (Scott, 1979, p. 233). Knowing this and watching for therapeutic regressions as a normal part of the therapeutic process are essential to assist patients in healing. The therapist can then educate the patient that the setback is temporary and a temporary response to change. The APPN then helps the patient to manage by exploring anxiety management techniques that have been helpful for this person in the past, and assisting with learning new resources, if needed.
Exploration
Exploring or investigative questions encourage the person to clarify, expand, elaborate, and focus, moving the patient from the general to the specific. Listen carefully to the patient so that your questions follow from what the person is saying, have a therapeutic purpose, and are clear, concise, simple, and judicious. Asking a question to which you think you know the answer but which the person is busy denying most often alienates the person and increases defensiveness. For example, a therapist may suspect that a person is having anxiety because of angry feelings toward his mother who neglected him, but the person may not be ready to examine this idea and instead be aware only of feeling disturbed about a friend’s negligence. A premature statement by the therapist (“Perhaps you are really angry at your mother, who was not there for you”) may be met with silence or vehement denial, further strengthening defenses. A better clarifica- tion type of question may be “What is the worst part about feeling neglected?” Gently leading the person to examine his or her feelings helps the patient to engage and can be an appropriate therapeutic intervention because through the inquiry, the person’s self- understanding is deepened.
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A caveat is that asking questions centers the control in the therapist because the con- versation is directed to an area the therapist wants to explore, and questions should therefore be used judiciously. Too many questions yield negative results and can be a barrier to listening. All questions should be patient centered, and only one question should be asked at a time. Sometimes, therapists ask multiple questions because they are uncomfortable, and this can leave the patient feeling overwhelmed or confused. Another problem is that asking many informational questions collects facts but often misses the point about the psychotherapy process and what is happening for the patient. Restating or paraphrasing may be less threatening and allows more space for the patient to pursue what he or she feels is relevant. For example, “What I hear you saying is that you have been having a great deal of trouble getting to sleep but, once asleep, you can sleep through the night.”
Listen to the person contextually by focusing on key themes and messages. For example, a man who came into therapy recounted a number of unfortunate events in his life, explaining that “bad stuff always finds me. I will never be happy, and I never get a break.” Rather than asking questions about each instance, it is beneficial for the therapist to identify the themes of hopelessness and helplessness and to explore other dimensions, such as genetic roots (when in the past did he feel this way?) or other more adaptive situations (has there been any time when he did not feel this way?) or future potential (what would he like to feel in the future?).
Exploring can be verbal or nonverbal; shaking the head yes or saying “I see” encour- ages the patient to continue with the story. It can be particularly helpful to use open questions that encourage the patient to be active in the conversation: “How did you feel when your friend told you that he did not want to see you?” Open questions begin with who, what, how, when, and where, and they invite the patient to elaborate and provide factual information. Open questions are preferable in therapy, but they should not be so broad that the person is confused. For example, rather than asking “What kind of person are you?” it may be more helpful to ask “How are you like your mother?” Hypothetical questions such as “What do you think would happen if you quit taking your medications?” or “What would being assertive in that situation be like for you?” help the person imagine future consequences or possibilities.
Avoid “why” questions because they tend to have a critical tone, are likely to make patients feel defensive, and may be associated with disapproval. For example, “Why did you say that to your son?” most likely will cause anxiety, leaving the person feeling put on the spot and explaining unnecessarily. Usually, why questions can be rephrased with “how” exploring-type questions that ask the person to give his or her perspective on the situation. For example, “How did you feel when you said that to your son?” or “What was going on with you when you said that to your son?” may lead to deepening the patient’s understanding of her feelings.
Closed questions such as “Are you still feeling depressed?” usually elicit one syl- lable answers such as “No” without elaboration and may be used to clarify informa- tion, but if they are used too much, the therapist begins to feel as if she is conducting an interrogation and the patient is passive. However, it is sometimes appropriate to ask a closed question to obtain specific information and then follow with an open question that elicits more information from the patient. Closed questions tend to be less arous- ing than open questions and sometimes can be interspersed with open questions that may be more anxiety provoking to assist the person who is hyperaroused. The therapist should not ask leading questions that imply how the patient should answer, such as “Do you think that your depression affects your relationship with your family?” or “You do believe that abortion is acceptable, don’t you?”
Observation, focusing, immediacy, and interpretation are higher on the treatment hier- archy continuum and are usually not used in the initial session, but they are employed
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later as therapy progresses. Making an observation is verbalizing what is perceived or observed, and this encourages the patient to recognize specific behaviors and compare his or her perception with those of others. Observation can be extremely helpful to the person. For example, a pattern of relating may contribute to the person’s problem, and the therapist may point out the pattern by making an observation: “I’ve been notic- ing that you joke a lot whenever I mention how devoted you are to your husband” or “You seem tense today.” The patient then can elaborate on the therapist’s comments. Observation can also involve pointing out discrepancies and distortions between verbal and nonverbal behavior in a nonjudgmental, tentative way. These types of observations are best delivered using I statements such as “I wonder whether you are thinking that you are not really drinking if you only have two beers?”
Focusing is drawing attention to a potentially anxiety-provoking issue for further exploration. It can help the patient become more specific, move from vagueness to clar- ity, and further understanding about an issue. In addition to the example in Table 4.4, another form of focusing is to polarize the two parts of the patient that are in conflict by asking the person to examine each part. For example, “A part of you may feel like coming here to work on your problems while another part of you feels hesitant to share so many feelings with me.” Alternatively, the therapist may say: “It seems that a part of you would really like to stop drinking but another part of you is afraid to consider this.” The therapist can then explore each part with the patient in a way that assists in under- standing relevant implicit issues through the matter-of-fact manner that the therapist accepts the two parts of the person: “Please tell me about the part that is afraid to stop.” This type of comment can deepen the patient’s understanding about implicit barriers to change, and it reframes resistance as anxiety. This type of communication points to the importance of the therapist’s empathy in recognizing the emerging inclination of the patient to change.
Immediacy and interpretation are probably the most anxiety-provoking therapeutic communication skills for any therapist. Immediacy is a type of confrontation that is chal- lenging and requires self-awareness by the therapist. Often, the patient is not aware of how he is affecting others and that the same pattern is occurring in the therapeutic relationship. Immediacy involves exploring what is occurring currently in the thera- peutic relationship, and it can help with problem resolution. The therapist can address a change in the process. For example, if the patient is suddenly withdrawn or hostile, the therapist may say: “What are you feeling at this moment?” or “What do you want to say right now?”
Egan (2006) identifies three types of immediacy: exploring what is occurring in the relationship in general; assessing what is happening at the moment between the patient and therapist; and giving present tense feedback to the patient. Examples for each type include “It is hard for you when you feel so misunderstood.” “What do you want to say right now?” and “It is hard for me when you cut me off while I am talking.” Immediacy may be used in situations in which factors impact the relationship, such as when trust is a concern, when the patient is ”stuck,” when boundaries are violated, or when tension or dependency is an issue. The patient’s acknowledgment of dependence can be invalu- able. Assertiveness, self-awareness, and courage are prerequisites for using this skill.
Interpretations can take the form of pointing out to the patient what the therapist hears him or her saying regarding conflicts that he or she is struggling with (i.e., mak- ing the implicit explicit). An interpretation is a statement that explains how a feeling, thought, behavior, or symptom is related to its unconscious origin. Repeated attention to unconscious material results in gradually expanding awareness and the integration of top-down and right-left neural networks (Cozolino, 2017).
Interpretations are largely the work of psychodynamic psychotherapy, and they serve to defuse the potency of defenses as coping strategies. Cozolino (2002) says, “Conscious
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awareness of the defenses often leads to experiencing the feelings against which the patient has been defending. The networks containing the negative emotions become disinhibited and activated. For example, if intellectualization is being used to avoid the shame and depression related to early criticism, recognition of the defense will bring these feeling memories to awareness” (p. 51). For example, a patient who may be warding off feelings of abandonment is angry and critical of her boyfriend, and the therapist offered this interpretation: “It seems that you feel so angry when you feel dependent on Dan.”
All communication techniques are only as good as the therapist’s understanding of the patient and the therapist’s sensitivity to nuances. How you understand your patient will inform what you say, and your understanding will deepen as you gently explore with your patient and expand your knowledge about human behavior and develop- ment. What is said is informed by the theoretical approach the therapist is using. For example, interpretations are largely used in psychodynamic or interpersonal psycho- therapy, whereas suggestion is used most often in cognitive behavioral therapy (CBT) or supportive psychotherapy. Communication depends on your theoretical understanding of the patient, the approach used, the phase of therapy, the context, your relationship with the patient, and your own self-awareness.
Situations in which interpretations can be particularly helpful are when patients engage in negative statements about themselves, constant excuses, complacency, ratio- nalization, procrastination, and passing the buck. Interpretations can increase the patient’s awareness, but because interpretations can be threatening, the therapist should allow time for the comment to be heard and should offer support with empathic state- ments. Interpretations often are most effective if delivered in two parts, with empathy offered first and with the second part containing the interpretation with but or however linking the two parts (Wachtel, 2011). For example, Wachtel provides an example of such an interpretation for an adolescent who refused to clean her room and who kept her mother in a constant state of agitation. The therapist stated: “It is hard to keep your room clean and neat, and I could be wrong about this, but from what you say, it sounds as if your mom gives you a lot of attention when your room is a mess.”
Therapeutic communication is a set of skills that can be improved for both expe- rienced and novice APPNs. Expanding one’s repertoire of skills can be accomplished through practice and by enhancing self-awareness. Therapists can gain understanding through their own psychotherapy and through reflection and mindfulness exercises. These include audio taping, clinical studies, assignments, clinical supervision, discus- sion, journaling, critical incident techniques, learning diaries, process recordings, lit- erature or vignettes, montage, painting, poetry, role playing, videotaping, and reading books that help to develop self-awareness and reflective thinking. Although time con- suming to write, process recordings provide an invaluable opportunity to scrutinize communication skills and require no special equipment. An example of a format and directions for a process recording are provided in Appendix 4.5. More information on selected exercises designed to enhance reflection can be found at www.nursingsociety. org/about/resource_reflective.doc. Mindfulness exercises are also helpful in deepening self-awareness and are included in Chapter 17.
MAINTAINING THE FRAME
Boundaries
The term boundaries in psychotherapy refers to the therapist’s ability to establish and maintain a treatment frame, set a schedule, and honor times; maintain a professional relationship; and protect the patient from intrusions into privacy and confidentiality.
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The frame of treatment is the APPN’s responsibility, and it is important in creating a safe environment for both the patient and the therapist. For patients with dysfunctional, out- of-control behaviors, adherence to limits and boundaries may be a major focus of the treatment. Most therapists do not allow eating, drinking, or smoking during sessions or any type of interruption during the session. All phones and beepers should be turned off. This is the patient’s time, and distractions from the business at hand are counterpro- ductive to good psychotherapy.
Therapists’ violations of the frame, such as extending sessions longer than usual, being late for sessions, forgetting the session, not following the standard protocol for all patients for any reason, making special allowances for a particular patient, feeling the patient is special having social contact with the patient, and violating confidentiality, are all breaches of boundaries and can alert the therapist to countertransference issues that he or she needs to address. The therapist is often not aware initially of feelings toward the patient and becomes aware only by taking note of his or her own behavior and the signs of countertransference (Box 4.5).
Countertransference reflects feelings that the therapist has toward the patient and is similar in some respects to transference. Countertransference involves past significant relationships and includes attitudes, feelings, and thoughts about another person. Contemporary theorists believe that countertransference is a response to the patient’s transference, and as such, it can be used to understand the patient. Countertransference can serve as a barometer in the relationship with the patient for the self-aware thera- pist. Although countertransference is usually associated with breaches of boundaries or problems in relationship, such as those listed in Box 4.5, like transference, counter- transference can also be positive, such as idealizing feelings or empathic resonance with the patient.
Countertransference involves activation of the therapist’s state-dependent memo- ries in the relationship with the patient. As occurs in transference, countertransference reflects a particular physiological state of consciousness triggered by the relationship, and therapists’ bodies can inform them about what is occurring. For example, one ther- apist reported that narcissistic patients triggered her to become exceedingly tired in
• Extending sessions longer than usual • Being late for sessions • Forgetting the session • Seeing the person socially • Violating confidentiality • Dreams about the patient • Difficulty staying awake during sessions • Anger at the patient’s inability to change • Arguing or irritability that occurs in sessions • Sexual or aggressive fantasies about the patient • Rescue fantasies and offering advice and “fix it” statements • Anxiety or guilt about what you did or did not say • Thinking a lot about or being preoccupied with the patient outside of sessions • Dreading the session • Postponing confrontations or questions about lateness or absence • Unnecessary reassurances and oversolicitousness • Denying the pathology, conflict, or resistance • Allowing the person to run up a high unpaid bill • Ignoring the therapist’s errors and the subsequent effect on the patient’s behaviors • Therapist’s body feelings, images, and thoughts during the session
BoX 4.5 Signs of Countertransference
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sessions, so much so that she often struggled to stay awake. For another therapist, the same patient may elicit tension in the chest. This is because state-dependent memo- ries are idiosyncratic biochemical profiles that depend on each therapist’s experiences and development and on the interaction with the patient’s contributions in the co- construction of the relationship.
Images and thoughts during the session can also alert the receptive therapist to what may be going on during the psychotherapeutic process. For example, one therapist had an image come to mind during a session with a patient from a movie scene he had seen that depicted a forbidden sexual encounter. This was a cue to the therapist about the erotic transference developing in the relationship, even though the manifest content of the session was seemingly about an unrelated topic. The astute therapist is aware of all emerging thoughts, images, and sensations, without judgment or censorship, as manifes- tations of countertransference. They are considered important data about the therapeutic relationship and deepen the therapist’s understanding about the unfolding process.
A therapist using his or her feelings as a clue to what may be going on for a patient is referred to as autognosis, and this can be very helpful in understanding the patient. Autognosis is similar but different from the nursing concept of therapeutic use of self, orig- inally described by Travelbee (1971). Therapeutic use of self is the ability to use oneself consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions (Travelbee, 1971). In contrast, autognosis is using one’s feelings to deepen understanding of the patient and use of oneself to diagnose the nature of the patient’s problems. Often, these feelings are implicit and not fully conscious.
Two types of countertransference identified are concordant and complementary (Racker, 1968). Concordant identification is a process in which the therapist takes on the experience of a patient’s personality as if it were his or her own. For example, when interacting with a sad patient, the therapist begins to feel sad. Complementary identifica- tion occurs when the therapist is treated transferentially by the patient as if the feelings were true. For example, one patient who had a critical father began to feel criticized and judged by the therapist, and the therapist did feel induced to act punitively toward the patient. Often, these types of countertransferential responses are transitory and serve to deepen the therapist’s understanding of the patient. The therapist who is able to moni- tor his or her own emotional reactions, thoughts, and fantasies throughout a session can deepen the process in a way that otherwise may not be possible.
Although we often think of countertransference feelings as strong sexual or hostile feelings or boredom, often the therapist’s feelings toward the patient are more nuanced and may include judgments or unconscious stigmatizing beliefs. For example, one graduate nursing student working with a patient who decided he wanted to go back to school and become a nurse created an uneasy feeling in the student who told him that he needed to not take on too many stressors (Buck & Lysaker, 2010). Responses such as these that are not enthusiastic or perhaps overly enthusiastic may reveal deeply held stigmatizing beliefs about mentally ill adults and be barriers to treatment. All feelings— the good, the bad, and the ugly—occur and can be used in the service of the therapeutic process by self-aware therapists. Strategies to enhance self-awareness are included in Chapters 1 and 17.
The relational-psychodynamic therapist may address or interpret the cocreated countertransference, whereas the cognitive behavioral therapist more likely may notice but not address it directly. Chapter 5, on supportive and psychodynamic psychother- apy discusses countertransference further. Even if the therapist decides it is best not to address what is going on with the person, the work is enhanced. For example, one patient seemed so vulnerable and childlike that the therapist would often have fanta- sies of protecting and rescuing her. Even though this was not directly addressed with the patient in treatment, knowing this allowed the therapist to contain these feelings so
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that support could be provided without infantilizing the patient. Occasionally, feelings can be so intense about a patient that they may be difficult to contain and be therapeu- tic. “Strong countertransference feelings can be invoked when working closely with patients who are resistant to change” (Jones, 2004, p. 18).
Supervision and one’s own therapy can help to process emotional reactions. Lifelong supervision is always a good idea, but extra consultation with an experienced therapist can help in managing countertransference. Supervision consists of meeting regularly, much like therapy sessions, and discussing issues germane to the work of psychother- apy that the therapist needs help with. Often, supervision is a mixture of the patient’s issues and the therapist’s issues, because the latter impacts the treatment process in significant, often unconscious ways. For example, one young woman who came for therapy was extremely demanding and devaluing to the point that the therapist was defensive and dreaded her appointment each week. Discussing this patient in supervi- sion helped the therapist to be more objective and understand how her own issues were triggered by the patient’s devaluation. The therapist then was able to be more empathic and understand how the patient must have felt in her relationship with her devaluing mother.
Empirical and clinical studies on countertransference have found five interrelated factors that are important for management of countertransference: (1) therapist quali- ties of self-insight (aware of one’s own feelings), (2) self-integration ( ability to set boundaries and manage internal reactions), (3) empathy, (4) therapist’s ability to admit a mistake, and (5) conceptualizing ability (i.e., the therapist understands the patient’s dynamics theoretically (Hayes, Gelso, & Kivlighan, 2019). Therapists who possess these characteristics are seen as excellent by peers and can control countertransference acting out, and it is thought that these qualities are positively related to treatment outcome. In contrast, the therapist may have personality characteristics that are called chronic coun- tertransference, such as a tendency toward rescuing the patient, being overly supportive or solicitous, or being authoritarian or antiauthoritarian and frequently violating the rules or frame of treatment. These attitudes can create chaos in the therapeutic relation- ship, and the therapist may need psychotherapy in addition to a consultation to ame- liorate such traits. It is essential to monitor countertransferential feelings throughout therapy because these feelings are implicit and state dependent, and they may come to awareness only through ongoing self-reflection. Countertransference can significantly enhance or inhibit the therapeutic process. Seeking consultation and keeping documen- tation in clinical notes are essential to protect the therapeutic relationship and patient from therapist boundary problems. Theory and personal awareness are key to manag- ing countertransference. See Appendix 4.6 for an Inventory of Countertransference.
Relationship Boundary Violations
Dual or multiple relationships pose a transgression of boundaries because of the power differential between the psychotherapist and the patient and thus the potential for exploitation. This means that a psychotherapist who is a teacher should not see his or her students in psychotherapy; that a psychotherapist should not see his or her patient’s immediate family members for individual psychotherapy; that the psychotherapist should not work with those with whom there is a business, family, or close personal relationship. All requests by the patient to see friends should be explored by the APPN to understand better the closeness of that relationship to the patient. If it is determined that the referral by the patient is more than an acquaintance, an appropriate referral should be made to another therapist. Explain to the patient that is it not ethical for thera- pists to see the patient’s family members or close friends because there may be a conflict
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of interest. An excellent website with resources on dual relationships, multiple relation- ships, and boundary decision is available at kspope.com/dual/index.php.
It is customary if the therapist sees the patient at a party or somewhere outside the therapy office, that the therapist waits for the person to acknowledge him or her so the person does not feel embarrassed or have other conflicting feelings. This may be an extremely uncomfortable situation for the patient and it is important to ask the person at the beginning of the next session how they felt about seeing you outside treatment.
The most egregious violation of boundaries is that of a sexual relationship with the patient. Sexual misconduct ranks as one of the highest causes of malpractice actions against mental health providers (Norris, Gutheil, & Strasburger, 2003). Often, patients express wishes to be closer to the therapist, occasionally sexually or as a friend. It is the therapist’s job to assist the person in understanding the wish for closeness and not to gratify it, no matter how well intended. Even a slight boundary violation sends the wrong signal and may lead to more serious violations. In discussing why the therapist should not hug the patient, even if requested, McWilliams (2004) says, “physical con- tact of this sort collapses the ‘space’ between the two parties—the area of symboliza- tion, play, and ‘as-if’ relating—that has been so carefully constructed over the course of the therapeutic work. Such a collapse reduces to a concrete physical act the complex metaphorical meanings of the longing to be held, and it creates unconscious anxiety that other strivings—ones that are not so attractive (such as the wish to attack physically or exploit sexually)—may also be acted out” (pp. 190–191).
Nurses are used to touching their patients, and the emphasis in some psychiatric nurse practitioner roles as primary mental healthcare practitioner may leave the nurse psychotherapist on a slippery slope. The blurring of boundaries in advanced practice nursing was first addressed in the literature by McCabe & Burnett (2006). Relatively few studies on touching patients in psychiatric settings have been conducted, and none has addressed touching in the role of APPN psychotherapist. Gleeson and Timmins (2004) studied caring touch, in contrast to task touch, in a long-term setting for older patients who suffer from dementia. They conclude with the caution against the wide- spread adoption of caring touch as an intervention for ethical reasons. Another qualita- tive study of seven outpatients, who had previously been hospitalized for psychosis, found that some of the informants felt violated and oppressed when touched by some- one with whom they did not have an established relationship (Salzmann-Erikson & Erikson, 2005). However, positive results were found for an inpatient adolescent pop- ulation when therapeutic touch was utilized (Hughes, Meize-Grochowski, & Harris, 1996).
Although some forms of therapeutic touch do not involve actually touching the patient (i.e., the nurse may keep hands an inch or two away from the patient’s body), use of this or any kind of touch significantly changes the parameters of the psycho- therapy frame. The setting, situation, patient population, and other factors dictate boundaries for the APPN role. The blurring of boundaries mandates that each APPN set limits based on the patient’s welfare. Because research on the APPN relationship with the patient and the integration of touch and psychotherapy has not been con- ducted, it is prudent to regard touch as a boundary violation. If the APPN conducts a physical assessment at intake or admission, it is not appropriate to continue with that person in ongoing psychotherapy. Erring on the side of caution ensures a judicious and ethical practice.
Chapter 19, further discusses maintaining the therapeutic frame and boundaries for those who have problems with addictions. However, the transference and therapeutic issues identified for this population are relevant in working with all patients, and the reader is referred to that chapter for a fuller discussion on how to work with those who have an idealized or erotic transference.
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Self-Disclosure
Minimal self-disclosure is part of maintaining a professional relationship. Self-disclosure is defined as the therapist revealing something personal. However, the therapeutic tech- nique of immediacy is a powerful type of self-disclosure, in which the therapist reveals feelings about himself or herself in relation to the patient or the therapeutic relationship. Therapists must be aware of their own motives and thoughts relating to self-disclosure. Gabbard (2010) says: “Because we cannot be sure what we are up to when we are dis- closing our own feelings to the patient, self-disclosure should be thought about care- fully before using it” (p. 159). Self-disclosure should not be used to meet the therapist’s own narcissistic or intimacy needs in that the focus is shifted from the patient. This can interfere with the flow of the session and may confuse or burden the patient. It is essen- tial for APPNs to be aware of patients with whom they would be more likely to confide, because this may herald a potential boundary issue.
Based on an extensive review of the research on self-disclosure, Hill, Knox & Pinto- Coelho (2019) suggest the following practice guidelines for therapists:
1. Be cautious, thoughtful, and strategic about self-disclosure. 2. Focus on the patient’s needs rather than the therapist’s. 3. Make sure the therapeutic alliance is strong before using self-disclosure. 4. Keep the disclosure brief with few details. 5. Monitor how patients respond by asking about their feelings about the self-disclosure. 6. Focus on similarities between therapist and patient.
In general, the less self-disclosure by the therapist, the more the transference is thought to be heightened. Less self-disclosure may be more helpful for some patients who are higher functioning so that through discussion of the transference, profound learning and change may occur.
However, for those who use more immature defenses, such as projection, it may be better if the therapist is judiciously self-disclosing and more real so that less implicit feelings, thoughts, and state-dependent memories from the past are transferred onto the therapist, resulting in less distortion. Patients who are paranoid especially may need the therapist to be candid because they may project so much that it is important to inform them what aspects of their observations are accurate and what is being misin- terpreted. Answering nondefensively and without evasion is usually warranted. For example, one patient who was schizophrenic asked the therapist why she dressed like a hippie. The therapist responded good-naturedly, “I kind of like these 60s outfits; I think I look groovy.” The inherent inequity in the therapeutic relationship creates a climate in which dependency and some distortion are inevitable, with one vulnerable person requesting caretaking from another. The dependency triggered by psychotherapy can be particularly problematic for those needing stabilization and for those who have been chronically disempowered.
Questions about one’s credentials and qualifications should be answered. The patient has a right to know the APPN’s general therapy orientation and the amount of experi- ence with the type of problem the patient has. A thornier issue related to self-disclosure and maintaining boundaries is how to answer patients who ask personal questions. If the patient asks the therapist personal questions, the therapist can say, “I’ll be glad to answer that, but first I’m wondering what your thoughts are about that and how is it that you are asking?” If the patient persists in asking personal questions that the thera- pist does not want to answer (e.g., “Are you divorced?” or “How many children do you have?”) the therapist should listen for the latent content and explore what the patient is really asking for. For example, “Are you married?” may mean “Are you available?” or
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“Are you gay?” Often, the question is really about the person wondering whether the therapist can be trusted and reflects concerns about whether the therapist likes him or her, can understand his or her culture, and can relate to the patient. The patient may be unsure about the intimacy of therapy versus the intimacy of a personal relationship. The therapist can say: “You are very curious about me. Can you tell me more about that?” or “This is your time to talk about you.” If the person persists, and the therapist does not want to answer the question, it is best to say this honestly, “I am not comfortable answering personal questions about myself, but I am interested in how this information is important to you.” It is possible to spend the whole session on the meaning of the person’s question by reflecting: “It sounds as if you are feeling that if I am not married like you, I will not be able to understand how you feel.” The therapist and patient then can explore the context for this belief. It is only through inviting the patient to express his or her reservations about therapy and about you that the process can proceed. Being curious, interested, and open to all communication are essential skills for all therapists.
Cancellations, Fees, and lateness
Even though the patient has signed a contract about the cancellation policy and fees were discussed during the initial session, the policy may need to be revisited as therapy proceeds. Undoubtedly, the patient will cancel and forget that he will be charged for missed sessions as the policy proscribes. Understanding money issues in psychother- apy is essential. For example, paying late may be a signal that the patient unconsciously expects to be taken care of or forgetting to pay may be a passive aggressive act, and there may be any number of other unconscious reasons that the patient may deviate from the agreed fee structure and cancellation policy. Addressing and exploring the behavior to clarify the psychological meanings and to reiterate the frame for payment are impera- tive. Often, forgetting to pay reflects deeper meanings than at first glance.
It is not good practice for the patient or the therapist to allow a large outstanding bill to accumulate. A better alternative is to explore the meaning of not paying and help the person deepen his or her understanding while maintaining the frame of the contract. Higher-functioning patients usually honor the therapist’s fee structure and are easier to work with when exploring money issues than those who are lower function- ing. For example, one patient who was a therapist herself expected a reduced fee after her insurance company changed and she no longer had good coverage for outpatient psychotherapy. In exploring this subject with her, deep feelings of sadness and aban- donment surfaced from her childhood related to the caretaking role she had played with her mother, who had significant emotional and financial problems. Implicit neural networks associated with dependency and entitlement were triggered in therapy when she was asked to take care of the therapist by paying more out-of-pocket fees for her sessions. As the therapist explored these issues and reworked them in the present, the patient was able to make new neural connections that allowed her to continue in treat- ment and pay the charged fee. This awareness reverberated to other areas of her life, and she benefited financially in her own practice as a consequence of her work on this issue. Often, money issues in treatment reflect similar difficulties for the person outside the therapy.
Essential to maintaining the frame is the therapist’s reliability and consistency of sessions. The therapist must be on time for sessions. It is important to keep the time of the session the same each week because changing appointment times often cre- ates chaos, and the patient may not honor the commitment if the therapist is a poor example. Informing the patient well ahead of time when you will be gone and trying to reschedule, if possible, are common courtesies and essential for integrity of the frame. The patient’s lateness and not showing up for appointments are likely to be forms of
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resistance, but it is important to understand that tardiness and absence may be caused by an unforeseen circumstance. Emergencies, such as illness, lack of childcare, transpor- tation problems, or weather problems do occur. It is important to determine whether this is an isolated event or whether a pattern is developing. If the lateness is a one-time event, you can open a discussion by observing: “I notice you were late today.” However, if the person has been late two or three times in a row, the cause is most likely resistance, which should be addressed, or the person may leave treatment altogether. It may be bet- ter to wait until an opening in the session presents itself or the person’s defenses may increase. If an opening does not present itself, the therapist can say: “You have been 10 minutes late for the past 2 weeks, and it seems hard for you to get here on time.” The person may launch into the real reasons for the tardiness. The therapist can then ask, “Do you have any other feelings about coming here lately?” Approaching with curiosity and understanding conveys caring and allows the patient to explore what is going on. It is important for the therapist to adhere to the established time for the session and not extend the time another 10 minutes if the patient is 10 minutes late.
If the person does not show up for a scheduled session and does not call, most thera- pists assume that the patient will come to the next session and do not contact the person. However, if two sessions are missed, the person is usually called, and a message is left that states: “I had in my appointment book that you were coming yesterday at 3, and you did not come. I hope everything is okay. Please call if you would like to schedule an appointment. I look forward to hearing from you.” Adding the last sentence is help- ful, because the person may feel that the therapist is angry if he or she has missed sev- eral times. If the person calls, confirms, comes the following week, and has not missed before, the therapist must explore what is going on with the person, because the resis- tance must be addressed if the patient is to continue. If the person does not address the absence, the therapist can ask: “How did you feel about missing the past few weeks?” If this is the first time a session was missed, the therapist can reiterate the policy about paying for missed sessions once before instituting it the next time. If the patient calls and says she or he wants to end treatment, the therapist should suggest that the person come in to discuss the issue first.
Even when issues are discussed and the patient still wants to terminate against the therapist’s best judgment, it can still be helpful to the patient to meet for a final session. The therapist can use this opportunity to explore what is going on and leave the door open for future work when the patient is ready. However, if the person does not call or come to the next confirmed appointment and has missed three sessions in a row, a ter- mination of treatment letter (see Appendix 4.7) should be sent to the person. This official termination letter protects the therapist from legal liability if the person has difficulties later. Chapter 24, provides further discussion of termination.
Telephone Calls and Emails
Being responsible for patients 24 hours a day is often a new experience for most new APPNs, and it is essential that emergency coverage is in place. It is important to state explicitly whether you will be available for phone calls between sessions and adhere to clear limits. How the patient contacts you between sessions and in emergencies is included in the contract given to the patient during the initial session. Although you need not be available around the clock, suitable arrangements should be made. Reasonable examples include having a pager or cell phone and providing patients with a number so that they may contact you if needed, hiring an answering service that con- tacts you when contacted by a patient, and sharing coverage with colleagues who are each on call every few days, provides uninterrupted coverage throughout the week and
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weekend. Checking messages at least once each day and calling back within 24 hours are good practice habits that are relevant for legal and ethical professional responsibil- ity. Some therapists leave a message on their answering machine that states that he or she will call back as soon as possible and that if this is an emergency, the patient should go to the ED or call a crisis hotline. In this way, you are not serving as the ED liaison and setting appropriate limits on your availability. Asking a colleague to cover is essential for vacations and time off, in addition to discussing fragile patients who may call while you are gone. It is helpful to write notes for the covering person with details about the patient’s name, address, phone number, and narrative about issues that may arise. This is a courtesy to your colleague and your patient.
Occasionally a patient may call between sessions to hear the therapist’s voice, and this can be quite soothing to those needing stabilization. Emails can also connect with patients and be helpful between sessions. However, this can create problems if the patient expects a timely response for lengthy journal entries. This puts an unnecessary burden on the therapist and complicates boundaries and the frame. Phone calls from patients between sessions should be discouraged by assessing quickly whether the call is truly an emergency and, if not, gently saying: “This sounds important, and we need to talk more about it when you come next week.” However, sometimes a phone call from a patient who has been averse to seeking help or afraid to trust can signify that a positive shift has occurred in the therapeutic relationship. In other cases, a phone call may mean increasing desperation and loneliness. It may be necessary to strengthen affect manage- ment strategies for those who have difficulties in this area.
No matter what the reason, it is important to limit conversations, because giving away free sessions over the phone violates the frame and cultivates an unhealthy dependency. If the APPN is receiving several urgent phone calls each week, the possibility exists that such calls are inadvertently being encouraged, and consultation with an experienced therapist is indicated. Conducting phone sessions in lieu of office sessions is not rou- tinely advised, but it may be necessary on occasion or in addition to a regularly sched- uled weekly appointment. Fees for phone sessions are the same as for regular sessions. Phone sessions also may serve as a way to wean the patient from psychotherapy during termination. This topic is covered in Chapter 24.
WORKING WITH RESISTANCE
Resistance has traditionally been viewed as an inevitable and unfortunate occurrence in the psychotherapeutic process. Historically, resistance was thought to reflect the uncon- scious forces of the patient that inhibit change but more recently resistance is thought of as an opportunity to increase understanding of the patient (Gabbard, 2017). Resistance is seen primarily as a defense that shows the therapist that the patient’s anxiety has increased and that defenses are near the surface, indicating an opportunity for insight. Despite this idea about resistance, research suggests that psychotherapy works best if the therapist induces as little resistance as possible while moving the patient toward his or her goals (Tryon, Birch, & Verkuilen, 2019). This is easier said than done, because change is always fraught with anxiety and resistance is a manifestation of anxiety. Resistance can be thought of as implicit memory networks created through earlier dysfunctional situations and relationships that serve a self-protective function. Resistances manifest in psychotherapy as aspects or issues in treatment that challenge the person’s ability to change. It is often these implicit neural patterns and ways of being that have brought the person into therapy in the first place. These defenses or resistances have been help- ful and were functional for the person in the past, and for this reason, understanding
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resistances can be valuable to the work of therapy. Chapter 5, discusses further how to work with resistance.
Often, a parallel process occurs, and the therapist’s defenses are also triggered when the patient manifests resistance. Resistance is not always easy to recognize, and if the issue is not addressed, the patient may not return. Traditionally, resistances are thought to be caused by anxieties about the unknown, loss of control, rejection, loss of meaning, physical pain, isolation, and self-loathing (Gabbard, 2017). These manifest as agitation, demanding behaviors, silence, noncompliance, chronic lateness, not coming to sessions, anger, eagerness to leave treatment, superficial chit chat, paranoia, irritability, lack of progress, requests for special favors, eating or drinking during sessions, homework not done, nonpayment or late payment of bills, sexual interest in the therapist, frequent requests for personal information from the therapist, and doorknob disclosures (i.e., bringing up important material or intense emotion at the end of the session). When patients introduce new information as they are on the way out, this ensures that there will not be enough time to deal with the issues. This represents resistance in the form of ambivalence. If this occurs, it may be helpful to bring up the issue at the beginning of the next session to open up exploration.
A more contemporary view of resistance through the lens of adaptive information processing (AIP) theory is that resistance may reflect blocked processing. The blocked processing is due to reactance, that is, a failure of the therapist to fit the treatment to the receptivity of the patient. Expert therapists tailor interventions to meet the person’s needs. For example, for those patients who are highly resistant, less directive models of therapy are used that allow more control for the patient. For example, directive therapies such as CBT may be better for patients who are less resistant, and nondirective forms such as psychodynamic therapy and interpersonal therapy may be better for highly resistant patients. A meta-analysis of 12 studies supports that nondirective techniques predict better treatment outcomes for highly resistant patients (Beutler, Harwood, Michelson, Song, & Holman, 2011). Clinically, it is important to identify those who are the low- or high-resistant patients. Several groups of those who are likely to be high resisters include adolescents, paranoid or distrustful patients, and those who are forced to come to treatment by the court, a spouse, a job, or a family member.
The therapist’s competency in dealing with resistance includes identifying problems in collaboration, recognizing defenses and obstacles to change, and understanding ways to address resistance. Responses by the therapist to the patient have been identified as help- ful: acknowledging and reflecting the patient’s concern, discussing the therapeutic rela- tionship, renegotiating the contract and goals, listening versus talking should shift more toward the patient, and using fewer instructions (Beutler & Harwood, 2000; Beutler et al., 2011). The therapist first observes and points out the behavior: “I notice that you have been pretty quiet the past couple of weeks during our sessions” or “You seem angry today” or “It is so hard for you to be here when you don’t want to be here.” Interventions that dis- cuss the therapeutic relationship are called process comments and include questions such as “How did you feel when you left the last session?” or “How do you think things are going here?” These questions invite the patient’s response. Sometimes, questions engender a limited or no response, but often such inquiries open up the process in a way that allows the patient to share feelings. The ensuing conversation may be surprising, because the person often responds quite honestly with feelings that are enlightening. If the person says that something is a problem or that things are not going so well, the therapist can explore further what would help to make it better. This can be very helpful for collaboration. On the other hand, the person may not know how he or she is feeling and may deny any negative feelings. The therapist can then explore with another question: “How did you feel when I asked you that?” These types of process questions encourage self-exploration and may enable the person to deepen self-awareness so that acting out can be minimized.
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Renegotiating the contract and goals may not be feasible, but discussion and flex- ibility may be indicated if content and process comments are not working. Maintaining firm limits may be the focus of therapy for some patients, such as those who have bor- derline personality traits and who desperately need structure and consistency. Others may be better served by flexibility and the APPN moving with the resistance. Box 4.6 provides an example of moving with the resistance and renegotiating the contract for a patient who suffered an alliance rupture. Two things are important to remember about resistance. If resistance is increasing and not addressed, the patient may never return; however, once articulated by the patient and heard by a curious, nonjudgmental thera- pist, the resistance can be defused, often allowing the patient to continue with the work of therapy. Perhaps it is the empathic connectedness of the therapeutic relationship that allows new expectations and learning to occur.
During the session in Box 4.6, Ms. A’s anger and hurt are acknowledged and vali- dated empathically, and the therapist apologizes. This session illustrates an example of moving with resistance based on a real issue that the therapist acknowledges, not
Ms. A is a 28-year-old woman, who initially sought help for panic attacks. A major theme in her treatment was her intense neediness and struggle for love and safety. Asking for help was fraught with anxiety because she was ridiculed in her family for asking for anything, and this was compounded by the fact that on some level she felt that others should know what she wanted without telling them. The following process was from a session that addressed her leaving her last session seemingly angry (i.e., her face appeared angry, and she slammed the door as she left). The therapist had a cold during the session and had to struggle to stay awake.
APPN: How did you feel when you left the last session? Ms. A: Angry; I wanted to shake you apart. APPN: Tell me more about how you felt. Ms. A: I felt lost; you don’t talk to me enough. You weren’t really with me. APPN: Thank you for telling me how you felt. I’m sorry. I was not feeling well and
really was not there for you. I understand how angry you must feel about being here and not being heard.
Ms. A: Yes, this is a waste of time, and I don’t want to come here anymore. APPN: You have been feeling that you are not getting better and that this is a waste
of time? Ms. A: I’m not that much better. I haven’t had any more panic attacks, but maybe they
are just going away on their own. APPN: When you first came here, that was what you wanted to work on, and it seems
that the panic attacks have lessened and are not such a problem for you any- more. Perhaps it would be helpful to discuss whether there are any other areas of your life in which you would like things to be different.
Ms. A: Well, can you find me a boyfriend? Jim [her boyfriend] is AWOL. APPN: What do you mean by AWOL? Ms. A: Jim wants his space and just wants to be by himself. [She then recounted numer-
ous instances of his inattention to her needs and rude behavior toward her.] APPN: How hurtful it is to feel so rejected and devalued. From what you have told me,
you are feeling so vulnerable with Jim right now that it might be helpful to talk about some resources to help you feel stronger in situations in which you feel dependent and needy. Would it be okay to continue for a few more sessions and see if we can come up with a plan that will help you and then reevaluate whether this is the best time for you to stop?
Ms. A: Okay, I suppose, but only for a few more sessions.
BoX 4.6 Moving With Resistance and Renegotiating the Contract
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• Be aware of subtle indications of ruptures in the relationship and explore the patient’s negative feelings.
• Respond nondefensively and accept responsibility for your contribution to the interaction.
• Emphasize with patient’s experience and validate the patient for bringing it up. • Consider changing the goals of treatment. • Consider linking ruptures in session to interpersonal patterns in the person’s life. • Empathically explore your own negative feelings so you can do the same for your
patient.
BoX 4.7 Therapeutic Strategies for Alliance Repair
on the patient’s distortions, which is what we frequently think of as resistance. This is important in that the therapist needs to be prepared to take responsibility for mistakes. The therapist moves with the resistance by inviting Ms. A to talk about how she felt, even though she suspected that the patient would criticize her, and the therapist then thanks Ms. A for telling her how she felt. This patient risked criticizing the therapist, and the therapist was glad that Ms. A was able to trust the relationship enough to be hon- est about her feelings. Ms. A’s feelings toward the therapist and Jim, her boyfriend, are similar and reflect current feelings and thoughts that are associated with implicit memo- ries of being ignored and not responded to. Although not explicitly linked by the thera- pist, this issue is addressed by the renegotiating of goals. Setting new goals is another example of moving with the resistance, and although the therapist does think that the therapy has been helpful in decreasing Ms. A’s panic attacks, she does not disagree with her about that because it will not serve to advance the process at this point. This also illustrates how the therapist moved with the resistance. This was a much different expe- rience for Ms. A from what she remembers in her family when she asked for help. After a few more sessions, the therapist again asked Ms. A how she was feeling, how things were going, and whether they were on track with her goal of enhancing resources.
This example illustrates what is called an alliance rupture, that is, tension or break- down in the collaborative relationship between the patient and the therapist (Eubanks et al., 2019). Such a rupture can occur at the beginning of treatment or anytime over the course of treatment. Unlike this example, sometimes patients may be only vaguely aware of their dissatisfaction and it is up to the APPN to help the person express nega- tive feelings. These ruptures often leave the therapist feeling confused, incompetent, and guilty. An extensive review of the literature and research found a number of thera- peutic strategies helpful to repair alliance ruptures (Eubanks et al., 2019). Please see Box 4.7.
Paradoxical Interventions
Paradoxical interventions are used for patients who are said to be highly resistant and experiencing much conflict about change. These communication strategies assist in looking at the problem in a new way and are paradoxical because they ask the person to embrace the behavior that the therapy is aiming to diminish (Wachtel, 2011). This approach often helps the person to become unstuck through bypassing the resistance and overloading the conscious mind with confusion. The problem that was thought to be uncontrollable becomes volitional and purposeful. Neurophysiologically, this may be arousing, particularly in the frontal and parietal lobes, which become activated during novel stimuli, and this allows a window of opportunity for new learning to occur. This parallels brain development in that repeated exposure to new stimuli in a supportive
4. ThE INITIAl CoNTACT AND MAINTAINING ThE FRAME ■ 227
interpersonal context results in the brain’s increased ability to tolerate increasing levels of arousal and permit ongoing neural integration (Cozolino, 2017). Paradoxical inter- ventions challenge the established neural networks in the context of guidance and sup- port that underlies all forms of successful therapy.
Paradoxical interventions are most appropriately used for patients who cannot see any other possibilities and are consistently self-defeating. The therapist connects with the person through understanding and empathy, agrees with the person, and then pre- scribes the problem behavior or may ask the patient to observe the behavior. One strat- egy is to ask the patient to not try to change the behavior but instead to observe it and keep track of it throughout the week. This changes the relation of the person to the behavior so that the behavior is no longer the enemy and becomes a curiosity because an antagonistic attitude often accompanies what should be changed. This also increases the therapeutic distance of the problem, and the person develops the capacity for an observing ego whereby the person is not the problem. For example, the insomniac who is battling to go to sleep dreads going to bed and may benefit from being told to try to stay awake and resist going to sleep. An analysis of two studies of treatment for chronic insomnia confirmed that paradoxical intention reported greater benefit compared to placebo (Morin et al., 1999). Another example of a paradoxical intervention is the thera- pist telling the person who is paranoid and highly distrustful, “It is probably a good idea not to trust me and wait until later to make sure that it is safe.” For patients who are locked into being helpless, hopeless, and self-defeating, a useful paradoxical communi- cation may be “I can understand believing that nothing will ever be better would make everything seem pretty impossible. Please continue this week to notice all the negative thoughts that come up for you without trying to make anything better.”
These interventions have been used and are embedded in various psychotherapy approaches such as family, behavioral, solution focused, and psychodynamic thera- pies (Wachtel, 2011). Erickson, the master of paradox and metaphor, developed elabo- rate interventions designed to intentionally confuse the patient through contradictory commands during trance (Lankton & Lankton, 1991). Westerman and colleagues found that brief paradoxical treatment was more effective for resistant patients than brief behavioral treatment (Westerman, Frankel, Tanaka, & Kahn, 1987). A meta-analysis of 15 studies supports the idea that paradoxical treatments are more effective than non- paradoxical treatments for various behavioral problems (Hill, 1987).
Paradoxical interventions may be inappropriate for the beginning therapist because if not used sparingly and sensitively, the therapist may be experienced as sarcastic. For example, a patient who is plagued by distressing, negative thoughts may be advised to take 5 minutes of every hour to worry. Suggesting this without proper empathy may serve to humiliate and further alienate the person from his or her therapist. Prefacing such a suggestion with “I can see how having such negative thoughts would make things look pretty impossible” conveys an appreciation of the person’s experience. There are a wide range of applications for paradoxical interventions such as smoking cessation, binge eating, anxiety disorders, behavioral problems, depressive thinking, or any problem where the person is entrenched in a self-defeating pattern of behavior that creates pain for the person.
Secondary gain means that the person develops an illness or perpetuates a behavior that results in favorable environmental, interpersonal, monetary, or situational benefits. Sometimes, these gains are explicit (i.e., in the person’s awareness), and other times they are implicit and can be brought to consciousness through exploration. For example, for a depressed patient who was asked to list the pros and cons of being depressed, the per- son identified and clarified the secondary gains received from being depressed, which the person may only have been dimly aware of before. The areas identified included avoiding confrontation and possible abandonment by his partner, sex with his partner,
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and work in an area he did not like. Once identified, these underlying issues could then be explored. Open-ended exploration of what would happen if the person changed and asking how this change would affect his or her life and important relationships are rel- evant questions to ask at the beginning of any treatment to examine whether there are secondary gain issues. Often, secondary gains are more apparent to others than to the person. Skillfully leading the person to his or her own discovery can potentiate signifi- cant, long-lasting change.
CONCLUDING COMMENTS
In the initial session, assessing safety, developing an alliance, and goal consensus begin the psychotherapeutic process through the use of open-ended therapeutic communica- tion. This applies to all models of psychotherapy and practice settings. Engagement of the patient is essential to ensure that the person returns after the intake process is com- plete. A review of early research on attrition reports that roughly 50% of patients drop out by the third session (Barrett et al., 2008). Despite managed care and the emphasis on brief treatment, keeping people in treatment until their goals are met is a hallmark of suc- cessful therapy. As you increase your skills in engagement and assessment, you will be able to achieve competency in assessment in a shorter period.
Both patients and therapists need to have the security of boundaries and a frame for practice to be comfortable with the anxiety-provoking work of psychotherapy. Early in the therapy process, it is thought that most patients consciously or unconsciously test the frame of the treatment. A person may forget to come or to pay, may be late, or continue to talk beyond the scheduled session time even when reminded that it is time to stop. It is always best to err on the side of consistency when setting boundaries. Both patients and therapists may have problems adhering to the frame. For example, ending the session and adhering to the time frame may be difficult for a variety of reasons for the therapist. The therapist may feel inadequate and extend the session, thinking perhaps that listen- ing longer will make the person feel better or that it is okay to make up the time the person missed if he or she is late. It is important for the APPN to maintain the frame and start the session on time and end on time so that if the person has an appointment at 12 and comes at 12:30, the session that is scheduled for 45 minutes will still stop at 12:45 as previously planned. Patients may have separation issues and not want to leave. The per- son may linger while writing a check, talk about a scheduling problem, ask for a referral for a friend, or bring up an issue that seems important to address sooner rather than later (i.e., doorknob disclosure). Other patients may get intensely emotional during the last 5 minutes of the session. Offering the person a few extra minutes may be appropriate but difficult, particularly when other patients are waiting. The therapist can gently say something such as: “I’m sorry, but we do have to stop now. You have touched on some very sad feelings that would be important to talk more about. Would you like to wait in the waiting room until you feel better?” Ending the session on time is an area that well- intended therapists often struggle with in maintaining the frame.
For the novice APPN psychotherapist, the frame of treatment, payments, session times, phone calls, emergencies, and other factors are usually decided by the setting in which the therapist accepts employment, and have little to do with the therapist’s preferences. Although the rules of the employing agency may not be what the therapist would choose, it is best for the patient if the therapist adheres to the policies. In open- ing a practice, the therapist is faced with a multitude of issues about the frame, such as setting fees, collecting money, availability, session times, cancellations, and records, that must be decided. The process of psychotherapy encourages powerful attachments for both participants, and these feelings may undermine the APPN’s confidence about
4. ThE INITIAl CoNTACT AND MAINTAINING ThE FRAME ■ 229
limits and sometimes obscure the importance of maintaining the frame. Boundaries, working with resistance, and setting limits are areas that challenge even experienced therapists. Errors will be made at times, but it is important to be able to recognize situ- ations when boundary or resistance issues arise, to regain balance, and to follow the frame for treatment as closely as possible. This is what the work of psychotherapy is about, no matter what approach or model is used.
DISCUSSION QUESTIONS
1. Discuss transference, and give a clinical example from your practice. Describe how your understanding of transference affects your response as a therapist.
2. Develop specific goals for how and what therapeutic communication skills you would like to integrate and further develop in your practice.
3. Generate a list of words for the various nuances that can be used to describe the feeling of anger, and generate another list for the feeling of sadness.
4. Discuss the goals of the first session. 5. Discuss why the therapeutic alliance is important, and identify psychotherapeutic
strategies that can help in developing this alliance. 6. Is empathy always a good thing? Give some examples of when it may be
a problem. 7. Using the example of a practice contract from Appendix 4.2 or from the website
cited in the chapter, develop a one-page contract or office policy that you could give to patients.
8. Identify from your clinical practice an example of complementary or concordant countertransference, and explain how your feelings might have helped you in understanding your patient.
9. Describe a clinical situation in which paradoxical interventions may be useful, and develop a plan to use this strategy.
10. Discuss communication techniques for dealing with three specific instances of resistance, and give examples for each.
11. Examine your own areas of chronic countertransference and what may be helpful to you in your future APPN practice.
12. What is meant by the slippery slope and what problems may arise as a result of inte- grating therapeutic touch and Reiki in your APPN practice? Discuss strategies for how you could address these issues.
13. A patient who has been depressed most of her life comes to therapy complaining that she is hopeless, helpless, and will never have a good life. Discuss your gut reaction with someone with this characterological issue and how this could impact frame issues such as money, time, and therapist availability.
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APPENDIX 4.1 Notice of Privacy Practices
This notice describes how psychologi- cal and medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations I may use or disclose your pro- tected health information (PHI), for treatment, payment, and health care operation purposes with your consent. To help clarify these terms, here are some definitions:
■ “PHI” refers to information in your health record that could identify you.
■ “Treatment, payment, and health care operations” – Treatment is when I pro-
vide, coordinate, or man- age your healthcare and other services related to your healthcare. An exam- ple of treatment would be when I consult with another healthcare pro- vider, such as your fam- ily physician or another psychologist.
– Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I dis- close your PHI to your health insurer to obtain reimbursement for your healthcare or to determine eligibility or coverage.
– Healthcare operations are activities that relate to the performance and operation of my practice. Examples of healthcare
operations are quality assessment and improve- ment activities, business- related matters such as audits and administra- tive services, and case management and care coordination.
■ “Use” applies only to activities within my (office, clinic, prac- tice group, and so on) such as sharing, employing, applying, utilizing, examining, and ana- lyzing information that identi- fies you.
■ “Disclosure” applies to activi- ties outside my (office, clinic, practice group, and so on), such as releasing, transferring, or providing access to informa- tion about you to other parties.
II. Uses and Disclosures Requiring Authorization I may use or disclose PHI for pur- poses outside of treatment, pay- ment, and healthcare operations when your appropriate authoriza- tion is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment, and healthcare operations, I will obtain an autho- rization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes I have made about our con- versation during a private, group, joint, or family counseling session, which I have kept separate from the
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rest of your medical record. These notes are given a greater degree of protection than PHI. You may revoke all such autho- rizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authori- zation was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.
III. Uses and Disclosures With Neither Consent nor Authorization I may use or disclose PHI without your consent or authorization in the following circumstances:
■ Child abuse: When in my professional capacity, I have received information that gives me reason to believe that a child’s physical or mental health or welfare has been or may be adversely affected by abuse or neglect, I must report such to the county Department of Social Services, or to a law enforcement agency in the county where the child resides or is found. If I have received information in my professional capacity which gives me rea- son to believe that a child’s physical or mental health or welfare has been or may be adversely affected by acts or omissions that would be child abuse or neglect if committed by a parent, guardian, or other persons responsible for the child’s welfare, but I believe that the act or omission was committed by a person other than the parent, guardian,
or other persons responsible for the child’s welfare, I must make a report to the appropri- ate law enforcement agency.
■ Adult and domestic abuse: If I have reason to believe that a vulnerable adult has been or is likely to be abused, neglected, or exploited, I must report the incident within 24 hours or the next business day to the Adult Protective Services Program. I may also report directly to law enforcement personnel.
■ Health oversight: The State Board of Examiners has the power, if necessary, to sub- poena my records. I am then required to submit to them those records relevant to their inquiry.
■ Judicial or administrative pro- ceedings: If you are involved in a court proceeding and a request is made about the pro- fessional services I provided you or the records thereof, such information is privileged under state law, and I will not release information without your written consent or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
■ Serious threat to health or safety: If you communicate to me the intention to com- mit a crime or harm yourself, I may disclose confidential information when I judge that disclosure is necessary to protect against a clear and substantial risk of imminent serious harm being inflicted by you on yourself or another person. In this situation, I must
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limit disclosure of the other- wise confidential information to only those persons and only that content which would be consistent with the standards of the profession in addressing such problems.
■ Workers’ compensation: If you file a workers’ compen- sation claim, I am required by law to provide all exist- ing information compiled by me pertaining to the claim to your employer, the insur- ance carrier, their attorneys, the South Carolina Workers’ Compensation Commission, or you.
IV. Patient’s Rights and Psychologist’s Duties
PATIENT’S RIGHTS ■ Right to request restrictions:
You have the right to request restrictions on certain uses and disclosures of PHI about you. However, I am not required to agree to a restriction you request.
■ Right to receive confidential communications by alterna- tive means and at alternative locations: You have the right to request and receive con- fidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. On your request, I will send your bills to another address.)
■ Right to inspect and copy: You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as
long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.
■ Right to amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.
■ Right to an accounting: You generally have the right to receive an accounting of dis- closures of PHI regarding you. On your request, I will discuss with you the details of the accounting process.
■ Right to a paper copy: You have the right to obtain a paper copy of the notice from me on request, even if you have agreed to receive the notice electronically.
NURSE PSYCHOTHERAPIST’S DUTIES
■ I am required by law to main- tain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
■ I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.
■ If I revise my policies and pro- cedures, I will mail you a copy of the new notice.
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V. Questions and Complaints If you have questions about this notice, disagree with a deci- sion I make about access to your records, or have other concerns about your privacy rights, you may ____________. If you believe that your privacy rights have been vio- lated and wish to file a complaint with our office, you may send your written complaint _____________. You may also send a written com- plaint to the secretary of the U.S. Department of Health and Human Services.
You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.
VI. Effective Date, Restrictions, and Changes to Privacy Policy This notice will go into effect on April 14, 2004. I reserve the right to change the terms of this notice and to make the new notice for all PHI that I maintain. I will provide you with a revised notice by mail.
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APPENDIX 4.2 Contract
Welcome to my practice. The following includes some essential information regarding psychotherapy. Please read and sign at the bottom to indicate that you have reviewed this information.
lENGTh AND FREQUENCY oF TREATMENT
Psychotherapy typically involves reg- ular sessions, usually 45 minutes in length. Duration and frequency vary depending on the nature of your prob- lem and your individual needs.
Confidentiality
Information you share with me will be kept strictly confidential and will not be disclosed without your written consent. By law, however, confidential- ity is not guaranteed in life-threatening situations involving yourself or others, or in situation in which children are put at risk (such as by sexual or physi- cal abuse or neglect). If I need to dis- cuss your treatment with a colleague, I will take pains to disguise identify- ing information, including using a pseudonym.
Fee Policies
My fee for an individual therapy ses- sion is ________ per session. If you need to cancel an appointment, please tell me at least 24 hours ahead of time; otherwise, you will be charged for the missed session. Please be aware that insurance carriers will not cover cancel- lation charges.
If you carry Anthem Blue Cross insurance coverage where I am a
provider, I will bill your carrier and assist with insurance reimbursement. In this circumstance, the insurance car- rier limits the fee charged for the ses- sion and you will not be charged for the difference between my ordinary fee and the cap placed by insurance. Any copayment necessary should be made at the time of the office visit. Unless we make another explicit arrangement, you are responsible for filing insur- ance claims for all other carriers where I am not a provider. I will give you a bill at the beginning of the month for the previous month and would like to receive payment at that time or at the next session.
Phone and Emergency Contact
If you need to contact me by phone, do not hesitate. When I am not available, my answering machine will take a mes- sage. I am usually able to return calls the same day. You will not be charged for phone calls unless we have a sched- uled conversation of an information- exchanging or problem-solving nature that lasts more than 10 minutes. If you cannot reach me in an emergency, you can find help at the Emergency Ser- vices number of the local hospital at 203-852-2000.
Physician Contact
Physical and psychological symptoms often interact. I encourage you to seek medical consultation if warranted. It may benefit your treatment for me to speak to your primary care provider, in which case, I will ask your permission first.
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Freedom to Withdraw
You have the right to end therapy at any time. If you wish, I will give you the names of other qualified psychotherapists.
Informed Consent
I have read and understood the preced- ing statements. I have had an opportu- nity to ask questions about them, and I agree to enter a professional psycho- therapy relationship with ___________ _______________.
Notice of Privacy Practices
I have read the NOTICE OF PRIVACY PRACTICES given to me by _________ __________________. I have been given a copy to keep. I understand my rights and responsibilities and know that I may ask questions about my personal health information and its safekeeping at any time.
Signed: __________ Date: ___________
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APPENDIX 4.3 Process Note
This page is a psychotherapy process note under the Health Insurance Portability and Accountability Act (HIPAA) regulations. It must not be included in or attached to any other part of the patient’s healthcare records except with other psycho- therapy notes. Patients may request access to these notes only under exceptional circumstances and access may be denied if it is deemed harmful to the patient. Releasing these notes requires a special authorization.
Patient name:
(for each entry, date code, time, and signature)
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APPENDIX 4.4 Progress Note
Kathleen Wheeler, PhD, PMHNP-BC, APRN, FAAN 69 Seabright Avenue Bridgeport, CT 06605
Patient name: ______________ Diagnoses (DSM-5): ______________ Date: ______________ S: O: A: P: CPT code: ______________ Prognosis: ______________ Signature: ______________ Visit time: ______________
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APPENDIX 4.5 Process Recording
Purpose
The process recording is a written account of a session between a patient and therapist. Through the reconstruc- tion of the interaction, the student is provided with an opportunity to retro- spectively examine and analyze your facilitative communication skills and therapeutic use of self and the patient’s contribution to the interaction. Through an analysis of what is said (the content of the interaction) and the flow of the inter- action (the process of the interaction), awareness is increased of your own feelings, values, attitudes, expectations, assumptions, and verbal responses and how all influence the interaction with the patient. The analysis also helps you to distinguish between your own thoughts and feelings and gain insight into how this influences the perception of the patient, the patient’s situation, and how the patient is coping.
The therapist analyzes what is said (the content) and the flow of the inter- action (the process of the interaction). This analysis is then used to increase self-awareness of your own feelings, values, attitudes, and beliefs and how they influenced the interaction with the patient. This analysis also helps to dis- tinguish between your own thoughts and feelings, and gain insight about how each influences your perception of the patient. The process recording also provides you with an opportunity to retrospectively examine and ana- lyze a patient’s behavior. Through this analysis, inconsistencies or consisten- cies between what the patient says and does can be identified and used to help patient gain insight about their prob- lems and function more effectively.
Directions
There should be four columns, the first designated as Therapist Said, the second, Patient Said, the third, Therapist Thought/ Feeling column, and the fourth, the Analysis column plus a Summary page. See criteria on the next page regarding what should be in each column and form for how to set up. At the end of the session, write down everything you can remember that the person said in the Patient Said column, then go back and fill in what you think you said in the Therapist Said column, then fill out the Therapist Thought/Feeling column, and the Analysis column last. After reading over, write a summary of the interac- tion on a separate page.
If you have gaps in your memory or cannot recall the exact flow of the inter- action, indicate this in the Analysis col- umn and examine why you think you might have “forgotten” (e.g., “I wonder whether the topic was anxiety provok- ing to me?”). Don’t write while talking with the person. The process recording is an efficient way to provide students with help with their communication skills; therefore, choose an interaction that was difficult or problematic (e.g., you were stuck, speechless, and over- whelmed). You will probably think of alternative ways of dealing with the situation after reading it over. Open- ness about problems encountered dur- ing the interaction will facilitate helpful feedback that will enhance both your communication skills and therapeutic use of self.
Some of the patients that you will encounter come from very different cul- tural and socioeconomic backgrounds, and have very different values,
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expectations, perceptions, and behavior. An important part of the learning expe- rience is to identify those differences and how they influence your ability to be sensitive, empathic, nonjudgmental, accepting, and therapeutic.
CRITERIA FoR EVAlUATIoN oF PRoCESS RECoRDING
Therapist __________________________ Patient’s initials _____________________ Date ______________________________
In Therapist Said Column
Reconstruct an interaction with a patient using the assigned format.
Document, in the “therapist said” column, verbatim statements (what you said as closely as you can remem- ber) during the interaction.
In Patient Said Column
Document, in the “patient said” col- umn, verbatim statements (what the patient said as closely as you can recall) during the interaction.
In Therapist Thought/Feeling Column
Separate out your thoughts and feelings and indicate by a T for Thought or F for Feeling at the end of each sentence.
Document the cognitive responses (what you thought) during the interaction. (T)
Document your affective response (your feelings and emotions such as anxiety and sadness) in response to what occurred during the interaction. (F)
In Analysis Column
■ Identify how thoughts and feelings influence own behavior.
■ Identify own values, beliefs, attitudes, expectations, and assumptions, and how they influence perceptions and responses to the patient.
■ Identify own expectations and how they influence perceptions and responses to the client. Identify inconsistencies between what the cli- ent is saying and doing, or between the patient’s situation and efforts to function effectively.
■ Identify discrepancies between ver- bal and nonverbal behavior.
■ Identify discrepancies between the patient’s perception of potential or existing problems and the reality of these problems.
on Summary Page
■ Identify patient resistances to dis- closing and examining potential or existing problems.
■ Identify nonverbal behavior that indicates resistance to dealing with existing or potential problems.
■ Identify verbal behavior that indi- cates resistance to dealing with exist- ing or potential problems.
■ Identify any defenses that you thought the patient manifested.
■ Identify responses to the patient that were ineffective or nontherapeutic.
■ Identify the verbal input that was a barrier to facilitating the relationship with patient.
■ Label the barrier to facilitating the relationship with the patient.
■ Identify alternative effective responses that would have facili- tated the interaction with the patient.
■ Identify examples of latent communication.
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Use the attached format to document the interaction
When documenting the interaction, set up the columns so that the reader can see the flow by staggering what is documented in the “therapist” and “patient” columns.
Therapist Said Patient Said Therapist Thought/
Feeling Analysis
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APPENDIX 4.6 Inventory of Countertransference
1. What are your reasons for becom- ing a nurse psychotherapist? How might these reasons hinder your effectiveness as a therapist?
2. Are you aware of reacting to cer- tain types of people in overprotec- tive ways or wanting to rescue people? If yes, what does this say about you?
3. Are you able to allow others to experience their emotional pain, or do you want to take the pain away and react quickly to alleviate the discomfort of others?
4. How do you feel when you are not appreciated by others who you have cared for?
5. How do you react when anger is expressed toward you?
6. How do you feel when your patients are not motivated to
change or do not follow your instructions and suggestions?
7. What types of patients do you find yourself wanting to distance from?
8. What can you learn about yourself by looking at those who you are likely to reject?
9. Do you need approval of your patients? How willing are you to confront a patient even at the risk of being disliked?
10. Do you offer patients a lot of “fix it” statement and advice?
11. Do you have a lot invested in stay- ing positive and find yourself reas- suring patients that they will be all right?
12. Do you frequently extend the time of the sessions or feel in general that you are not enough?
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APPENDIX 4.7 Sample Termination Letter
Date ____________
Dear ____________, The last session we had was on ________ (date) and you have missed two sched- uled appointments since then. I did leave you two telephone messages but you have not responded. I hope you are okay and will contact me in the near future to resume treatment. As the contract you signed stated when you initially came to therapy, regular appointments are important in order to continue to make prog- ress. I believe it is not in your best interests to terminate now. I would like to con- tinue to work with you but if you would like a referral elsewhere, please call me and I can make some suggestions for ongoing treatment. If I do not hear from you by ________ (date 2 weeks away), I will consider your treatment under my care to be terminated. If you have any difficulties, please go to your nearest emergency room. I hope to hear from you soon.
Best Regards, Kathleen Wheeler, PhD, PMHNP-BC, APRN, FAAN