Module2- Multicultural Competence in Counseling and Psychotherapy

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In 2002, the American Psychiatric Review Committee mandated that all psychiatric residency programs require competency training in psychodynamic therapy (PDT), cogni- tive behavioral therapy (CBT), supportive and brief psychotherapies, and psychotherapy combined with psychopharmacology in order to meet accreditation standards (Plakun, Sudak, & Goldberg, 2009). This list was further refined to what is termed the Y Model, with the stem of the Y being the shared elements or common factors in psychotherapy while the arms are PDT and CBT with supportive therapy at the base of the Y (Plakun et al., 2009). Delineation of these competencies is important in that this mandate was a direct response to the increasing emphasis on medication as the treatment for psychiatric disorders and reaffirmed the importance of psychotherapy in psychiatric treatment. These core competencies in psychiatrists’ education indicate a significant cultural shift that may also herald academic changes for advanced practice psychiatric nursing education.

Many factors in graduate psychiatric nursing education challenge APPNs in attaining competency in psychotherapy. One challenge for nursing education is how to teach the requisite competencies and essentials that are required in graduate nursing curricula without increasing the total credit load. To remain competitive, programs need to offer coursework that can be completed in a reasonable amount of time and with a reason- able number of credits. It is not possible in a short period—usually 2 years for most full- time graduate master’s degree nursing programs and 3 years or more for the Doctorate of Nursing Practice (DNP) degree, to attain proficiency in psychotherapy, but compe- tency must be achieved. Psychotherapy competency was identified as necessary for all psychiatric-mental health nurse practitioner (PMHNP) programs as of 2003 (National Panel for Psychiatric Mental Health NP Competencies, 2003) and reaffirmed with the 2013 revised PMHNP Competencies (2013). With these competencies delineated and endorsed by the Commission on Collegiate Nursing Education (CCNE) for accreditation, all gradu- ate APPN programs seeking CCNE accreditation must teach psychotherapy skills. In addi- tion, to sit for the American Nurses Credentialing Center (ANCC) certification exam as a PMHNP, applicants are required to have clinical training in a minimum of two modalities of psychotherapy (ANCC, 2020).

Another change in nursing education that significantly impacts APPNs is the endorse- ment of the DNP by leaders in nursing, the NONPF, and the American Association of Colleges of Nursing (AACN). The DNP degree is envisioned as a terminal practice degree and is proposed to supplant the Master of Science in Nursing (MSN) degree for nurse practitioners by 2025 and will include a clinical research focus. Impetus for this shift came from the lack of parity with other healthcare disciplines, the high amount of credits required in current master’s curricula, current and projected shortage of faculty, and the increasing complexity of the healthcare system (Dracup, Conenwett, Meleis, & Benner, 2005). Debate continues about whether this terminal practice doctorate will enhance or dilute advanced practice. It is not clear how curricula and program require- ments will evolve to provide the needed practice expertise for APPN students. Faculty need current expertise in psychiatric advanced practice to effectively teach, and concerns have been expressed about whether graduate faculty have greater academic experience than practice experience because academia traditionally rewards faculty who publish and do research. Clinical practice and teaching are often overlooked in promotion deci- sions, and faculty members tend to emphasize research over practice, which may not bode well for APPN faculty expertise in psychotherapy skills.

A survey of APPNs in 2009 revealed that most APPN practice time is spent prescrib- ing, conducting diagnostic assessments, and psychotherapy with medication manage- ment but rarely solely conducting individual psychotherapy (Drew & Delaney, 2009). A more recent national survey of 1,624 APPNs reveals that 82% provide education and 71% provide diagnostics, management, and prescribing, while 65% provide some type of psychotherapy, with 15% practicing psychotherapy alone. 65% is a significant

6 ■ I. GETTING STARTED

increase from the 2009 data (Delaney, Drew, & Rushton, 2019). Perhaps given the current and projected shortage of psychiatrists, the need for APPNs who can provide the full spectrum of mental health services will continue (Burke et al., 2013).

A significant challenge for graduate nursing education is the difficulty of finding preceptors and clinical sites for psychiatric graduate nursing students to practice psy- chotherapy. Most settings have social workers who conduct psychotherapy while the APPNs most often prescribe. This is a cost-effective approach for the agency or clinic because APPNs usually earn more per hour than social workers, but it does not provide the student nurse psychotherapist with adequate experience to practice psychotherapy. APPN students can sometimes work out an arrangement in which the student can see the preceptor’s patients for psychotherapy while the psychiatric APPN preceptor man- ages the medication, or preceptors from other licensed mental health disciplines who are conducting psychotherapy may be asked to serve as preceptors for a limited number of hours for APPN students. In addition to the liability issues with this arrangement, space constraints, agency policy, or lack of adequate psychotherapy supervision may prohibit the student from seeing an adequate caseload of patients for psychotherapy.

A national survey of 120 academic psychiatric-mental health nursing graduate pro- grams confirmed the scarcity of sites and found a wide range of individual psychotherapy practice hours required for students, ranging from a minimum of 50 to a maximum 440 hours in the programs for which a certain number of requisite hours are required for psychotherapy (Wheeler & Delaney, 2008). For approximately 50% of programs, how- ever, no designated number of psychotherapy practice hours was required, and medica- tion management hours were integrated along with psychotherapy. A more recent survey reveals significant differences in how APPN programs teach psychotherapy (Vanderhoef & Delaney, 2017). The lack of consistency points to the need for more specific competen- cies and guidelines for what and how psychotherapy content should be taught.

Consequently, most graduate psychiatric nurses leave their graduate studies with a less than adequate knowledge base in this area, and often do not feel competent to practice psychotherapy. Faculty teaching students in graduate programs, when asked whether their students had achieved competency on graduation, felt decidedly mixed, with some stating that they did not envision a future role as psychotherapist and others suggested further training and supervision for competency to be achieved.

Working with people in the intimacy of psychotherapy is an honor, and much good can be done, as well as a great deal of harm. At vulnerable times in their lives, people see the psychotherapist as an expert, and this role often is imbued with a great deal of power and credibility. This privilege also comes with an ethical responsibility for the nurse psy- chotherapist to get as much training, supervision, and experience as possible in gradu- ate studies and throughout her or his professional life. Expertise is a lifelong pursuit, and continuing education is imperative for those who wish to practice competently. Most licensed mental health professionals in other disciplines, which have considerably more psychotherapy practice in their programs than graduate psychiatric nursing pro- grams, agree that it takes at least 10 years to become a skilled psychotherapist.

Stages of Learning

How then does one begin to learn psychotherapy? Psychotherapy is a learned skill like any other. The learning process begins with studying each component and practicing the technique and then blending it back together again with what you already know as each separate skill is acquired. Remember how you learned to take blood pressure or any other nursing skill? This can only be accomplished through learning discrete steps and practicing competencies in a skill set until that skill becomes automatic. If it seems like hard work at first, it probably means you are doing it well.

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Benner (1984) offers a model of role acquisition from novice to expert that examines the levels of competency that can be applied for the novice nurse psychotherapist. It is likely that the graduate student who is pursuing a master’s degree or postmaster’s cer- tificate as an APPN has practiced as an expert in an area of specialization before graduate studies. To transition from expert back to novice is often a painful and anxiety-provoking process. The beginning nurse psychotherapist has most likely interacted professionally with many different types of patients, but there is usually much anxiety about the first session in the role as psychotherapist. There is usually no one right thing to say. In psy- chotherapy, there is much ambiguity and often no right answers.

Juxtaposed to Benner’s model is the four stages of learning model, which may help to allay anxiety for those who are beginning to learn psychotherapy (Table 1.2). Although there is some controversy regarding who developed this model, it is thought that learn- ing takes place in four stages:

1. Unconscious incompetence (i.e., we do not know what we do not know). 2. Conscious incompetence (i.e., we feel uncomfortable about what we do not know). 3. Conscious competence (i.e., we begin to acquire the skill and concentrate on what we

are doing). 4. Unconscious competence (i.e., we blend the skills together, and they become habits,

allowing use without struggling with the components).

The challenge initially for novices is that they are becoming increasingly aware of being incompetent as progress is made. This is likely to generate anxiety.

unique Qualities of Nurse Psychotherapists

The history of the one-to-one nurse–patient relationship and nurses conducting psycho- therapy is detailed by Lego (1999) and Beeber (1995). Table 1.3 highlights the important events. The late 1940s were marked by the development of eight programs for the advanced preparation of nurses who cared for psychiatric patients. An extremely important debate took place over the next few decades about the nurse’s role as psychotherapist. This cul- minated in the 1967 American Nurses Association (ANA) Position Paper on Psychiatric Nursing, which clarified the role of the clinical specialist in psychiatric nursing as psycho- therapist, and certification for the specialty began in 1979. In the 1990s PMHNP programs were developed, and this culminated in the PMHNP competencies that included psycho- therapy as an essential competency required for all PMHNPs (Wheeler & Haber, 2004).

TABLE 1.2 COMPARISON OF BENNER’S MODEL AND THE STAGES OF LEARNING

Stages of Learning Benner’s Model

Unconscious incompetency

Novice no experience, governed by rules and regulations

Conscious incompetency

Advanced beginner recognizes aspects of situations and makes judgments

Conscious competency Competency/proficiency 2–5 years experience, coordinates complex care and sees

situations as wholes, and long-term solutions

Unconscious competency

Expert flexible, efficient, and uses intuition

8 ■ I. GETTING STARTED

The APPN role of psychotherapist has solid historical roots from the inception of advanced practice psychiatric-mental health nursing, whereas the prescribing role is a much more recent step in the evolution of the specialty. The current role of APPNs is focused on pre- scribing psychotropics which is more aligned with the medical model (Delaney, Drew, & Rushton, 2019).

After the issue of whether nurses should do psychotherapy was resolved, the lit- erature examined the unique qualities that nurses might possess as psychotherapists compared with those in other disciplines who practice psychotherapy. Several strengths were cited: nurses have the ability to be patient because they have worked with the chronically ill and have respect for others’ limitations; nurses are realistic and possess excellent observational skills, resourcefulness, innovation, and creativity (Smoyak, 1990); nurses are able to view the patient in a holistic way, understand crisis orientation, and have a knowledge of general health concerns (Lego, 1992); and nurses are famil- iar with the daily life and experience of the hospitalized patients (Balsam & Balsam, 1974). Nurses usually have had a breadth of life experience and exposure to many different ages, ethnicities, occupations, socioeconomic status, cultures, and personali- ties. The novice nurse psychotherapist is well served through experience with com- municating and connecting with those from diverse backgrounds. Nurses being close to the patient’s everyday experience is crucial for connection and collaboration. This connection is reflected in the public perception of nurses as positive and trustworthy. In 2019 for the 18th year in a row, the Gallup poll found that nurses top the list of most ethical professions, with Americans rating nurses among the most trusted professionals.

TABLE 1.3 TIMELINE OF THE HISTORY OF THE NURSE PSYCHOTHERAPIST

1947 Eight programs established for advanced preparation of nurses to care for psychiatric patients

1952 Hildegard Peplau establishes the first master’s in clinical nursing and a “Sullivanian” framework for practice for psychotherapy with inpatients and outpatients

1963 Perspectives in Psychiatric Care first published as a forum for interprofessional psychiatric articles

1967 American Nurses Association (ANA) Position Paper on Psychiatric Nursing—PCS (psychiatric clinical specialist) assumes role of individual, group, family, and milieu therapist

1979 ANA certification of psychiatric and mental health clinical nurse specialist (PMHCNS)

2000 American Nurses Credentialing Center (ANCC) certification of psychiatric-mental health nurse practitioner (PMHNP)

2001 Family PMHNP ANCC Exam

2003 PMHNP Competencies developed and delineate “conducts individual, group, and/or family psychotherapy” for PMHNP practice

2011 American Psychiatric Nurses Association (APNA) and International Society of Psychiatric-Mental Health Nurses (ISPN) endorse PMHNP as the entry role for all advanced practice psychiatric nurses

2013 PMHNP Competencies revised

2014 Only PMHNP Across the Life Span ANCC certification

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Eighty-five percent of respondents rated nurses’ honesty and ethics as “very high” or “high” with medical doctors rated third at 65% (Gallup, 2020).

An additional quality that nurses bring to the role of psychotherapist is a pragmatic, problem-solving approach using the nursing process as an overall framework for practice. Usually, the patient has tried many things to feel better, and therapy is often a last resort. The patient’s problems have brought the person into treatment, and if these problems could be solved outside of therapy with friends or family, he or she would have already done so. The problem-solving approach needed in the psychotherapeutic process is the same as in the nursing process. Both involve an assessment, diagnosis, plan, intervention, and evalua- tion. Nurses are used to collaborating with patients and thinking about what will solve the problem, what the patient’s perspective is, what the person wants, and what the patient’s strengths are. These approaches are derived from a problem-solving, health-oriented, holistic model fundamental to nursing practice and the nurse–patient relationship.

In my experience working with graduate psychiatric nursing students, this problem- solving approach is useful but one that novice nurse psychotherapists often struggle with. Because nurses are used to taking care of people and are action oriented, begin- ning students often want to rescue the patient and help the patient to feel better. Helping the patient feel better is not the main goal of psychotherapy, and a focus on amelioration of symptoms may even be counterproductive to the process, although feeling better overall most likely will be a by-product of successful therapy. In a well-intended effort to help the person feel better, the nurse may be too directive and offer fix it sugges- tions, and this is antithetical to promoting empowerment. Letting the psychotherapeu- tic process unfold takes time, and that has typically not been a part of nursing practice, especially within the current healthcare system.

Requisites for Nurse Psychotherapists

Nurse psychotherapists have the honor of participating in the healing process, and as nurse theorists Dossey and Keegan (2013) point out, in the nurse–patient relationship, the nurse enters into a shared experience or field of consciousness that promotes the healing potential of others. Through consciousness, intent, and presence, the nurse psy- chotherapist’s therapeutic use of self facilitates others in their healing. To counter the learned patterns of nursing practice (i.e., busyness, task focused, and control), the nurse psychotherapist needs to cultivate reflection, mindfulness, and patience. According to Dossey and Keegan (2013), qualities essential for nurse healers include expansion of consciousness and continuing one’s own journey toward wholeness and resilience. This can be accomplished through many different venues: nature, relationships, your own therapy, ongoing supervision, meditation, mindfulness, self-awareness exercises, spiri- tual practices, chanting, prayer, journaling, openness to receiving one’s own healing treatments, and reflective activities such as hiking, walking, and yoga. Research has shown that the regular practice of mindfulness improves empathy, insight, immune function, attention, and emotional regulation (Dahlgaard et al., 2019). These changes correspond to changes in the brain that include increased activity and growth of regula- tory and integrative regions which foster resilience.

Mindfulness is a skill that can be learned through practice and discipline and used as a tool in the psychotherapeutic process. The vast literature on the development of mindfulness crosses many disciplines and orientations, from Buddhism to psy- choanalysis. Mindfulness is discussed more fully in Chapters 17 and 18. Safran and Muran (2000) state that mindfulness in psychotherapy has three characteristics:

(a) The direction of attention, (b) remembering, and (c) nonjudgmental awareness. The initial direction of attention involves intentionally paying attention to and observing

10 ■ I. GETTING STARTED

one’s inner experience or actions. This involves cultivating an attitude of intense curiosity about one’s experience. In mindful meditation, the individual can initially cultivate the ability to attend by focusing the attention on an object (e.g., the breath) and then noting whenever his or her attention has wandered and returning it to the intended focus of atten- tion. By noting whatever one’s attention has wandered toward (e.g., a particular thought or feeling) before redirecting one’s attention, the individual develops the ability to observe and investigate his or her experience from a detached perspective rather from being fully immersed in or identified with it. (p. 59)

Peplau (1991) stressed the need for self-awareness in the nurse–patient relationship and stated: “The extent to which each nurse understands her own functioning will determine the extent to which she can come to understand the situation confronting the patient and the way he sees it” (p. x). However, with the rise of psychopharmacology and biological psychiatry, self-awareness has not been a priority. Self-awareness is key to understanding others, and it reduces the likelihood that therapists will act out their own agendas and use patients for gratification or self-esteem needs. For example, one novice nurse psychotherapist was so rewarded emotionally by his work with a par- ticular patient that he went out of his way to meet with her when she needed him and to schedule additional office hours when he would not normally be in the office. The patient responded with gratitude, which enhanced the self-esteem of the nurse who was conscientious and overly responsible for this patient. It was only through supervision that he began to understand how his need for recognition fueled the overly accommo- dating stance; how his objectivity about the psychotherapeutic process had been com- promised; and how this cultivated an unhealthy dependency in the patient.

Peplau (1991) says that there is a tendency for all those doing therapeutic work to generate inferences from limited data and to assume that these data are complete. It is only natural that we would try to fit the problem into our own limited schemata of experiences, but the richness of clinical data belies this belief. Attributing motivation to one simple reason, such as “she’s borderline and manipulative,” is simplistic and may assuage our anxiety but does not account for complex, multifaceted interactions and contributions that are more often the norm than the exception. Symptoms are usually multidetermined and have many different contributing factors.

Overdeterminism refers to the idea that a problem most often has many different causes. The patient may not be able to provide a full description of these contributions and most likely is unaware of the multiple reasons for the current symptom. For exam- ple, a young woman with bulimia may have factors that contributed to the development of her problem: a history of sexual abuse, feelings of deprivation and neglect in her family, a recent loss in her family, a genetic predisposition, a fear of weight gain, cul- tural pressures about weight, an overemphasis on weight in her family, an inability to self-soothe, a hormonal imbalance, the stress of a new job, and a best friend who is also bulimic. The friend with the same problem may have a few of these contributing factors and others, such as conflict in her home with an abusive, alcoholic father; a depressed, unavailable mother; and financial difficulties that contribute to the instability of her home environment and compromise her ability to manage her emotions. There are no simple answers, and two people with the same problem may have developed and main- tained their symptoms for different reasons. Many factors, such as genetics, prenatal insults, parent–child interactions, abuse, neglect, school and social environments, fam- ily dynamics, and physical illness, have been studied, and all have been found to play a role in the cause of psychiatric disorders and mental health problems.

We all have preconceptions that are brought to every situation. It is not as important to eliminate these as to be aware of what they are and how they may influence our work. The extent of a nurse’s self-knowledge determines the extent to which he or she can

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understand another person. Neuroimaging studies have confirmed that being aware of another’s mind is related to a person’s ability to monitor his or her own mental state (Siegel, 2012). A person does not have to be a paragon of mental health to help another. Some feel that to be truly empathic, a person should have experienced psychological suffering, which can serve to deepen the work in psychotherapy. Most expert therapists consider personal therapy and supervision essential for the novice psychotherapist to cultivate emotional genuineness, authenticity, and objectivity. Supervision is not ther- apy, but it does assist the therapist in discussing difficult cases and understanding his or her own blind spots and how personal issues may impact the therapeutic relationship. Ongoing group or individual supervision after graduation is necessary for continued growth and an ethical practice. Expert psychotherapists usually seek supervision and consultation throughout their professional lives. A sample of suggestions for presenting a case that may be covered in supervision is included in Appendix 1.1.

Irvin Yalom cogently makes a case for therapy for the therapist:

Therapists must be familiar with their own dark side and be able to empathize with all human wishes and impulses. A personal therapy experience permits the student therapist to experience many aspects of the therapeutic process from the patient’s seat: the tendency to idealize the therapist, the yearning for dependency, the gratitude toward a caring and attentive listener, and the power granted to the therapist. Young therapists must work through their own neurotic issues, they must learn to accept feedback, discover their own blind spots, and see themselves as others see them; they must appreciate their impact upon others and learn how to provide accurate feedback. (Yalom & Ferguson, 2002, pp. 40–41)

The student of psychotherapy who undergoes his or her own psychotherapy has a model for what the psychotherapeutic process is and understands the power and the process of psychotherapy in an immediate, experiential way that no amount of reading or didactic study can convey. Many expert psychotherapists report that they have expe- rienced various modes of psychotherapy and this has enhanced their own technique as the skills others use are incorporated into their own practice.

In addition to self-awareness, enhancing one’s own resilience through promoting self-care is fundamental in caring for others. Self-care strategies start with exercising regularly, eating healthily, spending time with friends, getting enough sleep, and lim- iting work hours to avoid exhaustion. When a flight takes off, the airline attendant announces that all adults must put the oxygen mask over their faces first before securing the mask on a child. This is an appropriate metaphor for all caregivers. Much has been written about the trauma inherent in nursing. Various terms have been used to describe this phenomenon, such as burnout, compassion fatigue, and vicarious or secondary traumatization. A 2017 survey of employed RNs in hospitals reported that 63% experi- ence burnout (Kronos, 2017). Burnout may occur for many reasons: our collective his- tory as a profession of women, the patriarchal medical system and nurses’ subservient role, stressful healthcare environments, and caring for and witnessing trauma and pain in others. Most often, personal and professional trauma is unrecognized and therefore unaddressed. Sequelae of exposure to other’s trauma may include fatigue, depression, anger, apathy, detachment, headaches, insomnia, and gastrointestinal distress (Foli & Thompson, 2019), all of which mitigate against the ability to adopt the psychothera- peutic stance necessary for conducting psychotherapy. It is only in the recognition and processing of one’s own trauma that one can transcend it and be of help to others. A resource for understanding and overcoming compassion fatigue can be found at www. edumed.org/resources/compassion-fatigue-online-guide.

Competencies for Trauma and Resilience for Nursing Education have been devel- oped and include self-resilience competencies for APPNs (Wheeler & Phillips, 2019).

12 ■ I. GETTING STARTED

These competencies build on those for undergraduate and graduate level educa- tion and are copyrighted. The full document with subcompetencies are included online in the faculty resource website and at www.acesconnection.com/blog/ trauma-and-resilience-competencies-for-nursing-education.

HOLISTIC PARADIGM OF HEALING

In contrast to the biomedical model’s goal to cure with symptom relief treatment, the goal in a holistic paradigm is healing (see Figure 1.1). This is an important distinction, because curing is not always possible but healing is (Dossey & Keegan, 2013). The word heal comes from an old Anglo-Saxon word haelen, which means “to become whole, body, mind, and spirit within oneself”; but it can also be defined in a broader context as being in “right relationship” with oneself, others, and our world. Mariano defines healing as “an emergent process . . . bringing together aspects of one’s self and the body, mind, emotion, spirit, and environment at deeper levels of inner knowing, leading to an integration and balance” (2013, p. 60). Each component is interdependent and inter- related, based on the premise that when there is a change in one part of the system, the change reverberates in all dimensions. For example, minor changes in one’s emotions may potentiate a change in all other spheres as well as in the person’s relationship with others and his or her world. Conversely, a change in the context or relationships with others may create changes in other dimensions (e.g., body, mind, emotion, spirit) of the person. The context or background is the person’s culture as mediated by the person’s family and relationships.

Some of the goals of psychotherapy include the reduction of symptoms, improve- ment of functioning, relapse prevention, increased empowerment, and achievement of the specific collaborative goals set with the patient. Within the biomedical model, symp- toms are often thought to be the cause of the patient’s problem and psychotropic medi- cations are prescribed to target specific symptoms in an effort to eliminate or reduce the symptoms. For example, prescribing a selective serotonin reuptake inhibitor (SSRI) to increase serotonin levels is thought to treat the underlying cause of the depressive disorder. However, whether this chemical imbalance causes depression or coexists with some depressive disorders is a matter of speculation.

In contrast, in a holistic model, symptoms are seen as a form of communication and are useful for understanding the meaning of the dysregulation and disharmony that are

Biomedical/Allopathic model

Relationship

Holistic model

Aim is to cure Aim is to heal

Medication

Medication

Relationship

Self- care

FIGuRE 1.1 Paradigms of care.

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occurring for this person at a given time. By eliminating the symptoms with medica- tion, we are essentially “shooting the messenger.” Often therapists find that therapy works best with full access to emotion; that is, if the person’s emotions are damped down by benzodiazepines or other psychotropic medication, psychotherapeutic work may be compromised. For example, CBT seeks to allow the patient to become more comfortable with sensations and concomitant emotions related to panic attacks so that automatic thoughts about how dangerous these feelings seem can be confronted. If the patient reaches for medication for quick relief, the person may lose motivation to continue the treatment (Cloos & Ferreira, 2009). Of course when the patient’s function- ing is impaired, psychotropic medications do have their place in treatment. However, reframing symptoms as communication changes the way we view the relation of the problem to the person and enhances our ability to hear the meaning of the symptoms as we listen to our patient as well as access the person’s emotion in order to facilitate the treatment of the patient.

The holistic paradigm is consistent with the mandate for recovery-oriented behavioral care. The Substance Abuse and Mental Health Services Administration (SAMHSA, 2020) provides a definition of recovery: “A process of change through which individuals improve their health and wellness, live a self-directed life and strive to reach their full potential.” In addition to holistic care, elements of care aimed toward recovery include hope, respect, multidimensional care through many path- ways, person-driven, supported by peers, culturally based, addresses trauma, sup- ported through relationships and social networks, involving individual, family, and community strengths and responsibilities. Research has identified five gold standards of recovery for patients: hope, self-esteem, empowerment, self-responsibility, and a meaningful role in life (Livingston & Boyd, 2010; Siu et al., 2012). Practitioners who are recovery-oriented recognize the strengths and power of each person within the context of his or her life. The vehicle for recovery is through partnership and relation- ship with the practitioner and others so that the person is the driver of his or her own healing process (SAMHSA, 2020).

These elements and gold standards for recovery may feel familiar to APPNs because nurses have been educated to look at the context of the patient’s life as they work in the reductionistic, symptom-oriented environment of the psychiatric biomedical para- digm. Biomedical psychiatry is based on a descriptive/biological approach of special- ized knowledge that treats individuals as members of a diagnostic group. The diagnosis is based on observable clusters of symptoms or behaviors and there is no assumption about causation except for the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013) category of trauma-related dis- orders. What is considered pathological is determined by societal values and behaviors that are considered acceptable at the time by a panel of, until most recently, exclusively psychiatrists. For example, the DSM-III considered homosexuality a psychiatric dis- order while the DSM-5 includes new diagnoses such as Binge Eating and Hoarding Disorders (APA, 2013).

The diagnosis may not tell us very much about the person sitting in front of us. The nurse is often the only person caring for the patient who sees the whole picture. The nurse knows the patient as “a grandmother who lives alone in a walk-up, estranged from her daughter and often terrorized by her own internal demons” while those practicing from a medical model might describe the same person as “an 88-year-old elderly woman with bipolar disorder.” The former is relevant about who the person is while the latter tells us nothing about the uniqueness of that indi- vidual. Indeed the nurse practicing from a holistic paradigm respects the complexity of the person, and historically, this has been the foundation for nursing practice.

14 ■ I. GETTING STARTED

Relationship

Relationship has been considered foundational for psychiatric nursing since Peplau’s seminal work in 1952 (D’Antonio, Beeber, Sills, & Naegle, 2014). The healing that takes place in psychotherapy occurs through the relationship between the therapist and the patient. Lego (1992) maintained that psychiatric nurses develop “a relationship designed to change the patient’s interpersonal situation, changing the intrapsychic situation, thus changing the brain chemistry” (p. 148). Forchuk and associates (1998) observed that the nurse–patient relationship is the “active ingredient” in therapeutic change. Raingruber (2003) concurs and says that relationship and nurturing are hallmarks of psychiatric nursing. Dossey and Keegan (2013) say that the healing relationship occurs through the expansion of consciousness, during which a sacred space is created.

Emotional connection promotes interpersonal attunement, attachment, and coreg- ulation of physiological states (Schore, 2019). Emotional connection with the patient through relationship has been found to be important for successful psychotherapy outcomes with 50% of positive outcomes due to therapist, relationship, and expec- tancy while the specific technique or theory used by the therapist accounts for only 17% of improvement; 33% of the variance is due to extratherapeutic factors such as spontaneous remission, patient, and community factors (Norcross & Lambert, 2019). The ability of the patient to connect through collaboration depends on the therapist’s skills and on the patient’s emotional developmental level, with some patients much better able to join in collaboration than others. Tryon and Winograd (2002) found that the more troubled, resistant, less-motivated patients are those most likely to need help and the least likely to engage and collaborate with therapists. Chronically disempowered patients, especially those who have been severely traumatized in childhood, often are unable to connect with others and use support to reach new solutions. The challenge for the APPN is how to facilitate connection, particularly with patients who have difficulty with relationships. Inherent in this connection is the APPN’s curiosity and openness to learning about another’s experience. The receptivity and openness of the therapist to what is presented offers the patient a model for developing curiosity about him- or herself and for an observing ego. It is thought that this capacity to develop the ability to observe one’s own behavior with nonjudgmental curiosity is a hallmark of emotional health.

Caring in the nurse-patient relationship has been identified as essential for prac- tice (Dossey & Keegan, 2013; Morse, Solberg, Neander, Bottorff, & Johnson, 1990; Schoenhofer, 2002; Watson, 2012). Caring encompasses and expands Carl Rogers’s idea of unconditional positive regard that has been adopted by most mental health disciplines as essential to helping relationships (Rogers, 1951). A phenomenologi- cal study delineated the characteristics of the APRN–patient relationship that are foundational to caring (Thomas, Finch, Schoenhofer, & Green, 2004). They include the mutuality of nonromantic love based on a genuine knowing of the person, trust, and respect reflected in an acceptance of and authentic appreciation for the other. Every person is approached with acceptance with the nurse and patient as copartici- pants in the process of healing. Inherent in caring is respect for the autonomy and agency of the other person. Fundamental to caring is the understanding of another person’s unique configuration of attitudes, feelings, and values from that person’s perspective.

The nurse psychotherapist creates a healing presence of acceptance, patience, kindness, nonjudgmental attitude, understanding, good listening skills, honesty, and empathy. These qualities are the essence of presence (McKivergin, 1997) and allow the nurse psychotherapist to “be with” rather than “doing to” the patient. Bunkers (2009)

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says, “True presence involves listening to what is important to the other and listening to what the meaning of a situation is in the moment for that person” (p. 22). Scaer (2005), a neurologist specializing in trauma, says that presence involves a personal interac- tion that contributes to physiological changes in the person. He states, “This healing, empathic presence affects and alters the parts of the brain that process pain, fear, anxiety, and distress” (p. 167). Presence may facilitate healing through mediation of neurotrans- mitters and hormones that promote optimal autonomic functioning.

The antithesis to empowerment is authority; in this situation, the therapist knows what is best for the person. The process of psychotherapy cultivates dependency because there is unavoidable inequality in the relationship with the patient, who naturally feels disempowered by needing help at a vulnerable time. This reality and the inevitable transference–countertransference responses create dependent feelings in the patient. The psychotherapist’s competence lies in understanding that the patient’s autonomy is always in the foreground of the process. The overall goal for patients is to deepen their understanding of themselves in order for them to make their own decisions. Caring is fundamental to creating an atmosphere conducive to the cultivation of relationship and empowerment.

Resilience

Both relationship and resilience are overarching pantheoretical concepts that apply to all approaches of psychotherapy and practice settings. The term resilience refers to the ability of an individual, family, or community to cope with adversity and trauma, and adapt to challenges through individual physical, emotional, and spiri- tual attributes and access to cultural and social resources (adapted from SAMHSA, 2014). In fact, there is speculation that surviving a crisis can actually be a growth- promoting experience for some people. However, other research supports that resil- ience and posttraumatic growth are inversely related; that is, those who cope well and are resilient after a traumatic event retain equilibrium and do not need to find positive meaning to the event while those who emerge with posttraumatic growth feel the need to reframe the event as positive (Levine, Lalufer, Stein, Hamama- Raz, & Solomon, 2009). A more recent study supports that moderate resilience and emotional intelligence is associated with the most growth (Li, Cao, Cao, & Liu, 2015). That is, there is a curvilinear relationship between posttraumatic growth and resilience.

An elegant yet simple resilience model based on neurophysiology is proposed by Elaine Miller-Karas and deepens our understanding how to help patients access their resources (2015). Miller-Karas says that one’s resilient zone (RZ) is an internal state of adaptabiliy and flexibility that is regulated by our nervous system. We feel at our best and can think clearly and deal effectively with life when we are in our RZ. She states that there is a natural biological rhythm of the autonomic nervous system between the sympathetic nervous system and the parasympathetic nervous system and this corre- sponds to the RZ. The RZ is also referred to as the window of tolerance (Ogden, Minton, & Pain, 2006), or the therapeutic window of arousal (Siegel, 2012). Porges’s polyva- gal theory refers to this state of our nervous system as the myelinated ventral vagus social engagement response (Porges, 2011). The brain and the body communicate with each other unconsciously through the vagus nerve. Chapter 2 discusses the polyva- gal theory and the neurophysiology of the RZ and its role in well-being and healing trauma. The skilled psychotherapist helps the person through various techniques that assist the person to mediate the autonomic nervous system and stay in their RZ, that is, not too hyperaroused (sympathetic system) and not too hypoaroused (parasympathetic

16 ■ I. GETTING STARTED

system; see Figure 1.2). This is the optimal physiological state for the work of therapy and reflects the person’s natural rhythm and flow of energy and vitality. Although the person may feel sad, happy, angry, and other emotions when in their RZ, the person is able to both feel and think at the same time.

If the person becomes too anxious and hyperaroused, resistances or defenses may increase, and the work of therapy will be thwarted, perhaps not consciously, but neverthe- less, the person’s brain will not be able to integrate memories or gain insight. Immediate strategies in a session to decrease arousal levels might include deep breathing exercises or imagery. There are also many patients who have suffered significant trauma and are in a chronic state of either hyperarousal or hypoarousal or swing from one physiologi- cal state to the other (see Figure 1.3). If the person is chronically hypoaroused, he or she may be unable to access emotions. Strategies for hypoarousal to increase arousal might include focusing on sensations in the body, mindfulness exercises, and self- regulation strategies. Self-regulation refers to one’s ability to manage emotions and behavior and is further discussed in Chapter 2. Psychotherapy helps those with emotional dysregula- tion to widen and strengthen their RZ.

Severe trauma has been found to override constitutional, environmental, genetic, or psychological resilience factors (De Bellis, 2001). Studies have shown that factors that enhance resilience include the presence of supportive relationships and attach- ments as well as the avoidance of frequent and prolonged stress (Herrman et al., 2011). These factors are not inborn but can be fostered through psychotherapeutic interventions that focus on the strengths of the person, reducing risks, and improv- ing relationships. Chapter 11 further discusses the RZ specific strategies to enhance resilience. Relationships form the foundation of resilience and serve to create new experiences that promote neuronal and synaptic connections that allow for learning new meaning for prior adverse experiences.

Figures 1.2 and 1.3 illustrate a user-friendly model that the APPN can teach patients at the beginning of therapy when making a treatment plan. Illustrating the RZ on paper and then drawing Figure 1.3 helps patients to understand their symp- toms without judgment as something physiological that is happening to them. Many patients have no understanding why they feel so out of control, anxious, depressed, or numb and providing a simple explanation based on neurophysiology with visu- als such as Figures 1.2 and 1.3 can be very helpful and destigmatizing. The message conveyed is, “It is not what is wrong with you but what has happened to you,”

Sympathetic Nervous System

charge charge

R es

ili en

t Z on

e

release

Parasympathetic Nervous System

One’s Resilient Zone is the best physiological state for thinking clearly and functioning well.

FIGuRE 1.2 Therapeutic window of arousal/tolerance, or resilient zone.

1. ThE NuRSE PSychoThERAPIST AND A FRAmEwoRk FoR PRAcTIcE ■ 17

which lays the foundation for a trauma-informed approach to your work together. Techniques and resources to widen or strengthen the patient’s RZ will be further discussed within the context of the various psychotherapy approaches presented in this book. See Chapters 2 and 11, for a fuller discussion of the underlying neuro- physiology of the RZ.

ANXIETY

Understanding, assessing, and managing anxiety is a cornerstone of Peplau’s Interpersonal Relations Model for Nursing (1991). Anxiety is ubiquitous in the psy- chotherapeutic process, and the skilled APPN understands how to assist the patient in managing anxiety. Anxiety creates feelings of helplessness, which disempower the patient and prevent healing. Wachtel (2011) says:

One of the chief aims of the psychotherapist is to help the patient overcome the fears and inhibitions that have led him to react to his normal and healthy feelings as if they were a threat; to help him reappropriate parts of himself that have been dissociated from full awareness, that have motivated avoidances, and that are likely to generate still further areas of vulnerability, deficits in crucial skills in living, and impediments to the very rela- tionships that could in principle be correctives to the debilitating anxiety. (p. 87)

For the most part, people seek psychotherapy because anxiety or the effects of anxi- ety have in one way or another interfered with functioning. Sometimes, a person is seeking help for the anxiety itself, such as in cases of panic attacks or phobias, but often the presenting issue is related to the results of the person’s efforts to avoid anxiety. For example, a person with borderline personality traits may present with depression as

Stuck in Low Zone

Edgy Irritable Mania

Anxiety & Panic Angry outbursts

PainStuck in High Zone

Traumatic/Stressful Event or

Stressful/Traumatic Triggers

R es

ili en

t Z on

e

Depression/Sadness Isolated

Exhaustion/Fatigue Numbness

FIGuRE 1.3 Out of the resilient zone. Source: Adapted by Elaine Miller-Karas from an original graphic by Levine/Heller. Reprinted with per- mission from the Trauma Resource Institute, Claremont, CA.

18 ■ I. GETTING STARTED

a result of a lost relationship, but the central issue is a vulnerability to abandonment anxiety. It is likely that in the person’s zeal to avoid the feared abandonments, that person inadvertently creates the very situation that he or she is trying so hard to avoid (Figure 1.4). Wachtel (2011) calls this cyclical psychodynamics, which is explained further in Chapter 5.

Inherent in all the theoretical approaches and basic principles discussed in this textbook is the centrality of anxiety as key to the patient’s problems and the manage- ment of anxiety as key to solving these problems. In the safety of the therapeutic rela- tionship, patients are encouraged to tolerate the feared experiences, memories, and thoughts. Cozolino (2017) says that a major role for the therapist is to assist the patient in using anxiety as a compass to explore unconscious fears. In deepening his or her understanding of anxiety as a trigger for avoidance or acting out, the person can then approach with curiosity what is feared. Strategies for working with anxiety are central to all therapy approaches. For example, behavioral techniques such as desensitization or flooding may be taught and increase anxiety initially, with the hope of decreasing anxiety later, so the person can face what was fearfully avoided. Cognitive techniques may involve “restructuring” thinking so that the threat that is anxiety-provoking is not considered as dire as originally believed. Psychodynamic techniques use interpre- tations to deepen the person’s understanding of anxiously avoided thoughts, wishes, and feelings by making the unconscious conscious in order to understand the cause of anxiety.

For those patients with chronic hyperarousal and anxiety disorders, their RZ may be too narrow, and strategies and resources that help to widen their RZ may be needed. These can include basic stress management activities, such as exercise, decreasing caf- feine intake, relaxation exercises, and imagery. A useful weekly plan for increasing resources and a weekly goal sheet is included in Appendices 1.2 and 1.3. Asking the person what he or she does to relieve anxiety or stress is part of good history taking, and developing a plan together that is not overwhelming is essential. Books such as Bourne’s The Anxiety and Phobia Workbook (2015) can be very helpful and an important adjunct to therapy. The patient can be asked to read a chapter and complete the exer- cises in selected relevant chapters, and the next session is begun with a discussion about the person’s experience with the material. Additional strategies to manage anxi- ety are especially important for those with dissociation and trauma-related disorders, and these are discussed further in Chapter 17.

Projection/ Acting out

Depression

Anxiety

Abandonment

FIGuRE 1.4 Cyclical psychodynamics of a person with borderline personality disorder.

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However, a caveat is in order. Workbook exercises are only an adjunct to treatment and do not take the place of the real work in therapy, which is co-constructing a narra- tive and connecting through a therapeutic relationship. A consistent finding is that treat- ment manuals do not correlate positively with treatment outcome (Moncher & Printz, 1991; Strupp & Anderson, 1997; Truijens, Zühlke van Hulzen, & Vanheule, 2019). This may in part result from the constraints on creativity and flexibility with such a “cook- book” approach that is not context driven. Often, novice psychotherapists feel more comfortable with these structured approaches and with “doing” things; thus, it may help to manage the therapist’s anxiety more than it does the patient’s. In addition to monitoring the patient’s anxiety, the beginning APPN must be aware of and manage his or her own anxiety.

It is easy to see why therapy in and of itself is highly anxiety provoking. Change, even a positive change such as we hope occurs in psychotherapy, is anxiety provok- ing. A seminal study by the Menninger Foundation found that patients who had pos- itive outcomes from psychotherapy often reported an increase in anxiety, but they had learned to use anxiety as a signal rather than as a reality that danger was pres- ent (Siegel & Rosen, 1962). In the safety of the therapeutic relationship, the person is exposed to what has been avoided; and as the person begins to change toward healthier ways of functioning, increased anxiety is inevitable. It is important for the therapist to keep this in mind and monitor the patient’s anxiety level as the therapeu- tic process unfolds. If anxiety becomes too unbearable in psychotherapy, there may be acting-out behaviors and increased resistance to change, or the person may leave treatment prematurely.

Anxiety is inherent in any new enterprise, and learning psychotherapy can be partic- ularly anxiety provoking. In psychotherapy, we are trying to make sense of what is going on, and new information is emerging in every minute in our interaction with patients. One way the brain deals with ambiguous situations is to categorize information. This is largely what diagnosing is about—categorizing and labeling patients through a list of behavioral characteristics. The brain tries to fit the person into what is familiar, and this limits our ability to approach the patient with openness and without preconceptions. As anxiety increases, our focus becomes more limited, and it is harder to maintain the openness required to achieve a nonjudgmental, observational stance. Developing self- awareness about one’s own anxiety is essential in empowering the therapist to allow the space needed for the relationship to develop.

MENTAL HEALTH AND CULTURE

To practice psychotherapy, the therapist must have a model on which to base inter- ventions and some idea of what constitutes a mentally healthy person. Freud’s simple idea that the goal of therapy is to be able to work and love remains relevant, because it can be applied generally to all cultures and people. In contrast, Sullivan (1947) thought that self-awareness was key to mental health and said, “One achieves mental health to the extent that one becomes aware of one’s interpersonal relations” (p. 207). A more contemporary idea is offered by Siegel (2012) and is based on a systems per- spective. He says that mental health emerges from integration in the brain/body through relationships. Integration is the core of resilience and vitality and reflects coherence of one's own states of mind. “Internal integration allows for vital inter- personal connections that are themselves integrative.” (p. 351) Integration is accom- plished through information processing that links disparate parts into a functional whole. The neurophysiological underpinnings of integration are explained further in Chapter 2.

20 ■ I. GETTING STARTED

Maslow delineated the ideal of a mentally healthy person as one who is self-actualized and who has the characteristics summarized in Box 1.1. Maslow’s hierarchy of needs framework for problem solving is useful in conceptualizing the priority of patient needs (Maslow, 1972). Lower-level needs must be met before higher-level needs can be addressed. Meeting physiological needs is essential, with physical and emotional safety and security next (Figure 1.5). Safety in the world and the therapeutic relationship is essential to enable disclosure so that higher-level needs on the continuum, such as love, self-esteem, and self-actualization, can be achieved. This model is not fixed in that an individual may achieve self-actualization and then be faced with a trauma and have a need for physiological safety that would then take priority over self-actualization and needs higher in the hierarchy.

It is apparent from reviewing the characteristics of self-actualization in Box 1.1 that the meaning of mental health is culture bound; Maslow’s self-actualized person, embody- ing independence, autonomy, individuation, and nonconformance, is largely a Western idea. For example, Eastern cultural values of interdependence, communal integration, and group harmony which does not fit with Western ideas of self-actualization. Some

Appropriate perception of reality Spontaneity Ability to concentrate and problem solve Acceptance of oneself and others Intense emotional experiences Peak experiences Nonconformance Creativeness and ethics Interpersonal relationships Independence and autonomy Identification with humankind

BoX 1.1 Qualities of Self-Actualization

Physiological needs

Safety and security

Love and belonging

Self-esteem

Self- actualization

FIGuRE 1.5 Maslow’s hierarchy of needs.

Source: Adapted from Maslow, A. H. (1972). The farther reaches of human nature. New York, NY: Viking.

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dimensions of this framework may apply to certain cultures but not to others. Cultural relativity is a term that Horowitz (1982) identified as important to consider in any discus- sion of mental health; behavior that is considered normal or abnormal depends on social and cultural norms.

Culture is an integral part of all relationships. Our cultural context shapes our per- ceptions, emotions, attributions, judgments, and ideas about ourselves and others (Barrett, 2017). The powerful influence of culture permeates all dimensions of our life in a way that is often unconscious. We are all multicultural in the sense that we belong to many different cultures simultaneously. For example, a young man who recently returned from combat belongs to the military culture, which values winning in battle and requires following orders and acting bravely. He may return to a society that does not value the war he fought and find a clash of values on his return. He may also belong to an Irish cultural heritage that does not sanction overt expression of emotion, and his male gender has another set of cultural expectations about behavior. He may be homo- sexual and belong to the gay culture, with the expectations and prejudices that accom- pany this orientation. His Roman Catholic upbringing adds another cultural layer that may contribute to his guilt, conflict, and confusion. It is easy to see how all of these mul- ticultural influences provide the complex context that will impact his ability to resume his life in a healthy, productive way.

To diagnose and treat mental illness effectively, the APPN considers ethnicity, religion, race, class, cultural identity, cultural explanations of illness, and the cultural elements of the relationship between the individual and clinician. It is not possible to have extensive knowledge about many cultures, but a working knowledge of the backgrounds of those who most often seek treatment is essential. However, generalizations about another’s culture do not tell us how to work with individuals. For example, knowing that those from a Hispanic culture often tend to somatize conflicts does not inform us about how to work with a Hispanic woman who hears the voice of her dead husband. It is highly likely that she may not be psychotic but is instead grieving according to acceptable cul- tural norms. Allowing time and support may be more appropriate than prescribing an antipsychotic drug.

The DSM-5 includes a cultural formulation with interview questions designed for assessing information about the impact of a person’s social and cultural context and the person’s perceptions of the problem. This is a very helpful resource for mental health clinicians for effective assessment and clinical management and helps to establish rap- port and engage the patient. In addition, a glossary of cultural concepts of distress is included in the DSM-5 Appendix, which illustrates syndromes in selected cultures. These syndromes illustrate the idiosyncratic nature of emotional concepts for various cultures; that is, it is how the culture perceives the emotional and bodily experiences that determines the characteristics and expressions of the disorder.

Recent cross-cultural research reveals that culture not only determines what is con- sidered a psychiatric disorder but that neurobiological mechanisms linked to stress and trauma vary across cultures (Liddell & Jobson, 2016). For example, higher cortisol levels following a stressful event have been found in Chinese children compared with children from the United States (Doan et al., 2017) and in Brazilian older adults compared with Canadian older adults (Souza-Talarico, Plusquellec, Lupien, Fiocco, & Suchecki, 2014). This is important because relationships and culture shape not only our psychology but our biology. Research has also found that people from different cultural backgrounds vary in their interoceptive awareness (awareness of bodily states) (Ma-Kellams, 2014). Our bodily awareness, past experiences, and surroundings create emotions. Thus, emo- tions are constructed and predicted by the brain in the moment and learned in a rela- tional context with the embedded values and norms of a particular culture (Barrett,

22 ■ I. GETTING STARTED

2017). One’s perception about the world is shaped by predictions the brain is making about physical autonomic states; thus, we are deeply interacting with each other on a visceral level. Assisting the patient in labeling and identifying and exploring emotions without preconceived assumptions about what the person is feeling is essential in all psychotherapy.

If the APPN is unfamiliar with a particular person’s culture, consultation may be in order. It is also important to research that culture and to ask the patient about his or her own experience. Asking the person of a culture different from yours how he or she feels about working with you is respectful and opens up a dialogue about the experience for the patient. It is okay to tell the patient that you may make mistakes about his or her cul- ture and experience and to ask the person to let you know if you do. For people of color who come to a White therapist or vice versa, racial differences often are “the elephant in the living room” and should be addressed to enable the person to stay in treatment. Asking out of a genuine curiosity and admitting ignorance are collaborative and reduce the power imbalance in the relationship by allowing the patient to teach us. For exam- ple, one young Black woman who came to therapy for depression explained how she had experienced prejudice, and implicit in this communication was her concern that her White therapist might be prejudiced, too. Through acknowledging ignorance about the experience of prejudice and exploring her feelings and experiences, the therapist and patient deepened their understanding of her fears about therapy as a forum in which she might be judged. This strengthened the therapeutic alliance and connection, which allowed her to remain in treatment.

MENTAL ILLNESS

According to Luhrmann (2000), a cultural anthropologist, there are traditionally two frameworks for understanding mental illness. One framework is the psychodynamic approach, originally based on Freud’s theoretical speculations, but that has evolved into many other frameworks. This model attributes mental illness more or less to envi- ronmental and psychosocial problems (i.e., nurture). In contrast, the biophysiological model attributes mental illness to chemical imbalance (i.e., nature). The latter frame- work attributes mental illness to an imbalance of neurotransmitters in the brain, and the answer lies in correcting these imbalances, largely through medication. This model has revolutionized psychiatry and has been dominant since the 1950s, when phenothiazines were discovered with great excitement for the treatment of those with chronic mental illness or psychosis.

How changes in neurotransmitters produce symptoms has been an intense focus of investigation, beginning in the 1990s with the “decade of the brain.” These studies are based on the underlying premise that mental illness is a “brain disease” and should be treated as any other illness. This idea has been embraced by mental health providers and drug companies, as well as those diagnosed with a psychiatric disorder. However, a seminal research study found that this belief actually increases rather than decreases stigma and that people thought to have a brain disease are treated more harshly (Mehta & Farina, 1997). Perhaps diagnosing a person with a psychiatric disorder as “brain dis- eased” sets the person apart and further marginalizes the person as an “other.” Stigma toward those with psychiatric disorders can be reduced through deepening our under- standing of the effect of the environment on brain functioning. This knowledge may help to change the conversation from what is wrong with this person to what has hap- pened to this person.

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Both genetic vulnerability and environmental influences play significant roles in the development of mental illness. The term epigenetics has been coined to describe this interplay, that is, the environment selects, signals, modifies, and regulates gene activity. Heritable differences in gene expression are now thought to be not the result of DNA sequencing but the effects of the encryption of experience that can be transmitted and alter behavior over generations. Genetic, biological, traumatic, and social factors inter- act, and this complex interplay shapes thinking, feelings, and behavior.

The stress diathesis model of psychiatric disorders has evolved from the recognition that genetics (diathesis/nature) and environment (stress/nurture) both contribute to the development of psychiatric disorders (Hankin & Abela, 2005; Smoller, 2016). That is, for a person who has a genetic vulnerability and encounters significant early life stress- ors such as childhood trauma or neglect, loss, or viruses, the expression of the gene for the development of the psychiatric disorder most likely will be triggered. Evidence sug- gests that this is a result of changes in DNA through the process of methylation (Jiang, Postovit, Cattaneo, Binder, & Aitchison, 2019). Methyl groups affix genes that govern the production of stress hormone receptors in the brain and this prevents the brain from regulating the response to stress. Parental nurturing mediates this epigenetic response; however, in the absence of parental nurturing, regulatory and attention problems result.

Two psychiatric disorders that are thought to be strongly heritable, schizophrenia and bipolar disorder, are now thought to share epigenetic roots. Significant epigenetic chemicals were found in the genome of 22 pairs of identical twins diagnosed with either schizophrenia or bipolar disorder (National Institute of Mental Health [NIMH], 2009). That is, the twins had identical DNA but significant differences were noted in the gene activity caused by their environment. This is strong evidence that supports the hypoth- esis that epigenetic mechanisms may drive even those psychiatric disorders considered most heritable (Coghlan, 2011). In addition, genetically identical twins are 50% concor- dant for developing schizophrenia, which means that 50% of the variance is attributed to environmental or other nongenetic contributions (MacDonald & Schulz, 2009). Some psychiatric disorders such as PTSD, reactive attachment disorder, acute stress disorder, and adjustment disorders are identified in the DSM-5 as trauma-related disorders and are triggered by exposure to extreme stress in people who otherwise may not be vulner- able (APA, 2013).

Animal and human studies strongly indicate that genetic factors of stress reactivity and greater physiological reactivity to stressful events may predispose one to a psy- chiatric disorder (Smoller, 2016). Those who have a stronger, more persistent response to stressors tend to withdraw from stressful situations and have internalizing traits. These people may be inhibited and more fearful, thus predisposing the person to anxiety and depressive disorders. Likewise, those whose temperament tends toward externalizing traits may be predisposed to develop psychopathology with symptoms of impulsivity, aggressiveness, and attentional difficulties. Caregivers who are not able to mediate arousal for their offspring with either of these traits are likely to exac- erbate difficulties with affect and self-regulation that may lead to psychopathology (Schore, 2019).

Telomeres, DNA protein structures, have been found to be shortened in the pres- ence of trauma. Telomere length is associated with the production of destructive radi- cals and molecules, chronic inflammation, co-occurring psychiatrc disorders, and a shorter life expectancy. A large meta-analysis found that PTSD was associated with shorter telomeres across gender (Li, Wang, Zhou, Huang, & Li, 2017). Research suggests that childhood adversity affects our genes (Papale, Seltzer, Madrid, Pollak, & Alisch, 2018). Gene expressions and salivary samples compared 22 girls who experienced high stress with those with normative stress. The high-stress group had more behavioral

24 ■ I. GETTING STARTED

problems and 122 differentiated methylated genes. These genetic findings point to the transgenerational transfer of trauma from the first generation of trauma survivors to the second and further generations of offspring.

Adverse Life Experiences

It is now well established that adverse life experiences are associated with a wide range of psychiatric disorders and medical problems (Felitti & Anda, 2010; Hughes et al., 2017; Suglia et.al., 2018). Felitti’s (1998) seminal study of the long-term sequelae of adverse childhood experiences (ACE) for 17,421 middle class adults found a graded, positive relationship between ACE and significant heart disease, fractures, diabetes, obesity, unintended pregnancy, sexually transmitted diseases, depression, anxiety, sleep disor- der, dissociative disorders, eating disorders, and alcoholism.

Approximately 70% of adults world wide experience at least one traumatic event within their lifetime (Kessler, 2017). Exposure using DSM-5 criteria is high (89.7%); expo- sure to multiple traumatic event types is the norm (Kilpatrick et al, 2013). Childhood adversity is common. Globally, the World Health Organization (WHO, 2018) estimates that 25% of all adults have been physically abused as children. In the United States, 59% of adults report at least one adverse childhood experience (Shonkoff & Gardner, 2012). One in ten children have experienced three or more ACEs and, in a number of states, the prevalence rate rises to one in seven (Sacks & Murphy, 2018). Notably, a significant dose response relationship has been established: the higher the ACE score, the greater the likelihood of physical and mental illness. With an ACE score of 4 or more, the likeli- hood of chronic pulmonary lung disease increases 390 percent; hepatitis, 240 percent; depression 460 percent; attempted suicide, 1,220 percent (Fellitti & Anda, 2010).

Children are particularly vulnerable to adverse events due to the plasticity of the developing brain; those who are brought up in a chaotic or non-nurturing environ- ment suffer neurological consequences that are long-lasting and difficult to remediate (Shonkoff & Garner, 2012). Toxic stress and ACE have been found to result in lifelong consequences for both psychological and physical health that affect behavior, economics, education, and health outcomes (Shonkoff, 2010). A longitudinal study of 2,232 twins, which controlled for genetic effects, found that children who experienced maltreatment by an adult or bullying by peers were more likely to report psychotic symptoms at age 12 than those who did not experience traumatic events (Arseneault et al., 2011). Similarly, a large meta-analysis of prospective and cross-sectional cohort studies found that ACE are associated with psychosis and that psychosis would be reduced by 33% if that risk factor were removed (Varese et al., 2012). In one large study of 30,000 children, almost every diagnosis of depression, anxiety, substance abuse, or eating disorders was comorbid with PTSD (Seng et al., 2005). The effects of trauma on the developing brain are likely to be cumulative, profound, and long-lasting; they transcend the diagnosis of PTSD and contribute to a wide range of physical, emotional, and social problems (Afifi, Mota, Dasiewicz, MacMillan & Sareen, 2012; Nicholson et al, 2018; Porges, 2011; Schore, 2019; Teicher, 2012).

Toxic stress in early childhood also plays a role in the intergenerational transmis- sion of disparities in health outcome (Braveman & Barclay, 2009). Research supports the long-term negative sequelae related to the neurobiological responses to childhood stress and trauma (Jiang et al., 2019; Heins et al., 2011; Nicholson et al, 2018; Perry, 2001; Schore, 2012; Stien & Kendall, 2006; Van Dam et al., 2012). These effects may then be inherited by subsequent generations: higher maternal ACE scores have been associated with measures of prenatal stress, autonomic nervous system reactivity, and psychopa- thology in her offspring (Esteves et al., 2020; Jones et al., 2019).

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The link between trauma and mental illness is complex and interactive. Numerous studies have found that adults receiving treatment for severe and persistent mental ill- ness, substance abuse, eating disorders, anxiety, and depressive disorders are highly likely to be survivors of trauma, such as childhood sexual abuse, domestic or commu- nity violence, combat-related violence, or poverty (Brown et al., 2009; Chu, 2011; Danese et al., 2009; Read, 2010; Stien & Kendall, 2006; Teicher, 2012). The majority of people served by public health mental health and substance abuse service systems have expe- rienced repeated trauma since childhood and have been severely impacted by trauma (Grubaugh et al., 2011).

Racial trauma and the stress that results from danger related to real or perceived experiences of racial discrimination (Comas-Diaz, Hall, & Neville, 2019) – has been iden- tified as a precipitant of PTSD symptoms and is distinguished by the ongoing nature of its threat to the affected individual, such as through racial microagressions and vicari- ous experiences of bigotry (Helms, Nicolas, & Green, 2012). Higher PTSD prevalence and severity among African American and Latinx adults has been linked to a greater frequency of perceived experiences of racism and discrimination in these populations (Sibrava et al., 2019). In one large systematic review and meta-analysis, self-reported experiences with racism were correlated with negative mental health outcomes, includ- ing depression, anxiety, and PTSD (Paradies et al., 2015).

Judith Herman (1992), in her seminal book Trauma and Recovery, states: “Traumatic events are extraordinary, not because they occur rarely, but rather they overwhelm the ordinary human adaptation to life” (p. 33). Findings in the wake of the World Trade Center disaster indicate that many people experienced significant symptoms, such as insomnia, irritability, general anxiety, vigilance, and impaired concentration, but did not qualify for a diagnosis of PTSD as defined by the DSM-IV-TR. People sought help for a wide variety of disabling clinical responses, but their pathologies were not reflected in the available diagnostic categories (Amsel & Marshall, 2003). Similarly, in the absence of an identifiable Criterion A event (natural disasters, terrorist activities, war, incest, physi- cal abuse, car accidents, or other major life-threatening events), those who experience PTSD symptoms as a result of racial trauma do not qualify for a DSM-5 PTSD diagnosis (Williams, Metzger, Leins, & DeLapp, 2018).

van der Kolk (2014) says that while single-incident traumas may sometimes account for those diagnosed with posttraumatic stress disorder (PTSD), most adults who seek psychotherapy have had numerous traumatic events and suffer from a variety of psy- chological problems, many of which do not fall within this diagnostic category. Broadly speaking, these are problems such as aggression, self-hatred, dissociation, somatiza- tion, depression, distrust, shame, relationship problems, and affect regulation. Studies of children have found similar results; two thirds of children with documented abuse do not suffer from PTSD but do suffer from a variety of other psychiatric disorders, such as dissociative identity disorder, borderline personality disorder, depression, sub- stance abuse, and attention deficit hyperactivity disorder (Fellitti & Anda, 2010; Stien & Kendall, 2006; Teicher et al., 2003; Teicher, 2012).

Adults who encounter everyday hardships are also at risk. A survey of 832 people from a primary care practice found that there were more PTSD symptoms for those who had suffered stressful life events than for those who had PTSD Criterion A events (Mol et al., 2005). Relatively common life events, such as the loss of a relationship or job, result in more PTSD symptoms than an actual or threatened death (Mol et al., 2005; Robinson & Larson, 2010). Other studies confirm that even subthreshold PTSD results in significant functional impairments and a greater incidence of psychiatric disorders such as major depression, social anxiety, alcohol and drug use (McLaughlin et al., 2015; Mota et al, 2016).

26 ■ I. GETTING STARTED

Common sense dictates that suffering any emotional or physical illness is disruptive, disturbing, and stressful. Accordingly, those who experience acute or chronic illness have been found to develop post-traumatic stress symptoms, including those admit- ted to the ICU (Parker et al., 2015); cancer survivors (Cordova, Riba, & Spiegal, 2017); ischemic stroke patients (Stein et al., 2018); and people living with HIV (McLean & Fitzgerald, 2016). Edmondson and colleagues found that those who developed PTSD due to their acute coronary event doubled their risk of recurrent future cardiac events and mortality (2012). Negative childbirth experiences, cesarean sections, and perinatal depression are risk factors for postnatal PTSD (Ayers, Bond, Bertullies, & Wijma, 2016).

Pointedly, the experience of mental illness may in and of itself be regarded as a traumatic experience. For decades, studies have supported this possibility (McGorry et al., 1991; Meyer et al., 1999; Shaw et al., 1997). A diagnosis of PTSD plus depres- sion and associated dissociative or borderline personality disorder appears to be a dose–response predictor for developing a chronic illness such as fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, chronic pelvic pain, and dysmenorrhea (Buskila & Cohen, 2007). Moreover, after an exhaustive review of the literature on psy- chosis and trauma, Morrison and colleagues (2003) state, “... it does seem that at least a significant proportion of psychotic disorders do arise as a response to trauma and that PTSD-like symptoms can be developed in response to people’s experience of psychotic disorders” (p. 347). The literature suggests that trauma is both a cause and an effect of medical and psychiatric pathologies.

The above research supports Shapiro’s (2001, 2012, 2018) expanded conceptualiza- tion of trauma from the Criterion A events for PTSD to include adverse life experiences that occur often and to most people, such as emotional neglect or indifference, humili- ation, and family issues. For example, many childhood experiences, such as caregiver depression, chronic mother–infant misattunement, being bullied, chronic loneliness, significant loss, caregiver neglect, repeated separation from parents, betrayals, feeling stupid and humiliated in the classroom setting, abandonment, significant medical ill- ness and procedures, relationship problems between parents, personality problems of parents, exposure to domestic violence, economic hardships, poverty, critical or nega- tive comments from caretakers, social discrimination, prejudice, family instability, acci- dents, violence, frequent moves or changes of school, taking care of an alcoholic parent, and many other life events that impact the developing child, may contribute to mental health problems later in life. What is notable is that it is not just what has happened to the individual that is experienced as traumatic, but also what has not happened that should have happened, such as in situations of neglect and misattunement at critical periods of development.

The Substance Abuse and Mental Health Services Administration (SAMHSA) refers to trauma as:

.… experiences that cause intense physical and psychological stress reactions. It can refer to a single event, multiple events, or a set of circumstances that is experienced by an individual as physically and emotionally harmful or threatening and that has lasting adverse effects on the in-dividual’s physical, social, emotional, or spiritual well-being (SAMHSA News, 2014).

The word “trauma” is used in this book to denote this expanded conceptualization inclusive of all events and situations that are experienced by the person as overwhelm- ing and affect brain functioning through the interruption of information processing. This disruption in brain circuitry, regulatory systems, and information processing, results in the disturbing event or situation being stored dysfunctionally, sometimes

1. ThE NuRSE PSychoThERAPIST AND A FRAmEwoRk FoR PRAcTIcE ■ 27

affecting the person even decades later (Shapiro, 2018). It is a basic tenet of this book that such experiences are the basis of most psychopathology. Trauma is a response – a disconnection from oneself,– not an event (Mate, 2003; Porges, 2019). It is not so much what has happened to the person, but what happens inside the person. Healing trauma involves the reconnection with self and is always possible.

An individual’s response and the long-term sequelae of a disturbing event are highly individualistic and depend on a multitude of factors, such as the person’s age, develop- mental stage, coping skills, support system, cognitive deficits, preexisting neural physi- ology, and the nature of the trauma. It is not just the event itself that determines the long- and short-term effects of trauma, but the individual differences that the person brings to the situation. Traumatic experiences disrupt brain functioning as mediated by genetics, social support, age, development, and many other factors. Healthy func- tioning of the brain is reflected in the optimal integration and coordination of neural networks. Chapter 2 discusses the neurophysiological theory and research that provide the underpinnings for the psychotherapeutic framework for this book.

A FRAMEWORK FOR PSYCHOTHERAPY PRACTICE

The adaptive information processing (AIP) model, developed by Shapiro as an explanatory theory for EMDR, is a metamodel for understanding mental health and psychopathology, and provides direction for planning therapeutic interventions (Shapiro, 2018). AIP is a metamodel because mechanisms of action for all psychotherapy approaches can be explained by the neurophysiological underpinnings of AIP about how the brain works. AIP posits that normally information is taken in through the senses and connected adaptively to other memory networks so that storing and learn- ing occur. There is thought to be innate self-healing in the brain and just as the body strives for homeostasis, so too does the brain through the regulation and processing of information through neural transmission. However, if something is experienced as overwhelming emotionally, brain processing is interrupted owing to the massive influx of hormones and neurotransmitters. It is as if our brain is saying: “Don’t forget this, this is important!” These unprocessed experiences are considered to be the basis of the symptoms of many mental health problems and psychiatric disorders (Bergmann, 2020; Cozolino, 2017; Shapiro, 2018).

Once information processing is interrupted, the memory of the event becomes fragmented. The emotion related to the experience may become disconnected from the words to describe the event and/or the sound and/or physical sensations. Thus, the fragmented memory is not integrated but stored in the brain with each component existing in discrete units that are disconnected or dissociated from each other. The mem- ory is stored largely in implicit or unconscious memory and is experienced as being in the present once triggered. For example, a woman who was raped 40 years ago might be triggered by having sex with her partner and feel as though the rape was happening all over again, or she may be anxious and fearful around certain places or people that remind her of the event and be unaware of why she is anxious and does not connect her current anxiety to the original experience. These reactions are not in her control but come from neural associations deep within memory networks that are not connected with the conscious mind. Consciousness is defined as our subjective experience of being aware and having access to information about the experience (Siegel, 2012). It is under- standable that a person who has experienced multiple traumas may not be very con- scious or living in the present.

28 ■ I. GETTING STARTED

Psychotherapy interventions can be designed to target any or all areas of the dis- sociated memory or experience—behavior, relationships, beliefs, the body, images, and/or emotions—to facilitate healing and promote neurophysiological harmony (see Figure 1.6). For example, the therapist using a CBT model would focus on the person’s thoughts, beliefs, or behaviors; the therapist using a family therapy model would focus on the relationships and dynamics of the family; while the psychodynamic therapist would focus on emotions and thoughts assisting the person in deepening his or her understanding of how the past gets triggered and played out in the present. The EMDR therapist would target body, beliefs, images, and emotions in order to process trauma based on AIP. A change in any arena reverberates to all other dimensions for the overall purpose of facilitating healing and toward integration because all dimensions are inter- related and interconnected.

The treatment hierarchy framework for practice for this textbook based on AIP reflects a synthesis of research and theory developed by numerous clinicians and researchers (Briere & Scott, 2013; Cozolino, 2017; Davis & Weiss, 2004; Herman, 1992; Porges, 2011; Porges & Dana, 2018; Schore, 2019; Shapiro, 2018; Siegel, 2012; Wheeler, 2011). To begin the healing process, the APPN assesses where to target interventions, taking into con- sideration the patient’s culture and building on the strengths and resources the person already has. In general, the lower the patient is on Maslow’s hierarchy of needs, the more active the therapist must be. For example, the patient who is abusing substances, hungry, and homeless must first have physiological needs and safety met first, and the APPN attends to these needs largely through case management strategies.

The treatment hierarchy illustrates an overarching framework for therapeutic aims that must be ensured before the person can move up the levels in the triangle (see Figure 1.7). The patient’s physiological needs, such as diet, sleep, and exercise, are essential to a healthy emotional life and the work of psychotherapy. Nurses are knowl- edgeable about what constitutes a healthy lifestyle and this knowledge is invaluable to integrate into psychoeducation with patients in psychotherapy. Overall, resources must be procured and stabilization guaranteed before trauma can be processed, and then a vision can be developed of a possible future. The aim is toward integration of neural

Community and culture

Interventions

Behavior

Relationships

Images

Body

Emotion Beliefs

Adaptive information processing

FIGuRE 1.6 Where to target interventions.

1. ThE NuRSE PSychoThERAPIST AND A FRAmEwoRk FoR PRAcTIcE ■ 29

networks, of memories, of oneself and relationships, and of the person’s connection in the world. The patient’s ability to process information is variable, with some patients needing more stabilization so that adaptive memory and experiences are created or are reinforced if present, while other patients may be able to process information and quickly move toward integration. Stabilization strengthens and/or widens the person’s RZ so that daily functioning is improved. Integration through the phases of stabilization and processing or memory reconsolidation can be accomplished through the various psychotherapeutic approaches and techniques discussed in this book.

Some psychotherapeutic approaches may have more utility than others, depend- ing on the person’s state of need, resources already present, emotional development, past traumas, and support system as well as the expertise of the therapist. The thera- pist’s thorough and accurate assessment, as discussed in Chapter 3, helps to formulate a plan to assist the person to move upward on the treatment hierarchy to the next stage. Although treatment is discussed as a stage model, it is not static in that there is some fluidity of movement. Frequently, patients take two steps forward and then one backward; that is, often after therapeutic gain, a period of anxiety, confusion, and/or depression follows. This is because emotion is a powerful agent of change and cre- ates disruption (Damasio,  1999). Even a positive change may have a disorganizing effect on the brain and behavior because of the proliferation of synapses that occurs with new learning (Stien & Kendall, 2006). This idea is supported by a developmental principle of all biological systems that “there can be no reorganization without disor- ganization” (Scott, 1979, p. 233). It is the therapist’s responsibility to assist the person in understanding that the gains being made are often followed by increased sadness and anxiety. Explaining this to the person, keeping the overall plan and therapeutic aims in the foreground, and conveying hope is essential for the process and progress to continue.

Increase

external

resources

Increase

internal

resources

Case Management Food, Sleep, Exercise

Safety

T R E A T M E N T

H I E R A R C H Y

Stabilization

Processing

Increase ability to

tolerate negative/positive

affect/distress

Enhance

future visioning

FIGuRE 1.7 Treatment hierarchy framework for practice.

Source: Adapted from Davis, K., & Weiss, L. (2004). Traumatology: A workshop on traumatic stress disorders. Hamden, CT: EMDR Humanitarian Assistance Programs.

30 ■ I. GETTING STARTED

Stabilization

Essential to all approaches discussed in this book is providing for safety and increas- ing resources, if needed, to attain stabilization and a robust RZ. For positive psycho- therapy outcomes, Norcross and Lambert state to “begin by leveraging the patient’s resources and self-healing capactities” (2019, p. 13). Resources might include a per- son’s positive memories of past experience, spiritual beliefs, the availability of nur- turing and caring people, a sense of inner strength or a belief in oneself, and coping strategies. Techniques used during the stabilization stage are sometimes referred to as case management or supportive psychotherapy but may also include any of the strate- gies included in Box 1.2 and community resiliency model (CRM) skills, included in Chapter 11. Competency in case management includes the ability of the therapist to garner the necessary environmental resources on behalf of the patient and requires an active approach on the part of the therapist. Setting limits, educating, connecting the person to community resources, supporting the patient’s ego functions, and assisting the patient in managing emotions are key to successful outcomes. A worksheet for treatment and case management strategies is included in Appendix 1.4 from Seeking Safety: A Treatment Manual for PTSD and Substance Abuse, by Najavits (2002); it is an excellent resource for case management.

Stabilization strategies assist the person to be better able to make state changes, that is, to change one’s present physiology in order to function more effectively in the moment. Crucial in case management is the ability of the therapist to assess regres- sive and adaptive shifts in ego functioning and to recognize conflict to help the per- son to manage anxiety. Although the therapist may understand what is happening for the patient dynamically, this does not need to be interpreted to the person. Accurate assessment of where the person is in the change process is essential. A stage of change model is helpful in determining where the therapist needs to aim interventions. This is especially useful for interventions aimed at behavioral change. Stages of change are discussed in Chapter 9.

Along with behavioral change and shoring up external resources, if needed, inter- nal resources often need to be increased before processing. Internal resources are less tangible than external resources, and include the person’s ability to manage positive and negative emotions. Indicators that the person has sufficient internal resources include the person’s ability to self-soothe, to demonstrate adequate impulse control, to identify stressful triggers, to regulate moods, and to communicate honestly. In gen- eral, the patient’s resources and the traumas experienced need to be balanced. For the person who has a history of many adverse life experiences without positive memories

• Through therapeutic relationship • Bibliotherapy/role play • Case management • Cognitive behavioral therapy • Community resiliency model skills • Dialectical behavioral therapy • Education about RZ • Managing physiological arousal

• imagery

• Container • Calm place

• Mindfulness/meditation • Medication • Stress management/education • Provide safety • Yoga/exercise

BoX 1.2 Selected Stabilization Strategies

1. ThE NuRSE PSychoThERAPIST AND A FRAmEwoRk FoR PRAcTIcE ■ 31

or experiences, more resources may be needed to manage the deleterious effect of these experiences on functioning to enhance the RZ. For example, a 6-year-old, learn- ing-disabled boy, whose dog recently died, started to wet his bed nightly and was brought to the clinic by his mother. He lived with his mother, who was single, chroni- cally depressed, and had significant economic problems. Figure  1.8 illustrates that more resources may need to be developed for this child to counteract the imbalance between his traumas and resources or strengths. The assessment of adverse experi- ence and resource balance is based on a comprehensive history and assessment as outlined in Chapter 3.

A stabilization checklist is included in Appendix 1.5 to help the clinician determine whether adequate stabilization has been achieved. The person does not need to meet all the criteria on this list before processing and the therapist’s clinical judgment is essential in order to determine appropriate strategies. Sometimes the instability is driven by the trauma and once the traumatic memory has been processed, symptoms will dissipate. Specific strategies designed to widen or strengthen the RZ are delineated in the psycho- therapy approaches included in this textbook.

Processing

After stabilization has been achieved, the person is ready to move to the next stage of processing. As represented toward the top of the treatment hierarchy in Figure 1.7, processing reflects access to all dimensions of memory: behaviors, affect, sensations, cognitions, and beliefs associated with the trauma (Shapiro, 2018). Processing usu- ally involves assisting the person in constructing a narrative through the explora- tion of the meaning of significant adverse life experiences and traumas that impair functioning. Changes in physical and emotional responses occur as components of the dysfunctional memory are integrated with other, more adaptive networks. In contrast to state changes that occur in stabilization, processing creates trait changes, that is, enduring relationship and personality changes (Shapiro, 2018). The therapist assists the person in processing using the models and techniques discussed through- out this textbook. Some psychotherapy approaches involve components of stabi- lization as well as processing such as psychodynamic psychotherapy and EMDR therapy; others such as imaginal or in vivo exposure are designed primarily for processing a specific traumatic event. Processing strategies are included in Box 1.3.

Resources:

Physical health Loving extended family impulse controlTraumas:

Poverty Caregiver depression Learning disability Pet recently died

FIGuRE 1.8 Trauma and resource balance.

32 ■ I. GETTING STARTED

Communication techniques can also facilitate stabilization or processing and are discussed in Chapter 4.

Processing is based on the idea that humans have an inherent information pro- cessing system that usually integrates experiences to a physiological adaptive state in which information can be taken in, and learning occurs (Shapiro, 2012, 2018). Memory is stored in neural networks that are linked together and organized around early events with associated emotions, thoughts, images, and sensations. Healthy functioning is reflected in the optimal integration and coordination of these neural networks, and this occurs through processing information. The neurophysiology underlying processing is discussed in Chapters 2 and 7.

Clinically, processing has been achieved once relationships are adaptive, work is productive, self-references are positive, there are no significant affect changes, affect is

Processing

leads to expansion of consciousness...

Trauma

Integration

Stabilization

Stabilization

Stabilization

Stabilization

Stabilization

Processing

Processing

Processing

Processing

Processing

FIGuRE 1.9 Spiral of treatment process.

• Through therapeutic relationship • Psychodynamic psychotherapy • Imaginal or in vivo exposure • Cognitive processing • Somatic processing • Eye movement desensitization and reprocessing

BoX 1.3 Selected Processing Strategies

1. ThE NuRSE PSychoThERAPIST AND A FRAmEwoRk FoR PRAcTIcE ■ 33

proportionate to events, and there is congruence among behavior, thoughts, and affect. A processing checklist is included in Appendix 1.6 to assist the therapist in determin- ing whether processing has led to adaptive change. Periods of processing are usually followed by periods of destabilization, and the treatment process often looks more like a spiral alternating with interventions aimed at stabilization and then processing (Figure 1.9). Ongoing assessment and attunement to the person’s therapeutic process are important in order to monitor progress and plan treatment strategies. The psycho- therapeutic relationship is the vehicle for therapeutic change with the therapist’s pres- ence serving to stabilize the person and provides the foundation needed to assist the integration of dimensions of memory and all parts of the self at deeper levels of under- standing. The therapeutic relationship may also facilitate processing as dimensions of earlier significant relationships through transference are triggered and reworked in the present. Empowerment and autonomy are fostered as the person moves toward envi- sioning and planning for the future.

CASE EXAMPLE

Ms. A is a 26-year-old married woman who works as a costume designer and seamstress for a theater company. She has been in psychotherapy numerous times since the age of 13 for past psychiatric diagnoses of major depressive disorder, bipolar II, panic disor- der, and anorexia nervosa. She reports numerous psychosomatic complaints including frequent stomachaches, irritable bowel syndrome, acid reflux, headaches, restless legs syndrome, and generalized pain as well as cold chills all over her body. Her reason for seeking treatment was her anxiety and insomnia related to her loud, annoying neigh- bors at her condo. Ms. A’s early history involved significant attachment problems with both her mother and father abusing drugs, and subsequently Ms. A was taken away from her parents and into custody by her aunt when she was 2,years,old. Ms. A said her aunt favored her own biological daughter and neglected her throughout her childhood. Her adult trauma history included two previous car accidents. On intake, she scored 63 on the Spielberger Trait Anxiety Scale; 22 on the Beck Depression Inventory; and 27 on

wee k 1

wee k 2

wee k 3

wee k 4

EM DR

EM DR

wee k 1

wee k 2

wee k 3

wee k 4

6 m

on th

s

100

90

80

70

60

50

40

30

20

Anxiety

DES

BDI

HRU

GAF

10

0

FIGuRE 1.10 Ms. A’s psychotherapy outcomes.

Anxiety, Spielberger trait anxiety scale; BDI, Beck depression inventory; DES, dissociative experiences scale; GAF, global assessment of functioning; HRU, health resource utilization

34 ■ I. GETTING STARTED

the Dissociative Experiences Scale. All scores were significant for anxiety, depression, and dissociation, respectively.

Because Ms. A had significant attachment problems by history, discomfort with her body and physical sensations, difficulty self-soothing, some dissociation, difficulty tol- erating negative emotions, and inadequate trust of others, her RZ was quite narrow. Ms. A perceived her current problem with her neighbors as an unmanageable crisis. The RZ was explained to Ms. A: “There is a biological basis for the symptoms you are experiencing. When the nervous system is in balance we feel like our best self and are in our resilient zone. It sounds like you have been under a lot of stress lately and are being triggered by your neighbors’ noise, which has knocked you out of your resilient zone so you are feeling anxious and depressed. It would be helpful to begin first with working on some strategies to help stabilize your nervous system. Would that be okay?” The beginning phase of therapy focused on developing a therapeutic alliance, teach- ing Ms. A stabilization strategies that were practiced in sessions such as imagery of safe/calm place (Appendix 1.7) and container exercises (included in Appendix 1.8); the Fraser Table Technique, which is an imagery exercise designed to facilitate knowledge of various parts of the self (Fraser, 1991); attachment imagery exercises (Steele, 2007); somatic awareness where she perceived feelings in her body (tracking in Chapter 11); and building resources outside therapy by increasing activities she liked such as regular exercise and yoga classes. Prozac 20 mg was also prescribed to help Ms. A manage her anxiety. Adequate resources must be present in order to ensure safe processing. EMDR therapy was integrated with these stabilization strategies to process her traumas. Ms. A was seen over a 6-month period.

At termination, Ms. A’s scores on all measures showed significant improvement (see Figure 1.10). Ms. A’s creativity, visual imaging skills, and humor were great assets to her in our work together. Less tangible outcomes than the reported quantitative data were qualitative outcomes, which included an integrative narrative about herself and her aunt that included a recognition of the impact of her past history; greater abil- ity to express herself and advocate for her own needs; better emotional and physical self- regulation; a sense of security about herself and others; and greater access to full expression of emotion. Her somatic complaints greatly decreased and as illustrated in the graph in Figure 1.10, she did not need or seek medical care for her many illnesses during the course of her psychotherapy treatment in contrast to the 6 months prior to therapy when she had sought help from her primary care provider a total of 12 times. She appeared more robust and stronger at termination, stating that she had never felt this good before.

CONCLUDING COMMENTS

Psychotherapy has been identified as an important competency that all APPNs must achieve (ANA, 2013; National Panel for Psychiatric Mental Health NP Competencies, 2003; Wheeler & Haber, 2004). Nurses who are beginning graduate study in psychiatric nursing and expanding their roles to become psychotherapists have unique resources and challenges. The holistic paradigm inherent in nursing provides the context and a compass for psychotherapy practice, whereas the models of psychotherapy presented in this textbook provide the vehicle, anchored in the mooring of the healing nurse–patient relationship. Providing a context rich in resources enables further growth toward heal- ing and wholeness. An appropriate metaphor is that of building a house with the foun- dation and frame necessary for support before furnishing and decorating. Providing for safety and stabilization by strengthening external and internal resources facilitates resilience so that healing can occur.