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iPsychotherapy for the Advanced Practice Psychiatric Nurse

Kathleen Wheeler, PhD, PMHCNS-BC, PMHNP-BC, APRN, FAAN, is a professor and coordinator of the Psychiatric Mental Health Nurse Practitioner Program at Fairfield University School of Nursing in Fairfield, Connecticut. She has practiced as an advanced practice psychiatric nurse specializing in trauma for the past 30 years. She is certified as a clinical specialist in adult psychiatric-mental health nursing and a psychiatric-mental health nurse practitioner. She has additional certifications in psychoanalysis and psychotherapy, hypnosis, and eye movement desensitization and reprocessing (EMDR). Dr. Wheeler served as co-chair of the national panel that developed the 2003 Psychiatric-Mental Health Nurse Practitioner (PMHNP) Competencies and is the president of the EMDR International Association. The first edition of her book, Psychotherapy for the Advanced Practice Psychiatric Nurse, was awarded an AJN Book of the Year Award and the American Psychiatric Nurses Association (APNA) Media Award. She has also received awards from APNA for Excellence in Practice and Excellence in Education; is a distinguished alumna of Cornell University–New York Hospital School of Nursing where she received her BSN; and is a Fellow in the American Academy of Nursing. She received her MA and PhD in nursing from New York University.

iiiPsychotherapy for the Advanced Practice Psychiatric Nurse

A How-To Guide for Evidence-Based Practice

Second Edition

KATHLEEN WHEELER, PhD, PMHCNS-BC, PMHNP-BC, APRN, FAAN

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Library of Congress Cataloging-in-Publication Data Wheeler, Kathleen, 1947– author, editor of compilation. Psychotherapy for the advanced practice psychiatric nurse : a how-to guide for evidence-based practice/Kathleen Wheeler.—Second edition.

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I. Title. [DNLM: 1. Psychiatric Nursing. 2. Advanced Practice Nursing. 3. Evidence-Based Nursing. 4. Nurse-Patient Relations. 5. Psychotherapeutic Processes. WY 160] RC440 616.89’0231—dc23

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vRave Reviews and Awards for Psychotherapy for the Advanced Practice Psychiatric Nurse, First Edition

2008 American Psychiatric Nurses Association Media Award 2008 AJN Book of the Year Award

“Wheeler emphasizes Shapiro’s adaptive information processing model; this scholarly psychotherapy text offers other important contemporary contributions to the field of psychiatric nursing. It is a valuable read for the APPN psychotherapist as well as for clinicians from other mental health disciplines, who will learn much about the neurophysiology of psychotherapy. What distinguishes this book from others of its type is its perspective on treatment from a nursing framework and the integration of evidence-based psychotherapy models with current research from the affective neurosciences and the field of traumatology.” Journal of Trauma & Dissociation Robert M. Greenfield, PhD Private Practice, Staten Island, New York

“Dr. Wheeler’s book is for all levels of advanced practice psychiatric nursing. Students and faculty in academic settings, beginning practitioners, and experienced psychotherapists will find it useful educationally, clinically, and as a resource. It includes material from practical case examples to complete presentations of neurophysiology of psychotherapy. It supports, from a practice-based perspective, the ‘National Competencies for Psychiatric Mental Health Nurse Practitioners’ and the ‘Scope and Standards for Practice of Psychiatric Nursing.’ In a thorough, comprehensive, research-based manner, this text clarifies and refines the role and practice of the nurse psychotherapist. This is a pioneering presentation of psychiatric nursing literature in today’s world. It will be used and referred to over and over until it is dog-eared and tattered, as the reviewers’ texts have become.”

APNA Newsletter Susan Jacobson, PMHNP, CNS, and Linda Manglass, APRN-BC

“The text provides excellent examples (e.g., boxes, figures, case studies), websites, and other bibliographic resources to explain or illustrate specific aspects of the APPN role including how to assess, accomplish, and document the therapeutic alliance and other therapeutic tasks. All in all, this primer clearly stands as a timely exemplar for anyone who wants to develop clinical expertise as a therapist. It can easily serve as an excellent reference as well for any seasoned APPN that wishes to home in on a particular skill set. Students and APPNs alike should buy the text to support their clinical work with patients.” Perspectives in Psychiatric Care Margaret England, PhD, RN, CNS

“This is a much needed introduction to the ‘how to’ of psychotherapy for beginning advanced practice psychiatric nurses, including those nurses who have prescriptive authority. This easy-to-read book is like having a mentor ready at all times to prepare and assist the advanced practice psychiatric nurse for competent practice based in knowledge and wisdom…. I thoroughly enjoyed reading the well researched and written chapters. The author holds the appropriate credentials and has the experience to make her a very credible authority…. The quality of this book is outstanding and the need for it is great. There are no books in the field that compare. I am a practicing advanced practice nurse prescriber as well as a college professor who teaches psychiatric mental health nursing theory and practice. It would have been wonderful to have this book all those years ago when I first began my psychiatric nursing practice.”

Doody Review, July, 11, 2008; 4 stars Leona F. Dempsey, PhD

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Contents

Contributors Foreword Judith Haber, PhD, APRN, BC, FAAN Foreword Jeanne A. Clement, EdD, APRN, PMHCNS-BC, FAAN Preface Acknowledgments

Part I. Getting Started 1. The Nurse Psychotherapist and a Framework for Practice

Kathleen Wheeler 2. The Neurophysiology of Trauma and Psychotherapy

Kathleen Wheeler 3. Assessment and Diagnosis

Pamela Bjorklund 4. The Initial Contact and Maintaining the Frame

Kathleen Wheeler

Part II. Psychotherapy Approaches 5. Supportive and Psychodynamic Psychotherapy

Kathleen Wheeler 6. Eye Movement Desensitization and Reprocessing Therapy

Kathleen Wheeler 7. Motivational Interviewing

Edna Hamera 8. Cognitive Behavioral Therapy

Sharon M. Freeman Clevenger 9. Interpersonal Psychotherapy

Patricia D. Barry and Kathleen Wheeler 10. Humanistic–Existential and Solution-Focused Approaches to Psychotherapy

Candice Knight 11. Group Therapy

Richard Pessagno 12. Family Therapy

Candice Knight

Part III. Psychotherapy With Special Populations 13. Stabilization for Trauma and Dissociation

Kathleen Wheeler 14. Dialectical Behavior Therapy for Complex Trauma

Barbara J. Limandri

15. Psychopharmacotherapy and Psychotherapy Lisabeth Johnston

16. Psychotherapeutic Approaches for Addictions and Related Disorders Susie Adams and Deborah Antai-Otong

17. Psychotherapy With Children Kathleen R. Delaney with Janiece DeSocio and Julie A. Carbray

18. Psychotherapy With Older Adults Georgia L. Stevens, Merrie J. Kaas, and Kristin Hjartardottir

Part IV. Documentation, Evaluation, and Termination 19. Reimbursement and Documentation

Mary Moller 20. Termination and Outcome Evaluation

Kathleen Wheeler

Afterword Index

Contributors

Susie Adams, PhD, APRN, PMHNP-BC, PMHCNS-BC, FAANP Professor and Director, PMHNP Program, Vanderbilt University School of Nursing, Nashville, Tennessee

Deborah Antai-Otong, MS, RN, PMHCNS-BC, FAAN Continuous Readiness Officer, Behavioral Health Consultant and Provider, Department of Veterans Affairs, Veteran Integrated Service Network, Arlington, Texas

Patricia D. Barry†, PhD, PMHCNS-BC, APRN Psychotherapist and Consultant, Private Practice, Hartford, Connecticut

Pamela Bjorklund, PhD, RN, PMHCNS, PMHNP-BC Associate Professor, Department of Graduate Nursing, College of St. Scholastica, Duluth, Minnesota

Julie A. Carbray, PhD, APN, PMHCNS-BC Clinical Professor, Administrative Director, Pediatric Mood Disorders Clinic, Institute for Juvenile Research, Chicago, Illinois

Sharon M. Freeman Clevenger, PhD, PMHCNS-BC CEO, Indiana Center for Cognitive Behavior Therapy, PC, Secretary/Treasurer, International Association for Cognitive Psychotherapy; Diplomate, Fellow and ACT Certified Trainer/Consultant; Academy of Cognitive Therapy; Associate Faculty, Indiana Purdue University, Fort Wayne, Indiana

Kathleen R. Delaney, PhD, DNSc, APRN, PMHNP-BC, FAAN Professor, Rush College of Nursing, Chicago, Illinois

Janiece DeSocio, PhD, APRN, PMHNP-BC Interim Dean and Director of the Doctor of Nursing Practice Program, PMHNP Track Lead, Seattle University, Seattle, Washington

Edna Hamera, PhD, APRN, PMHCNS-BC Associate Professor, University of Kansas, School of Nursing, Kansas City, Kansas

Kristin Hjartardottir, DNP, RN, PMHNP-BC University of Minnesota, Boynton Health Services, Minneapolis, Minnesota

Lisabeth Johnston, PhD, APRN, PMHCNS-BC Psychotherapist and Psychopharmacologist, Private Practice, West Hartford, Connecticut

Merrie J. Kaas, PhD, RN, PMHCNS-BC, FGSA, FAAN Associate Professor, Specialty Director, Psychiatric/Mental Health Graduate Nursing, Minneapolis, Minnesota

Candice Knight, PhD, EdD, APN, PMHNP-BC, PMHCNS-BC Coordinator, Psychiatric-Mental Health Nurse Practitioner Program, New York University College of Nursing, New York City, New York; Licensed Psychologist and Psychiatric Nurse Practitioner, Wellspring Center for Health and Wellbeing, Flemington,

New Jersey

Barbara J. Limandri, PhD, APRN, PMHNP-BC Professor of Nursing, Linfield College, Portland, Oregon

Mary Moller, DNP, ARNP, APRN, PMHCNS-BC, CPRP, FAAN Associate Professor, Specialty Director, Psychiatric Mental Health Nursing, Yale University School of Nursing, New Haven, Connecticut

Richard Pessagno, DNP, RN, PMHNP-BC, CGP Clinical Assistant Professor, Specialty Director, Psychiatric Nurse Practitioner Program, Rutgers, The State University of New Jersey, College of Nursing, Newark, New Jersey

Georgia L. Stevens, PhD, APRN, PMHCNS-BC Director, P.A.L. Associates, Partners in Aging & Long- Term Caregiving, Washington, DC; Best Georgia Geropsychiatric Nurse Coordinator, Behavioral Health System Baltimore, Baltimore, Maryland

†Deceased.

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Foreword

JUDITH HABER, PhD, APRN, BC, FAAN

The Ursula Springer Leadership Professor in Nursing Associate Dean for Graduate Programs College of Nursing New York University

The second edition of Psychotherapy for the Advanced Practice Psychiatric Nurse by Kathleen Wheeler is destined to surpass the high impact of the first edition. This landmark book has fulfilled its promise as a groundbreaking publication that has established a new generation of psychiatric nursing scholarship. Most important is its reaffirmation of the essential cornerstone of advanced practice psychiatric nursing practice: therapeutic use of self in the psychotherapeutic relationship.

Today, psychotherapy is regarded as an essential advanced practice competency fundamental to advanced psychiatric nursing practice. Validation about the importance of psychotherapy is evident in major professional documents that guide 21st-century implementation of advanced practice clinical practice roles. The newly revised Psychiatric-Mental Health Nurse Practitioner Competencies (2013) and the Scope and Standards of Psychiatric-Mental Health Nursing Practice (2007) both reaffirm that individual, group, and family psychotherapy are core population competencies for psychiatric-mental health nurse practitioners and clinical nurse specialists.

Dr. Wheeler and the psychiatric nursing leaders she has chosen as contributors reflect a strong complement of clinical and academic talent; outstanding nursing professionals whose wealth of clinical and teaching experience inform the psychotherapy discussion presented in each chapter. The in-depth discussion of psychotherapeutic models used to achieve quality clinical outcomes is enhanced by the presentation of the “best available evidence” to support the efficacy of psychotherapy. The neuroscience foundation informs the biological basis for the effectiveness of psychotherapy, an essential intellectual discussion that establishes psychotherapy as more than a healing art and propels it into the realm of science and evidence-based practice.

The unique consideration of culture to psychotherapy, that is, awareness of cultural differences, cultural sensitivity, and cultural competence, addresses how culture interfaces with the practice of psychotherapy. New chapters on motivational interviewing, dialectical behavior therapy, eye movement desensitization and reprocessing therapy (EMDR), therapeutic approaches to addictions, new Current Procedural Terminology (CPT) codes, and reimbursement promise to make this second edition a “must have” for advanced practice psychiatric nurses and their colleagues. From a teaching–learning perspective, the rich examples in each chapter provide learning anchors that facilitate contextual learning for students, and that support integration of theory and clinical practice. I am confident that the second edition of Psychotherapy for the Advanced Practice Psychiatric Nurse will make an even greater contribution to the academic and clinical practice literature. I salute Dr. Wheeler, a close colleague for over 30 years, for continuing this important project and creating an innovative new edition!

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Foreword

JEANNE A. CLEMENT, EdD, APRN, PMHCNS-BC, FAAN

Associate Professor Emeritus The Ohio State University Psychotherapist Central Ohio Behavioral Medicine, Inc.

Six years ago, Dr. Kathleen Wheeler and a carefully selected group of expert practitioners gave all advanced practice psychiatric nurses a gift. The gift was one of the first books written by and for advanced practice nurses. Psychotherapy for the Advanced Practice Psychiatric Nurse is a book with carefully crafted, empirically supported frameworks for the practice of psychotherapy and it enabled us to re-embrace the bedrock of our practice: the therapeutic use of self. In addition to updating the knowledge, skills, and processes of practice, this second edition expands upon the most crucial elements involved in building upon our practice bedrock: self-knowledge, self-acceptance, genuine presence, belief in change, and lifelong learning.

Although all the therapies in this book are evidence-based, this book is not only about the knowledge, processes, and skills of therapy, but it also highlights the importance of developing ourselves personally. Openness to self-knowledge and self-acceptance is a necessary condition to effective and ethical practice. “The force and spirit of who the therapist is as a human being most dramatically stimulates change, especially the personal attitudes that we display in the relationship” (Kottler, 2003, p. 3). As nurse therapists, we create environments in which the people with whom we are privileged to work are able to discover who they are and to rediscover and/or develop new strengths. We may be seen as role models at times, but “modeling takes the form of presenting not only an ideal to strive for but also a real, live person who is flawed, genuine and sincere” (Kottler, 2003, p. 32). The therapist’s positive, directed energy sincerely conveys hope and belief in the person’s ability to change.

Prior to 2003, psychiatric-mental health clinical nurse specialists (PMHCNS) practiced psychotherapy; now all psychiatric advanced practice nurses in doctoral and master’s programs must meet this competency. “The burgeoning mental health needs of the population demand access to highly qualified providers. Psychiatric mental health advanced practice nurses (PMH-APRN) include both the clinical nurse specialist and the nurse practitioner. Both are prepared at the graduate level in research, systems, and direct patient care to provide psychiatric evaluations and treatment, including psychopharmacological interventions and individual, family and group therapy, as well as primary, secondary and tertiary levels of prevention across the lifespan. They are a vital part of the workforce required to meet increasing population mental health needs” (APNA, 2010).

After 54 years as a nurse, in that time both a psychiatric nurse and a therapist, I am still learning and delighted to have a second edition of this text. For the experienced therapist, it is both validating and enlightening. For those who are neophyte practitioners, this book provides the evidence base for psychotherapy, teaches the beginner the competencies essential in order to conduct therapy, and emphasizes the importance of relationship and lifelong learning. Congratulations and thank you to Kathleen Wheeler and the group of expert practitioners and educators who have contributed to this excellent revision.

REFERENCES

American Psychiatric Nurses Association (APNA). (2010). APNA Position Statement: Psychiatric Mental Health Advanced Practice Nurses. Retrieved from: www.apna.org/i4a/pages/index.cfm?pageid=4354

Kottler, J. (2003). On being a therapist (3rd ed.). San Francisco, CA: Jossey-Bass.

http://www.apna.org/i4a/pages/index.cfm?pageid=4354

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Preface

Six years have passed since publication of the first edition of Psychotherapy for the Advanced Practice Psychiatric Nurse. At the time the book was published, it was the only book in print written specifically for advanced practice psychiatric nurses (APPNs). It was warmly welcomed into the APPN community with positive reviews, several awards, and adoption by many APPN programs. Since then, a number of other books for APPNs have been published and the number of graduate psychiatric nursing programs and APPNs has steadily increased (Hanrahan, Delaney, & Stuart, 2011).

These past 6 years have been marked by significant developments for APPNs: master’s graduate programs transitioning to Doctoral Nursing Practice (DNP) programs, the Consensus Model for APRN Regulation (Licensure, Accreditation, Certification & Education, also known as LACE), revised Psychiatric- Mental Health Nurse Practitioner (PMHNP) Competencies, endorsement of the PMHNP as the one APPN role by American Psychiatric Nurses Association (APNA) and International Society of Psychiatric Nursing (ISPN), a new Diagnostic and Statistical Manual (DSM), new Current Procedural Terminology (CPT) codes for reimbursement, the Patient Protection Affordable Care Act, integrated behavioral care, parity of mental health with medical illness, American Nurses Credentialing Center (ANCC) discontinuation of all APPN exams except PMHNP (across the life span) in 2014, and the Institute of Medicine (IOM) 2010 report on the Future of Nursing advocating removal of scope-of-practice barriers for advanced practice nurses. What do these cataclysmic changes in nursing, mental health, and health care portend for APPNs and the practice of psychotherapy7

Since the completion in 2003 of the Psychiatric-Mental Health Nurse Practitioner Competencies and the adoption of these standards for evaluation by CCNE for accreditation, psychotherapy has been recognized as an essential competency that all PMHNPs must achieve. This has been reaffirmed with the revision of the PMHNP Competencies in 2013. The challenge for nurse educators is how to teach these competencies in addition to the essentials that are also required for graduate nursing curricula without increasing the total credit load. Psychotherapy skills must be acquired expeditiously in a short amount of time.

A 2009 survey of APPNs found that APPN practice involved prescribing, diagnostic assessments, and psychotherapy combined with medication management (vs. solely conducting individual psychotherapy; Drew & Delaney, 2009). Many of the jobs available to APPN graduates are in community mental health centers with 15- to 30-minute medication checks the norm. APPN graduates are encouraged to negotiate for longer sessions as needed and for a broader role that includes psychiatric evaluations and psychotherapy if they wish as well as prescribing medication. The marginalization of psychiatrists to the prescriber role should serve as a warning to APPNs who embrace a prescriber-only role without such negotiation. Often more seasoned APPNs develop their own preferred private practice once confidence is gained.

It has been more than 60 years since Peplau proposed that it is the relationship between the nurse and the patient through which recovery and health are achieved. Relationship-centered care has been the hallmark of psychiatric nursing. This book expands Peplau’s interpersonal paradigm from a two- person model to a more contemporary holistic perspective. Interpersonal neuroscience and attachment research validate the scientific basis of the centrality of this relationship for healing. The overall framework for practice proposed in this book is based on relationship science with adaptive information processing providing the neurophysiological explanatory mechanism of action. APPNs who understand neuroscience can decide what treatment to use for which problem based on results from brain-imaging studies, psychotherapy outcome studies, and practice guidelines.

The nurse psychotherapist must have a context for practice, an overarching framework for when and how to use techniques germane to various evidence-based psychotherapy approaches for the specific client problems encountered in clinical practice. Given the complexity of people, no one-size-fits-all model is presented in this book. It is rare for a therapist to adhere to only one model in a pure form; most often the clinically skilled therapist bases treatment choices on a formulation of the person’s problem that takes into

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account such factors as the developmental history, pattern of relating, behavioral analysis, coping skills, and support system. Ethical psychotherapy practice demands no less. If the APPN has a solid theoretical understanding to guide interventions and training in several evidence-based approaches, it is possible to adapt the therapy to the needs of the patient rather than requiring that the patient adapt to the demands of the therapist’s orientation.

The skillful therapist must know how to respond, engage, and accurately assess the problem in order to formulate a treatment plan. A comprehensive and accurate assessment at the beginning of treatment as well as throughout psychotherapy serves as a compass to guide treatment. This book strives to assist the beginning therapist in accurate assessment through a comprehensive psychodynamic understanding of the client. Understanding development and psychodynamic issues is imperative in order to make sense of what is happening for the client in the treatment. Even if the therapist decides to use behavioral or cognitive techniques, such as a thought diary, to track lifelong false negative beliefs rather than psychodynamic psychotherapy, understanding the client as fully as possible assists in making treatment recommendations. This knowledge is essential when collaborating with other mental health providers.

How then does one learn psychotherapy if not in a pure form through adherence to a specific model? 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.

The contributing authors to this book are all expert APPNs. Throughout, liberal use of examples and case studies provide pragmatic examples for the novice as well as the expert nurse psychotherapist to use as a guide for practice. To aid the readers, Springer Publishing Company offers the appendices, figures, and tables that appear in this book in pdf format at www.springerpub.com/wheeler-ancillary. The aim is to provide helpful strategies, starting with the first contact through termination. These authors have integrated the best evidence-based approaches into a relationship-based framework for APPN psychotherapy practice. This how- to compendium of evidence-based approaches honors our heritage, reaffirms the centrality of relationship for psychiatric advanced practice, and celebrates the excellence, vitality, depth, and breadth of knowledge of our specialty. We are fortunate to have the expertise of these esteemed colleagues and I am honored and pleased to be able to share and disseminate their clinical wisdom. This book is a testament to the bright, exciting future of psychotherapy practice for APPNs.

This book, however, will only be as useful as the depth of the APPNs’ own acceptance and knowledge of self. Compassion and wisdom cannot be taught in a book. Nurses who are healers understand that they can only accompany the patient on his or her journey if they have begun their own self-healing and that self- healing is a continuous process whereby one continues to develop clarity about one’s own strengths and weaknesses. As an early supervisor of mine told our class at the beginning of graduate studies: “Don’t walk around in someone’s head with muddy boots.” Openness and curiosity to self-discovery are essential in order to cultivate self-knowledge. Much of the work of psychotherapy takes place in the shared consciousness of two people and it is in those healing moments of connection that both participants grow. Indeed, the opportunity for personal growth in the transition from nurse to nurse psychotherapist is an exciting, rewarding journey leading toward a lifetime of professional satisfaction.

Kathleen Wheeler

REFERENCES

Drew, B., & Delaney, K. (2009). National survey of psychiatric mental health advanced practice nursing: development, process, and finding. Journal of the American Psychiatric Nurses Association, 15, 101–110. doi: 10.1177/1078390309333544

Hanrahan, N. P., Delaney, K. R., & Stuart, G. W. (2012). Blueprint for development of the advanced practice psychiatric nurse workforce. Nursing Outlook, 60(2), 91–106. doi:10.1016/j.outlook.2011.04.007

http://www.springerpub.com/wheeler-ancillary

xviiixixAcknowledgments

I am very grateful to the expert clinicians and scholars who contributed chapters to this book. Their expertise is a gift to our current and future graduate students, advanced practice psychiatric nurses, and to our patients. I would like to recognize Katherine Davis posthumously for her wisdom, clinical excellence, and supervision, which gave shape to the first edition of this book. Francine Shapiro’s work informed the theoretical and practice framework and I continue to be inspired by all that she has contributed to our understanding of the treatment of adverse life experiences and trauma.

A special thank you to my colleagues, Uri Bergmann, for his careful review of the neurophysiology in Chapter 2, and Michael Rice, who contributed the section on telepsychiatry in Chapter 4. I thank my supervisors, students, and patients who have taught me so much over the years. I am especially grateful to those who allowed me to include some of our work together in this book. The assistance, professionalism, guidance, and attention to detail of the entire team at Springer Publishing Company; Margaret Zuccarini, Publisher, Nursing; her Assistant Editor, Chris Teja; Lindsay Claire, Managing Editor; and the production team at Exeter Premedia Services Private Ltd., are greatly appreciated.

I am also deeply grateful to my family: my mother and father whose enduring presence is always with me; my connections to my brothers and sisters and their families, which sustain me; my husband, Robert Broad, who read many of the chapters and contributed case examples for Chapters 5 and 6; and my children, Elizabeth and Michael, who are a source of wonder and pride.

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Getting Started

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The Nurse Psychotherapist and a Framework for Practice KATHLEEN WHEELER

his chapter begins with the historical context of the nurse’s role as psychotherapist and the resources and challenges inherent in nursing for the development of requisite psychotherapy skills. Using a holistic

paradigm, elements of psychotherapy described include caring, connection, narrative, and anxiety management. Attention is then turned to the development of a framework for practice, beginning with a discussion of mental health and illness viewed through a cultural lens. The significant role of adverse life experiences in the development, contribution, and maintenance of mental health problems and psychiatric disorders is highlighted. A hierarchy of treatment aims is introduced on which to base interventions using a stage model for psychotherapy. This framework is based on the neurophysiology of adaptive information processing and research, which posits that many mental health problems and symptoms of psychiatric disorders are due to a disturbance or dysregulation in the integration and connection of neural networks that occur in response to adverse life experiences. A case example is presented to illustrate the treatment framework proposed for psychotherapy practice.

WHO DOES PSYCHOTHERAPY?

The various disciplines licensed to conduct psychotherapy, depending on their respective state licensing boards, include psychiatrists, psychologists, social workers, marriage and family therapists, counselors, and advanced practice psychiatric nurses (APPNs) (Table 1.1). Educational preparation, orientation, and practice settings vary greatly among and within each discipline. In addition to basic educational requirements unique for that discipline, there are many postgraduate psychotherapy training programs that licensed mental health practitioners may pursue, such as psychoanalytic, family therapy, eye movement desensitization and reprocessing therapy (EMDR), cognitive behavioral, hypnosis, and others. Each of these training programs offers certification and requires some length of training: approximately 1 year for EMDR therapy (i.e., 40 academic didactic and 10 consultation hours for basic Levels I and II training; plus, in order to obtain certification an additional 20 consultation hours, 12 continuing educational units, 2 years’ experience with a license in mental health practice, and a minimum of 50 sessions with 25 patients) and 4 to 5 years for psychoanalytic training (i.e., 4 years of coursework and supervision, ongoing practice, and one’s own experience in psychoanalysis).

TABLE 1.1 Basic Education, Orientation, and Setting of Psychotherapy Practitioners

Postgraduate training and ongoing supervision are encouraged for APPNs who wish to gain proficiency and deepen their knowledge in a particular modality of psychotherapy. Because it is highly unlikely that any one method will work for all problems for all people, the APPN who has additional skills such as hypnosis, EMDR therapy, family therapy, imagery, or ego state work will be more likely to help those who seek help. There are many ways to help the diverse number of patient problems and patients who seek our help, and beware of therapists who believe that “one size fits all”; in other words, if the only tool you have is a hammer, you are likely to treat every problem you encounter as a nail.

In 2002, the American Psychiatric Review Committee mandated that all psychiatric residency programs require competency training in psychodynamic therapy (PDP), cognitive behavioral therapy (CBT), supportive and brief psychotherapies, and in 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 PDP and CBT with supportive therapy at the base of the Y (Plakun, Sudak, & Goldberg, 2009). Delineation of these competencies is important in that it is a direct response to the increasing emphasis on medication as the treatment for psychiatric disorders and reaffirms the importance of psychotherapy in psychiatric treatment. These core competencies in medical 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 reasonable 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 competency must be achieved. Psychotherapy competency was identified as necessary for all psychiatric-mental health nurse practitioner (PMHNP) programs as of 2003 (National Panel, 2003) and reaffirmed with the 2013 revised PMHNP Competencies (NONPF, 2013). With these competencies delineated and endorsed by the Commission on Collegiate Nursing Education (CCNE) for accreditation, all graduate APPN programs seeking CCNE accreditation must teach psychotherapy skills.

Another change in nursing education that will significantly impact APPNs is the endorsement of the DNP by leaders in nursing, the National Organization of Nurse Practitioner Faculty (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 2015 and will include a clinical research focus. Impetus for this shift came from the lack of parity with other health care disciplines, the high amount of credits required in current master’s curricula, current and projected shortage of faculty, and the increasing complexity of the health care system (Dracup et al., 2005). Debate continues about whether this terminal practice doctorate will enhance or dilute advanced practice. It is not clear how curricula and program requirements 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 decisions, and faculty members tend to emphasize research over practice, which may not bode well for APPN faculty expertise in psychotherapy skills.

A survey in 2009 revealed that most APPN practice time is spent prescribing, conducting diagnostic assessments, and psychotherapy with medication management but rarely solely conducting individual psychotherapy (Drew & Delaney, 2009). A significant challenge for graduate nursing education is the difficulty of finding preceptors and clinical sites for psychiatric graduate nursing students therapy to practice psychotherapy. 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 manages the medication. 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 programs confirmed the scarcity of sites and found a wide range of individual psychotherapy practice hours required for students, ranging from a minimum of 50 to a maximum 440 hours in the programs for which a certain number of requisite hours are required for psychotherapy (Wheeler & Delaney, 2005). For approximately 50% of programs, however, no designated number of psychotherapy practice hours was required, and medication management hours were integrated along with psychotherapy. Consequently, most graduate psychiatric nurses leave 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 suggesting further training and supervision for competency to be achieved.

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

Stages of Learning

Benner offers a model (1984) of role acquisition from novice to expert that examines the levels of competency for the novice nurse psychotherapist. It is likely that the graduate student who is pursuing a master’s degree or postmaster’s certificate as an 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 psychotherapy, 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 learning 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 psychotherapy is detailed by Lego (1999) and Beeber (1995). Table 1.3 highlights the important events. The late 1940s were marked by the development of eight programs for the advanced preparation of nurses who cared for psychiatric patients. An extremely important debate took place over the next few decades about the nurse’s role as psychotherapist. This culminated in the 1967 American Nurses Association Position Paper on Psychiatric Nursing, which clarified the role of the clinical specialist in psychiatric nursing as psychotherapist, and certification for the specialty began in 1979. In the 1990s PMHNP programs were developed, and this culminated in the PMHNP competencies that included psychotherapy as an essential competency required for all PMHNPs (Wheeler & Haber, 2004). 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 (Bailey, 1999).

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 to 5 years experience, coordinates complex care and sees situations as wholes, and long-term solutions

Unconscious competency Expert flexible, efficient, and uses intuition

After the issue of whether nurses should do psychotherapy was resolved, the literature examined the unique qualities that nurses might possess as psychotherapists compared with those in other disciplines who practice psychotherapy. Several strengths were cited: nurses’ 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’ view of the patient in a holistic way, crisis orientation, and a knowledge of general health concerns (Lego, 1992); and familiarity of daily life and experience of the hospitalized patients (Balsam & Balsam, 1974). Nurses usually have had a breadth of life experience and exposure to many different ages, ethnicities, occupations, socioeconomic status, cultures, and personalities. The novice nurse psychotherapist is well served through experience with communicating and connecting with those from diverse backgrounds. Nurses being close to the patient’s everyday experience is crucial for connection and collaboration. This connection is reflected in the public perception of nurses as positive and trustworthy. In 2014 for the 13th year in a row, the Gallup poll found that nurses top the list of most ethical professions, with Americans rating nurses among the most trusted professionals. Eighty-five percent of respondents rated nurses’ honesty and ethics as “very high” or “high” with medical doctors rated third at 70% (Gallup, 2012).

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 PMHCNS

2000 American Nurses Credentialing Center (ANCC) certification of PMHNP

2001 Family PMHNP ANCC Exam

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

2011 APNA and 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

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

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

Requisites for Nurse Psychotherapists

Nurse psychotherapists have the honor of participating in the healing process, and as nurse theorists Dossey and colleagues (2013) point out, in the nurse–patient relationship, the nurse enters into a shared experience or field of consciousness that promotes the healing potential of others. Through consciousness, intent, and presence, the nurse psychotherapist’s therapeutic use of self facilitates others in their healing. To counter the learned patterns of nursing practice (i.e., busyness, task focused, and control), the nurse psychotherapist needs to cultivate reflection, mindfulness, and patience. According to Dossey and colleagues (2013), qualities essential for nurse healers include expansion of consciousness and continuing one’s own journey toward wholeness. This can be accomplished through many different venues: nature, relationships, your own therapy, ongoing supervision, meditation, mindfulness, self-awareness exercises, spiritual practices, chanting, prayer, journaling, openness to receiving one’s own healing treatments, and reflective activities such as hiking, walking, and yoga. Research has shown that the regular practice of mindfulness improves empathy, insight, immune function, attention, and emotional regulation (Siegel, 2012). These changes correspond to changes in the brain that include increased activity and growth of regulatory and integrative regions. Mindfulness is a skill that can be learned through practice and discipline and used as a tool in the psychotherapeutic process. The vast literature on the development of mindfulness crosses many disciplines and orientations, from Buddhism to psychoanalysis. Mindfulness is discussed further in Chapters 13 and 14.

Safran and Muran (2000) state that mindfulness in psychotherapy has three characteristics:

(a) The direction of attention, (b) remembering, and (c) nonjudgmental awareness. The initial direction of attention involves intentionally paying attention to and observing one’s inner experience or actions. This involves cultivating an attitude of intense curiosity about one’s experience. In mindful meditation, the individual can initially cultivate the ability to attend by focusing the attention on an object (e.g., the breath) and then noting whenever his or her attention has wandered and returning it to the intended focus of attention. By noting whatever one’s attention has wandered

toward (e.g., a particular thought or feeling) before redirecting one’s attention, the individual develops the ability to observe and investigate his or her experience from a detached perspective rather from being fully immersed in or identified with it. (p. 59)

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

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

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

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

Irvin Yalom (2002) 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. (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 can convey. Many expert psychotherapists report that they have experienced various modes of psychotherapy and this has enhanced their own technique as the skills others use are incorporated into their own practice.

In addition to self-awareness, self-care is fundamental in caring for others. 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. Burnout may occur for many reasons: our collective history as a profession of women, the patriarchal medical system and nurses’ subservient role, stressful health care environments, and caring for and witnessing trauma and pain in others. Most often, recognition of 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 (Boyle, 2011), all of which mitigate against the ability to adopt the psychotherapeutic stance necessary for conducting psychotherapy. It is only in the recognition of one’s own trauma that he or she can transcend it and be of help to others.

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 is 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. Dossey and colleagues define 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…” (Mariano, 2013, p. 60). Each component is interdependent and interrelated, based on the premise that when there is a change in one part of the system, the change reverberates in all dimensions. For example, minor changes in one’s emotions may potentiate a change in all other spheres as well as in the person’s relationship with others and his or her world. Conversely, a change in the context or relationships with others may create changes in other dimensions (e.g., body, mind, emotion, spirit) of the person. The context or background is the person’s culture as mediated by the person’s family and relationships.

Some of the goals of psychotherapy include the reduction of symptoms, improvement of functioning, relapse prevention, increased empowerment, and the specific collaborative goals set with the patient. Within the biomedical model, symptoms are often thought to be the cause of the patient’s problem and psychotropic medications are prescribed to target specific symptoms in an effort to eliminate or reduce the symptoms. For example, prescribing a selective serotonin reuptake inhibitor (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 is occurring for this person at a given time. By eliminating the symptoms with medication, we are essentially “shooting the messenger.” Often therapists find that therapy works best with full access to emotion, that is, if the person’s emotions are damped down by benzodiazepines or other psychotropic medication, psychotherapeutic work may be compromised. For example, 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 functioning 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 utilize the person’s emotion in the treatment of the patient.

FIGURE 1.1 Paradigms of care.

The holistic paradigm is consistent with the mandate for recovery-oriented behavioral care. The Substance Abuse and Mental Health Services Administration (SAMHSA, 2012a) 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 pathways, person-driven, supported by peers, culturally based, addresses trauma, supported 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 relationship with the practitioner and others so that the person is the driver of his or her own healing process (SAMHSA, 2012b).

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 paradigm. Biomedical psychiatry is based on a descriptive/biological approach of specialized 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 (DSM-5) category of trauma-related disorders. 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 disorder while the new 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 illness.” The former is relevant about who the person is while the latter tells us nothing about the uniqueness of that individual. Indeed the nurse practicing from a holistic paradigm respects the complexity of the person and, historically, this has been the foundation for nursing practice. The holistic paradigm has been a natural extension of the biopsychosocial model of the 1960s.

Holistic care fosters resilience and recovery. The term resilience refers to positive adaptation, or the ability to maintain and regain mental health despite adversity. In fact, there is speculation that surviving a crisis can actually be a growth-promoting experience for some people. However, research supports that resilience 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 et al., 2009). Severe trauma has been found to override constitutional, environmental, genetic, or psychological resilience factors (deBellis, 2001). Studies have shown that factors that enhance resilience include the presence of supportive relationships and attachments as well as the avoidance of frequent and prolonged stress (Herrman et al., 2011). These factors are not inborn but can be fostered through psychotherapeutic interventions that focus on the strengths of the person, reducing risks, and improving relationships. 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.

ELEMENTS OF PSYCHOTHERAPY

The following elements of psychotherapy are pantheoretical concepts. They apply to all approaches of psychotherapy and practice settings and include caring, connection, narrative, and anxiety management (Wheeler, 2011).

Caring

Caring has been identified as central to nursing and as the foundation for practice (Dossey & Keegan, 2013; Morse, Solberg, Neander, Bottorff, & Johnson, 1990; Schoenhofer, 2002; Watson, 2013). Caring encompasses and expands Carl Rogers’s idea of unconditional positive regard that has been adopted by most disciplines as essential in helping relationships (Rogers, 1951). A phenomenological study delineated the characteristics of the advanced practice nurse–patient relationship that are foundational to caring (Thomas et al., 2005). 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 and love with the nurse and patient as coparticipants 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, lovingness, nonjudgmental attitude, understanding, good listening skills, honesty, and empathy. These qualities are the essence of presence (McKivergin, 1997) and allow the nurse psychotherapist to “be with” rather than “doing to” the patient. Bunkers (2009) says that: “True presence involves listening to what is important to the other and listening to what the meaning of a situation is in the moment for that person” (p. 22). Scaer (2005), a neurologist specializing in trauma, says that presence involves a personal interaction that contributes to physiological changes in the person. He states, “This healing, empathic presence affects and alters the parts of the brain that process pain, fear, anxiety, and distress” (p. 167). Presence may facilitate healing through mediation of neurotransmitters and hormones that promote optimum 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 to make their own decisions. Caring is fundamental to creating an atmosphere conducive to the cultivation of empowerment.

Research has found that spirituality emerges as a significant theme in caring and is related to a deepening sense of patients’ inner peace, emotional well-being, and hope in the context of personal crisis (Edmands et al., 1999). Caring results in enhanced personhood for the nurse and the patient. The authors of the study speculate that the personhood of the patient is enhanced because of the advanced practice nurse’s ability to address all domains—behavioral, psychosocial, addictive, psychosomatic, and mental health care. A phenomenological study found that a caring presence by nurse practitioners provides a safe space for patients; empowers patients to make positive health care decisions; return for care; and facilitates physical and emotional well-being (Covington, 2005).

Connection

The healing of psychotherapy occurs through the connection of relationship between the therapist and the patient. Nurses have always recognized the primacy of relationship (Benner & Wrubel, 1989). Lego (1992) maintained that mental health 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 mental health nursing.

Dossey and colleagues (2013) say that the healing relationship occurs through the expansion of consciousness, during which a sacred space is created. Emotional connection promotes interpersonal attunement, attachment, and coregulation of physiological states (Siegel, 2012). Emotional connection with the patient through relationship has been found to be far more important for successful psychotherapy outcomes than the technique or theory used by the therapist (Norcross & Wampold, 2011). This connection allows the therapeutic alliance to occur. The therapeutic alliance is further discussed in Chapters 3 and 4.

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 a collaborative role 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 therapist 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 offer the patient a model for developing curiosity about herself or himself 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.

Narrative

Psychotherapy is first and foremost a narrative discourse. The narrative involves what Peplau terms as shared experiences with patients (1952). These occur when the nurse becomes absorbed into an individual’s narrative to the extent that the patient has the experience of being understood. It is through narrative that patients are empowered by “exploring and developing the meanings and values the person attaches to or associates with his or her experience” (Barker, 2001, p. 81). Patients agree that narrative is an essential ingredient for psychotherapy’s positive outcomes (Kaiser, 2009; Shattell, Mc Allister, Hogan, & Thomas, 2006). Narrative integration is key to healing.

The narrative’s context is generally what the person feels is problematic and difficult as framed by the particular psychotherapy approach used. For example, in Freudian psychodynamic psychotherapy, the narrative is an exploration into the past and how it relates to present feelings and behaviors. The idea is to gain insight to identify and resolve issues originating in the past. In cognitive behavioral psychotherapy, thoughts are the primary vehicle for constructing a narrative; through changing dysfunctional thoughts that have led to the problems, the person’s feelings and/or behaviors can be managed. Regardless of the model of psychotherapy used, the therapist assists the patient in constructing a narrative through exploration, clarification, and focusing on the patient’s strengths. The narrative integrates emotional knowledge by changing implicit memory networks to more explicit memory adaptive connections. One outcome of successful therapy is a more coherent autobiographical narrative for specific traumatic events and for the person’s life in general (Siegel, 2012).

The revision of life stories through narrative is the essential work of psychotherapy as the person reconsiders events and experiences (Cozolino, 2010). Through telling one’s own story, the person anchors his or her experiences to events with regard to time and place while linking past, present, and future within the context of the meaning. In describing an event, the therapist helps the patient develop the ability to focus attention on one aspect of a situation, making sense of data, naming feelings, identifying nuances that may have not been apparent, and assisting the person to formulate meaning through a narrative to “put into words” the person’s experience. For example, what does the patient mean who says that she is “upset”? The therapist helps to elicit the details of the event in such a way that the person becomes more self-disclosing and self- examining, with deeper self-understanding emerging as a by-product of this collaboration.

Cozolino delineates a number of important functions of narrative, which include: grounds our experience in a linear sequential framework; sequences events and steps in problem solving; serves as blueprints for emotion, behavior, and identity; keeps goals in mind and establishes sequences of goal attainment; provides for affect regulation; and allows a context for self-definition. For example, one young woman who came to therapy to get help with her work situation stated she was upset and felt rattled by her boss. The therapist gently stated, “Tell me more about how you feel.” Further exploration revealed how humiliated she felt in his presence and that this was reminiscent of how she felt with her father. It was only through this narrative that she was able to understand the childlike role she had inadvertently played with her boss and how her passivity

compromised her ability to be assertive. She invited aggression, which essentially became a self-fulfilling prophecy.

Management of Anxiety

Understanding, assessing, and managing anxiety is a cornerstone of Peplau’s Interpersonal Relations Model for Nursing (1991). Anxiety is ubiquitous in the psychotherapeutic process, and the skilled 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 relationships that could in principle be correctives to the debilitating anxiety. (p. 87)

FIGURE 1.2 Cyclical psychodynamics of a person with borderline personality disorder.

For the most part, people seek psychotherapy because anxiety or the effects of anxiety have in one way or another interfered with functioning. Sometimes, a person is seeking help for the anxiety itself, such as in cases of panic attacks or phobias, but the presenting issue often is related to the results of the person’s efforts to avoid anxiety. For example, a person with borderline personality traits may present with depression as a result of a lost relationship, but the central issue is a vulnerability to abandonment anxiety. It is likely that in the person’s zeal to avoid the feared abandonments, he or she inadvertently creates the very situation that he or she is trying so hard to avoid (Figure 1.2). Wachtel (2011) calls this cyclical psychodynamics, which is explained further in Chapter 5.

Inherent in all the theoretical approaches and basic principles discussed in this textbook is the centrality of anxiety as key to the patient’s problems and the management of anxiety as key to solving these problems. In the safety of the therapeutic relationship, patients are encouraged to tolerate the feared experiences, memories, and thoughts. Cozolino (2010) 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 fearful. “In this way, anxiety becomes woven into a conscious narrative with the possibility of writing a new outcome to our story” (Cozolino, 2010, p. 22).

Strategies for working with anxiety are central to all therapy approaches. For example, behavioral techniques such as desensitization or flooding may be taught to increase anxiety initially, with the hope of decreasing anxiety later, so the person can face what was fearfully avoided. Cognitive techniques may involve “restructuring” thinking so that the threat that is anxiety-provoking is not considered as dire as originally believed. Psychodynamic techniques use interpretations to deepen the person’s understanding of anxiously

avoided thoughts, wishes, and feelings by making the unconscious conscious in order to understand the cause of anxiety.

However, a challenge in psychotherapy is to keep the person within a physiological window of tolerance (Ogden et al., 2006; Siegel, 2012). The skilled psychotherapist helps the person to confront anxiety through various techniques that assist the person to mediate the autonomic nervous system and stay in the window of tolerance, that is, not too hyperaroused (sympathetic system) and not too hypoaroused (parasympathetic system) (see Figure 1.3). This is the optimum physiological state for the work of therapy. If the person becomes too anxious and hyperaroused, resistances or defenses may increase, and the work of therapy will be thwarted, perhaps not consciously but nevertheless, the person’s brain will not be able to integrate memories. 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 may be in a chronic state of either hyperarousal or hypoarousal. If the person is chronically hypoaroused, he or she may be unable to access emotions. Strategies to increase arousal might include focusing on sensations in the body, mindfulness exercises, and self-regulation strategies. These techniques will be further discussed in this text within the context of the various psychotherapy approaches.

FIGURE 1.3 Therapeutic window of arousal.

For those patients with chronic hyperarousal and anxiety disorders, their window of tolerance may be quite small and strategies to widen the window of tolerance may be needed. Traumatized people most likely have difficulties managing stress, so additional anxiety management strategies and resources may be necessary for the patients to incorporate into daily life. These include basic stress management activities, such as exercise, decreasing caffeine 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 & Phobia Workbook (2010) can be enormously helpful and an important adjunct to therapy. The patient can be asked to read a chapter and complete the exercises 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 anxiety are especially important for those with dissociation and posttraumatic stress disorder (PTSD), and this topic is discussed further in Chapter 13.

However, a caveat is in order. Workbook exercises are only an adjunct to treatment and do not take the place of the real work in therapy, which is co-constructing a narrative and connecting through a therapeutic relationship. A consistent finding is that treatment manuals do not correlate positively with treatment outcome (Moncher & Printz, 1991; Strupp & Anderson, 1997). This may in part result from the constraints on creativity and flexibility with such a “cookbook” approach that is not context driven. Often, novice psychotherapists feel more comfortable with these structured approaches and with “doing” things, thus it may help to manage the therapist’s anxiety more than it does the patient’s. In addition to monitoring the patient’s anxiety, the beginning 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 provoking. A seminal study by the Menninger Foundation found that patients who had positive outcomes from psychotherapy often reported an increase in anxiety, but they had learned to use anxiety as a signal rather than as a reality that danger was present (Siegel & Rosen, 1962). In the safety of the therapeutic relationship, the person is exposed to what has been avoided, and as the person begins to change toward healthier ways of functioning, increased anxiety is inevitable. It is important for the therapist to keep this in mind and monitor the patient’s anxiety level as the therapeutic process unfolds. If anxiety becomes too unbearable in psychotherapy, there may be acting-out behaviors and increased resistance to change, or the person may leave treatment prematurely.

Anxiety is inherent in any new enterprise, and learning psychotherapy can be a particularly anxiety- provoking. In psychotherapy, we are trying to make sense of what is going on, and new information is emerging in every minute of 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 can be enormously helpful 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 interventions and some idea of what constitutes a mentally healthy person. Freud’s simple idea that the goal of therapy is to be able to work and love remains relevant, because it can be applied generally to all cultures and people. In contrast, Sullivan (1947) thought that self-awareness was key to mental health and said, “One achieves mental health to the extent that one becomes aware of one’s interpersonal relations” (p. 207). A more contemporary idea is offered by Siegel (2012) and is based on a systems perspective. He says that mental health is “viewed as emerging from integration in the brain/body and in relationships. The mind as a self-organizing, emergent, embodied, and relational process moves the system toward integration and sense of resilience, harmony, and vitality” (p. A1-49). Integration is accomplished through information processing that links disparate parts into a functional whole. The neurophysiological underpinnings of integration are explained further in Chapter 2.

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 1.4). Safety in the therapeutic relationship is essential to enable disclosure so that higher- level needs on the continuum, such as love, self-esteem, and self-actualization, can be achieved. This model is not fixed in that an individual may achieve self-actualization and then be faced with a trauma and have a need for physiological safety that would then take priority over self-actualization and needs higher in the hierarchy.

It is apparent from reviewing the characteristics of self-actualization in Box 1.1 that the meaning of mental health is culture bound; Maslow’s self-actualized person, embodying independence, autonomy, individuation, and nonconformance, is largely a Western idea. For example, Eastern cultural values of interdependence, communal integration, and group harmony do not fit with western ideas of self- actualization. Some dimensions of this framework may apply to certain cultures but not to others. Cultural relativity is a term that Horowitz (1982) identified as important to consider in any discussion of mental health; behavior that is considered normal or abnormal depends on social and cultural norms.

BOX 1.1

QUALITIES OF SELF-ACTUALIZATION

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

A glossary of cultural concepts of distress is delineated in the back of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) (APA, 2013), and however interesting, it does little to assist the novice psychotherapist in understanding how to help the patient. A further section in DSM-5 includes an outline for cultural formulation for assessing information about the features of a person’s social and cultural context and how this relates to his or her mental health problems. Another resource that is an invaluable and practical guide to understanding the effects of culture on the therapeutic process is Culture and the Therapeutic Process (Leach & Aten, 2010). These resources provide information, but as Campinha-Bacote (2002) points out, cultural competence involves more than knowledge and must be accompanied by other dimensions that are interdependent, such as awareness, skill, encounters, and desire. This model of cultural competency suggests questions for the psychiatric nurse to use in assessing his or her cultural competency (Table 1.4).

FIGURE 1.4 Maslow’s hierarchy of needs. Adapted from Maslow (1972).

TABLE 1.4 Cultural Competence: Have You Asked the Right Questions? Awareness

Are you aware of your personal biases and prejudices toward cultures different than your own?

Skill

Do you have the skill to conduct a cultural assessment and perform a culturally based physical exam?

Knowledge

Do you have the knowledge of the patient’s worldview, cultural-bound illnesses, and the field of biocultural ecology?

Encounters

How many face-to-face encounters have you had with patients from diverse cultural backgrounds?

Desire

What is your desire to “want to be” culturally competent?

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

To diagnose and treat mental illness effectively, the 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 somaticize 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 cultural norms. Allowing time and support may be more appropriate than prescribing an antipsychotic drug.

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 culture 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 must 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 example, 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 environmental and psychosocial problems (i.e., nurture). In contrast, the biophysiological model attributes mental illness to chemical imbalance (i.e., nature). The latter framework attributes mental illness to an imbalance of neurotransmitters in the brain, and the answer lies in correcting these imbalances, largely through medication. This has revolutionized psychiatry and 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, drug companies, as well as those diagnosed with a psychiatric disorder. However, a seminal research study found that this belief actually increases rather than decreases stigma and that people thought to have a brain disease are treated more harshly (Mehta & Farina, 1997). Perhaps diagnosing a person with a psychiatric disorder as “brain diseased” sets the person apart and further marginalizes the person as an “other.” Stigma toward those with psychiatric disorders can be reduced through deepening our understanding of the effect of the environment on brain functioning. This knowledge may help to change the conversation from what is wrong with this person to what has happened to this person.

Both genetic vulnerability and environmental influences play significant roles in the development of mental illness. The term epigenetics has been coined to describe this interplay, that is, the environment selects, signals, modifies, and regulates gene activity. Heritable differences in gene expression are now thought to be not the result of DNA sequencing but on the encryption of experience that can be transmitted and alter behavior over generations. Genetic, biological, traumatic, and social factors interact, 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). That is, for a person who has a genetic vulnerability and encounters significant early life stressors such as childhood trauma or neglect, loss, or viruses, the expression of the gene for the development of the psychiatric disorder most likely will be triggered. Evidence suggests that this is a result of changes in DNA through the process of methylation (Champagne, 2010). 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 hypothesis that epigenetic mechanisms may drive even those psychiatric disorders considered most heritable (Coglan, 2011). In addition, genetically identical twins are 50% concordant 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 triggered by exposure to extreme stress in people who otherwise may not be vulnerable (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 psychiatric disorder (Bradley, 2000; Hankin & Abela, 2005; Pineles et al., 2011). Those who have a stronger, more persistent response to stressors tend to withdraw from stressful situations and have internalizing traits. These people may be inhibited and more fearful, thus predisposing the person to anxiety and depressive disorders. Likewise those whose temperament tends toward externalizing traits may be predisposed to develop psychopathology with symptoms of impulsivity, aggressiveness, and attentional difficulties. Caregivers who are not able to mediate arousal for their offspring with either of these traits are likely to exacerbate difficulties with affect and self-regulation that may lead to psychopathology (Schore, 2012).

Adverse Life Experiences

There is a growing recognition that adverse life experiences due to a variety of reasons underlie a wide range of psychiatric disorders and medical problems (Briere & Scott, 2013; Chu, 2011; Shapiro, 2001). Felitti’s (1998) seminal study of the long-term sequelae of adverse childhood experiences (ACE) for 17,421 adults found a graded positive relationship between ACE and significant heart disease, fractures, diabetes, obesity, unintended pregnancy, sexually transmitted diseases, depression, anxiety, sleep disorder, dissociative disorders, eating disorders, and alcoholism. Epidemiological studies confirm that most, 55% to 90% of people, have experienced at least one traumatic event in their lifetime with an average of five traumatic events reported per person (Centers for Disease Control and Prevention, 2010). “Traumatic events are extraordinary, not because they occur rarely, but rather they overwhelm the ordinary human adaptation to life” (Herman, 1992, p. 33).

Even though traumatic incidences are reported as quite high, only 25% of the individuals who are exposed to trauma go on to develop PTSD (Kessler et al., 1999). Lifetime prevalence rates for PTSD are approximately 7.8% overall in the United States. Findings from the World Trade Center disaster indicate that many people did have significant symptoms, such as insomnia, irritability, general anxiety, vigilance, and impaired concentration, afterward but did not qualify for a diagnosis of PTSD. This is important because a great variety of clinical responses were quite disabling, but people who sought help did not fit into the diagnostic categories of the DSM-IV-TR (Amsel & Marshall, 2003). A more recent 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).

For both adults and children, PTSD is just the tip of the iceberg for the many mental health and medical problems caused or potentiated by a traumatic event or adverse life experience. The consequences of trauma transcend the diagnosis of PTSD and contribute to a wide range of physical, emotional, and social problems (Afifi, Mota, Dasiewicz, MacMillan, & Sareen, 2012; Porges, 2011; Schore, 2012; Teicher, 2012). A diagnosis of PTSD plus depression 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.

van der Kolk (2003) says that single-incident traumas may sometimes account for those diagnosed with posttraumatic stress disorder (PTSD), but most adults who seek psychotherapy have had numerous traumatic events and suffer from a variety of psychological problems, many of which do not fall within this diagnostic category. Broadly speaking, these are problems such as aggression, self-hatred, dissociation, somatization, 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, substance abuse, and attention deficit hyperactivity disorder (Anda et al., 2006; Stien & Kendall, 2006; Teicher et al., 2003; Teicher, 2012).

Children brought up in a chaotic or non-nurturing environment suffer neurological consequences that are long lasting and difficult to remediate (Shonkoff & Garner, 2012). Toxic stress and 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).

Toxic stress in early childhood also plays a role in the intergenerational transmission of disparities in health outcome (Braveman & Barclay, 2009). Research supports the long-term negative sequelae related to the neurobiological responses to childhood stress and trauma (Champagne, 2010; Heins et al., 2011; Perry, 2001; Schore, 2012; Stien & Kendall, 2006; Van Dam et al., 2012). A large-scale recent national survey reported that harsh physical punishment for children was associated with an increase of mood disorders, anxiety disorders, alcohol and drug abuse/dependence, and several personality disorders after adjusting for socioeconomic variable and family history of dysfunction (Afifi et al., 2012). The effects of trauma on the developing brain are likely to be cumulative, profound, and long-lasting, particularly in those with a genetically encoded vulnerability. 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).

Although children are particularly vulnerable to adverse events due to the plasticity of the developing brain, adults who suffer a significant loss of a relationship or job or illness are also at risk for developing PTSD symptoms. Relatively common life events such as problems with relationships or work, result in more PTSD symptoms than an actual or threatened death, which is considered a Criterion A event for a diagnosis of PTSD (Mol et al., 2005; Robinson & Larson, 2010). Those who suffer from acute or chronic illness have been found to suffer from PTSD including those who have received organ transplants (Mintzer et al., 2005); breast cancer survivors (Elklit & Blum, 2011); post myocardial infarction or angina patients (Edmondson et al., 2012); and individuals who have had a cardioversion (Habibovic et al., 2011). Further, 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. The literature suggests that trauma is both a cause and an effect of many acute and chronic illnesses and that PTSD symptoms occur after common adverse life experiences such as losing a job or ending a significant relationship.

This research supports Shapiro’s (2001, 2012) expanded conceptualization of trauma from the Criterion A events for a PTSD diagnosis (natural disasters, terrorist activities, war, incest, physical abuse, car accidents, or other major life-threatening events) to include adverse life experiences that occur often and to most people, such as emotional neglect or indifference, humiliation, 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 illness and procedures, relationship problems between parents, personality problems of parents, exposure to domestic violence, economic hardships, poverty, critical or negative comments from caretakers, social discrimination, prejudice, family instability, accidents, 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.

Although trauma undoubtedly contributes to the development of mental illness, 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). Common sense dictates that suffering any emotional or physical illness is disruptive, disturbing, and stressful. After an exhaustive review of the literature on psychosis 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 link between trauma and mental illness is complex and interactive. Numerous studies have found that adults receiving treatment for severe and persistent mental illness, substance abuse, eating disorders, anxiety, and depressive disorders are highly likely to be survivors of trauma such as childhood sexual abuse, domestic or community violence, combat-related violence, or poverty (Brown et al., 2009; Chu, 2011; Danese et al., 2009; Read, 2010; Stien & Kendall, 2006; Teicher, 2012). A large meta-analysis of prospective and cross-sectional cohort studies found that ACE are associated with psychosis and that if this risk factor was removed, psychosis would be reduced by 33% (Varese et al., 2012). The majority of people served by public

health mental health and substance abuse service systems have experienced repeated trauma since childhood and have been severely impacted by trauma (Grubaugh et al., 2011; Jennings, 2004). In one study intrafamilial sexual abuse was much higher (77%) for psychiatric patients than for women who reported sexual abuse in the general population (50%) (Chu, 2011).

SAMHSA (2012c) has developed the following definition of trauma after extensive discussion and review of the research: Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being. The word trauma is used in this book to denote this expanded conceptualization inclusive of all events and situations that are experienced by the person as overwhelming that effect brain functioning through the interruption of information processing. These events render the person helpless and result in the disturbing event or situation being stored dysfunctionally disrupting brain circuitry, regulatory systems, and information processing that affect the person sometimes decades later (Shonkoff & Garner, 2012). It is a basic tenet of this book that such experiences are the basis of most psychopathology.

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

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, 2001). 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 learning 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 due 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, 2012; Shapiro, 2001, 2012).

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

Psychotherapy interventions can be designed to target any or all areas of the dissociated memory or experience—behavior, relationships, beliefs, the body, images, and/or emotions—to facilitate healing and promote neurophysiological harmony (see Figure 1.5). For example, the therapist using a CBT model would focus on the person’s thoughts 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. A change in any arena reverberates to all other dimensions for the overall purpose of facilitating healing and toward integration because all dimensions are interrelated and interconnected.

The treatment hierarchy framework for practice for this textbook is based on AIP and illustrated in Figure 1.6. This framework reflects a synthesis of research and theory developed by numerous clinicians and researchers (Briere & Scott, 2013; Cozolino, 2010; Davis & Weiss, 2004; Herman, 1992; Porges, 2011; Schore, 2012; Shapiro, 2001, 2012; Siegel, 2012; Wheeler, 2011). To begin the healing process, the APPN assesses where to target interventions, taking into consideration 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 of safety met, and the APPN attends to these needs largely through case management strategies.

FIGURE 1.5 Adaptive information processing model.

FIGURE 1.6 Treatment hierarchy framework for practice. Adapted from Davis and Weiss (2004).

The treatment hierarchy illustrates an overall framework for therapeutic aims that must be ensured before the person can move up the levels in the triangle. Resources must be procured and stabilization guaranteed before trauma can be processed, and then a vision can be developed of a possible future. The overall aim is toward integration of neural networks, of memories, of oneself and relationships, and of the person’s connection in the world. The patient’s ability to process information is variable with some patients needing more stabilization so that adaptive memory and experiences are created or are reinforced if

present, while other patients may be able to process information and quickly move toward integration. Overall, integration through stabilization and processing can be accomplished through the various psychotherapeutic models and techniques discussed in this book.

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

Stabilization

Foundational to all approaches discussed in this book is providing for safety and increasing resources, if needed, to provide stabilization. Resources might include person’s positive memories of past experience, spiritual beliefs, the availability of nurturing 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 strategies included in Box 1.2. 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.

BOX 1.2

SELECTED STABILIZATION STRATEGIES

Through therapeutic relationship Cognitive behavioral therapy Case management Dialectical behavioral therapy Mindfulness/Meditation Imagery Medication Stress management/Education Yoga/Exercise

Stabilization strategies assist the person to be better able to make state changes, that is, to change one’s present physiology in order to function more effectively in the moment. Crucial in case management is the ability of the therapist to assess regressive and adaptive shifts in ego functioning and to recognize conflict to help the person to manage their anxiety. The therapist may understand what is happening for the patient dynamically but does not need to interpret this 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 7. Along with behavioral change and shoring up external resources, if needed, internal resources often need

to be increased before processing. Internal resources are less tangible than external resources, and include the person’s ability to manage positive and negative emotions. Indicators that the person has sufficient internal resources include the person’s ability to self-soothe, adequate impulse control, ability to identify stressful triggers, regulate moods, and communicate honestly. In general, the patient’s resources and the traumas experienced need to be balanced. For the person who has a history of many adverse life experiences without positive memories or experiences, more resources may be needed to manage the deleterious effect of these experiences on functioning. For example, a 6-year-old, learning-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, chronically depressed, and had significant economic problems. Figure 1.7 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 experience and resource balance is based on a comprehensive history and assessment (see 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 memory has been processed, symptoms will dissipate. Specific strategies designed to increase internal resources are embedded in the psychotherapy approaches included in this textbook.

FIGURE 1.7 Trauma and resource balance.

Processing

After stabilization has been achieved, the person is ready to move to the next stage: processing. As represented toward the top of the treatment hierarchy, processing reflects access to all dimensions of memory: behaviors, affect, sensations, cognitions, and beliefs associated with the trauma (Shapiro, 2001, 2012). Processing usually involves assisting the person in constructing a narrative through the exploration of the meaning of significant adverse life experiences and traumas that impair functioning. Changes in physical and emotional responses occur as components of the dysfunctional memory are integrated with other, more adaptive networks. In contrast to state changes that occur in stabilization, processing creates trait changes, that is, enduring relationship and personality changes (Shapiro, 2001). The therapist assists the person in processing using the models and techniques discussed throughout this textbook. Some psychotherapy approaches involve components of stabilization as well as processing such as psychodynamic psychotherapy and 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. 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 processing system that usually integrates experiences to a physiological adaptive state in which information can be taken in, and learning will occur (Shapiro, 2012). Memory is stored in neural networks that therapy 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, 5, and 6.

Clinically, processing has been achieved once relationships are adaptive, work is productive, self- references are positive, there are no significant affect changes, affect is proportionate to events, and there is congruence among behavior, thoughts, and affect. A processing checklist is included in Appendix 1.6 to assist the therapist in determining whether processing has led to adaptive change. Periods of processing are usually followed by periods of destabilization, and the treatment process often looks more like a spiral alternating with interventions aimed at stabilization and then processing (Figure 1.8). Ongoing assessment and attunement to the person’s therapeutic process are important in order to monitor progress and plan treatment strategies. The psychotherapeutic relationship is the vehicle for therapeutic change with the therapist’s presence serving to stabilize the person and provides the foundation needed to assist the integration of dimensions of memory and all parts of the self at deeper levels of understanding. The therapeutic relationship may also facilitate processing as dimensions of earlier significant relationships through transference that are triggered and reworked in the present. Empowerment and autonomy are fostered as the person moves toward envisioning and planning for the future.

BOX 1.3

SELECTED PROCESSING STRATEGIES

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

FIGURE 1.8 Spiral of treatment process.

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 anxiety, depression, and anorexia. Her past psychiatric diagnoses include major depressive disorder, bipolar II, panic disorder, and anorexia nervosa. She reports numerous psychosomatic complaints including frequent stomachaches, irritable bowel syndrome, acid reflux, headaches, restless legs syndrome, generalized pain as well as cold chills all over her body. Her reason for seeking treatment was her anxiety and insomnia related to her loud, annoying neighbors at her

condo. Ms. A’s early history involved significant attachment problems with her both her mother and father abusing drugs and subsequently Ms. A was taken away from her parents and into custody by her aunt when she was 2 years old. Ms. A said her aunt favored her own biological daughter and neglected her throughout her childhood. Her adult trauma history included two previous car accidents. On intake, she scored 63 on the Spielberger Trait Anxiety Scale; 22 on the Beck Depression Inventory; and 27 on the Dissociative Experiences Scale. All scores were significant for anxiety, depression, and dissociation, respectively.

Because Ms. A had significant attachment problems by history, discomfort with her body and physical sensations, difficulty self-soothing, some dissociation, difficulty tolerating negative emotions, and inadequate trust of others, stabilization strategies were taught and practiced so that adequate resources were present before processing. Prozac 20 mg was also prescribed to help Ms. A manage her anxiety because she perceived her current problem with her neighbors as an unmanageable crisis. Ms. A was seen over a period of 6 months for EMDR psychotherapy that was integrated with other stabilization and processing strategies. Stabilization strategies included medication, imagery of safe 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), and attachment imagery exercises (Steele, 2007). Processing strategies included EMDR and our therapeutic relationship. Stabilization and processing strategies were woven throughout her treatment.

At termination, Ms. A’s scores on all measures showed significant improvement; see Figure 1.9. Ms. A’s creativity, visual imaging skills, and humor were great assets to her in our work together. Less tangible outcomes than the reported quantitative data were qualitative outcomes which included: an integrative narrative about herself and her aunt that included a recognition of the impact of her past history; greater ability to express herself and advocate for her own needs; better emotional and physical self-regulation; felt 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, 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.

FIGURE 1.9 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.

CONCLUDING COMMENTS

Psychotherapy has been identified as an important competency that all APPNs must achieve (ANA, 2013; National Panel, 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, for working with mental health problems. Providing a context rich in resources enables further growth toward healing and wholeness. An appropriate metaphor is that of building a house with the foundation and frame necessary for support before furnishing and decorating. Providing for safety and stabilization by strengthening external and internal resources facilitates the ambient environment needed so that healing can occur.

Adverse experiences have the potential to abort the wholeness of the brain, interfering with information processing, and this disruption and dysregulation, sometimes in tandem with neurobiologically encoded genetic vulnerabilities, are the basis for many mental health problems and psychiatric disorders. Psychotherapy assists in reintegration of neural networks that have become dysregulated or disconnected, enhancing the development of the brain so that continued growth and healing can occur. This framework is based on neurophysiology embedded in a holistic paradigm in that psychotherapy restores harmony, balance, connection, and integration of neural networks on a cellular level, which is reflected in deeper connections with oneself and others. The neurophysiological basis for this model is discussed in the next chapter.

DISCUSSION EXERCISES

1. In light of Benner’s Model, where do you see yourself in relation to your past practice of nursing, and where are you now in your nurse psychotherapy practice?

2. How does your choice of intervention affect the outcome of treatment? 3. How can a person be healed and still have a diagnosed psychiatric disorder? How is curing

different from healing? How do you know when healing has occurred? 4. Discuss a time when you and your patient had a different perception of health and illness and

what this experience was like for you. How was this worked out then, and what would you do differently now?

5. Discuss how your self-understanding may affect your work with your patient. How has your own growth changed since you first began to work with others? Include your thoughts about how your prior practice as a nurse can be a help or hindrance to your practice as a psychotherapist.

6. What factors in your life led you to a nurse psychotherapist’s role? 7. Discuss the elements of psychotherapy, and give a clinical example of each from your past nursing

practice. 8. Describe a patient you have worked with, explain the person’s traumas and resources, and discuss

in general the priorities for treatment using the practice treatment hierarchy.

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www.april-steele.ca Stien, P., & Kendall, J. (2006). Psychological trauma and the developing brain. New York: Hawthorne Press. Strupp, H. H., & Anderson, T. (1997). On the limitations of treatment manual. Clinical Psychology: Science and Practice, 4, 76–82. Sullivan, H. S. (1947). Conceptions of modern psychiatry. Washington, DC: William Alanson White Institute. Teicher, M. (2012). Windows of vulnerability: The neurobiology of childhood abuse. Retrieved November 17, 2012 from

http://www.bocyf.org/child_maltreatment_workshop_teicher_presentation.pdf Teicher, M., Polcari, A., Andersen, S., Anderson, C. M., & Navalta, C. (2003). Neurobiological effects of childhood stress and trauma. In S.

Coates, J. Rosenthal, & D. Schechter (Eds.), September 11: Trauma and human bonds. Hillsdale, NJ: The Analytic Press. Thomas, J. D., Finch, L. P., Schoenhofer, S. O., & Green, A. (2005). The caring relationships created by nurse practitioners and the ones

nursed: Implications for practice. Topics in Advanced Practice Nursing Journal, 4(4). Tryon, G. S., & Winograd, G. (2002). Goal consensus and collaboration. In J. Norcross (Ed.), Psychotherapy relationships that work (pp. 109–

125). New York, NY: Oxford University Press. van der Kolk, B. (2003). Posttraumatic stress disorder and the nature of trauma. In M. Solomon & D. Siegel (Eds.), Healing trauma. New York,

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Wachtel, P. (2011). Therapeutic communication: Knowing what to say when (2nd ed.). New York, NY: Guilford Press. Watson, J. (2013). Jean Watson’s theory of caring. From http://currentnursing.com/nursing_theory/Watson.xhtml Wheeler, K. (2011). A relationship-based model for psychiatric nursing practice. Perspectives in Psychiatric Care, 47(3), 151–159. doi:

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programs. Perspectives in Psychiatric Care, 44(2), 72–80. Wheeler, K., & Haber, J. (2004). Development of psychiatric nurse practitioner competencies: Opportunities for the 21st century. Journal of the

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http://currentnursing.com/nursing_theory/Watson.xhtml

38APPENDIX 1.1

Suggestions for Presenting a Case

Presenting a case can seem overwhelming, especially with complex patients. The following guidelines are intended to help you organize your thinking, summarize salient information about your patient in a coherent manner, identify areas where the therapy is stuck (resistance), and formulate questions that may offer insight into the process. Identifying information should be disguised.

Basic Information

Demographics: age, race/ethnicity, gender, sexual orientation, education, occupation Family: relationship status, living arrangement, members of immediate family, extended relevant family members Working Diagnosis and Symptoms: dissociation, anxiety, depression, eating disorder, substance abuse, self- injury, and suicide attempts, destructive or violent behavior Relevant Medical Problems and Physical Disabilities: diabetes, asthma, chronic pain, birth defects, sensory impairment, impaired mobility, and so on Patient’s Coping Mechanisms: both healthy and unhealthy, defenses, ego functioning Treatment History: inpatient, outpatient, how long and intensive, treatment failures and responses Current Treatment: inpatient, outpatient, partial individual, group, family Medication(s): current and past history

Case Conceptualization

1. What are the reasons the patient came for treatment now? 2. What are the patient’s goals? How would the person know if the treatment was successful? 3. When did the current symptoms start? 4. What other situations may be contributing to the problem now? 5. Speculate on what experiential contributors from the past might be driving the current symptoms? 6. Is there a current crisis? 7. Resources and strengths 8. Draw a timeline with the patient of the most disturbing and pleasant events in the person’s life and rate

disturbances on a 0 to 10 scale with 10 being the most disturbing. See Chapter 13 for example of timeline.

Questions to Ponder

What’s going well in the therapeutic process, and what is problematic? Have you established a therapeutic alliance? Is the patient’s life stabilized? Is the patient avoiding or working on issues? Undermining the therapy? Flooding with memories or decompensating? What makes you want to present this patient? What’s unusual, special, difficult, confusing, arousing, frustrating, scary, overwhelming? What do you experience with this patient that is unusual for you? Do you feel intense emotions, like or

dislike, anger, admiration, humiliation, fear, revulsion, sleepy, dizzy, disoriented, a desire to nurture or rescue, the urge to confront. Do you wish you could get rid of this patient, or are you afraid of losing him or her?

Treatment Hierarchy

Based on this information and the hierarchy of treatment in your book, what do you think is the most appropriate interventions/treatment for this person now? What are treatment priorities?

40APPENDIX 1.2

Weekly Plan for Increasing Resources

Check off, in the column to the left, all activities that you currently do and keep track of how often you do them for 1 week in the columns to the right. Then put a + in the column to the left of those activities you would like to try in the future. Select one with your therapist to try for the following week, and check off how often you do it. Some of these are learned skills that your therapist may teach you. The idea is to gradually build up and integrate more resources into your life.

42APPENDIX 1.3

Weekly Plan

Please fill in two to three goals for the week and check off each day that you meet that

43APPENDIX 1.4

Treatment and Case Management

Client: Address: Date: Phone: Insurance: Note: At the end of this form is the form for Client Case Management Needs, which clients can fill out before the session to identify their key areas of need. However, it is still important for the therapist to assess each goal directly, because clients may not be aware of some needs. 1. Housing Characteristics

Goal Stable and safe living situation.

Notes Unhealthy living situations include short-term shelter, living with a person who abuses substances, an unsafe neighborhood, and a domestic violence situation.

Status If the goal is already met, check here ________ and describe. If the goal is not met, check here ________ and fill out the Case Management Goal Sheet.

2. Individual Psychotherapy Goal Treatment that client finds helpful.

Notes Try to get every client into individual psychotherapy. Inquire whether the client has any preferences (e.g., gender, theoretical orientation).

Status If the goal is already met, check here ________ and describe. If the goal is not met, check here ________ and fill out the Case Management Goal Sheet.

3. Psychiatric Medication Goal Treatment that client finds helpful for psychiatric symptoms (e.g., depression, sleep

problems) or substance abuse (e.g., naltrexone for alcohol cravings).

Notes If the client has never had a psychopharmacologic evaluation, one is strongly recommended, unless the client has serious objections; even then, evaluation and information are helpful before making a decision.

Status If the goal is already met, check here ________ and describe. If the goal is not met, check here ________ and fill out the Case Management Goal Sheet.

4. HIV Testing and Counseling

Goal Test as soon as possible, unless one was completed in the past 6 months and there have been no high-risk behaviors since then. For a client at risk for human immunodeficiency virus (HIV) infection who is unwilling to get testing and counseling, it is strongly suggested that the therapist hold an individual session with the client to explore and encourage these

goals.

Notes Assist patient with accessing community resources in your geographic area.

Status If the goal is already met, check here ________ and describe. If the goal is not met, check here ________ and fill out the Case Management Goal Sheet.

5. Job, Volunteer Work, and School Goal At least 10 hours per week of scheduled productive time.

Notes If the client is unable to meet the goal of 10 hours/week, have the client hand in a weekly schedule with constructive activities out of the house (e.g., library, gym).

Status If the goal is already met, check here ________ and describe. If the goal is not met, check here ________ and fill out the Case Management Goal Sheet.

6. Self-Help Groups and Group Therapy Goal As many groups as the client is willing to attend.

Notes Elicit the client’s preferences, and consider a wide range of options (e.g., dual-diagnosis groups, women’s groups, veterans’ groups). For self-help groups (e.g., Alcoholics Anonymous), give the client a list of local groups, strongly encourage attendance, and mention that the sessions are free. However, do not insist on self-help groups or convey negative judgment if the client does not want to attend. If the client participates in self-help groups, encourage seeking a sponsor.

Status If the goal is already met, check here ________ and describe. If the goal is not met, check here ________ and fill out the Case Management Goal Sheet.

7. Day Treatment Goal As needed and based on the client’s level of impairment, ability to attend a day program,

and schedule.

Notes If possible, locate a specialty day program (e.g., substance abuse, posttraumatic stress disorder). If the client is able to attend (e.g., job, school, volunteer activity), do not refer to day treatment, because it is usually better to have the client keep working; however, if the client is working part-time, some programs allow partial attendance.

Status If the goal is already met, check here ________ and describe. If the goal is not met, check here ________ and fill out the Case Management Goal Sheet.

8. Detoxification and Inpatient Care Goal To obtain an appropriate level of care.

Notes Detox is necessary if the client’s use is so severe that it represents a serious danger (e.g., likelihood of suicide, causing severe health problems, withdrawal requires medical supervision, such as for painkillers or severe daily alcohol use). If the client is not in acute danger but cannot get off substances, detox may or may not be helpful; many clients are able to stay off substances during the detox but return to their usual living environment and go

back to substance use. For such clients, helping set up adequate outpatient supports is usually preferable. Inquiring about client’s history (e.g., number of past detox episodes and their impact) can be helpful in making a decision.

Psychiatric inpatient care is typically recommended if the client is a serious suicide or homicide risk* (i.e., not simply ideation, but immediate plan, intent, and inability to contract for safety) or the client’s psychiatric symptoms are so severe that functioning is impaired (e.g., psychotic symptoms prevent a mother from caring for her child). In some circumstances, the client may need to be involuntarily committed; seek supervision and legal advice on this topic.

Status If the goal is already met, check here ________ and describe. If the goal is not met, check here ________ and fill out the Case Management Goal Sheet.

9. Parenting Skills and Resources for Children Goal If the client has children, inquire about parenting skills training and about referrals to help

the children obtain treatment, health insurance, and other needs.

Notes You may need to gently inquire to assess whether the client’s children are being abused or neglected. If so, you are required by law to report it to your local protective service agency. The same rule applies for elder abuse or neglect.

Status If the goal is already met, check here ________ and describe. If the goal is not met, check here ________ and fill out the Case Management Goal Sheet.

10. Medical Care Goals Annual examinations for (1) general health, (2) vision, (3) dentistry, and (4) gynecology (for

women), including (5) instruction about adequate birth control and prevention of sexually transmitted diseases.

Notes Other medical care may be needed if the client has a particular illness.

Status If all five goals are already met, check here ________ and describe. If any of the five goals is not met or other medical issues need attention, check here ________ and fill out the Case Management Goal Sheet for each.

11. Financial Assistance (e.g., food stamps, Medicaid) Goal Health insurance and adequate finances for daily needs.

Notes It is crucial to help the client obtain health insurance and entitlement benefits (e.g., food stamps, Medicaid), if needed. The client may need help filling out the forms; the client may be unable to manage the task alone, because the bureaucracy of these programs can be overwhelming. If much help is needed, you may want to refer the client to a social worker or other professional skilled in this area. If the client is a parent, be sure to check whether the children are eligible.

Status If the goal is already met, check here ________ and describe. If the goal is not met, check here ________ and fill out the Case Management Goal Sheet.

12. Leisure Time Goal At least 2 hours per day in safe leisure activities.

Notes Leisure includes socializing with safe people and activities such as hobbies, sports, outings, and movies. Some clients are so overwhelmed with responsibility that they do not find time for themselves. Adequate leisure is necessary for maintaining a healthy lifestyle.

Status If the goal is already met, check here ________ and describe. If the goal is not met, check here ________ and fill out the Case Management Goal Sheet.

13. Domestic Violence and Abusive Relationships

Goal Freedom from domestic violence and abusive relationships.

Notes It may be extremely difficult to get the client to leave a situation of domestic violence. Be sure to consult a supervisor and a domestic violence hotline representative.

Status If the goal is already met, check here ________ and describe. If the goal is not met, check here ________ and fill out the Case Management Goal Sheet.

14. Impulses to Harm Self or Others (e.g., suicide, homicide) Goal Absence of such impulses, or if such impulses are present, a clear and specific safety plan is

in place.

Notes Many clients have thoughts of harming self or others; however, to determine whether the client is at serious risk for action and how to manage this risk, see the guidelines developed by the International Society of Study for Dissociative Disorders in Chapter 3.

Status If the goal is already met, check here ________ and describe. If the goal is not met, check here ________ and fill out the Case Management Goal Sheet.

15. Alternative Treatments (e.g., acupuncture, meditation) Goal The client is informed about alternative treatments that may be beneficial.

Notes Clients should be informed that some people in early recovery benefit from acupuncture, meditation, and other nonstandard treatments. Try to identify local referrals for such resources.

Status If the goal is already met, check here ________ and describe. If the goal is not met, check here ________ and fill out the Case Management Goal Sheet.

16. Self-Help Books and Materials Goal The client is offered one or two suggestions for self-help books and other materials, such as

audiotapes or Internet sites, that offer education and support.

Notes All clients should be encouraged to use self-help materials outside of sessions as much as possible. For clients who do not like to read, alternative modes (e.g., audiotapes) are suggested. Self-help can address posttraumatic stress disorder, substance abuse, or any other life problems (e.g., study skills, parenting skills, relationship skills, leisure activities, medical problems).

Status If the goal is already met, check here ________ and describe. If the goal is not met, check here ________ and fill out the Case Management Goal Sheet.

17. Additional Goal Goal Notes

*For homicide risk or any other intent to physically harm another person, the therapist must follow “duty to warn” legal standards, which usually involve an immediate warning to the specific person the client plans to assault. Always seek supervision and legal advice, and be knowledgeable in advance about how to manage such a situation.

CASE MANAGEMENT GOAL SHEET

Client: Date: Goal:

Referrals given to client, date given, and deadline (if any) for each:

Describe client’s motivation to work on this goal:

Emotional obstacles that may hinder completion (and strategies implemented to help client overcome these):

Therapist to do:

Follow-up (date and update):

CLIENT CASE MANAGEMENT NEEDS

Do you need help with any of the following? (circle one) 1. Housing characteristics Yes/Maybe/No

2. Individual psychotherapy Yes/Maybe/No

3. Psychiatric medication Yes/Maybe/No

4. HIV testing and counseling Yes/Maybe/No

5. Job, volunteer work, and school Yes/Maybe/No

6. Self-help groups and group therapy Yes/Maybe/No

7. Day treatment Yes/Maybe/No

8. Detoxification and inpatient care Yes/Maybe/No

9. Parenting skills and resources for children Yes/Maybe/No

10. Medical care Yes/Maybe/No

11. Financial assistance (e.g., food stamps, Medicaid) Yes/Maybe/No

12. Leisure time Yes/Maybe/No

13. Domestic violence and abusive relationships Yes/Maybe/No

14. Impulses to harm self or others (e.g., suicide, homicide) Yes/Maybe/No

15. Alternative treatments (e.g., acupuncture, meditation) Yes/Maybe/No

16. Self-help books and materials Yes/Maybe/No 17. Additional goal Yes/Maybe/No Permission to photocopy this form is granted to purchasers of this book for personal use only. Adapted from Najavits (2002).

49APPENDIX 1.5

Stage I

STABILIZATION CHECKLIST

Please check all indicators below to help assess whether client is stabilized and ready to move to Stage II.

Comfort with own body and physical experience

Client is able to establish a useful distance from the traumatic event

No current life crisis such as impending litigation or medical problems

Client accepts diagnosis and has a working knowledge of trauma

Client’s mood is stable, even if depressed

Client has at least two or more people to count on

Client knows and uses self-soothing techniques

Client gives honest self-reports

Client’s living situation is stable

Client is able to communicate

Client has stable therapeutic relationship and adequate trust of others

Client has adequate impulse control, no injurious behavior to self or others

Client stays grounded and oriented x3 when distressed

No major dissociation present

Client can identify triggers and reports significant symptoms

Client can set limits and is able to leave dangerous situations if necessary

Client can tolerate positive and negative affect, and shame

If DID, is cooperative and has contractual agreement among parts

Client can establish “useful distance” from traumatic event

50APPENDIX 1.6

Stage II

PROCESSING CHECKLIST

Please check all indicators below to help assess whether client has adequately processed trauma and is moving to Stage III, future visioning. The stabilization checklist should already have been achieved.

No significant affect changes

Self-referencing cognitions are positive in relation to past event

Can dismiss thoughts of trauma at will

Relationships are adaptive

Work is productive

Good quality of decision making

Creativity begins to emerge

Boundaries improve

Complaints tend to deal with present day events

Affect is proportionate to current events

Congruence between behavior, thoughts, and affect

51APPENDIX 1.7

Safe-Place Exercise

The safe-place exercise described below helps the client to enhance skills during stabilization as well as to decrease distress after processing. Through the ability to create one’s own safe place, the person is empowered. As with all learning, the more it is practiced, the more readily available it is when needed. Thus, it should be used on a day-to-day basis. If a client feels there is no place—real or imaginary—that is safe, have the client focus on one time in his or her life when he or she felt safe or on a person he or she admires who exemplifies positive attributes, such as strength or control. If the person still cannot find a safe place, ask them to think of a place where they feel relaxed or comfortable. Sometimes clients become more distressed when they relax and it may take some time before the person is able to identify a positive resource. Identifying a safe place resource may take several sessions. Ask the person to sit with his or her feet firmly planted on the floor. Sometimes this exercise is conducted with soothing music and/or background nature sounds. Some therapists tape the exercise with their voice to give to the client to practice at home. The safe-place exercise follows.

Ask the person to identify an image of a safe place that he or she can easily evoke that creates a personal feeling of calm and safety. Use soothing tones to enhance the imagery, asking the person to “see what you see,” “feel what you feel,” “notice the sounds, smells, and colors in your special place.” Once identified, ask the person to focus on the image, feel the emotions, and identify the location of the pleasing physical sensations and where he or she is in the body. “Concentrate on those pleasant sensations in your body and just enjoy as you breathe deeply, relaxing and feeling safe.” After you have slowly deepened his or her experience of this, slowly ask the person to come back and tell you a description of the place. Ask for details so that you can assist the person in accessing this place in the future. Ask how he or she feels and if the experience has been difficult for the person and/or no positive emotions are experienced, explore other resources that might be helpful. If at any time the person indicates that he or she is not feeling safe, the exercise should be stopped immediately.

If successful in accessing a safe place, the person is asked for a single word that fits the picture (i.e., beach, forest…) and then asked to repeat the exercise using the person’s words for the experience along with deep breathing. Then ask the person to repeat on his or her own, bringing up the image, emotions, and body sensations. Reinforce, after this exercise, that his or her safe place can be used as a resource and ask the client to practice over the next week, once a day.

During the next session, practice again with the person. Then ask the client to bring up a minor annoyance and notice the negative feelings while guiding the person through the safe place until the negative feelings have dissipated. Then ask the person to bring up a negative disturbing thought once again and to access the safe place but this time on his or her own without your assistance.

Occasionally the safe-place exercise triggers intense negative affect. Clients should be made aware about the possible activation of issues during the safe-place exercise. Reassure the person that even if temporary activation of issues does occur, this is not beyond the limits of expectation, and that it may identify issues that will be addressed in the course of therapy anyway.

52APPENDIX 1.8

Container Exercise

This exercise is an important affect management strategy that can be taught to the client and practiced so that the person can feel in control and develop mastery over his or her emotions. It also assists with self-soothing, decreasing arousal, and reinforces a sense of safety. The person should already have a safe place. This exercise should be initiated toward the end of the session when the person has intense negative feelings of anxiety, anger, fear, and/or sadness.

The therapist introduces by saying something like: “Did you know that we can put those bad feelings into a container so you won’t feel so overwhelmed when you leave?” The person’s curiosity is usually piqued at this point even if he or she does not believe you. Continue with: “I can help you do this and then you can take out those feelings when you want and deal with them the next time we meet or when you decide it is okay.” Usually the person agrees if for no other reason than he or she is curious and may think you are really strange to suggest such a thing. The therapist continues in a soothing tone: “So, just imagine you have a container, you can close your eyes or not as you wish. It can be made out of anything that you want and be any size you want but be sure it has a tight lid that you can cover or lock because we are going to put all those negative feelings in. Let me know once you have an image in your head.” Once the person says he or she has the image, ask him or her for a few details regarding size and so on. Then ask the client to “return to the image and imagine all those bad feelings going into the container. Once you have all the bad feelings in the container, lock it up. Let me know when they are in there.” Once the person says they are in the container, ask the person whether there is any percentage that is still not in the container and usually the person will say something like 10% or 20%. At that point, ask the person: “Do you need a bigger container to accommodate all the bad feelings? You can make it as big as you want. See whether you can put the rest of those feelings in the container now. Let me know when the rest of the feelings are all in the container and locked.” If more negative feelings come up, continue with either imaging another container or making the one he or she has bigger. Ask the person what this was like for him or her, checking to see whether he or she is okay.

It is important to do this exercise slowly and use pacing so that the person does not feel rushed. The session can then be ended with the safe place exercise. Ask the person to practice the container exercise during the week when negative feelings come up. The client can also practice allowing the feelings to come out if they think they can manage this and journal about these feelings between sessions. Asking the person at in the next session: “What was different for you this past week?” and exploring how feelings were or were not manageable are important follow-up steps and help to assess how to increase the effectiveness of this exercise. Modified and adapted with permission from Ginger Gilson, from Gilson and Kaplan, The Therapeutic Interweave in EMDR (2000).

532

The Neurophysiology of Trauma and Psychotherapy KATHLEEN WHEELER

his chapter considers the neurophysiological basis for psychotherapy with the adaptive information processing (AIP) model as the overall framework for practice. The confluence of neurobiology,

attachment theory, and infant development research is transforming the way we think about and work in psychotherapy, deepening our understanding of what causes change and the role of trauma and its effects on the individual. A new age of psychotherapy is dawning with the ability to document differential responses to therapy and medication through positron emission tomography (PET), electroencephalography (EEG), and functional magnetic resonance imaging (fMRI). The ability to study brain activity enhances our potential to decide what treatments to use and how to use them based on neuroscience findings. Advanced practice psychiatric nurses (APPNs) who understand underlying neurophysiology can make informed decisions about what needs to change and how to benefit patients and family members in ways that we are only beginning to imagine.

Neuroscience is a vast, complicated area of study, and this chapter highlights only selected relevant topics. It is not meant to be comprehensive, and some working knowledge of neurophysiology is assumed. Much exciting research is ongoing, and the references at the end of this chapter should be consulted for further information. Excellent reviews of neurophysiology for psychiatric nursing care can be found in the works of Boyd (2011), Fortinash and Holoday (2012), Keltner, Bostrom, and McGuinness (2011), Kneisl and Trigoboff (2012), Stuart (2012), Varcarolis and Halter (2013), or Videbeck (2010).

Selected topics for discussion in this chapter include information processing, memory, brain development, brain structures and the neurophysiology of trauma, and the role of psychotherapy in restructuring neural networks.

The word trauma is used throughout this chapter to reflect an adverse life experience or event that is perceived as disturbing and overwhelming by the individual (see Figure 2.1). The trauma response begins with the normal stress response but evolves into a failure of adaptation or recovery from extreme stress. It is thought that the more helpless and less in control of the situation people feel, the more vulnerable they are to pathophysiological changes. Thus stress can be conceptualized as on a continuum with mild stressors at one end and extreme helplessness/trauma at the other end.

Psychotherapy mediates the reintegration and connection of neural networks that have become maladaptively linked due to adverse life events facilitating healing of the brain. This goal is accomplished by changing implicit memory networks into more explicit adaptive connections and linking memory fragments through information processing. Neurophysiological research and theory provide the evidence and rationale that this healing and integration occur primarily in the context of a therapeutic relationship.

FIGURE 2.1 Continuum of stress/trauma.

ADAPTIVE INFORMATION PROCESSING MODEL

The AIP model was developed by Shapiro through her development and observations of the effects of eye movement desensitization and reprocessing (EMDR) therapy (Shapiro, 2001). AIP hypothesizes that humans have an inherent information processing system that usually processes experiences to a physiological adaptive state in which information can be taken in and learning can occur. This model posits that there is an innate self-healing quality in the brain that strives to regulate its internal environment to survive and to maintain a stable, constant condition by means of dynamic regulation. Positive and negative experiences affect neurophysiological harmony. Optimally, memory is stored in a way that allows for connection with other adaptive memory networks (Shapiro, 2001).

Memory is stored in neural networks and learning is reflected as changes in synaptic strength among neural systems that are linked together and organized around early events with associated emotions, thoughts, images, and sensations (Bergmann, 2012). Interconnected neuronal and biochemical patterns are developed as templates for future experiences through interaction with others with specific profiles emerging that may be adaptive or nonadaptive. Information pathways exist throughout the brain and display synchronized oscillations so that neural networks entrain to each other’s action potential. This synchronization allows for the creation of neural maps from the interactions of these neural networks. These pathways of neurons are forged by experience so that perception, memory, cognition, and emotion result and then are continually revised by new and ongoing experiences throughout life.

Learning changes the pattern of receptors in neural networks with integration and interconnections either top down (cortex to subcortical) or left right (across the two hemispheres of the brain). The top-down integration allows the processing of and organizing of impulses and emotions generated by the limbic and brainstem structures while the left–right integration allows for feelings to be put into words and for negative and positive emotions to be integrated. These systems are not necessarily independent of one another and involve multiple structures along the way (Cozolino, 2010).

Adaptive processing means that neural connections are associated that allow the experiences to be integrated into positive emotional and cognitive schemas (Shapiro, 2001). Healthy functioning is reflected in the optimal integration and coordination of these neural networks with the brain existing in a balance of interconnectivity. “When the brain is operating efficiently, multiple assemblies of neurons are firing in unison, and information is flowing freely from one area to another” (Stien & Kendall, 2004, p. 19).

Psychopathology is thought to result from a dysregulation that disrupts integrated neural processing of these networks. If an experience is perceived as emotionally intense or overwhelming, the event may not be fully processed. The memory is stored as it was at the time of the event and does not get linked to other networks in an adaptive way. The experience disrupts the biochemical balance of the information processing system and prevents the information from processing to an adaptive resolution by thwarting integration with other adaptive memory networks. Perceptions of the incident are etched into the information system as a result of the influx of messenger molecules, particularly norepinephrine (NE) for distressing experiences and dopamine for intensely positive experiences (Higgins & George, 2007). When a similar event occurs in the future, physiological information connected with the previous experience is matched against previous state-dependent memories that involve emotional, motor, and body memories. Reminders of these experiences by either internal or external factors trigger and continue to activate specific neurobiological responses that then drive behavior and the symptoms of most mental health problems and psychiatric disorders. To understand how experiences such as these affect brain function, it is helpful to review the stages of brain development and how the brain stores information.

BRAIN DEVELOPMENT

The brain allows us to accumulate and distill experiences through complex physiological processes. Elements of the collective experience of our species are reflected in the genome, and the experience of the individual is reflected in the expression of the genome. Life experience and environmental influences determine the degree of expression of the genome through complex physiological processes (Champagne, 2010). Blood flow, energy use, and metabolism in various areas in the brain are determined by the person’s environment and experience. The nuclei of various cells of the body modulate the expression of genes, and genes direct cells to produce various molecules that regulate the metabolism, growth, and activity level for every system of the body.

Genes are turned on and off by the messenger molecules that are chemical substances classified as hormones (endocrine system), neurotransmitters (autonomic nervous system [ANS]), immune cells (immune system), and neuropeptides. More than 300 messenger molecules have been identified. Some of these

messenger molecules, such as hormones and neuropeptides, regulate the effects of the neurotransmitters and are specific for selected neural networks. Neurotransmitters have specific actions at receptor sites but are not considered the cause of mental illness (Melchitzky & Lewis, 2009). See Box 2.1 for action of selected messenger molecules.

On a cellular level, messenger molecules percolate across the synaptic space and bind to receptor sites found in cell walls, thereby changing receptor structure and cell wall permeability and causing ions to shift and second messenger molecules to direct the cell’s activities. The receptors vibrate, and the messenger molecules are attracted to specific receptor sites. Receptors on each cell decrease or increase depending on the amount of their specific messenger molecule available at that moment (see Figure 2.2). A single neuron can get input from an average of 5,000 other neurons. With more than a half-million receptor sites per cell, 100 billion neurons in the brain, and 300 messenger molecules, it is easy to see that the number of possible interactions or communications is enormous. Modulation of receptors regulates what information (i.e., memories, perceptions and sensations) percolates across the synapse. The energy in the nerve impulse is the flow of ions down the axon and, along with the information contained in the messenger molecules, is fundamental to our subjective sense of self.

The brain stores experiences and creates templates—connections among neurons—against which everything is matched. These templates of neural networks begin to be laid down in utero, developing rapidly. The human brain develops many more neurons than it needs, and through apoptosis, or programmed cellular suicide, approximately 50% of them are eliminated before birth. The primary task of development is the sequential acquisition of various memories or networks of neurons. Sequential acquisition means that the brain develops from the bottom up, and templates of neurons are laid down to form these structures: from primitive regulation of body processes (e.g., respiration, sleep) to motor (i.e., simple to complex) to limbic (i.e., reaction to affiliation) to thought (i.e., concrete to complex). The brain develops from the lower brain structure of the brainstem to the midbrain through the limbic structures; the cortex is the last area and the most “plastic” area of the brain. Neuroplasticity refers to areas that are responsive to the environment and that can change; the lower brain structures, such as the brainstem, are more fixed than the higher brain functions of the cortex, which continue to develop throughout life. Figure 2.3 shows the stages of brain development, regulation, and memory.

BOX 2.1

ACTION OF SELECTED MESSENGER MOLECULES

Acetylcholine: this neurotransmitter occurs in cholinergic tracts extending from the limbic structures to the cortex, and a decrease in concentration is associated with memory and cognitive impairments. An increase is associated with Alzheimer’s disease.

Cortisol: a potent stress hormone that mobilizes energy stores, stimulates the release of glucose, potentiates the release of adrenaline, increases cardiovascular tone, and inhibits growth, immune, and inflammatory responses. An increase leads to cell atrophy and a decrease leads to cell growth.

Dopamine: produced in the substantia nigra and other areas in the brainstem, it is a key neurotransmitter for motor action and the reward system. Too much may change mood, increase motor behavior, and disturb frontal lobe functioning, resulting in depression, memory impairment, and apathy. Parkinson’s disease has been linked with decreased levels of dopamine.

Endocrine messenger molecules: all are hormones composed of amino acids (in peptides, proteins, or glycoproteins) and are produced by one tissue and conveyed through the bloodstream to effect a change in growth or metabolism on another tissue. Moderate stress triggers the release of certain hormones that enhance cortical reorganization and new learning.

Endorphin: this endogenous opioid is found in a number of brain areas. It produces analgesia, reduces anxiety, and promotes calmness, and it is involved in self-harm and stress addiction.

Gamma-aminobutyric acid (GABA): this inhibitory neurotransmitter contributes to a momentary refraction of neuron firing, and the glutamate derivative is found in most neurons in the central nervous system. It is involved in postsynaptic inhibition when benzodiazepines are given for anxiety, which further decreases the firing of the neurons. A decrease is associated with anxiety disorders.

Glutamate: it is found in all cells, and its major receptor, N-methyl-d-aspartate (NMDA), helps to regulate brain development. Too much glutamate is toxic to neurons.

Immune messenger molecules: these substances are produced by the immune system and by nerve cells. Some produce neuropeptides and communicate directly and indirectly with the brain; others mediate behavioral responses, such as mild anxiety, avoidance, sleepiness, and lethargy. Selected substances include cytokines, interleukin-2, and immunocytes.

Norepinephrine (NE): produced mainly in the locus ceruleus, NE is a key neurotransmitter in the flight, fight, or freeze stress response. Too much can result in anxiety, vigilance, and aggressive behavior, but it can enhance memory and cognitive

functioning up to a certain point. A decrease is associated with depression.

Oxytocin: this hormone is released from the pituitary to contract the uterus in childbirth and during orgasm. It is thought to enhance affiliative and monogamous relationships and social interactions. Early stress can produce a lifelong decrease.

Serotonin (5HT): produced in the raphe nucleus, 5HT plays a role in arousal and the sleep–wake cycle and in modulation of mood; in anxiety and affective disorders; and in temperature regulation and pain control. A decrease is associated with depression.

Vasopressin: the antidiuretic properties and high concentrations can lead to arterial constriction. It enhances sexual arousal. Early stress produces a lifelong increase; diabetes insipidus may result from a deficiency.

See Keltner, Bostrom, and McGuinness (2011) for more detailed information on the specific action of neurotransmitters.

FIGURE 2.2 Neuron and receptor site.

Brain development consists of laying down neural networks during the various stages of development, and as synapses change, brain structures change on the basis of experience. The interplay of experience and developmental period is important in that there are certain critical periods, especially in the first 3 years of life, when specific neural networks are particularly malleable or plastic (Bergmann, 2012; Schore, 2012). The brain triples in size up to age 5 years, largely due to myelinization, and this increases the rate of information processing. Infancy and adolescence are two critical periods for the process of making new neurons, or neurogenesis. The right hemisphere develops first, and a left hemisphere growth spurt occurs in the middle of the second year of life. The right hemisphere is more densely connected with subcortical areas and is associated with the sense of our bodies, images, perception of emotions, regulation of the ANS, and unconscious memories, whereas the left is primarily responsible for language, logic, and conscious problem solving (Schore, 2012) (see Figure 2.3).

Healthy brain development is contingent on early experience and sequential completion of critical windows of opportunity for establishing neural connections. All subsequent development is dependent on the basic circuitry of systems of neural networks. Given the timetable of the developing brain, it is easy to see that a frustrated 3-year-old child whose cortex is not fully developed will have a hard time modulating the arousal levels of the lower brain structures and may scream, kick, and bite, whereas the older child who has more cortex will be able to inhibit these urges when frustrated. This is consistent with theoretical speculations about the sequential development of ego and superego functions, which are cortically mediated functions that modulate impulse control. Loss of cortical functions can occur in many pathological processes, such as dementia or stroke, whereas loss of the cortical ability to modulate arousal and aggression in the brainstem and midbrain may result in hyperactivity and impulsivity and predispose the person to violence (Camchong & MacDonald, 2012).

58FIGURE 2.3 Stages of brain development, regulation, and memory.

The brain develops in a use-dependent fashion, which means that the more the neuronal network is activated, the more likely a template will be created and the connection and pattern formed between neurons and networks of neurons will be strengthened with the brain changing in response to this patterned neuronal activity. This process is called long-term potentiation (Siegel, 2012). According to Hebb’s axiom, neurons that fire together wire together; that is, the brain is more likely to activate this clustering of neurons in the future as a cohesive state of mind. Neural networks interconnect with multiple other neural networks so that if one network is activated, it can trigger another one and so forth. As the brain develops, there are increasingly synchronous patterns and activation of the neural networks of the cortex. As the cortex develops, top-down neural networks connect with the subcortical networks below.

Unused neural connections are eliminated through a process called pruning. This occurs primarily during critical periods after a growth spurt: between 15 months and 4 years, between 6 and 10 years, during prepuberty, and during middle adolescence (Ornitz, 1996). Pruning results in decreases in cortical volume and decreases in gray matter and increases in white matter that are reflected in enhanced cortical connections and information processing (Bava & Tapert, 2010). A stimulating environment facilitates the development of dendritic branching in neurons, a process referred to as arborization. The proliferation of new connections among neurons increases the potential for learning. These changes develop as a result of experience either through sensations from our external world or internal world.

Neural networks are shaped and continue to be developed by environmental experiences, which is reflected in increasingly complex behavioral patterns. Interconnected neuronal biochemical patterns are developed as templates for future experiences through interaction with others, and specific chemical and neuropeptide profiles emerge that may serve adaptive or nonadaptive functions. For example, sensations from a person’s internal world arise from the brainstem, and the midbrain learns to respond to decreased temperature or increased glucose levels, and sensory input from the external world, such as light, sound, or pressure, comes in through our senses to our brain and tells our bodies how to respond.

MEMORY

Depending on when they are formed or when the neural connections are made, some memories are less plastic or harder to change than others (Siegel, 2012). Memory is determined by the stage of development when the neural connection was made, the area of the brain, and the nature of the memory itself. For example, structures in the brainstem, midbrain, and limbic areas are almost fully formed by the time the child is 3 years old. These memories are much harder to change than those in some areas of the cortex, which remain plastic throughout life (see Figure 2.2).

The sequential acquisition of various memories is the primary task of development, and this is determined by genetics and interaction with the environment. Memory of a specific event is not stored in one particular place in the brain; it is distributed across neural networks in different brain areas. The brain takes associations from a single or specific event and generalizes to other events. For example, a scent memory can

activate the chain of memories connected with that odor so that a complete physiological state is produced based on that one sensation, or a particular song can activate a vivid memory with other associated sensual responses related to an earlier experience. Each memory has a particular biochemical profile depending on how it was perceived and stored in the brain. Each event can be thought of as a particular state of consciousness that is triggered by a sensation unique to that physiological template. In this way, a somatic feeling such as an accelerated heart rate can trigger associated memories, thoughts, images, emotions, and sensations connected with it.

Memory is linked to the emotions surrounding the event from the moment it occurred and to the specific physiological state we are in when we have the experience. Emotions are the result of the physiological changes triggered by the experience (Damasio, 1999). Retrieval of this information depends on the chemical state of the brain at the time of storage and at the time of retrieval and depends on where language is stored. Information can be stored verbally, emotionally, somatically, and in images, and what we learn depends on our physiological state at the time of the experience. The more intense the emotion, either positive or negative, the more likely the memory will be etched into an enduring neural template. This is what Rossi (1996) calls state-dependent learning. That is, state-dependent learning reflects the biochemical template for the specific emotions at the time of the experience, which reflects a specific physiological state we are in at the moment of the event. Research has found that retrieval of memory is best when the physiological state in which we learned the information matches the physiology of the current situation (Chu, 2011). For example, if we study for a test while smoking cigarettes and drinking coffee, we will fare better in retrieving this information if we smoke cigarettes and drink coffee while taking the examination (Pert, 1999).

Pert (1999) observes that we are all like multiple personalities in that each emotional state has a specific template or profile that is linked to a specific physiological state along with its concomitant thoughts, images, sensations, and physiology. Different states of consciousness are triggered by stimuli throughout the day as we slip in and out of various physiological templates. We literally change our minds on a moment-to-moment basis, but unlike those with dissociative identity disorder, we are more or less aware of the interconnection of our experiences. Each experiential state is reflected in the specific activities of our external environment. For example, although we may “space out” when we are driving and cannot remember exactly how we got to where we were going, we do remember generally that we were driving. The numerous states of consciousness that occur throughout the day are part of the seamless whole we experience as ourselves and are fairly consistent through time. Other “normal” dissociative experiences include “spacing out” during a lecture or induced altered states of consciousness, such as those that occur while praying, chanting, drumming, or meditating. These specific dissociative periods are considered normal, and each has a specific physiological state and brain wave pattern that is triggered by the specific event (i.e., driving, listening to a lecture, or church attendance).

Memory research has expanded dramatically in the past few years, and our understanding about what happens in the brain when we learn and about the different types of memory has greatly increased. Usually, when we think of memory, we think of cognitive memory, such as learning phone numbers or names. This is referred to as explicit, declarative, or semantic memory (see Figure 2.3). This is the type of memory that Freud would have called conscious memory. Autobiographical memory refers to knowing about oneself through recollection of the past, present, and possible future (Siegel, 2012). In normal development, self-awareness and autobiographical narratives are interwoven, but in trauma, this type of memory may be greatly impaired. Rapid eye movement (REM) sleep is thought to be essential for consolidation of neocortical semantic memories (Bergmann, 2012).

The other type of memory is called implicit memory, and it involves motor or procedural memories, emotional memories, and somatic memories that are most often formed earlier in development than explicit memories. Motor memories are procedural and include vestibular memories such as riding a bicycle, brushing your teeth, typing, or driving a car. These memories do not require conscious recall; after you know how to drive, you do not have to learn again. Other implicit memories include emotional and body memories. These experiences exist on a nonverbal, semiautomatic level and involve the here and now. These procedural, implicit memories ensure survival. It is thought that these implicit memory systems are essential for understanding development, psychopathology, and psychotherapy (Schore, 2012). This type of memory includes what Freud would have called the unconscious.

Emotional-state-dependent memories are implicit and include specific emotional experiences such as fear, grief, anxiety, and complex attachment feelings that form from interaction with caretakers based on the experiences of the developing child. There may not be words for somatic or emotional memories, only felt experiences. How we have a relationship is an implicit emotional memory. Implicit memories exist in our neural networks in a pattern of neural associations that are formed early in life from attachment experiences.

For example, a person may have a sense of sadness and agitation whenever alone, and it may be related to being left alone frequently as a child, with the subliminal connection patterned as a template in the brain.

Defense Mechanisms

Defense mechanisms are implicit memory networks that develop through reciprocal interaction with caregivers and interpersonal experiences for the purpose of regulating anxiety, grief, anger, and self-esteem, and they keep from conscious awareness disturbing thoughts and feelings. Defense mechanisms are not categorical; they exist on a developmental continuum that evolves through parent, environment, and child interactions. Defenses serve the purpose of allaying anxiety and help the child survive painful emotional experiences and relational loss, but they may be dysfunctional in adulthood when no longer needed. For example, a child may need to deny that his mother’s behavior is unloving to believe that he is safe; he can continue to survive “knowing” that he is cared about. Later, as an adult, this denial may interfere with his ability to clearly see his mother as unloving, and due to cognitive immaturity the person concludes that he is defective and that it is his fault because he is an unlovable person.

Early literature examined the development of specific defenses related to specific stages of psychosexual development, with the more immature defenses evolving earlier in development than those considered more mature (Brenner, 1982; Freud, 1966; Kernberg, 1975). It is thought that those with more primitive or immature defenses are “stuck” in an earlier, less neuroplastic way of reacting to the world that is more difficult to change. Primitive and immature defenses represent unintegrated neural networks that distort reality and result in functional impairment. Under stress, there is often regression to earlier, more immature defenses. Someone who is said to be defensive or well defended seems impervious to change and may remain inflexible no matter what the situation.

Defenses are the good news and the bad news because they may enhance mental health or may contribute to mental illness if too reality distorting. Everyone needs defenses, and mature defenses allow a healthy, flexible, adaptive way of experiencing the world. Mature defenses are rooted in neural networks that allow the person to navigate reality with reactions that are reality-respecting with a minimum of defensiveness. We can speculate that a person with mature defenses has some facility and flexibility in using a variety of defenses and is not locked into a specific template of defense to be used no matter what the situation. Cozolino (2010) posits that mature defenses, such as humor and sublimation, allow us to lessen strong feelings, keep in contact with others, and remain attuned to a shared reality.

Sadock and Sadock (2007) delineate defenses into four categories—primitive or narcissistic, immature, neurotic, and mature—to illustrate the continuum of defenses. Defenses are not static, and rarely does a person fall exclusively into one category. It is probable that there are clusters of defenses used more often in certain contexts and that differences are a matter of degree. Sadock and Sadock (2007) state that mature defenses such as sublimation and suppression are often found in obsessive–compulsive and histrionic patients, whereas the primitive and immature defenses, such as projection and denial, are associated with adolescents and some nonpsychotic patients. Those who use a preponderance of primitive or narcissistic defenses often have greater problems in work and relationships. Those who have had a “nervous breakdown” are those whose defenses did not allow adaptation and the ability to ward off unpleasant affects. These individuals are flooded with anxiety and negative affect that render them incapacitated and unable to cope. Box 2.2 lists selected primitive or narcissistic, immature, neurotic, and mature defenses (Sadock & Sadock, 2007).

BOX 2.2

DEFENSE MECHANISMS

Primitive or Narcissistic Defenses Denial: avoiding the reality of painful reality by ignoring or refusing to acknowledge reality (e.g., a man with schizophrenia denies that he is ill and does not take his medication).

Projection: perceiving and reacting to unacceptable feelings and impulses as if they were outside the self (e.g., instead of the person feeling anger, anger is experienced as coming from others toward the person who is doing the projecting, as during paranoid delusions).

Immature Defenses Acting out: avoiding conscious experience of the emotion through impulsive action (e.g., instead of feeling sad, a person gets drunk).

Regression: avoiding emotional pain through returning to an earlier level of development (e.g., a child begins wetting the bed after a sibling is born).

Hypochondria: exaggerating an illness arising from unacceptable feelings (e.g., anger and hostility are transformed into pain and somatic complaints).

Introjection: internalizing the qualities of the other (e.g., identification with the aggressor through which the person becomes aggressive to gain control).

Somatization: converting emotion into bodily symptoms (e.g., instead of getting angry, the person gets a headache).

Splitting: inability to integrate positive with negative aspects of oneself and then projecting this onto other people or situations (e.g., a woman tells her husband she loves him one day and hates him the next day, even though nothing has changed to warrant this).

Neurotic Defenses Displacement: shift of emotion from a person or object to one that is less distressing (e.g., instead of expressing anger at his boss, the man kicks his dog).

Dissociation: avoiding emotional distress through an altered state of consciousness, such as fugue states or conversion reactions (e.g., a person loses several hours of time and does not remember what happened).

Intellectualization: using intelligence to avoid intimacy and expression of disturbing feelings (e.g., a woman explains in great detail all the pluses of the new city where she is moving to assuage her anxiety about leaving a significant relationship).

Rationalization: offering explanations in an attempt to explain behaviors or feelings that are unacceptable (e.g., after doing poorly on a test, the student believes the test or teacher is stupid).

Reaction formation: transforming an unacceptable impulse into the opposite (e.g., a woman unexpectedly runs into someone she does not like on the street and is overly friendly).

Repression: thought to be the basis of all other defenses and involves withholding from consciousness an idea or feeling that is unacceptable (e.g., the child cannot remember her anger or hitting her mother).

Mature Defenses Sublimation: person is able to pursue socially acceptable goals through channeling unacceptable impulses (e.g., a young man who is aggressive and impulsive pursues a career as a boxing coach).

Suppression: consciously deciding to forget an unpleasant feeling (e.g., a woman is preoccupied with the illness of her father and decides to not worry about it because there is nothing she can do about it).

Altruism: using service to others and vicariously experiencing pleasure through doing good for others to avoid negative feelings about oneself (e.g., a young woman is a social activist).

Humor: using comedy to express feelings and thoughts without discomfort (e.g., a person uses self-deprecating humor to put others at ease).

In psychotherapy, the therapist assesses the level of the person’s ego development through identification of the defenses that the person uses for the purpose of gauging ego strength (i.e., integration of neural networks). If someone primarily uses primitive or immature defenses, the person most likely has poor ego strength and early issues of trauma. This may indicate that a longer period of stabilization in psychotherapy is indicated. The therapist supports the defenses that are adaptive and helps the person to develop higher-level defenses, if needed. This can be accomplished through clarification and exploration so that the person’s awareness of his or her defenses is enhanced.

Conscious awareness of the defense often leads the person to experience the emotion against which the person is defending (Cozolino, 2010). For example, one man who was in rehabilitation for alcohol abuse told his therapist that he wanted his marriage to work but said he had to drink so that he could cope with his bad marriage. Pointing out the discrepancy between his actions and his stated wishes made the rationalization a less effective coping strategy. In subsequent psychotherapy sessions, he experienced much anxiety about the possibility of losing his wife and realized how angry he had been for a long time about not feeling cared about. Through releasing emotion in the context of a supportive relationship, neural networks associated with state- dependent memories of not feeling loved were activated, and this enhanced growth because integration of

more positive neural networks could then link to this experience.

Attachment

Attachment experiences are embedded in implicit somatic memory networks. The brain develops only in the context of another brain (Schore, 2012). The human infant survives based on the caretaking abilities of those around him or her. Developmental and attachment research supports that the infant uses the parent to regulate inner states until psychoneurobiological functions are mature and autonomous. These shared states of affect, known as dyadic states of consciousness, shared attunement, or limbic resonance, are internalized and encoded as procedural memory, enabling stable and secure connections to others (Siegel, 2012). Attunement is the capacity to read signals (often nonverbal) that indicate the need for engagement or disengagement. Attunement is considered to be a requisite of integrative relationships where differences are respected and compassionate connections are cultivated (Siegel, 2012). These states of attunement begin the process of self- regulation through rhythmic autonomic cycling, which modulates the response to arousal, directing the flow of energy through the system. If there are problems in attachment, there are concomitant problems in the self- regulation of stress and core affects. Core affects refer to emotions hardwired from birth and include seeking/curiosity, fear, rage, and panic (Panksepp, 2004). Other affective circuits evolve later on. These core affects are modulated by higher brain structures when we learn to express our feelings depending on the circumstance.

Attachment research has classified attachment patterns or schemas that develop over the first few years of life in response to parental availability and attunement. Ainsworth developed the Infant Strange Situation, a test that categorized how infants reacted when their mother left them in a strange situation and how they reunited with their mother when she returned. She found four categories of response and labeled these: secure attachment, avoidant, ambivalent/preoccupied, or disorganized/disoriented patterns (Ainsworth, 1967). On maternal separation, the securely attached infant is easily comforted and resumes play and exploration when the mother returns. The avoidant infant remains aloof and disinterested when the mother returns, whereas the resistant/ambivalent infant is not easily soothed and remains preoccupied, vigilantly scanning for mother’s whereabouts. The disorganized or disoriented infant has not developed a consistent strategy for coping with the stress of separation (Meyer & Pilkonis, 2002). These neural pathways of infant attachment form blueprints of perceptions, feelings, and responses that manifest as personality characteristics that predict later adult attachment. A corresponding test for adults termed the Adult Attachment Interview has been developed (Hesse, 1999). Attachment patterns have been found to be relatively stable and reflect how adults form attachment to others, including their partners and their therapist. See Table 2.1 for attachment schemas.

TABLE 2.1 Attachment Schemas Infant Strange Situation Adult Attachment Interview Secure Secure/Autonomous

Avoidant Dismissing

Ambivalent/Resistant Preoccupied Disorganized/Disoriented Unresolved/Disorganized

Source: Ainsworth (1967); Hesse (1999).

The newborn’s brain development depends on interaction with others with relationships serving as regulators of physiological processes (Schore, 2012; Siegel, 2012). Schore describes the face-to-face and gaze- to-gaze connection of mother–infant bonding and posits that it facilitates development, especially of the right cerebral hemisphere, which develops first. Biochemical reactions through these interactions with caregivers enhance the development and connection of neural networks. The connection of neural networks allows discrete states of self to be integrated and linked. Siegel (1999) states, “The structure and function of the developing brain are determined by how experiences, especially within interpersonal relationships, shape the … maturation of the nervous system” (p. 149). These neural networks encoded in implicit procedural memories of sensory, motor, affective, and cognitive memories of caretaker experiences regulate physiological processes. Attuned caregivers share emotional states with the infant. This shared attunement, or limbic resonance, regulates emotions by modulating overstimulation or underarousal of the ANS for the cortically challenged infant. Through interaction, the mother creates a psychobiological state similar to her own (Schore, 2012; Stien & Kendall, 2004). Research has found that self-regulatory function is developed in a hierarchical fashion, as illustrated in Figure 2.3 (Feldman, 2009).

Porges’s (2011) research on the ANS has important implications for attachment and the brain’s response to threat. Through evolution, the ANS has an information processing system that continually evaluates danger through neuroception, which modulates behavior and physiological states without our conscious awareness. Contrary to previous thinking, the ANS is composed of not just the sympathetic and parasympathetic systems but two parasympathetic branches: the myelinated ventral vagal, which originates in an area toward the front of the brainstem and develops around age 3, and the unmyelinated dorsal vagal, which originates in the back of the brainstem and is present early in fetal development. The myelinated ventral vagal controls the face, neck, and head and develops rapidly after birth and supports attachment, inhibits the sympathetic system, and promotes a calm state that allows us to be interested in others and our surroundings. It is the vagal nerve that regulates heart rate, and heart rate variability provides an index of vagal tone so that your vagal tone helps to regulate cardiovascular, glucose, and immune responses. Ventral vagal tone is central to facial expressivity and the ability to tune into the human voice.

By increasing ventral vagal tone, the capacity for empathy and connection is increased so that the more attuned one is to others, the healthier one is. This explains why a lack of social contact diminishes people and why face-to-face contact is crucial for not only human development but to enhance the plasticity of the brain. It is through the predictability and familiarity of the caretaker that secure attachment and the ability to respond flexibly develops. The dorsal vagal branch is activated and accompanied by a freeze immobility response once the sympathetic options of fight or flight or stillness are exhausted. These three systems are constantly adjusting our brains and bodies in response to our environments.

The first response to the environment is that of social engagement through the myelinated parasympathetic ventral vagus; the second reaction if there is danger is through the sympathetic nervous system manifesting as fight, flight, or stillness; with finally, the third response, unmyelinated dorsal vagal shutdown or immobilization if the sympathetic stillness does not prevent the attack. The parasympathetic system is responsible for states of hypoarousal, manifested by symptoms of dissociation, pain blunting, depression, shame, loss of energy, and self-loathing (Corrigan et al., 2011). Shame is particularly implicated in impaired attachment. See Figure 2.4 for the therapeutic window of arousal as conceptualized by Porges.

FIGURE 2.4 Therapeutic window of arousal. Adapted from Porges (2011).

Schore (2012) says that higher levels of sympathetic activation increase production of endorphins, dopamine, and NE, which increase energy and pleasure in the child. Brain-derived neurotrophic factor (BDNF) is stimulated, modulating glutamate-sensitive NMDA receptors that regulate neuroplasticity and long-term potentiation, which appear to buffer the hippocampus from stress. Sympathetic dominance is associated with states of arousal, and parasympathetic dominance is associated with conservation withdrawal (Scaer, 2005; Schore, 2012). If misattunement is present, the infant may begin to frequently withdraw, and this is thought to be an early manifestation of dissociation. These are right-brain implicit memories and responses to early relational trauma. Secure attachment experiences are reflected in an optimal balance of the sympathetic and parasympathetic nervous systems, with synchronous connections among neural networks.

An important research finding about attachment and learning involves mirror neurons, which help us make sense of how we learn at critical periods by watching others (Dobbs, 2006). Mirror neurons are located in the lateral frontal cortex, the posterior parietal areas, and other regions that correspond to the ability to comprehend someone else’s feelings and intention. Mirror neurons fire when we watch someone else do something, and they fire as if we were doing the action ourselves. Neuroimaging studies have found that these neurons are present at birth. For example, if an infant watches an adult smile, the same neurons in the infant’s brain will fire as if the infant were smiling. This occurs for visual stimuli and for sounds and other sensations.

Our brain mirrors others’ brains, so that one does not have to experience something directly to feel what someone else is feeling. Mirror neurons are thought to play a key role in perceiving intentions, which is a first step in feeling empathy. The idea of shared minds and dyadic states of consciousness is a physiological reality that has implications for understanding the importance of attachment relationships for affect regulation and learning. It is thought that a dysfunction in mirror neurons may create significant problems in attachment, from autism to violence.

Attachment problems and unresolved trauma in the mother breed attachment problems and trauma in the child. Inability of the mother to connect and think about her own thoughts and feelings has been found to be a significant predictor of attachment problems. Results of one study illustrate the importance of affect attunement and regulation of affects in understanding the cycle of trauma and violence that persists across generations. This research on intergenerational maternal trauma found that the distressed child represents a possible posttraumatic trigger for the violence-exposed caretaker who has a history of violent trauma and insecurity of attachment that then adversely affects maternal perception (Schechter, 2003). The more negative and distorted the maternal perception of the child, the more the child is likely to be distressed and behaviorally disorganized. For children younger than 4 years, inability to regulate emotions is the norm, and this state in the child sometimes triggers in caregivers their own horror, helplessness, and outrage about violent perpetrators who had hostile aggression and difficulty with negative affect toward them. The caretaker with her own affect regulation problems due to trauma has great difficulty with soothing and connecting with her child and may attribute malevolent motivations to her child that are related to her earlier feelings about her perpetrators. This study points to the importance of the parents’ role in the co-regulation of stressful states. In summary, attachment research has found that attachment neural networks impact learning, neural plasticity, the ability to cope with stress, and maternal behavior in adulthood.

Without the presence of a protective relationship with an adult, a child cannot develop the coping skills or sense of control to mediate stressors and regulate arousal. Early adversity and traumatic stress affect future stress reactivity through the development of neural circuits that control neuroendocrine responses (Roth, Lubin, Funk, & Sweatt, 2009; Szyf, 2009). Significant early trauma and lack of attachment have also been demonstrated to have effects on neurotransmitters, specifically irregular serotonin activity (Schlozman & Nonacs, 2008). Research has demonstrated that even in the absence of PTSD or a diagnosable psychiatric disorder, there may be abnormal cortisol activity so that through exposure to trauma, significant long-term physical changes in the body can occur (Scaer, 2005).

TRAUMA AND RELEVANT BRAIN STRUCTURES

Both significant traumatic events and adverse experiences affect brain development and structure. Most of the research has been done on significant traumas, such as posttraumatic stress disorder (PTSD) and its sequelae. These findings can be applied to better understand what may happen neurophysiologically when adverse life experiences accumulate or occur at significant times critical for the developing brain. Any event that is experienced as overwhelming by the individual has the potential to affect brain functioning. An overview of the brain structures that play the most significant role in memory is important to understand psychopathology and the neurobiology of psychotherapy. Brain structures are networks of neurons, and some, such as the thalamocortical circuitry or extensions of the locus ceruleus, project over wide areas of the brain. Through the neuromodulating chemistry of messenger molecules, these neural systems activate other neuronal networks. Figures 2.5 and 2.6 show the relevant structures of the brain.

The discussion that follows addresses some of the complex systems and brain structures affected by trauma. Further information on PTSD and dissociative disorders is included in Chapter 13. Although this chapter focuses on brain structure and function, brain structures are not isolated entities. Scaer (2005) says: “Sensory input from the body shapes and changes the structure of the brain, which concurrently shapes and alters the body in all its parts, particularly those that provided this sensory input to the brain” (p. 11). The brain and body are in constant reciprocal, dynamic interaction, adapting to and influencing each other.

67FIGURE 2.5 Structures of the brain.

Thalamus

The brainstem develops first in utero and is responsible for regulating bodily function such as heart rate, breathing, temperature, sleep, and states of alertness (Siegel, 2012). The thalamus, located deep in the brain, acts as a relay station for the top-down, bottom-up neural networks that connect the cortex to the limbic system. Consciousness originates from the constant interaction between the thalamus and the cortex, and all sensory information, except for smell, is routed through the thalamus to the cerebral cortex. The thalamus mediates the interaction between attention and arousal and is therefore relevant to the phenomenology of trauma.

If neural networks in the thalamus are altered, neurological and psychiatric problems ensue. High levels of arousal during traumatic experiences are thought to lead to altered thalamic processing (Bergmann, 2012), and neuroimaging studies have found decreased thalamic activity in subjects with PTSD (Lanius et al., 2001). Thalamic dysregulation can result in significant memory problems, and the person may be unable to integrate memories into the present and personal memory into identity. These memories are isolated from consciousness and thought to underlie the experiences of flashbacks, nightmares, avoidances, and dissociation.

FIGURE 2.6 Cerebral cortex and brainstem.

Cerebellum

The cerebellum is just above the brainstem and helps coordinate motor, social, emotional, and cognitive functioning. This structure, along with the brainstem, is often referred to as the reptilian brain. The brainstem

regulates level of arousal, some reflexes, and cardiovascular functions. The cerebellar vermis is a worm-shaped structure between both parts of the cerebellum. This structure helps regulate activity in the limbic system and is important for regulating emotional balance, attention, and posture. Reduced size of this structure has been found in traumatized children and this has been linked to numerous disorders such as attention deficit hyperactivity disorder (ADHD), depression, bipolar disorder, schizophrenia, and autism (Teicher, 2000).

Locus Ceruleus

The locus ceruleus is a dense group of neurons found on both sides of the pons in the brainstem between the medulla oblongata and the midbrain, with projections to the amygdala, the prefrontal cortex, and the hippocampus. Stress activates this structure, which makes NE (Charney, 2004). This contributes to sympatho-adreno-medullary (SAM) axis and the hypothalamic–pituitary–adrenal (HPA) axis stimulation, which inhibits frontal cortex functions, allowing instinctual responses to override cognition. Complex feedback loops during acute stress, if unchecked, can result in chronic anxiety, fear, intrusive memories, and an increased risk for physical health problems, such as hypertension, tachycardia, bladder infections, asthma, migraines, fibromyalgia, irritable bowel syndrome, gastroesophageal reflux disease, ulcers, thermoregulation, and eating disorders (Bergmann, 2012; Heitkemper et al., 2001; Scaer, 2005).

Hippocampus

The hippocampus is located deep within the brain’s unconscious core, in the midbrain, and it is important for explicit memory, reality testing, and inhibition of the amygdala. This area of the brain allows formation of a coherent narrative about personal history: what happened and where and when so that explicit memory can weave an autobiography. Normally, the hippocampus is not fully developed until the child is 16 to 18 months old (Siegel, 2003). The slow maturation and myelinization of the hippocampus is thought to be responsible for infantile amnesia. The hippocampus is necessary for forming new explicit memories while the amygdala organizes emotional experience and tells the hippocampus what is important to learn.

Research has found that the hippocampus in traumatized individuals is smaller for those who have suffered physical or sexual abuse (Bremner et al., 1997; Teicher et al., 2003; Zhang et al., 2011). Inability to integrate memories into a coherent narrative keeps images and bodily sensations distinct from other life experiences so that the person’s experiences are fragmented and may feel ego-alien (not part of oneself) and timeless. For those who have been significantly traumatized, it is much harder to process any new experience if there are not enough cells in the hippocampus to store the memories.

During high states of arousal, amygdala and hippocampal networks become dissociated so that learning is impaired. A lack of early attunement because of abuse or trauma can compromise the function of the amygdala and hippocampus (Kitchur, 2005). Decreased functioning of the hippocampus is caused by increased levels of cortisol combined with other substances, such as glutamate, that damages dendrites in the hippocampus and eventually causes cell death. Glucocorticoids secreted during a traumatic experience shut down the hippocampus and make it impossible for memory to be stored. These hormonal changes result in behavioral disinhibition and an inability to learn from experience. Arousing stimuli are then perceived as threatening, and the person may react through aggression or withdrawal. Research has found that both medication and psychotherapy ameliorate these problems and increase hippocampal size (Bossini, 2011; Bossini, Fagiolini, & Castrogiovanni, 2007). Earlier research found that recovery from dissociative identity disorder was associated with a 9% to 18% increase in hippocampal volume (Bremner et al., 1997). The hippocampus is one area of the brain where replication of new neurons is possible.

Amygdala

Nearby is another important structure, the amygdala, which is a bulbar structure at the end of the hippocampus. The amygdala, hippocampus, thalamus, hypothalamus, orbitomedial prefrontal cortex (OMPFC), and anterior cingulate make up the limbic system, which is often referred to as the emotional

brain. The amygdala mediates the crisis response and powerful emotions such as anger, fear, and rage. The amygdala makes connections with thalamic pain centers through a rich array of connections to visual and other sensory modalities. Neuroimaging studies show that people experiencing intense emotions, such as fear, sadness, anger, or happiness, have increased activation in these subcortical brain regions and significant reductions of blood flow in various areas of the frontal lobe (van der Kolk, 2006). Such research provides a neurophysiological understanding of why it is difficult to think straight when experiencing intense emotions. It is thought that a hyper-responsive amygdala causes the symptoms of irritability, anger, hypervigilance, and exaggerated startle responses in PTSD (Weiss, 2007).

The amygdala projects directly to cholinergic nuclei in the brainstem, geniculate nucleus of the thalamus, and the occipital nuclei. It initiates REM sleep, triggering the eye movements that occur during REM sleep and arbitrates REM-to-wake transitions (Bergmann, 2012; Woodward, 2004). Down regulation of the amygdala results in better sleep because fear systems are inactivated. Sleep disturbances often occur in those with depression and PTSD, and it has been suggested that REM disturbances interrupt the emotional processing of traumatic memories that would normally occur in REM sleep (Bergmann, 2012). The REM dream state is thought to be a time when unprocessed memories are being integrated, and if the disturbance is too great, these memories cannot be assimilated and nightmares result (Shapiro, 2001).

Recent studies have found that there are two types of reactions to traumatic events: one in which there is emotional undermodulation with intrusive symptoms where the medial prefrontal cortex is hyperactive and inhibition of the amygdala, while the other type indicates hypoarousal of the prefrontal cortex and activation of the amygdala (Felmingham et al., 2008; Lanius et al., 2010). These emotional memories are subcortical and indelible. When the amygdala is overactivated and irritable, kindling occurs. Kindling refers to the lowering of the excitability threshold of neurons, rendering the person increasingly likely to develop certain symptoms (van der Kolk et al., 2006). With repeated stress, kindling is thought to sensitize limbic neurons so that reactions are set off by stimuli that were previously subthreshold. The neuronal excitability of the amygdala may trigger panic attacks and even cause temporal lobe seizures (Teicher et al., 2003). Although panic attacks are triggered by stress and conflict in the person’s life, seldom is this association made by the person, as the episodes are experienced as unrelated to any real threat. The person is left feeling as if he or she is going crazy or having a heart attack. Irritability of the amygdala has also been implicated in ADHD, PTSD, substance use disorders, and borderline personality disorder (Teicher et al., 2003). Individuals with dissociative disorders have increased activation of the orbital frontal cortex that inhibits activation of the amygdala and insular cortex as well as the hippocampal areas (Spiegel et al., 2011).

Hypothalamus

The amygdala can transmit signals directly to the hypothalamus through the orbitofrontal cortex and bypass other areas in the cerebral cortex so that we are in an immediate state of flight or fight without even thinking about it (Scaer, 2005). The hypothalamus is located deep in the middle and base of the brain and is the region of the brain where the nervous system intersects and communicates with the endocrine system. The hypothalamus regulates blood pressure, body temperature, sleep, appetite, glucose levels, and the ANS. During stress, a cascade of physiological responses occurs, with the limbic–hypothalamic system modulating and coordinating the biochemical activity of the autonomic, endocrine, and immune systems (see Figure 2.5). Hormonal equilibrium is altered from severe stress in childhood so that genetic expression can be affected across generations. What this means is that our ability to regulate stress is based on the stresses our grandparents experienced or epigenetic changes (Siegel, 2012).

Research in animals has found that an intense, single stimulation of the amygdala produces lasting changes in neuronal excitability and behavior in stress responses (van der Kolk, 2003).

Cerebral Cortex

The cerebral cortex is considered to be the thinking part of our brain; it organizes experiences and determines how we interact with the world. Each of the four lobes that make up the cortex—frontal, temporal, parietal, and occipital—has specialized functions, with the prefrontal cortex the foremost portion of the frontal lobe. The frontal lobe is responsible for motor behavior, expressive language, executive functioning, abstract

reasoning, and directed attention, and the foremost area is referred to as the prefrontal cortex. The parietal lobe is responsible for linking the senses with motor abilities and for creation of the experience of a sense of our body in space. The occipital lobe is responsible for visual processing, and the temporal lobe is responsible for auditory processing, receptive language, and memory functions.

Axonal connections between the limbic system and the prefrontal cortex modulate arousal and emotional regulation and are developed between 10 and 18 months of age. The prefrontal cortex barely starts to myelinate in adolescence, and myelinization continues late into the 20s (Bergmann, 2012). This structure plays a role in the extinction of fear responses by exerting an inhibitory influence over the limbic system, modulating arousal by serving as a damper switch to the amygdala, thereby regulating emotions and the generalization of fearful behavior (van der Kolk, 2006). Sensations and impulses are compared with previous information for the integration of experience. Researchers have confirmed cortical neuronal loss and dysfunction in those who have suffered significant stress and trauma (Teicher et al., 2003; van der Kolk, 2003). Persons with an underdeveloped cortex are less able to modulate emotion, inhibit the emotional lower brain, and problem solve. A decrease in cortical activation and an increase in anterior regions of the cingulate and insula occur in depression and anxiety symptoms (Kennedy et al., 2007).

Orbital Medial Prefrontal Cortex

A particularly relevant part of the prefrontal cortex for survival is the orbital medial prefrontal cortex (OMPFC); the first region of the frontal lobe to develop is located within the frontal lobes and just above the orbits of the eyes. This area of the brain serves an inhibitory function in response to stress in other regions of the brain, and it regulates planning behavior associated with reward and punishment and is considered part of the limbic system because of its role in emotional processing. The OMPFC assesses the reality of the danger and serves an inhibitory role when the amygdala is activated, modulating the timing of emotional response. The right OMPFC is thought to be the master regulator of the limbic system, modulating the person’s response to threat and processing and regulating arousal-based information (Scaer, 2005). The reciprocal relationship between the amygdala and OMPFC determines how we handle emotional experience. These connections are shaped and rooted in early experiences and attachment experiences (Scaer, 2005; Schore, 2012).

Schore’s work (2012) on attunement and self-regulation highlights the importance of the OMPFC in development. In a way, the mother serves as the OMPFC for the developing infant by regulating sensory input and emotions and inhibiting behavior. As this area of the brain matures, the child becomes better able to assume more and more of the reflective, regulatory, and inhibitory skills needed to function. Schore’s research findings suggest that emotionally arousing interactions between the infant and caretaker lead to increases in dopamine concentrations, which trigger brain development, particularly in the OMPFC in the right hemisphere. This is accomplished through facial expressions of the caregiver that stimulate the production of opioids, which activate the dopamine neurons. In this way, positive attachments activate the dopaminergic and beta-endorphin systems, laying down implicit memory networks so that intimacy and connection continue to be rewarded throughout life. However, if attachment problems occur during early development, the OMPFC’s ability to regulate cortical and autonomic processes is reduced, and long-standing regulatory and relationship difficulties may result (Schore, 2012; Siegel, 2012). Consequently, the child’s development of a coherent sense of self is greatly impaired. A number of studies report that the OMPFC activity is inversely related to severity of PTSD symptoms (Shin, Rauch, & Pitman, 2006). That is, the activity of the OMFC decreases significantly during increased stress and consequently the problem-solving part of the brain is impaired.

Anterior Cingulate

Another important area in the cortex that is considered to be part of the limbic system and the OMPFC is the anterior cingulate, which is thought to be the last step before consciousness and serves as the gatekeeper of emotion (Stien & Kendall, 2004). This structure helps decide which emotional information to pay attention to and assists in processing emotion arising from the limbic system by recruiting other areas of the cortex to respond to emotions. Siegel (2003) calls this the chief operating officer of the brain because it plays a key role

in orchestrating the autonomic, neuroendocrine, and behavioral expression of emotions. The volume of the anterior cingulate has been reported to be smaller in patients with PTSD (Shin, Rauch & Pitman, 2006).

Insula

The insula is another important area of the cortex and is buried beneath and within the folds of the cortex. The insula provides a means to connect body states to the expression and experience of emotions and behavior so that we are aware of what is happening inside our bodies and can reflect on emotional experiences. The insula, the OMPFC, and the anterior cingulate evaluate whether the information from the amygdala is threatening. These areas are especially sensitive to social interactions, are unconscious, and play a crucial role in coordinating perceptions with memory and behavior (Siegel, 2012). Imaging studies have found reduced activity in the anterior cingulate for those with PTSD symptoms (Bremner, 1999). Thus, it is thought that in PTSD the OMPFC is hypo-responsive, the amygdala is hyper-responsive, and the hippocampus and OMPFC fail to inhibit the amygdala (Shin, Rauch, & Pitman, 2006). Early neglect, stress, and trauma affect the development of anterior cingulate, and lifelong cognitive and emotional deficits may result (Cozolino, 2010).

Corpus Callosum and Hemispheres

An important brain structure relevant for discussion is the corpus callosum, which consists of long neural fibers connecting the right and left hemispheres of the cerebral cortex. Researchers have found that early stress results in decreased hemispheric integration and increased laterality (Teicher et al., 2003). A marked reduction in the size of this structure is associated with childhood history of neglect, especially for children who were sexually abused. This structural change results in diminished communication between the hemispheres. It is speculated that failure of left hemisphere functioning during states of extreme arousal is responsible for the derealization and depersonalization experiences reported in PTSD. These left–right neural information loops need to communicate with each other and other processing neural information networks for optimal functioning in language, bodily awareness, emotional regulation, and many other processes (Cozolino, 2010).

The left hemisphere, which is usually dominant, is associated with problem solving, analyzing, elaboration, and processing of verbal communication, words, and numbers, and it is dominant for motor abilities (Feinberg & Keenan, 2005). The Wernicke area (i.e., comprehension of language) and Broca area (i.e., expression of language) are located in the left hemisphere of the cerebral cortex. Research has shown that the left hemisphere is responsible for the tendency to seek solutions and take action (Stien & Kendall, 2004). Left hemisphere deficits occur most frequently in those who have had trauma. There is speculation that interference of the myelinization of nerve fibers due to trauma may contribute to the underdevelopment of the left hemisphere (Teicher, 2000). If the left hemisphere is damaged, the right hemisphere may predominate.

Traumatic memories do not form a coherent narrative but persist as implicit, behavioral, and somatic memories (van der Kolk, 2003). Anything that is overwhelming to the individual results in information being linked dysfunctionally, that is, components of the memory are fragmented. These memories are seemingly unattached to other experiences and are considered a right-brain phenomenon, stored as images, sensations, and emotions, not in a coherent narrative and context, which is a left-brain function. The right hemisphere is mute in terms of responding verbally (Feinberg & Keenan, 2005).

Neuroimaging studies have found that as trauma survivors reminisce about their terrifying experiences, activity in the right hemisphere of the brain increases. The right hemisphere processes negative emotional states and bodily arousal while the left hemisphere is associated with positive emotions. At the same time, there is a decrease in activity in the left hemisphere in Broca’s area, which is our expressive speech area that allows us to put experiences into words. The idea of being speechless with terror is physiologically based. Perhaps this right or left hemisphere dysfunction also explains why those who have suffered trauma are unable to express feelings in words but instead somaticize or act out feelings. Language is key for integration, and putting words to our experiences forms new dendritic branches that activate and establish interhemispheric integration between the right and left brain. See Figure 2.7 for right- and left-brain functions.

73FIGURE 2.7 Right- and left-hemisphere functions.

The right hemisphere has been linked to implicit information processing, as opposed to the more explicit and more conscious processing of the left hemisphere (Bergmann, 2012). The right hemisphere is dominant for the perception of nonverbal emotional expressions in facial expressions or voice patterns, nonverbal communication, processing bodily based visceral stimuli, implicit learning, and affect regulation. Right-brain to right-brain communication between mother and infant is thought to be responsible for affect regulation and interpersonal behavior. Schore (2012) says that the right hemisphere represents the unconscious and is the psychobiological core of the self. The right hemisphere mediates our somatic or emotional autobiographical memory, and it is this area that drives emotion, cognition, and behavior. Our personalities are largely based on these accumulated memories mediated by the right hemisphere. Problems in connection and integration of the right and left hemispheres have been implicated in alexithymia, somatization, depression, dissociative disorders, borderline personality disorder, substance abuse, and mania (Cozolino, 2010; Teicher et al., 2003).

NEUROPHYSIOLOGICAL RESPONSES TO TRAUMA

Once a significant threat occurs, information processing is disrupted and challenges the ability of the brain and body to meet these demands. Information from the body or the senses is matched or processed to previously stored patterns of activation, and a cascade of neuronal activity begins. Signaling pathways travel from the brainstem (i.e., locus ceruleus) through the thalamus to the amygdala (which evaluates emotional content) to the hippocampus (which evaluates the cognitive content) to the anterior cingulate and the OFC, which activates the SAM axis to initiate the physiology of survival (Scaer, 2005). Often, the brain reacts even before the cerebral cortex has a chance to sort out and interpret what is happening (see Figure 2.8).

FIGURE 2.8 Trauma response pathway. Courtesy of Scaer (2005).

Neuronal pathways connect perceptual information with the amygdala and lower brain structures, bypassing the hippocampus where conscious memory is mediated, and implicit memories of important emotional events may be triggered without knowing why. For example, characteristics of others such as tone of voice or appearance may be associated with a previous threat or if unknown, an initial alarm response occurs, and a complex wave of physiological processes begins that are orchestrated to promote survival. This begins with the classic stress response involving the autonomic, endocrine, and immune systems (i.e., SAM and HPA axes) and all the attending messenger molecules, such as vasopressin, oxytocin, NE, dopamine, endorphins, serotonin, corticotropin (i.e., adrenocorticotropin hormone [ACTH]), corticotropin-releasing factor, glucocorticoids, and cytokines. The simultaneous activation of cortisol (HPA) and norepinephrine (SAM) stimulates active coping behaviors, whereas increased arousal in the presence of low glucocorticoid levels is thought to promote undifferentiated fight-or-flight reactions (Porges, 2011). This response pattern continues after the initial alarm with an elevated heart rate, vigilance, increased startle response, behavioral irritability, and increased locomotion.

Cortisol puts a brake on NE and modulates the arousal response so that if the person survives, cortisol manages ongoing stress through changes in circulation, metabolism, and immune response. Prolonged exposure to cortisol results in dysregulation through the release of glutamate, which inhibits its removal from the synaptic space, initiating long-term potentiation of synaptic connectivity, and as a consequence, fewer glucocorticoid receptors are available. The increased glutamate levels and chronic arousal cause atrophy of dendrites and neurons, especially in the prefrontal cortex and hippocampus, which results in impaired learning and memory. This in turn is thought to be the cause of avoidance, numbing, and memory loss (Weiss, 2007). See Box 2.3 for major components of the stress response system.

Research in the past decade has demonstrated that long-term physiological and structural changes in the brain and body often occur as a result of chronic stress. Victims of child abuse and neglect have been found to be at risk for high inflammation levels and clustering of metabolic risk biomarkers (overweight, high blood pressure, high total cholesterol, low- or high-density lipoprotein cholesterol, high glycated hemoglobin, and low or maximum oxygen consumption levels) (Heins et al., 2011). These physiological changes predispose the person to develop cardiovascular disease and the risk for heart disease is doubled. Medical problems related to chronic stress and increased cortisol levels are associated with suppression of the immune response and include infections and other immune system problems; increased levels of serum lipids, promoting atherosclerosis; storage of calories as fat in the abdominal region, promoting obesity; and increased blood volume, resulting in hypertension.

BOX 2.3

COMPONENTS OF THE STRESS RESPONSE

1. The HPA axis, which regulates Cortisol, a potent hormone that inhibits growth, immune responses, and inflammatory responses.

2. The amygdala, hippocampus, thalamus, hypothalamus, orbitofrontal cortex, and anterior cingulate make up the limbic system, which with the locus ceruleus, adrenal glands, and the sympathetic nervous system, mobilize a person for flight or fight.

3. Vasopressin and oxytocin peptide response, which causes the pituitary to release ACTH. The vasopressin–oxytocin response has been less researched than other aspects, but it is thought that early stress produces excessive levels of vasopressin and decreased levels of oxytocin throughout life and that this may result in enhanced sexual arousal but diminished capacity for sexual fulfillment.

Source: Teicher et al. (2003).

The adaptive physiological response to acute stress is called allostasis, and the burden borne by the brain and body adapting to physiological and psychological changes is called allostatic load (Charney, 2004). Allostasis and allostatic load illustrate how persistent stress is linked to adverse consequences in the body, and physiological markers have been identified that predict functional decline in the elderly. Allostatic load from chronic stress or trauma can cause neuronal death if prolonged because of the effect of hypercortisol and increased glutamate while low levels of cortisol promote cell growth (Bergmann, 2012).

Under normal stress, the hyperarousal in the sympathetic system is balanced by the parasympathetic system. In severe and prolonged stress, the HPA feedback to the pituitary gland is impaired and the hypothalamus does not decrease its activity, thus continuing to pump too much cortisol. Overwhelming chronic stress and trauma induce desensitization to the stress response through a negative feedback loop on the hypothalamus, and the pituitary activity is increased, which in turn decreases cortisol level production by the adrenal cortex (Briere & Scott, 2013). The dysregulation of cortisol during overwhelming stress and trauma results in suppression of cortisol and may be the brain’s attempt to protect itself from hyperarousal. A person with PTSD has chronically lower levels of cortisol and, when and if traumatized again, a blunted cortisol response occurs with a quicker return to baseline (Briere & Scott, 2013). Low levels of cortisol have been documented in combat veterans, holocaust survivors and their offspring, and in pregnant women with PTSD after the 9/11 tragedy and their newborns (Yehuda et al., 2005). The offspring of holocaust and 9/11 mothers did not always develop PTSD but the hypocortisolemia puts them at risk for auotimmune diseases such as Crohn’s disease, Sjögren’s syndrome, Graves’ disease, fibromyalgia, rheumatoid arthritis, Hashimoto’s thyroiditis, type 1 diabetes, multiple sclerosis, chronic fatigue syndrome, lupus, and complex regional pain syndrome as adults (Bergmann, 2012).

For those with PTSD, it is hypothesized that the brain may become hypersensitive to the effects of cortisol. The person has a consequent loss of stimulus discrimination, and even minor triggers may cause the person to overreact. A variety of internal and external stimuli may result in extreme reactions as the amygdala is activated. Internal sensations include bodily sensations of anxiety, and external sensations include instances such as loud noises or specific reminders of the trauma. The person overreacts to minor events and underreacts to major problems and misinterprets stimuli that are not threatening as potentially dangerous. This person may function well in an emergency, but if something is spilled in the kitchen, he or she startles, overreacts, and exaggerates the significance of the event.

The capacity of triggers with diminishing strength to produce the same response over time is called kindling (van der Kolk, 2003). If a person has suffered multiple traumas, there is a stronger physiological response with triggers of diminishing strength. This tendency to overreact to cues can increase the potential for aggression and violence. Kindling explains why a bout of depression lowers the threshold for another depression. The depressive state becomes linked with state-dependent implicit memory with all the attending feelings, thoughts, and body memories. Consequently, the longer one stays in an untreated depression and the more frequent the episodes, the more resistant to treatment that person becomes because these neural networks become firmly established.

Hyperarousal of the sympathetic nervous system in times of significant stress is balanced by the parasympathetic nervous system like a brake on a car, which shuts down the sympathetic nervous system. Thus, following exposure to violence and trauma, the parasympathetic response triggers a hypoaroused state with dysregulation of the HPA axis, resulting in dissociation. Dissociation is a disconnection of thoughts, emotions, sensations, and behaviors connected with a memory with some dissociation considered a normal experience for most people such as when we “space out” during a movie or when driving. However, severe dissociation or “mindflight” occurs for those who have suffered significant trauma (Steele, 2012). This episodic failure of dissociation causes intrusive symptoms such as flashbacks, thus dysregulating cortisol,

resulting in either too much or too little cortisol. Neurotransmitters, particularly NE and vasopressin, produce long-term potentiation and help us to

remember up to a point, whereas the opioids (i.e., endorphins) and oxytocin interfere with memory consolidation. It is the elevation of endogenous opioids that are responsible for numbing, blunting of pain, and dissociation. Memories become disrupted or fragmented and may even be blocked from consciousness completely through dissociation that is mediated by the parasympathetic system. This has been called the immobilized freeze response, and it is posited that being repeatedly threatened in a state of helplessness can result in a parasympathetic-dominant response (Porges, 2011; Schore, 2012).

Trauma-induced neurohormonal changes mediate the reward systems in the brain. The arousal that occurs in stress states (i.e., sympathetic response) with the attending release of NE, serotonin, oxytocin, and endorphin is followed by decreases in the levels of these neurochemicals, which produces an opiatelike withdrawal with increased symptoms of restlessness and agitation that signal the need for physiological arousal again. The threat–arousal–endorphin cycle is activated, producing what van der Kolk (1996) calls addiction to trauma. Massive secretion of neurohormones at the time of the traumatic event plays a role in the long-term potentiation and the overconsolidation of traumatic memories. These ANS changes become powerfully linked into implicit memory as templates of response for arousal. The physiological changes provide a compelling rationale for why trauma is reenacted as a conditioned response to related stimuli (van der Kolk, McFarlane, & Weisaeth, 1996).

The release of endogenous opioids soothes the person temporarily so that abuse in the future triggers opioids and reflects the body’s attempt to physiologically right itself. This is true for both individuals who have been significantly traumatized as adults as well as adults who have suffered early trauma as children (van der Kolk et al., 1996). This mechanism explains why patients with early histories of childhood abuse often use self-abuse by cutting or burning to relieve tension but do not experience such acts as painful because they are in a parasympathetic dissociated state. The brain is physiologically programmed or primed to recreate arousal or withdrawal states.

Dissociation can be useful, especially in childhood when no escape may be possible, except to temporarily leave the self in times of overwhelming danger. The dissociative processes of derealization and depersonalization allow the person to watch from a safe distance without experiencing the pain at that moment. However, dissociation at the time of the trauma is predictive for subsequent development of PTSD (Scaer, 2005). Development of dissociative memory networks of fear contributes to deficits in affect regulation, attachment, and executive functioning (van der Kolk et al., 1996). Particularly in patients with a history of early attachment trauma, rhythms of the body are severely dysregulated, and affective states of the self are not integrated. These unintegrated and dissociated self-states evolve from family environments that are chaotic, abusive, or neglectful (Howell, 2005; Schore, 2012).

Results of neuroimaging studies demonstrate different brain activation patterns for those with PTSD dominated by arousal symptoms from those with PTSD dominated by dissociative symptoms (Lanius et al., 2002). These differences point to different pathways of response for similar experiences. Scaer (2005) differentiates the diseases of stress from the diseases of trauma. He posits that the diseases of stress are related primarily to the sympathetic system, whereas the diseases of trauma result from the physiology of helplessness that occurs when the parasympathetic system is dominant, which is a physiological state of entrapment and disempowerment. The latter illnesses occur when a person enters into a state of physiological collapse and withdrawal that is characteristic of features of the parasympathetic freeze response, and can manifest when seemingly trivial life events represent a life threat based on the cumulative burden of negative life experiences and the similarity of the present event to any of the past experiences. This response occurs when autonomic regulatory functions are altered and there is a dramatic oscillation of autonomic activity, with manifestations of an exaggerated sympathetic and a parasympathetic response.

Dissociated neural networks are implicated in other psychiatric disorders, such as addictive disorders, eating disorders, obsessive–compulsive disorder, PTSD, borderline personality disorders, and dissociative disorders (Howell, 2002; Teicher et al., 2003). Other psychiatric disorders such as autism or schizophrenia are linked with impaired neuroception, the inability to detect whether the environment is safe (Porges, 2011). These individuals have difficulty with social engagement, with areas in the temporal cortex that inhibit ANS responses not activated. Compromised social behavior also occurs in those with anxiety disorders and depression with difficulties manifesting in the regulation of heart rate and reduced facial expressiveness. Children with reactive attachment disorder are either inhibited (emotionally withdrawn and unresponsive) or uninhibited (indiscriminate in their attachment), which also suggests faulty neuroception.

RESTRUCTURING NEURAL NETWORKS

Twenty years of research supports the efficacy of psychotherapy for brain changes and improved functioning for various psychiatric disorders. Neuroimaging studies have confirmed that changes in the cortical and limbic areas of the brain occur in response to psychotherapy for those with substance use (DeVito et al., 2012; Westbrook et al., 2011), obsessive–compulsive disorder (Apostolova et al., 2010; Baxter et al., 1992), panic disorder (Beutel et al., 2010), depression (Goldapple et al., 2004; Hirvonen et al., 2010; Karlsson et al., 2010; Kennedy et al., 2007; Martin et al., 2001), PTSD (Bossini et al., 2007; Bossini, 2011; Felmingham et al., 2007), and social and specific phobias (Furmark et al., 2002; Paquette et al., 2003; Straube et al., 2006). Different psychotherapies are thought to affect different areas in the brain. Recent studies indicate that mindfulness and EMDR operate primarily through bottom-up processing (limbic system to cortex) while cognitive behavioral therapy (CBT) seems to enhance top-down processing (cortex to limbic system) (Wetherill & Tapert, 2012). Thus CBT assists in inhibitory control and self-regulation through cortical changes while mindfulness and EMDR appear to improve attention and improve tolerance of unpleasant feelings and thoughts through changes deeper in the brain in the limbic system.

Some studies compare medication with psychotherapy and have found that both treatments produce physiological changes in the brain but that the brain changes are different for medication than for psychotherapy (Goldapple et al., 2004; Karlsson et al., 2010; Kennedy et al., 2007; Martin et al., 2001). Meta- analyses of psychotherapy versus psychopharmacology studies show a greater effect size for psychotherapy (0.73–0.85) compared to 0.17 for tricyclics and 0.24 to 0.31 for selective serotonin reuptake inhibitors (SSRIs) (Shedler, 2010). An effect size of 0.8 is considered large while an effect size of 0.2 is considered small. Overall, studies have found that better, longer-lasting positive outcomes occur when psychotherapy is combined with medication compared with medication alone (Antonuccio et al., 2002; Burnand et al., 2002; DeRubeis et al., 1999; Rothbaum et al., 2006).

Other studies have found that psychotherapy is superior to medication. Depressed patients with a history of child abuse responded better to psychotherapy than to medication, which only showed small benefits (Nemeroff et al., 2003). A more recent study found that psychotherapy with EMDR was superior to medication for sustained reductions in symptoms for PTSD patients (van der Kolk et al., 2007). Another study (Shalev et al., 2012) found that at 5-month follow-up 20% of those who had received psychotherapy had PTSD compared to 60% of those on medication and 58% of those receiving placebo. The greater change for those who receive psychotherapy makes sense because medications cannot change relationships, beliefs, and behavior; only emotional and interpersonal learning can do this. Medication can help the person control symptoms when taking the drug; however, the receptor sites compensate by increasing or decreasing depending on the amount of neurotransmitter available at the synaptic site.

It is assumed that combining psychotherapy and psychopharmacology is more effective than either treatment alone; however, three large long-term studies suggest that medications may interfere with the learning that takes place during psychotherapy (Barlow et al., 2000; Haug et al., 2003; Marks et al., 1993). When medication was stopped, the groups in all the studies that received medication and psychotherapy did worse than the group that received psychotherapy alone. Thus it is thought that the “therapeutic changes that occur in the brain with psychotherapy are impeded by the presence of the psychoactive medication” (Higgins & George, 2007, p. 248). This speaks to the importance of state-dependent learning, that is, if the person is in one physiological state with all the attending neurotransmitters, then whatever is learned in that state will be best remembered when the person is in that same physiological state (Chu, 2011).

Exactly how psychotherapy works to create positive outcomes is only beginning to be understood. Contemporary thinking about psychotherapy based on neurophysiological research about memory, trauma, and brain development led to the development of the AIP model (Shapiro, 2001). AIP provides a cogent explanation for a possible mechanism of psychotherapeutic action and serves as the underlying model for the treatment hierarchy framework discussed in Chapter 1. AIP posits that information is normally taken in and associated or connected to other memory networks to be used and stored constructively (Shapiro, 2001). For example, if we have an unpleasant interaction with a friend, we may talk about it or think about it until we feel better about the event, and then we know better in the future how to deal with this particular person. We have adaptively processed this information. Inherent in this model is the idea of self- healing, which is similar to the body’s self-healing capacity. If there is an injury, there are natural mechanisms that assist in healing. Similarly, there is a natural healing mechanism in the brain for adaptively processing information. Scaer (2005) says that processing allows for limbic, autonomic, endocrine, and immune homeostasis.

A problem arises when an overwhelming event occurs and the brain is flooded with changes in messenger

molecules, and the brain is unable to process or integrate this information in an adaptive way. The information is stored as it was during the time of the trauma with all the attending images, feelings, and sensations of that moment (Shapiro, 2001). This state-dependent information is isolated and disconnected from more adaptive memory systems. Cozolino (2010) states that psychopathology is “a reflection of suboptimal development, integration, and coordination of neural networks” and that “unresolved trauma can cause ongoing information processing deficits that disrupt integrated neural processing” (p. 24). It is these unintegrated or underdeveloped neural networks that create the problems for which people seek psychotherapy.

Dysfunctionally linked information that is isolated or disconnected must be linked or forged with adaptive neural networks to construct or return to full consciousness. If the person has had many traumas, there may be many areas of dissociated memories, with each containing its own somatosensory or autonomic and limbic or emotional cues (Scaer, 2005). These cues, powerfully linked in neural networks, serve as triggers for the past and significantly limit the person’s experience of the present. For example, a man who had suffered early emotional neglect and criticism from his perfectionist, distant parents experienced most interactions in his adult life as an evaluation of his worth. Consequently, he felt shamed and judged, and his moment-to-moment experience was filled with negative evaluations of himself and those around him. This left little room for present reality because everything was filtered through a shame-based lens. Feeling like a disappointment and unlovable, he reacted to others with sarcasm or childlike passivity in an attempt to please, even though this created the experience he most feared, being rejected by others.

Because dysfunctional information needs to be linked to adaptive neural networks to enable synchronized integrated brain functioning to occur, the existence of positive memories or experiences is needed. For some patients who have suffered early neglect or trauma, positive experiences may need to be created first for adaptive networks to be present. For others, adaptive networks may exist but need to be strengthened. Adaptive networks are created or strengthened through enhancing or creating internal resources and positive experiences. For those who have had complex childhood-onset trauma, a long period of stabilization and resource development may be indicated. Specific resource strategies for stabilization are described throughout this book.

van der Kolk (2006) says that it is important to “explore previous experiences of safety and competency and to activate memories of what it feels like to experience pleasure, enjoyment, focus, power, and effectiveness before activating trauma-related sensations and emotions” (p. 289). Shapiro (2001) agrees and says that the person must be able to manage state changes before processing trauma. State changes reflect transient physiological states such as anxiety that can be assuaged through relaxation techniques or other strategies and resources that decrease sympathetic arousal. This contrasts with trait changes, which Shapiro (2012) says can occur, but only after the person has fully processed trauma. This speaks to the importance of an accurate assessment not only of deficits (i.e., what is wrong) but also the person’s strengths (i.e., what is right) and available resources so that an appropriate plan of care can be developed. This type of assessment is a hallmark of the holistic health-oriented model of nursing practice.

The person is stabilized after external and internal resources are available and positive and negative affect state changes can be managed. Adaptive memory networks are then present so that dysfunctional memory networks can be restructured. Clinical indices reflect whether the person is stabilized (see Appendix 1.5). According to Fuchs (2004), the focus of psychotherapy is to restructure “neural networks, particularly in the subcortical-limbic system, which is responsible for unconscious emotional motivations and dispositions” (p. 480). Schore (2012) agrees and says, “Both optimal development and effective psychotherapy promote an expansion of the biological substrate of the human unconscious, the right brain, which is considered the dynamic core of the implicit self.” Accessing dysfunctionally linked material and connecting it to existing or newly created adaptive networks is the work of psychotherapy.

Through talking, journaling, and articulating experiences, a person is able to weave a coherent narrative with a past, present, and future. The narrative, primarily a language-based, left-brain activity, allows connections and expression of the images, feelings, and somatic/emotional autobiographical memories mediated by the right brain to connect with the language-based left brain. In addition, it is thought that this increases prefrontal activity, thus downregulating negative emotional activation of the amygdala (Dolcos & McCarthy, 2006). The narrative, in tandem with experiencing emotional components of the memory, allows processing and change to occur. Identifying emotions correlates with decreased amygdala response and an increase in prefrontal activity (Cozolino, 2010). Information in unconscious, implicit memory areas is brought to an adaptive resolution through connecting subcortical areas with cortically mediated higher brain functions for the purpose of changing dysfunctional symptoms.

In psychotherapy, trait change can occur through processing dysfunctional information (Shapiro, 2012).

Processing detraumatizes painful state-dependent memories by changing the pattern of receptors in existing synapses in the information network. Processing involves acquiring new learning, connecting adaptive neural networks with dysfunctionally linked information through activation of emotions associated with traumatic memories (Shapiro, 2001). Because trauma memories are linked differently and dimensions of the memory are disconnected from other memory networks, a similar state of consciousness must be re-created to access them. State-dependent memory has important implications for processing in psychotherapy because remembering events marked by sadness, anger, or fear activates areas where emotional memory is mediated, re-creating dimensions of the experience. This provides the opportunity and a portal that allows for the restructuring of neural networks. Emotional arousal and novel sensory experiences are necessary to access these implicit memories and to change dysfunctional neural networks. Briere and Scott (2013) say that processing is primarily emotional, involving implicit, nonverbal, relational memories, and that cognitions do not necessarily need to be addressed. Chapter 5 provides a psychodynamic model for processing relational trauma; Chapter 6 discusses how to process with EMDR; and Chapter 8 discusses processing with cognitive processing therapy (CPT).

Most dysfunctional symptoms arise from the lower or limbic areas of the brain, which are more difficult to modify than the higher cortical areas. Highly emotionally arousing memories become powerfully linked in our brain and are mediated by amygdaloid functioning without connecting to the thinking part of our brain, the frontal cortex. Language and reason cannot change or access these memories. This is important for psychotherapists to understand, because intellectual understanding can take the patient only so far. Intellectual understanding, a prefrontal cortex activity, may not change the person’s physiological reaction and responses. The subcortical areas involved with the emotional brain (i.e., limbic areas) are less plastic than are the cortically mediated functions involved with left-brain language functions. These types of procedural motor skills are much more difficult to learn than memorizing a phone number, which is a cortically mediated memory. That is why it is much harder for an adult to learn tasks involving procedural memories, such as playing a musical instrument or a new sport, because the lower areas of the brain are less plastic in adulthood than in childhood.

The challenge for psychotherapists lies in changing implicit state-dependent memories that have formed through prolonged interaction, experience, and repeated activation of neurophysiological states of stress. These memory systems were adaptive and crucial for survival for people who have been threatened by an unsafe situation. A hungry infant who looks into the nonresponsive, lifeless eyes of a depressed mother may be just as threatened for survival as the caveman confronting a saber-toothed tiger (Cozolino, 2010). Maintaining vigilance and suspiciousness is a good idea in a potentially threatening environment because it enables a person to detect danger quickly and respond. The psychotherapy process has the potential to change state- dependent memories that are powerfully linked in the brain to more adaptive states of consciousness for the current circumstances, such as forming a loving, trusting relationship and remaining calm in situations when attachment is perceived as a threat.

Psychoeducation and learning skills assist in creating resources and provide a necessary foundation for the work, but they can take the person only so far because they are largely left-brain activities carried out in the cortex. Cozolino (2010) says that cortical processing from psychoeducation occurs through affective arousal and that this, paired with relaxation, allows cortical integration. Although the cortex rapidly learns new information, limbic information needs to be accessed for trait change to occur, and this may require repetition and a relational context. Education in the context of a supportive relationship allows implicit memory systems to be accessed. The process of psychotherapy is emotionally arousing because it is an attachment relationship. Changing implicit memory systems that are less accessible and amenable to change requires a safe attachment relationship.

Safety and stabilization are foundational to all psychotherapies for adaptive processing of traumatic memories. Strategies that enhance the therapeutic alliance and set appropriate boundaries provide a safe relationship. Stabilization strategies help the person so that state changes are possible, that is, the person will be able to change his or her physiological state at the moment through strategies that decrease hyperarousal such as deep breathing, self-soothing, and other approaches listed in Box 1.2 in Chapter 1. Safety and stabilization are priorities during emotional arousal to prevent the person from being retraumatized so that the information can be integrated. Adhering to the practice treatment hierarchy by increasing external and internal resources is essential and foundational for safe processing. Periods of stabilization alternate with periods of processing as therapy proceeds because processing can be potentially destabilizing temporarily. See Appendix 1.6 for a checklist of outcomes for successful processing.

In processing, hyperarousal of the sympathetic nervous system must be modulated with anxiety- management strategies for information to be brought to an adaptive resolution so that further dissociation and

dysregulation do not occur. High levels of emotional arousal decrease cerebral efficiency, which prevents emotional processing. The irritability of the amygdala must be decreased to enable effective integration to occur. Neuroplastic potential is maximized by moderate but not excessive arousal (Cozolino, 2006). Scaer (2005) says that by bringing the left hemisphere online while re-creating a traumatic event, the amygdala is downregulated, which allows integration and reconsolidation of the implicit memory cues associated with the trauma. When working with traumatized individuals, van der Kolk (2006) agrees and says, “Learning to modulate the arousal level is essential for overcoming the resulting passivity and dependency [that occurs in traumatized individuals]” (p. 284).

Imaging studies have found that for those with significant trauma, there is decreased activation in the prefrontal cortex, resulting in reduced cerebral efficiency and difficulty in modulating emotional arousal and in problem solving. Increasing activation and functioning of the prefrontal cortex enhances the person’s ability to manage emotions and to plan better for the future (van der Kolk, 2006). Mindful attention, such as occurs during meditation, has been found to increase the thickness of the prefrontal cortex and right anterior insula (Lazar et al., 2005). Exercises that incorporate dual awareness and mindfulness are helpful in increasing frontal lobe functioning so that the person learns to pay attention to his or her internal experience without being overwhelmed by the sensations. This attention is called interoceptive awareness. Traumatized individuals are afraid of themselves and their own physiological sensations, because the situation is reminiscent of earlier states of helplessness and fear (van der Kolk, 2006). It is thought that through mindfulness, the person gradually becomes more aware of internal sensory stimuli, and this awareness increases the capacity to manage potentially stressful encounters. Mindfulness and dual awareness strategies may include somatic awareness, safe place, anchors, dual awareness exercises, progressive muscle relaxation, establishing boundaries, pacing the trauma narrative, and bridging the implicit with the explicit (Rothschild, 2000).

Relationship and Emotion

The process of psychotherapy is not about uncovering the past so much as providing safety through a new attachment relationship and processing dysfunctional implicit memory so that new expectations can be formed through reintegration of neural networks. Schore (2012) says that the psychotherapeutic relationship is inherently physiological and that through limbic resonance, the limbic brain is restructured. Limbic resonance refers to communication between two mammals’ limbic systems, and this connection is necessary for survival and growth. In seminal studies, Harlow’s monkeys and Bowlby’s attachment research provide early evidence of the parallels between bonding behavior and neurophysiology of animals and humans.

Relationships stabilize and regulate physiology, and in early relationships with others, when the brain is most plastic, long-lasting patterns are developed in the brain’s neural networks. Re-creating the adverse experience and experiencing attachment through psychotherapy is done in a supportive environment in which there is a sense of control and appropriate boundaries. A therapeutic alliance allows the person to stay safely within the window of arousal so that experiences can be verbalized instead of defenses mobilized. When a limbic connection has established a neural pattern, it takes a limbic connection to revise it (Lewis et al., 2000). As the patient becomes attached, relational templates are revealed within the context of the therapeutic relationship. Through attunement, developmental recapitulation is potentiated as opportunities are cocreated for corrective emotional experiences that can generate a new relational template and neural integration (Cozolino, 2010). This is possible because the therapeutic relationship provides the optimal context neurophysiologically for neural plasticity.

In psychotherapy, the patient encodes new information through numerous psychotherapeutic interactions that facilitate limbic connection. “Healing is a physical process within the brain that produces a physiological pattern of function that in turn promotes homeostasis and optimal autonomic arousal” (Scaer, 2005, p. 168). This is accomplished over time through connection and emotional responsiveness. Affect or emotional regulation is an essential element of the therapeutic alliance and thereby of the change process of psychotherapy (Schore, 2012; van der Kolk et al., 2006). The role of emotional regulation has been a significant focus of neurobiological studies and theoretical speculations. Emotional states are fundamentally physiological and involve basic bioregulation and homeostasis of all systems (Schore, 2012).

Affect development parallels affect regulation; that is, as a person develops emotional awareness, there is a greater capacity for increasing levels of affect regulation. Normal development in the context of an attuned caregiver facilitates the evolution of affects from their early form, in which they are experienced as bodily sensations, to subjective states that can gradually be verbally articulated (Stolorow & Atwood, 1996). This is

consistent with Lane and Schwartz’s (1987) theoretical speculations that there are various levels of emotional development, with the lowest level of emotions experienced as bodily sensations, such as occurs during infancy, and the highest level blending feelings and the capacity for fantasy, imagination, and empathy. Emotional development is derailed during trauma, whether through a specific traumatic event or the more chronic and insidious types of trauma, such as those that occur in attachment misattunements.

Emotions are physiological states, and reflect our conscious interpretation of visceral sensations (Damasio, 1999). Emotions are not caused by our thoughts but by our response to physiological changes in our body in response to external stimuli. The body tells us about our well-being. A simple exercise illustrates this. Think of an unpleasant event, situation, or person for a minute, and then tune into where that feeling registers in your body. Then think about a happy time or a person you like for a minute, and notice where you feel that in your body. Siegel (2002) says: “Emotion, body state, and a core consciousness of the self emerge from the same brain circuitry” (p. 97). He further posits that emotion serves an integrative function and strengthens neural circuits through the release of neurotransmitters, which promotes self-regulation.

Healing is reflected in the capacity to experience a wider range and intensity of emotions. Experiencing all emotions fully is posited to be synonymous with being fully alive and salubrious to health (Pert et al., 1998). Contemporary theorists have further refined the idea that emotion serves to connect systems in the brain as well as connect people to each other, with emotional regulation being the key to integration. Too much emotional arousal creates chaos, while too little emotional arousal is manifested by rigidity and depletion of energy for life (Siegel, 2012). This balance or regulation of emotion is the outcome of orbital frontal prefrontal integration. The APPN psychotherapist assists the patient in clarifying and identifying nuances of emotion, facilitating neural connections and energy flow. However, emotions must be experienced and not just talked about, that is, the full range of emotions are expressed and communicated and received by an empathic person. In this way, psychotherapy assists in affect development and regulation.

The groundbreaking work of Pert and colleagues (Pert et al., 1998) on neuropeptides theoretically supports the primacy of emotion and the importance of emotional expression in psychotherapy. Neuropeptides are the chemical substrates of emotion, and Pert says that emotional expression balances the flow of neuropeptides and that this generates a functional healing system throughout the body. Emotional regulation has a major impact on physical and psychological health. Pert says that emotional expression is salubrious to health and that some emotions are especially beneficial, such as the primary emotions of anger, joy, grief, sadness, and fear, whereas other emotions that produce long-term states of distress, such as helplessness, hopelessness, depression, and despair, create significant biochemical changes deleterious to psychological and physical health. Emotional regulation occurs through identification and expression of the primary emotions in an ambient emotional environment.

Emotional changes and affect regulation involve implicit memory systems and largely occur through right-brain communication between the therapist and patient in the therapeutic alliance (Schore, 2012). The therapeutic alliance forges a bond of emotional connection that is thought to be inherently psychobiological in that there is a mutual coregulation of affects involving implicit right-brain communication with the right hemisphere dominant in psychotherapy (Schore, 2012). Siegel (2002) agrees and says that the therapist serves as an attachment figure and helps to assist the patient toward more autonomous self-regulation through coregulation of internal states. Much of this communication is nonverbal, unconscious, implicit, and reflected in subtle shifts of positive and negative emotions. Nonverbal behavior, such as facial expression, respiration, body posture, gestures, eye contact, and the tone, rhythm, cadence, volume, and speed of verbal communication, determines the nature of the relationship and alliance (Scaer, 2005). These nonverbal aspects of the primary attachment relationship are functions of the right hemisphere, and they apply to the therapeutic alliance. Implicit communication precedes understanding words in development and in psychotherapy.

Psychotherapy offers the person the opportunity to transform and process implicit memories through relationship. Responses to early relational trauma are reenacted in the therapeutic relationship. Similar to one’s original attachment relationship with a caretaker, the new attachment relationship with the therapist allows a secure base for the person to make changes. For those who already have a secure attachment schema, the capacity for reflection and mindfulness is present but may need to be supported through the unfolding narrative as the person reflects on their experience. The securely attached patient can self-regulate, express feelings within the relationship, and generally functions well in life, that is, he or she can both feel and deal.

In contrast, the person with an insecure/disorganized attachment style presents significant challenges because there often is intense anxiety and great difficulty in self-soothing and regulating emotion. This patient alternates between overwhelming emotion and dissociative states. Stabilization and resourcing are needed with the APPN teaching the person how to reflect on experiences and this in turn helps to regulate affects and

to integrate experiences that have been dissociated. Through narrative and the “holding” (Winnicott, 1976) of the therapeutic relationship, a more solid coherent sense of self can emerge. This parallels attachment research that demonstrates attachment security and self-reflective capacity can change over the life span and this change correlates with a coherent narrative (Siegel, 2012). This is because the OMPFC integrates social relationships, emotional regulation, and self-knowledge and remains plastic throughout life. For a more thorough discussion on working with those with attachment trauma, see The Transformation of Affect: A Model for Accelerated Change by Diana Fosha.

Emotions serve as a portal to implicit memories and are considered the central agent of change. Accessing emotion engages relevant neurobiological processes for early trauma that may not be language based but reflect the right hemisphere language of emotions, images, sensations, and impressions. The emotional arousal inherent in psychotherapy provides an opportunity to access implicit memory to facilitate information processing. Even though implicit memory is unconscious, it is demonstrated through the person’s feelings, attitudes, beliefs, behaviors, and symptoms. For example, faulty information processing may have led the person to core negative beliefs of defectiveness that are ingrained. These are false beliefs about oneself due to early developmental and/or attachment traumas and ingrained as part of the person’s identity (see Box 2.4).

Entrenched negative thoughts and beliefs of defectiveness coexist with chronic depression and arise from childhood neglect or abuse in an effort by the child to preserve the relationship with caretaker(s). For example, a child who is physically abused by her mother learns that those who love her hurt her, and due to cognitive immaturity and in an effort to preserve the relationship, probably concludes, “There is something wrong with me.” The negative emotion and sensations coupled with the thought are linked in memory networks and are triggered in future situations when similar feelings of powerlessness, despair, and worthlessness occur. The alternative that something is terribly wrong with those who have your life in their hands would lead to intolerable anxiety and utter hopelessness. Defenses evolve in the form of denial to protect the child from overwhelming anxiety and, ultimately, these false beliefs about oneself limit the person and are not linked to positive thoughts.

BOX 2.4

CORE NEGATIVE BELIEFS OF DEFECTIVENESS

I am bad I am not good enough I am a failure I am worthless I am unlovable I am damaged I am invisible I am not important

Source: Shapiro (2001).

Otherwise the person may idealize her mother (reaction formation) or have no memories or feelings about her childhood (dissociation). Lack of memories before age 2 is normal because the hippocampus is not myelinated until 18 months. However, if there are no memories of childhood, this may suggest that dissociative defenses may be warding off a high level of anxiety. The child may have an ambivalent or dismissing attachment style and had to turn away from caretakers to self-regulate. Chapter 13 provides information on how to assess for early memories through use of a timeline that can be constructed with the patient on intake.

The plasticity and malleability of neural networks is a double-edged sword in that the psychotherapist can play a significant role in the construction of beliefs for better or worse. In psychotherapy, therapeutic suggestions are powerful, and the therapist’s beliefs, even if unspoken, influence the patient (Cozolino, 2006). The media attention to false memories as a basis for litigation highlights this issue. The reality is that there is no objective truth that the psychotherapist is seeking; there is only the pursuit of truth as the patient feels and remembers his or her experience. It is the person’s perception that matters, not whether the memories are literal and true. This is important because a person’s history is not destiny and what actually happened is not

as relevant as how the people make sense of their lives. It is essential for the psychotherapist to remain impartial and listen with equal attention to all dimensions of the narrative without unwittingly encouraging elaboration in areas that the therapist feels are more interesting or valid. An important caveat is to not lead the patient toward the conclusion that she or he was abused, even if the therapist thinks it is true.

On the positive side, psychotherapists can use the malleability of memory for therapeutic change through creative use of the power of suggestion. Therapeutic communication, imagery, therapeutic alliance, and assisting the person in enhancing internal resources facilitate the formation of new neural connections that enable patients to expand the possibilities for improved functioning. For example, one woman who was emotionally and physically abused severely as a child had great difficulty in enhancing internal resources because there was no memory of soothing interactions that she could draw on as a resource in stressful situations. Over time, as the therapeutic alliance deepened and with practice in sessions and then out of sessions, she was able to image her therapist with her, first in situations that were not stressful and then eventually during times of stress. The therapeutic alliance parallels the brain growth— promoting aspects of the mother–infant dyad—and it creates new dendritic connections in the brain that can serve as a resource for opening up possibilities for positive new experiences. Subsequently, the woman enrolled in yoga classes, which she previously found too stressful and she extended her network of friends to include more supportive relationships. These changes can happen only when there is a strong therapeutic alliance providing a safe emotional relationship for the person.

Alexithymia

Alexithymia is an emotional regulation problem that has generated a considerable amount of research, and it is relevant for consideration in psychotherapy. Alexithymia is a specific communication style, which literally means no words for feelings. Individuals with alexithymia often express their emotions in bodily symptoms; for example, instead of feeling angry, the person may get a headache. Other patients may report a vague sense of dissatisfaction and may binge eat in an effort to alleviate this feeling. Somatizing is the experiencing of emotion without the ability to translate the emotion into the feeling. Alexithymia is significantly associated with psychosomatic disorders (Taylor et al., 1992), depression and childhood sexual abuse (Thomas et al., 2011), substance use disorders (Aleman, 2007), eating disorders (Wheeler et al., 2005), PTSD (Zahradnik et al., 2009), and emotional neglect (Aust et al., 2012).

Research supports a bidirectional interhemispheric transfer deficit for alexithymic and psychosomatic patients (Taylor, 2000). The emotional and somatic information systems of the right hemisphere are not connected optimally with the linguistic cognitive systems of the left. This is thought to be a problem in neural network connection and communication between the right and left hemispheres. A person may be born alexithymic (i.e., primary alexithymia), or alexithymia may be caused by trauma (i.e., secondary alexithymia) (Freyberger, 1977). Whatever the cause, alexithymia can be thought of as a continuum because there are different degrees of this state or trait. Expression depends in part on the situation and the person. Under stress, an individual with primary or secondary alexithymia may have even more difficulty with affect regulation than during nonstressful times. Those with alexithymia have great difficulty in self-caring, self- soothing, and self-regulating functions because they cannot identify their own sensations, emotions, and physical states. Thus, there is an inability to gauge and modulate internal states. These individuals do not seem to have an inner sense of themselves and become easily overwhelmed if asked to attend to inner sensations. Other deficits include a marked absence of fantasy and lack of empathy.

This constellation of features has important implications clinically because traditional techniques used in talk therapy, such as roleplaying, imaging, expressing feelings, and discussing dreams, are significantly compromised because the severely alexithymic patient may not have dreams or be able to image. For example, if the therapist asks the alexithymic patient to keep a feelings journal, the response is likely to be confusion or resistance because the person really does not know what feelings are and has no language with which to articulate emotions.

Assessment of alexithymia is indicated for all those whom the APPN suspects have been significantly traumatized, have chronic pain, have many somatic complaints with few identifiable causes, or have difficulty identifying their feelings beyond saying they are upset and appear confused when questioned further about their feelings. Assessment for alexithymia is described in Chapter 3. After confirmation through administration of tools that measure alexithymia, the therapist should explain to the person that he or she has a problem in identifying emotions and that this has created some of the problems he or she is

experiencing. This is important, because people with alexithymia often do not know what is missing, especially if they have never experienced feelings. Alexithymia has been compared with color blindness in that a person with color blindness does not know what colors are, just as the alexithymic person does not know what feelings are (Krystal, 1979).

Overall treatment strategies for alexithymia include supportive psychotherapy, psychoeducation, and assisting the patient in labeling emotions by tracing antecedents to somatic complaints and symptoms so that the person can develop an understanding of trigger events and consequences (Wheeler, 2000). Tacon (2001) describes several staged approaches that are most helpful for the treatment of alexithymia. In one model, the first stage focuses on educating the person and observing; the second stage increases affect tolerance; and in the third stage, the person learns how to verbalize feelings and experiences. A similar staged model includes (1) identification of physical symptoms; (2) encouraging differentiation of somatic symptoms from feelings and using correct emotions to label feelings; and (3) guided reflections so that the person can understand past experiences. Dialectical behavior therapy (DBT) developed for working with borderline personality disorder, is also helpful in increasing affect tolerance and the ability to self-regulate, which helps those with alexithymia. Specific strategies are delineated in the Skills Training Manual for Treating Borderline Personality Disorder (Linehan, 1993). DBT is discussed in Chapter 14.

Overall, these strategies aid in increasing interhemispheric connection, strengthening right and left hemispheric integration, and the ability to regulate affect. Integration of the right and left hemispheres occurs through activation of conscious language (top left) with unconscious emotional (lower right) processes that have been dissociated by childhood stress or adult trauma (Cozolino, 2006). Siegel (2012) says that right and left hemispheric integration is achieved through coherent narratives. He believes that CBT, psychodynamic psychotherapy, and EMDR are successful in that they selectively activate processes in each hemisphere and promote integration through this activation.

Psychotherapy is about helping people to make sense of their inner lives, emotions, and interpersonal experiences. Siegel notes that integration of neurons may not just be about verbal recall but instead involve all modalities that memory is stored in. “The sense of safety and the emotional ‘holding environment’ of a secure attachment within a therapeutic relationship … may be essential for these integrative processes to occur within the traumatized person’s mind” (Siegel, 2003, p. 29). Strategies that enhance the therapeutic alliance, and setting appropriate boundaries provide a safe place for the work of healing. The evidence-based psychotherapeutic approaches included in this book, CBT, DBT, EMDR, motivational interviewing, humanistic existential therapy, psychodynamic therapy, family therapy, and group therapy, provide approaches that guide the APPN in working therapeutically and safely.

CONCLUDING COMMENTS

The neurophysiology discussed in this chapter lends support to the elements of psychotherapy identified in Chapter 1: caring, connection, narrative, and anxiety management. These elements transcend all psychotherapy models and approaches and serve as the vehicle through which neural networks are integrated. Integration is accomplished through adaptive processing of dysfunctional information, which affects all dimensions of the person so that healing can occur. The neuroscience of psychotherapy is embedded in the paradigm of holism. Returning to the definition of healing from Chapter 1: “the emergence of right relationship at or between all levels … the process of becoming whole … toward integration and expanded consciousness” (Dossey et al., 2012). This is the essence of healing and psychotherapeutic change. Information processing through psychotherapy restores harmony, balance, connection, and integration of neural networks. This approach is key to wholeness and healing and is reflected in deeper connection with oneself and others.

DISCUSSION EXERCISES

1. Give a clinical example of each defense mechanism listed in this chapter from your practice or personal life. Identify which defense mechanism can be classified as primitive or narcissistic, immature, neurotic, or mature.

2. Discuss memory and how traumatic memories are stored differently than nontraumatic memories.

3. Discuss alexithymia, and present a case in which you thought the patient was alexithymic. 4. Define state-dependent learning, and give an example from your own experience. 5. Identify five neurophysiological changes that can result from trauma. 6. Describe how psychotherapy works neurophysiologically. 7. Discuss the author’s ideas about truth and false memories in psychotherapy. 8. What is meant by primacy of emotion in psychotherapy? 9. How does neurophysiology lend support to the elements of psychotherapy, caring, connection,

narrative, and anxiety management, as outlined in Chapter 1?

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Assessment and Diagnosis PAMELA BJORKLUND

comprehensive assessment of the patient who presents for psychotherapy is necessary to develop an appropriate treatment plan. In some settings, a comprehensive assessment must be conducted during the

initial session. This chapter presents the format and tools for such an assessment. The comprehensive psychiatric database and instruments included in this chapter can also be integrated in a setting that allows the therapist to conduct an assessment over several sessions. The therapist may bill for an initial, comprehensive assessment only once during the course of the assessment process. In reality, however, most assessments continue throughout the treatment; and therapists initially use only selected instruments in acquiring a database. The setting and population with whom a therapist works determine what is necessary and what is optional. There may be other screening tools not included in this chapter that are required by the agency or employer or that are necessitated later by an evolving understanding of the patient.

Even if the APPN sees the person only for the assessment, a sensitively crafted intake assessment can be a powerful therapeutic tool. It can establish rapport between patient and therapist, further the therapeutic alliance, alleviate anxiety, provide reassurance, and facilitate the flow of information necessary for an accurate diagnosis and appropriate treatment plan. For better or for worse, an assessment is a relational process. It represents a verbal and nonverbal dialogue between two therapeutic partners, whose behaviors reciprocally influence each other’s style of communication and result in a specific pattern of interaction (Shea, 1998). To the degree this pattern of interaction transcends its question-and-answer format to constitute an authentic encounter between the patient and therapist, an assessment can play a significant role in the change process (Safran & Muran, 2000). At the very least, a sensitively crafted assessment can help ensure that a patient in crisis or distress returns for follow-up care.

Shea (1998) identified the broad goals of clinical assessment as follows:

1. To effectively engage the patient in the data-gathering process 2. To collect information and form a valid database 3. To develop an evolving and compassionate understanding of the patient 4. To develop an assessment from which a differential diagnosis can be made 5. To use the diagnosis as a guide to the choice of an appropriate treatment plan 6. To effect some decrease in the patient’s anxiety 7. To instill hope and ensure that the patient will return for the next appointment

The goals of engaging the patient in a therapeutic alliance, data gathering, uniquely understanding the person who presents as a patient, and arriving at the most appropriate diagnosis and treatment plan are parallel assessment processes (Shea, 1998). Generally, the more powerfully engaged the patient and therapist are during the assessment process, the more valid are the data on which to base the diagnosis that will guide the choice of treatment plan.

In a clinical sense, validity refers to the accuracy of the database (i.e., whether the clinician is eliciting the information he or she is trying to elicit) (Shea, 1998). The more valid the database—and by implication, the more valid the diagnosis—the more confidence the therapist can have in the treatment plan and the more reassuring he or she can be in parlaying information to patients about their probable course or expected outcomes. The successful engagement of patients in the assessment process—which requires empathy, patience, a willingness to afford patients sufficient time to tell their stories in their own manner, the ability to structure patients when necessary, and careful attention to patients’ needs for comfort, privacy, and security— is key to the validity of assessment data. Consequently, this chapter examines important areas for assessment, providing specific screening tools to aid in the assessment process and attending to the manner in which the therapist fosters the therapeutic alliance. It describes the process of taking a history and the comprehensive assessment of areas of patient functioning important to the practice of psychotherapy, including ego functioning, affective development, interpersonal relationships, and belief systems. The chapter ends with a discussion of diagnosis and case formulation, without which the treatment plan has no rationale.

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TAKING A HISTORY

Fundamentally, the psychiatric history is a kind of life story told to the therapist by a patient in his or her own words and from his or her own point of view (Sadock, Sadock, & Ruiz, 2009). In some situations and with the patient’s consent, excluding only emergency situations, the history may include information from other sources such as a parent, spouse, former therapist, other referral source, or medical record. The therapist must collaborate with a consenting patient in negotiating the details of how and when to obtain collateral information from other sources. A comprehensive history includes information about the current illness (i.e., factual data related to the onset and chronology of current symptoms) and the past and present psychiatric and medical history. It includes a psychiatric review of systems, a medication history, a history of substance use and abuse, a history of violence or self-destructive behavior, trauma history, and developmental, family, social, educational, occupational, and legal histories. Box 3.1 provides an outline of the major sections, or clinical domains, of the psychiatric history as adapted from the American Psychiatric Association’s (APA) Practice Guidelines for Psychiatric Evaluation of Adults (APA, 2006) (Box 3.2) and Kaplan & Sadock’s Comprehensive Textbook of Psychiatry (Sadock et al., 2009). Appendix 3.1 outlines the content of a comprehensive psychiatric database developed from multiple sources, including professional experiences in various clinical assessment venues (APA, 2006; Gordon & Goroll, 2003; Marken et al., 2005; Morrison, 2008; Sadock et al., 2009; Scully & Thornhill, 2012; Shea, 1998). Appendix 3.2 presents a sample intake assessment form adapted from Shea (1998) that includes all sections of the comprehensive psychiatric database.

Obtaining such a comprehensive history from the patient and, if necessary, from informed sources close to the patient is essential to making an accurate, culturally appropriate diagnosis and developing a specific, culturally sensitive, and effective treatment plan (Sadock et al., 2009). From this life story, the therapist can begin to paint a picture of the patient’s personality characteristics, strengths and areas for growth, interpersonal style, cultural context, and development from his or her earliest years to the present moment. Taking a history—a cocreative act of constructing a comprehensive life story—allows the therapist and ultimately the patient to more completely understand who the patient is, where the patient has come from, and where the patient may go in the future (Sadock et al., 2009). It is an essential first step to rewriting that story. The fact that people in psychotherapy come to change their life stories over the course of treatment is a positive development, because patients’ reflections on their past conditions in light of the changing present herald the creation of a different future (Barker, 2001). The revision of life stories through narrative is the essential work of psychotherapy, which is a unique form of encapsulated experience that focuses on the life experiences of another such that those experiences can be reconsidered, more deeply understood, reframed, and thus reconstructed (O’Toole & Welt, 1989). It all starts with taking a history.

BOX 3.1

MAJOR SECTIONS OF THE PSYCHIATRIC HISTORY

I. Reason for the evaluation

A. Identifying data

B. Patient-identified problem

II. History of the present illness

III. Past psychiatric history

A. Trauma history

IV. History of substance use

V. General medical history

VI. Developmental, psychosocial, and sociocultural history

A. Stressors

B. Strengths

C. Support systems

VII. Occupational and military history

VIII. Family history

IX. Genogram

X. Review of systems

XI. Mental status examination

XII. Values or belief systems

XIII. Differential diagnosis

XIV. Case formulation

Sources: APA (2006); Sadock, Sadock, and Ruiz (2009).

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Opening Moves

Practically speaking, how does the therapist take a comprehensive history in one session? In those settings where this is necessary, in the first moments of an initial assessment the therapist must accomplish a number of important alliance-building tasks, including an appropriate greeting, introductions (if not already made in an earlier contact), an indication of seating preference, a brief introduction to the assessment process, and an open-ended invitation to the patient to tell the therapist how he or she can be of assistance. In these moments, the therapist should indicate what the interview will be like, how much time it will take, what sort of questions will be asked, and what sort of information the patient is expected to share. The therapist needs to create a comfortable and secure environment that allows the patient as much control as possible (Morrison, 2008). Early in the assessment, a nondirective interview style with open-ended questions yields control to the patient, generally builds rapport, and garners facts that are more reliable (Morrison, 2008; Shea, 1998). As studies have shown that patients give the most valid information when they are allowed to answer freely, in their own words, and as completely as they wish, it is generally desirable to employ open-ended questions that allow the widest possible scope of response (Morrison, 2008). To illustrate how a therapist may begin the data-gathering process, Box 3.3 summarizes the first moments of an initial clinical assessment with a fictive psychotherapy patient, who has indicated in an earlier phone contact her preference to be called by her first name, Beth.

BOX 3.2

WEBSITES FOR APA PRACTICE GUIDELINES

Practice Guideline for the Psychiatric Evaluation of Adults: psychiatryonline.org/guidelines.aspx

www.psych.org/practice/clinical-practice-guidelines

In the medical model, the patient’s response to the therapist’s opening question is called the chief complaint, but it might better be called the patient-identified problem in a holistic nursing model. It is the patient’s stated reason for seeking help and is recorded verbatim. It often reveals the problem uppermost in the patient’s mind (Morrison, 2008) and can indicate the content region (Shea, 1998) or clinical domain (APA, 2006) the therapist should explore first. When the patient’s response to the therapist’s opening question is a denial that anything is wrong, it is often helpful to rephrase the question in terms of why others may think the patient should seek help, such as “Can you tell me what went on that your (mother, spouse, friend, employer, primary care provider, court officer) thought you might benefit from coming in?” Another technique is to ally with the patient’s resistance or sidestep it; for example, “Nothing may be wrong, but because you’re already here, perhaps we can try to figure out if there is something else I can help with.” Such denials are the first indication that the therapist may encounter significant resistance by the patient to engaging in psychotherapy, and they are cogent reminders that the first task of data gathering is alliance building.

BOX 3.3

BEGINNING THE CLINICAL ASSESSMENT

Therapist: Hello, Beth. It’s nice to meet you in person. Please, sit down. You can make yourself comfortable here. [Points to a chair.]

Patient: Okay, thanks.

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http://psychiatryonline.org/guidelines.aspx

http://www.psych.org/practice/clinical-practice-guidelines

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Therapist: As I mentioned on the phone, I am an advanced practice psychiatric nurse, and in today’s session, I hope to get a clearer sense of the difficulties you alluded to on the phone. I will be asking questions about important areas of your life, and with your permission, I would like to be able to take a few notes. I don’t want to forget anything. [Smiles, waits for a response.]

Patient: That’s fine.

Therapist: I would like to get as much history as I can today, but if we aren’t able to get to everything, we’ll continue next week. I’ll be asking lots of questions about your present circumstances and your past history, so if any of my questions make you uncomfortable, please let me know. I do not want to contribute to your distress, but I do want to hear as much about your thoughts and feelings as you are comfortable telling me.

Patient: That’s fair. I’ll try.

Therapist: Could you tell me in whatever way you like what brings you in today?

Patient: [Takes 5 to 10 minutes to tell her story, with open-ended prompts by the therapist only as needed, e.g., “What happened then?” “Could you tell me more about that?” “How were you feeling at that time?” “What else was going on?”]

During the minutes that follow the patient-identified problem, while the patient is freely telling his or her story, much is signaled that the therapist will need to explore in greater depth later in the interview. The therapist needs to mentally note or write down these areas of clinical interest (i.e., clinical domains or content regions, so that specific questions can be asked at the appropriate time). Box 3.4 summarizes the content from Beth’s response to the therapist’s opening question.

BOX 3.4

EXPLORING THE PATIENT-IDENTIFIED PROBLEM

Therapist: Can you tell me in whatever way you like what brings you in today?

Patient: I don’t know. [Long pause.] Donna N. [referral source] sent me. She and my mom and my advisor thought I had depression. Actually, I’ve been depressed on and off since the 10th grade. [Another long pause.] I have a lot of problems getting along with my parents, especially my mom. I’ve been thinking about dropping out of school until spring semester to get my head together, but my advisor talked me out of it. I am dropping only one class. I’m not really happy about deciding to stay in school. I cried for 3 hours about it. I’m overwhelmed with school. I can’t catch up. I don’t care about anything anymore. I’m happy just to stay in bed. The slightest things make me feel bad. I’m angry all the time. My mother thinks my personality has changed. I don’t know. Maybe it has. I’m more irritable around my boyfriend. The slightest things he does put me on edge. My mother, too. She calls me every night in the middle of studying, and it gets on my nerves. If she didn’t call me, I wouldn’t even think about her.

Therapist: Beth, you mentioned you are quite irritable these days and have been crying a lot. Can you tell me more about the depressive symptoms you’ve been having?

Patient: Well, I sleep okay, but I wake up tired, and I have no energy for anything. I’m not really sad, just angry and irritable and overwhelmed with everything.

Therapist: Anything else?

Patient: A few days ago I thought about suicide. It just crossed my mind. I don’t really want to die. I just want my problems to end.

Therapist: What did you think about? [Therapist takes this opportunity to thoroughly assess current suicide risk and to explore the past history of suicidal behavior. She then returns to the “depression” content region to more thoroughly assess the possibility of a diagnosable mood disorder, such as major depression or dysthymia.]

Expanding the Assessment

Although there are no rules about which content region to explore first or in what order to address them, it is generally advisable to thoroughly explore one before moving on to another (Shea, 1998). In this example, the therapist chooses to first explore the symptoms of a possible mood disorder and, when the patient (Beth) broaches the subject, to assess her current suicide risk. However, she makes a mental note to follow these content regions with the developmental, family, and social histories, focusing on Beth’s strained relationships with her mother and boyfriend and on her academic decline. After a thorough assessment of the current suicide risk and any history of suicidal behavior, the therapist returns to the depression content region—the history of the present illness (HPI)—to get a more thorough sense of the onset, extent, and chronology of mood symptoms. In doing so, she learns more about Beth’s hostile and enmeshed relationship with her mother. It seems the patient has been dysthymic since the 10th grade, when Beth’s mother put her daughter’s dog to sleep without her knowledge. This occurred on the day Beth got her braces removed from her teeth. A family celebration had been planned: “It was supposed to be a happy day for me. It wasn’t.” Apart from the fact that it is the humane thing to do, an engaged clinician should take this opportunity to further strengthen the therapeutic alliance—which facilitates continued data gathering—by empathizing with the patient’s distress about what appears to have been a significant loss and a rather cruel act of sabotage by the patient’s mother (e.g., “You must have been very hurt by this.”). The therapist then needs to move to the developmental and family history to learn more about this incident and to more thoroughly assess the family

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dynamics, especially the patient’s relationship with her mother (e.g., “Tell me more about that day, your relationship with your mother, and your family situation.”).

In this way, the therapist proceeds to take a history, thoroughly exploring all the major sections of the comprehensive psychiatric database (see Box 3.1) by opening new content regions as opportunities arise. Open-ended questions invite exploration in new content regions, reveal what is uppermost in a patient’s mind, and may yield important information about the patient’s capacities, defenses, or degree of resistance to engaging in psychotherapy. Closed-ended questions elicit the specific details that are necessary to assess a new clinical area, such as symptom type, severity, frequency, duration, and the context in which a symptom occurs. Table 3.1 provides an outline of open-ended and closed-ended assessment questions along a continuum of openness. Opportunities to open new content regions do not always arise spontaneously; and in those cases, the therapist must guide the assessment into new clinical areas. Occasionally, time constraints may dictate that the therapist makes an abrupt transition to unexplored content regions to obtain a thorough assessment within the allotted timeframe. However, it can be done skillfully, sensitively, and in a manner that continues to facilitate the therapeutic alliance. Box 3.5 illustrates the use of open-ended and closed-ended questions to facilitate skillful, even if abrupt, transitions to new content regions.

Organizing the History of the Present Illness

Of all the major content regions of the psychiatric history, the most important is the HPI. It represents the heart of the assessment interview. It is the most substantial part of the initial clinical assessment and includes a description of the patient’s key symptoms, their timing and associated problems, and the stressors that account for their exacerbation. When well organized, the HPI develops much like a mystery short story (Kluck, n.d.). It outlines the onset of the patient’s key symptoms and progresses chronologically until the time of the patient’s presentation for evaluation. By the end of the HPI, an experienced clinician should be able to read the written assessment and construct a near complete differential diagnosis. A thorough and well-constructed HPI contains the following components, roughly in the following order:

TABLE 3.1 Assessment Questions: Continuum of Openness Type Example Open-Ended Types

Open-ended questions What brings you in today? How can I help you? How would you describe your relationship with…?

Gentle commands Tell me about your family situation. Try to describe how you felt when… Share with me what you think a good outcome would be.

Intermediate Types

Swing questions (client can say “no” or client can elaborate) Can you describe the depressive symptoms? Can you tell me anything more about that? Can you tell me what you’re thinking right now?

Qualitative questions How have you been sleeping? How is school going? How have you been getting along with your mom?

Statements of inquiry So you have never before received any therapy? Your mother decided to go back to school when you did? You say you just want to stay in bed all the time?

Empathic statements You must have been so hurt by that. That is very frustrating. It is hard to lose someone you love.

Facilitating statements Go on. I see.

Closed-Ended Types

Closed-ended questions How many drinks did you have? How often do you feel that way?

Closed-ended statements You can sit down here. We’ll take about 50 minutes to… Medications can be very effective in these cases.

Adapted from Shea (1998).

1. A statement of the patient’s baseline functioning or last period of stability 2. Any previous diagnoses of psychiatric disorder and a brief synopsis of the course and treatment 3. The onset of the first symptom and its precipitant 4. A chronology of one to three key symptoms, including when they worsened and the precipitant events that

caused them to worsen

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BOX 3.5

TRANSITIONING TO NEW CONTENT REGIONS

Therapist: Beth, you’ve told me a great deal of very helpful information about your family situation. I’m beginning to understand the kinds of things you’re dealing with. But I’ve noticed the clock, and we have only 15 minutes left. There are some other things I need to know before we can talk about where to go from here. Can you handle a few more questions? [closed-ended question]

[Note: Using a patient’s name judiciously can comfort, contain, invite closeness, and facilitate the therapeutic alliance. If used artificially or too often, it can seem ingratiating or insincere and can distance the patient and impede the therapeutic alliance.]

Therapist: You mentioned that you saw a school counselor when you were in the 10th grade and your dog was put to sleep. Can you tell me more about that treatment? [open-ended, swing question]

Well, there’s not much to tell. I saw her only once. It wasn’t really a treatment. We talked for about 30 minutes. A teacher was concerned when she saw me crying at school. I didn’t go back. She said I didn’t have to if I didn’t want to.

Therapist: Were there any other times that you saw a counselor, therapist, or psychiatrist? [closed-ended question]

Patient: No.

Therapist: So you’ve never before received any therapy or any psychiatric treatment, either as an inpatient or outpatient? [closed-ended statement of inquiry]

Patient: No.

Therapist: Okay. What about substance abuse? [open-ended question]

Patient: Treatment? No, never. In fact, I don’t use anything. I don’t even drink coffee. I suppose … [long pause; therapist waits]

Therapist: Go on. [facilitating statement]

Patient: Well, I have tried some things, but it was a long time ago.

Therapist: Tell me. [open-ended, gentle command]

5. Associated symptoms related to the one to three key symptoms 6. Documentation of the “why now” (i.e., why the patient presents for treatment now) 7. Repetition of components 3, 4, and 5 if there is more than one diagnosable disorder 8. A list of pertinent negative symptoms (i.e., symptoms that are not present) 9. A list of additional stressors not mentioned (Kluck, n.d.)

Box 3.6 documents the HPI in the case of Beth, inserting numbers 1 through 9 at appropriate points in the text to mark the essential HPI components listed.

Mental Status Examination: To Do or Not to Do

The mental status examination (MSE) has become a standard component of the initial clinical assessment. It is the clinician’s description of the patient’s current mental functioning. It is a direct examination of the patient’s behavior and the examiner’s inferences from what the patient says and does. In making these inferences, the clinician must carefully consider the patient’s educational and cultural background. Illiteracy and differences in ethnic, cultural, and linguistic backgrounds can distort the results of the MSE (Jacob, 2012). The principles of symptom elicitation during the MSE are comparable to those employed in interpreting diagnostic laboratory tests, which require both sensitivity and specificity, and are employed to screen, exclude, or confirm abnormalities (Jacob, 2003, 2012). Although it is beyond the scope of this chapter to discuss in detail how to perform a formal MSE, Appendix 3.1 includes a comprehensive outline of the content and possible organization of a formal MSE. Many of its sources (see Appendix 3.1) describe the performance of the MSE in great detail.

BOX 3.6

DOCUMENTING THE HISTORY OF PRESENT ILLNESS

Beth is a 20-year-old college junior majoring in business administration who has felt chronically depressed since approximately the 10th grade, when her mother put her dog to sleep without her knowledge on a day the family planned to celebrate the removal of her braces (1).* She has no previous history of psychiatric treatment (2). In August, she moved away from home for the first time after having an argument with her parents about money and college expenses. The focus of the conflict was Beth’s

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resentment about their refusal to help her more with college expenses when they had money for new recreational vehicles, house remodeling and, most significantly, her mother’s sudden enrollment in the Denton Business University, which coincided with Beth’s change of majors from psychology to business administration. She moved in with her boyfriend of the past year and a half and found herself feeling increasingly irritated with him (3). Despite these stressors and her increasingly low mood, she functioned relatively well in school until approximately 3 weeks ago, when she began to feel more depressed, apathetic, and fatigued than usual. She wanted to drop out of school but was talked out of it by her academic advisor and ended up dropping only one course. She states she sleeps well but wakes up tired and has no energy. She “doesn’t care about anything anymore” and is “happy to stay in bed.” The “slightest things make her feel bad,” and she has crying episodes three or four times per week. She has lost approximately 8 pounds in the past 3 weeks. She reports that she does not feel sad, hopeless, or helpless, just overwhelmed by school, work, changing majors, having to interact with her parents—her mother calls her every evening during her study time—and having to work harder to get along with her boyfriend in close quarters. All her symptoms have worsened over the past 1 to 2 weeks and are exacerbated by the seemingly daily conflict with her mother and boyfriend (4). Within the past week, she has begun scratching on her wrists with plastic, serrated knives—something she has not done since high school (5). Three days ago, a particularly loud and hostile phone conversation with her mother annoyed Beth’s boyfriend, causing a bitter argument between the two of them. He stomped out of the apartment and did not return that night (6). She felt “abandoned” and “panicky”; thoughts of suicide (no plan or intent) crossed her mind, which scared her enough that she contacted her college vocational counselor, who referred her for psychiatric evaluation (7). She denies acute suicide ideation today, as well as any symptoms of mania or hypomania, psychosis, or severe anxiety (8). Additional stressors include 20 to 25 hours per week of work at McDonald’s while carrying 12 semester credits, a substantial tuition bill that comes due very soon, and a growing sense that she needs to move again because she cannot tolerate the increased closeness with her boyfriend (9). *Parenthetic numbers 1 through 9 mark the essential components of the history of present illness that are listed in the text.

BOX 3.7

TRANSITIONING TO THE MSE

Therapist: You mentioned a short while ago that you’re having trouble with your memory, so let’s see exactly what that difficulty is. Can you tell me today’s date?

Therapist: You say that you cannot concentrate. Let’s take a closer look at that. I’m going to give you three things to remember and then ask you in a few minutes to recall them: a red ball, 37 Elm Street, and a clock radio. Can you repeat them now?

All APPNs must learn to perform a comprehensive, formal MSE; and there is value in performing one even in the case of psychotherapy patients who present as cognitively intact. A formal MSE may elicit subtle abnormalities not readily apparent earlier in the assessment process. Although the volume of material to cover can seem daunting, much of the MSE is obtained during the general history-taking interview, requires no special questions or tests, and can be assessed through informal observation that begins the moment the therapist first encounters the patient. The key is to know what elements to look for and to be systematic in looking for them. When comfortable with a format for a complete MSE, the therapist can tactfully transition from informal observation to a direct, systematic examination of the patient’s cognitive status when a suitable opportunity presents itself (Box 3.7). General introductory questions followed by specific confirmatory questions are standard. Open-ended formats and general probes are sensitive screening strategies (e.g., “Have you felt like odd things are happening that you cannot explain?”). More precise confirmatory questions provide specificity (e.g., “Are your thoughts read by other people?”) (Jacob, 2003).

Sometimes, opportunities for a smooth transition to the formal MSE do not present themselves. Occasionally, a complete examination is impossible, such as with a very agitated or uncommunicative patient; and sometimes, it can seem insulting to ask apparently high-functioning people what today’s date is or whether they can remember a “red ball” and “37 Elm Street” for a period of 5 minutes. Nevertheless, when a clinician inadvertently fails to perform a formal MSE or makes a deliberate decision not to perform one in a patient who seems unimpaired, the therapist risks missing important information that may emerge only through a direct, systematic examination of a patient’s cognitive function. Until it becomes second nature, APPNs should choose a format, memorize it, and perform the MSE the same way each time (Morrison, 2008).

Box 3.8 presents one way of organizing the data from an MSE. It summarizes the results of Beth’s formal MSE as it might appear in a formal diagnostic report or on a clinical assessment summary. However, therapists must develop their own systematic method of obtaining, organizing, and recording the MSE, so the process becomes second nature. Although Beth’s MSE result is essentially within normal limits, there is value in recording specific examples of mental status abnormalities.

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Timeframes and Closing Moves

The patient’s unique circumstances determine how much time the therapist spends on each major section of the psychiatric history. In Beth’s case, the therapist will spend much of her time gathering data for the HPI and the family, developmental, and social histories. Very little time is needed for the psychiatric history, medical history, substance use history, and MSE because the patient is young, physically healthy, cognitively intact, and has no history of prior psychiatric treatment or significant substance use. Although the needs of the patient determine which content regions are most appropriate for deeper exploration, and taking into consideration time constraints, usually 50 to 60 minutes for an initial assessment, Morrison (2008) and Shea (1998) provide guidance on how to carve up the allotted time when the assessment data must be gathered in one session. Morrison (2008) suggests the following:

BOX 3.8

DOCUMENTING THE MSE

Beth is an attractive, subdued, casually and appropriately dressed, 20-year-old single, White female who appears to be her stated age. She is quite distressed and seems to be fighting back tears. However, she makes good eye contact and readily engages with the examiner. Her speech is fluent, soft, and quavering; her affect ranges from flat to sad and angry. Her mood is dysthymic and congruent with her affect. Her movements are graceful and without abnormality. She is alert, is fully oriented, and evidences no problems with attention, concentration, or memory. She can recall 6/6 objects at 0 and 5 minutes, can do serial sevens without difficulty, repeats five digits forward and backward, can abstract proverbs, and has an adequate fund of general knowledge. Her thought processes are logical, linear, and goal directed. Prominent themes in her thought content include her smoldering resentment toward her parents, particularly her mother, and her feelings of being overwhelmed by her schoolwork. There is no evidence of thought disorganization. She denies current, active suicide or homicide ideation, as well as all signs and symptoms of psychosis. Superficially, her judgment is intact. She appears to be of above-average intelligence; however, her problem-solving abilities are transiently overwhelmed. She is excessively worried about “not being ahead of the game,” as she customarily would be.

15%: Chief complaint and free speech

30%: HPI; pursuit of information relevant to the differential diagnosis; histories of suicide, violence, or substance use

15%: Medical history; review of systems; family history

25%: Personal (developmental and social) history

10%: MSE

5%: Discussion of the diagnosis and treatment plan; plan for next visit

Shea (1998) suggests at least 7 to 8 minutes for the scouting period, which is what Morrison (2008) calls free speech and what is essentially the time it takes for the patient to narrate his or her story. By the end of the first 30 minutes of the initial assessment, the therapist should be nearing the completion of the content regions that seem most pertinent for that patient. Often, during the third 15-minute period, the family history, medical history, social history, and the formal MSE are completed (Shea, 1998). In Beth’s case, exploration of the family, developmental, and social issues would have been explored in depth earlier, because they are uniquely important content regions for her and might have extended into the third 15-minute assessment period.

In any case, Shea (1998) recommends that the therapist monitor, at least every 5 to 10 minutes, the progress of his or her data gathering and adjust the pace as necessary. It is probably a good idea to check with the patient by asking, “Is this okay for you?” During the last 15 minutes of the assessment period, regional content explorations of the major sections of the psychiatric history are completed; final points of clarification are pursued; and termination occurs. Time can get away from even experienced psychotherapists, especially

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when a patient is particularly distressed, verbose, or disorganized. However, whenever possible, the last 5 to 10 minutes of the assessment period should be devoted to discussing the diagnosis, treatment recommendations, and follow-up plan; answering whatever questions the patient may have about those findings; processing the patient’s assessment experience; paving the way for the next visit; and in doing all that, continuing to build the strong therapeutic alliance on which a good psychotherapy outcome depends. Box 3.9 illustrates the closing minutes of Beth’s initial clinical assessment.

BOX 3.9

ENDING THE CLINICAL ASSESSMENT

Therapist: [Summarizes diagnostic impression and treatment recommendations.] So that’s what I’m thinking right now. What are your thoughts?

Patient: What happens if the medication doesn’t help?

Therapist: We have lots of options, including trying a different medication, but it is important to remember that medication is only one tool at our disposal. Even when it works, it doesn’t solve relationship problems, although it can give you more energy to deal with them. That’s why psychotherapy is so important. Do you have thoughts about that?

Patient: Not really, except … [long pause; therapist waits] I don’t really like talking about my family. It leaves me with a bad feeling.

Therapist: Yes, I have a pretty clear sense of how difficult that was for you. Is there anything I could have done differently to make that easier for you?

Patient: No, I don’t think so.

Therapist: Tell me more about what this [assessment] experience has been like for you?

Patient: Actually, it wasn’t as bad as I was thinking it would be. In a way, I feel relieved. I’m willing to try anything.

Therapist: I can hear how distressed you’ve been. On the other hand, that’s a very positive attitude. I think there is every reason to believe you can feel significantly better very soon. And if not, we will work together to figure out why. How does that sound?

Patient: Good.Sounds good.

Therapist: Will this time next week work for you? [details of follow-up are negotiated]

Assessing Ego Functioning

The assessment of ego functioning from the perspective of ego strength, as opposed to ego deficit, is a valuable skill for nurse psychotherapists. The identification and assessment of ego strength help the therapist locate a patient on a developmental continuum, suggest a place to join with the patient to begin the therapeutic work, provide data to develop therapeutic goals, and create a valid construct for psychotherapy outcome measurement (Bjorklund, 2000; Burns, 1991). The person who gains ego strength as a result of his or her work with a therapist has made noteworthy therapeutic progress. Broadly defined, ego strength is the capacity for effective personal functioning (Burns, 1991). It encompasses specific capacities such as adaptability, resourcefulness, self-efficacy, self-esteem, interpersonal effectiveness, life satisfaction, and the many other mental health indicators succinctly encapsulated in Freud’s (1961) well-known phrase “to love and to work.” Like the solid foundation of a well-built house, ego strength supports the individual in the pursuit of life goals, dreams, and ambitions, especially during times of trouble. It ensures coping abilities, provides an individual with a sense of identity, can be recognized during initial assessment and throughout therapy, and increases as patients grow in maturity (Bjorklund, 2000). To the degree each ego function can be identified and assessed in the clinical situation, ego strength can be acknowledged, rated, reinforced, supported, built on, or “loaned” to some degree to lower-functioning patients by their relatively higher-functioning therapists in the process of identifying with the therapist’s own ego strength (Bjorklund, 2000).

TABLE 3.2 Ego Functions for Assessment Reality Testing Differentiating Inner From Outer Stimuli Judgment Aware of appropriateness and likely consequences of intended behavior

Sense of reality of the world and of the self Experiences external events as real; differentiates self from others

Affect and impulse control Maintains self-control; can tolerate intense affect and delay of gratification

Interpersonal functioning Sustains relationships over time despite separations or hostility

Thought processes Attention, concentration, memory, language, and other cognitive processes are intact; thinking is realistic and logical

Adaptive regression in the service of the ego Relaxation of ego controls, allowing creative perceptual or conceptual integrations to increase adaptive potential

Defensive functioning Defenses satisfactorily prevent anxiety, depression, and other unpleasant affects

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Stimulus barrier Aware of sensory stimuli without stimulus overload

Autonomous functioning Cognitive and motor functions (i.e., primary autonomy) and routine behavior (i.e., secondary autonomy) are free from disturbance

Synthetic-integrative functioning Integrates contradictory attitudes, values, affects, behavior, and self-representations

Mastery competence Performance consistent with existing capacity Object constancy Ability to provide for oneself, caretaking and soothing in the absence of the caretaker Adapted from Bellak (1989).

Identification occurs through the ongoing corrective emotional experience that constitutes therapy and the therapist’s repetitive modeling of the kinds of coping behaviors indicative of ego strength. Table 3.2 identifies 12 ego functions and their definitions (Bellak, 1989). The list can be used as an assessment outline for the purpose of identifying patient strengths, or it can serve as the basis for self-reported or observer-rated ego strength assessment scales to measure more concretely a patient’s emerging ego strength. Table 3.3 provides an example of an observer-rated ego strength assessment scale constructed in everyday language. The assessment items in Table 3.3 suggest specific questions the therapist may ask to elicit information about the ego functions outlined in Table 3.2 and Box 3.10.

The assessment of ego functioning yields important information about a patient’s sense of self and the degree to which he or she has consolidated a core identity. Where ego strength is lacking with respect to the ego functions identified in Table 3.2—particularly interpersonal functioning, defensive functioning, synthetic- integrative functioning, affect regulation, and sense of reality of the world and the self-identity diffusion can be discerned in the clinical interview, because there is a close connection between ego strength and identity (Bjorklund, 2000). The features of identity diffusion include markedly contradictory personality traits, temporal discontinuity in the self-experience, feelings of emptiness, gender dysphoria, and subtle body-image disturbances (Akhtar, 1995; Bjorklund, 2000). Even though not all these features can be elicited and explored to an equal degree through formal questioning, Akhtar (1995) believes it is almost always helpful to ask the individual to describe himself or herself. In the resulting description, “one should look for consistency versus contradiction, clarity versus confusion, solidity versus emptiness, well-developed and comfortably experienced masculinity or femininity versus gender confusion, and a sense of inner morality and ethnicity versus the lack of any historical or communal anchor” (p. 103). Box 3.11 provides an illustration in Beth’s case, prompting the therapist to flag the possibility of identity diffusion.

TABLE 3.3 Observer-Rated Ego Function Assessment Tool* Assessment Item Ego Function

Always (1) Almost Always (2) Usually (3) Sometimes (4) Hardly Ever (5) Never (6)

1. When dealing with strong feelings, has trouble with getting too upset or Regulation and control of affects and impulses losing control with words or actions

2. Explains problems as being caused almost entirely by others Defensive functioning; interpersonal functioning

3. Has trouble sitting back and looking at own behavior in a realistic way Defensive functioning; interpersonal functioning

4. Believes he or she is basically a good person, worth caring about, Synthetic-integrative functioning but with some problems

5. Seems to feel good or bad about self, depending mostly on how others Affect regulation and control of affect; synthetic-integrative are feeling about him or her functioning

6. Seems able to recognize how he or she is feeling Regulation and control of affect; defensive functioning

7. Seems able to express his or her feelings in an appropriate manner Regulation and control of affect and impulses

8. Seems really weird, bizarre, or out of touch with reality Reality testing; sense of reality of the world and of the self; thought processes

9. Able to look at self fairly realistically in terms of good and bad qualities Sense of reality of the world and of the self; synthetic-integrative functioning

10. Explains his or her problems by means of hallucinations, false beliefs, control by supernatural power

Reality testing; sense of reality of the world and of the self; thought processes

11. Seems as if he or she does not notice other people exist Interpersonal functioning

12. Seems afraid of being close to others Interpersonal functioning

13. Tends to see others as having both good and bad qualities Synthetic-integrative functioning

14. Seems to need others to lean on Interpersonal functioning

15. Can structure his or her own time and enjoy it Autonomous functioning

16.

Tends to lump people together and see them as much the same Interpersonal functioning

17. When left alone, has a hard time taking care of himself or herself Autonomous functioning

18. Seems to perform up to his or her capabilities Mastery competence

19. Seems basically to trust other people Interpersonal functioning

20. Seems to use people to get things he or she needs Interpersonal functioning

21. Sees his or her problems as resulting from being a bad person Regulation of affect; synthetic-integrative functioning

22. Seems able to recognize and respond to the feelings of others in an appropriate manner Regulation and control of affect and impulses

23. Is the type of person others want to be friends with Interpersonal functioning 24. Recovers from significant emotional upset relatively quickly with previous capacities intact or

improved Adaptive regression in the service of the ego

*Not a validated tool.

Adapted from Tulloch (1984).

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SAMPLE QUESTIONS TO ASSESS EGO FUNCTIONING

How do you deal with strong feelings? (1)* How would you describe yourself? (9) What kind of person is your mother? (13) Describe your most important relationships. (16) How do you think others view you? (23) What do you think is the cause of your problems? (2) What part do you play in these difficulties? (3) Tell me about your hobbies and interests. (18) How do you deal with downtime? (15) What is it like for you to be alone? (17)

*Parenthetic numbers refer to the assessment items in Table 3.3.

BOX 3.11

ASSESSING IDENTITY DIFFUSION

Therapist: What sort of person are you?

Patient: I don’t know. [long pause] I don’t feel like I know who I am.

Therapist: How would you describe yourself?

Patient: It’s funny … I hate being alone, but I’m not really very social. I keep to myself a lot. I want to be around people, but they really irritate me most of the time. I don’t think I’m an irritable person. Not really. [long pause; therapist waits] Sometimes, I hate myself. I’m really bright, but I don’t seem to accomplish much. I have friends, but I don’t fit in anywhere. It seems like it doesn’t take much for me to fall apart.

Therapist: You look troubled.

Patient: [Silence]

Therapist: How would other people describe you?

Patient: Some people think I’m really sweet. My mother thinks I’m very arrogant and

conceited. I don’t know. A lot of people tell me I look angry all the time, but I don’t feel that way.

Goldstein (1995) provides an alternative mode of assessing ego functioning. She discusses the nature of ego-oriented assessment as a process of data collection focused over several interviews on a patient’s current and past functioning and on his or her inner capacities and external circumstances. The following five questions (Bjorklund, 2000, p. 126) are an important guide to the therapist in the overall assessment of ego strength:

1. To what extent is the patient’s problem a function of stressors imposed by his or her current life roles or developmental tasks?

2. To what extent is the patient’s problem a function of situational stress or of a traumatic event? 3. To what extent is the patient’s problem a function of impairments in his or her ego capacities or of

developmental difficulties or dynamics? 4. To what extent is the patient’s problem a function of the lack of environmental resources or supports or of

a lack of fit between his or her inner capacities and external circumstances? 5. What inner capacities and environmental resources does the patient have that can be mobilized to improve

his or her functioning?

These questions are important, but questions 1 through 4 may be difficult to ascertain, especially if the person has had frequent or early trauma of which they may not even be aware. For question 5, collaboration with the patient about available resources may be helpful in the initial assessment. Although the assessment of ego functioning is not essential to all forms of giving help, it can assist a psychotherapist in determining whether initial interventions should be directed toward enhancing resources, including nurturing,

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maintaining, enhancing, or modifying inner capacities; mobilizing, improving, or changing environmental conditions; or improving the fit between inner capacities and external circumstances (Bjorklund, 2000; Goldstein, 1995).

When a patient is overwhelmed by current stressors but shows good past ego functioning and has some environmental supports, the practitioner may use a brief, supportive, and cognitive approach aimed at stress reduction and more effective problem solving. In contrast, if not too severely and persistently ill, a patient with limited ego strength and developmental deficits that interfere with his or her ability to cope with intimate relationships or current life roles may need interventions targeted at improving ego function (Bjorklund, 2000; Goldstein, 1995), including perhaps deeper exploration, longer psychotherapy, or more frequent psychotherapy sessions.

In Beth’s case, given what turned out to be a significant lack of object constancy (see Table 3.2), dysregulation of affect and impulse control, an inability to tolerate the closeness of her most significant interpersonal relationships, and an inability to integrate contradictory feelings about those significant others— and about many other things, such as continuing her college career—she and her therapist will need to nurture, maintain, and modify some important inner capacities. Given the severity of current environmental stressors, such as the move away from home, withdrawal of her parents’ financial support, her mother’s hostility and intrusive neediness, significant debt, an unsatisfactory living situation, a stressful job, and a change in college majors, she will also need the therapist’s support to mobilize, improve, or change environmental conditions.

Assessing Affective Development

When affective development has proceeded optimally, people have capacities for affect awareness, affect tolerance, and affect modulation (i.e., affect regulation and control). They are aware of their feelings and can identify and describe those feelings, express those feelings in socially appropriate ways, tolerate unpleasant feelings in themselves and others, and find ways to soothe themselves until unpleasant feelings pass. They can maintain their self-esteem and their generally positive outlook and feelings about others even when angry or hurt. They can contain the most intense feelings without losing control and can maintain their equilibrium and their boundaries in the midst of others’ intense emotional expression. They can experience a full range of emotions and have developed an appropriate capacity for empathy, caring, and concern without falling prey to affect contagion (i.e., feeling exactly what another feels). They can orient to internal experience when necessary or desirable and have a capacity for fantasy and imagination.

Significantly, persons whose affective development has proceeded optimally can also realistically interpret the social meaning of emotional experience; it is an individual’s interpretation of an unpleasant affect that leads to the experience of a specific negative emotion and to the intensity of the emotional arousal (Bradley, 2000). In other words, experience and cognition allow the individual to elaborate positive or negative affect throughout the gamut of emotional experience (Bradley, 2000). Compared with those whose affective development is impaired, persons whose affective development is optimal can tap into their inner worlds and use experience and cognition to interpret diffuse affective arousal as meaningful emotional experience—as both significant and less than catastrophic. They are simultaneously more affectively aware, less emotionally reactive, and able to achieve therapeutic distance from emotions if necessary. Their interpreted emotional experience is construed as manageable, and they have a repertoire of strategies to cope with it. These are the capacities the therapist examines when assessing a patient’s affective development.

Much psychopathology ensues as a consequence of impaired affective development (Bradley, 2000). Conversely, much good therapeutic work has been done when a patient has grown in the capacity to identify, tolerate, regulate, and appropriately express affective experience. All types of psychotherapy promote affect regulation. Some therapies do this with the acquisition of specific behavioral skills to reduce the intensity of affect, such as breathing or distracting techniques to cope with anxiety. Others emphasize adaptive coping strategies, such as mindfulness, positive self-talk, or the correction of cognitive distortions to mitigate distress. Others involve re-experiencing and reprocessing of painful affects or repeated exposure to previously avoided situations so that desensitization and mastery can occur. Ultimately, they all work to modify the internal mental representations or cognitive–emotional schemas that produce automatic, maladaptive emotional responses (Bradley, 2000).

Affective regulation and control is an important ego strength (see Tables 3.2 and 3.3), and all effective therapy promotes it. However, some individuals described as alexithymic have such extreme difficulty

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experiencing, describing, and seeing connections between feelings and symptoms that they fare poorly in and frequently drop out of expressive psychotherapies, that is, those that discuss and examine affects (Bradley, 2000). These individuals are notably lacking in psychological mindedness, the awareness of internal experience and its relationship to external situations, events, or behaviors that are very important for successful psychotherapy outcomes (Bradley, 2000; Taylor, 1995). Defined as the inability to describe or be aware of emotions or mood (Sadock et al., 2009), alexithymia is a multifaceted construct that encompasses several different factors, including difficulty identifying subjective emotional feelings and distinguishing between feelings and the bodily sensations that constitute emotional arousal; difficulty describing feelings to other people; an impoverished fantasy life; and an externally oriented cognitive style (Taylor et al., 2003).

The most widely used measure of the alexithymia construct is the Toronto Alexithymia Scale (TAS-20) (Bagby et al., 1994a, 1994b). The TAS-20 is a self-report scale with a three-factor structure that corresponds to the multifaceted construct described previously. Factor 1 assesses the ability to identify feelings and to distinguish them from the somatic sensations that accompany emotional arousal (i.e., “I am often confused about what emotion I am feeling” and “I have feelings that I can’t quite identify”). Factor 2 assesses the ability to describe feelings to other people (i.e., “I am able to describe my feelings easily,” and “It is difficult for me to reveal my innermost feelings, even to close friends”). Factor 3 assesses externally oriented thinking and, indirectly, reduced fantasy and imaginable activity (i.e., “I prefer to analyze problems rather than just describe them” and “Looking for hidden meanings in movies or plays distracts from their enjoyment”) (Parker et al., 2003; Taylor et al., 2003). A therapist can administer the TAS-20 at the outset of therapy as part of an overall diagnostic evaluation or to assess a patient’s psychological mindedness, suitability for an expressive psychotherapy, or capacity for affect awareness and tolerance. Even if not administered directly, the TAS-20 and the observer-rated ego function assessment tool in Table 3.3 (Box 3.12) nevertheless suggest questions the therapist can ask to assess affective development (i.e., capacities for affect awareness, tolerance, modulation, regulation, and control) in the context of an initial clinical assessment.

BOX 3.12

SAMPLE QUESTIONS TO ASSESS AFFECTIVE DEVELOPMENT

Are you generally able to recognize how you feel at any given time? (6)* How would you describe your feelings right now? (6, 7) Can you describe how you felt when that happened? (6, 7) What is your internal experience like? (2) What do you suppose prompts/are the feelings that prompt your mother to call during your study time each evening? (22) What do you think your mother was feeling when you hung up on her? (22) How do you deal with especially strong feelings? (1) How do you think others feel about you? (23) What happens when you are upset? (1, 7) How do you calm yourself when you are upset? (1, 7) How long does it take to calm down? (24) How do you feel about yourself when you are angry/frustrated/upset? (4, 9) Are you still able to see yourself as a good person when she gets angry at you? (5)

*Parenthetic numbers refer to the assessment items in Table 3.3.

Assessing Interpersonal Relationships

Identification of a patient’s interpersonal strengths is a necessary first step in affirming and supporting them. It is also important in keeping a balanced view of the potential for adaptation, growth, and successful psychotherapeutic outcome in a patient with other areas of less optimal ego functioning. It is possible to assess the depth of a patient’s interpersonal relationships—one indicator of ego strength—by reviewing the patient’s past and present interpersonal environment to elicit detailed descriptions of significant others, including mothers, fathers, spouses, friends, and pets (Akhtar, 1995; Bjorklund, 2000; Horowitz et al., 1993; Shea, 1998). The presence of the following three features in the patient’s descriptions of significant others suggests

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some impairment in interpersonal functioning (Akhtar, 1995; Bjorklund, 2000):

1. An insistent emphasis on the patient’s feelings and views about the person described, rather than on that person’s independent attributes (Box 3.13)

2. An extreme and affectively charged verdict, rather than a balanced account that permits mixed feelings toward the person described (Box 3.14)

3. An inability to see independent motivations in others (Box 3.15)

BOX 3.13

INSISTENT EMPHASIS ON OWN FEELINGS

Therapist: Can you tell me what sort of person your mother is?

Patient: I hate her. I think she’s a witch. It’s always all about her, not me. I’ve tried and tried to get along with her, but it’s impossible. If she didn’t call me every night, I wouldn’t even think about her. [As opposed to this: She’s prickly. She’s bright and beautiful, but she makes a lot of demands on people and likes to be the center of attention.]

BOX 3.14

EXTREME ACCOUNTS OF OTHERS

Therapist: How would you describe your mother?

Patient: She’s a horrible mother. She is completely selfish. She has never done anything for anybody her entire life. She has never once told me she’s proud of me or that she wants me to do well in school. [As opposed to this: She tries to be a decent mother. I imagine she loves me and my brother in her own way, but she competes with me. It’s like she’s jealous of me. When I changed my major to Business Administration, she enrolled in Denton (Business University). What does that tell you? I guess she’s got some problems of her own to deal with.]

As conveyed in the alternate responses detailed earlier, descriptions of important relationships that evidence the ability to see significant others as separate individuals, with independent motivations and reasons of their own, suggest significant ego strength in the area of interpersonal relationships. The same is true for descriptions of significant others that show the patient has the capacity to experience others ambivalently—as whole people with good and bad qualities, who can simultaneously gratify and care for others, as well as frustrate and disappoint them. More ominous are descriptions that indicate a patient functions in relationships at the level of need gratification (i.e., people have value only to the degree they can meet his or her needs); descriptions that indicate a patient cannot clearly differentiate people or differentiate self from others (i.e., people are always “just like me” or “pretty much all the same”) or worse, descriptions that indicate a patient functions more or less autistically (i.e., other people seem not to exist or are experienced as aversive stimuli). Table 3.3 includes several assessment items that indirectly measure interpersonal functioning and that suggest questions the therapist can ask to explore the quality of a patient’s interpersonal relationships (Box 3.16).

BOX 3.15

INABILITY TO SEE INDEPENDENT MOTIVATIONS

Therapist: What do you suppose prompts your mother to call you and interrupt your studying every night?

Patient: She wants me to fail. It makes her look good. Sometimes, I think she just likes upsetting me. She gets something out of it. I think she hates me as much as I hate her. [As opposed to this: I’m sure she has her reasons. I just can’t figure out what they are. Like I said before, she’s got problems of her own to deal with. Sometimes, I think she is having as hard a time with my moving away from home as I am. Other times, I think she really is jealous of my success. It’s painful to realize, but I think she has mixed feelings about me, and I certainly have mixed feelings about her.]

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115BOX 3.16

SAMPLE QUESTIONS TO ASSESS INTERPERSONAL FUNCTIONING

What is your part/their part in that relationship problem? (2, 3, 21)* Can you trust people? (19) What is it like to have to trust or depend on someone else? (12, 19) What type of friend to others are you? (23) What makes a relationship a close one? (20) Do you have any close relationships? (12) How do you do with intimacy in relationships? (12) What do relationships mean to you? (20) What happens if there is no one around to lean on? (14, 17) How would you feel about the person if he or she could no longer provide or could no longer meet your needs for_? (20)

*Parenthetic numbers refer to the assessment items in Table 3.3.

The importance of understanding the nature of a patient’s interpersonal problems and the quality of his or her interpersonal functioning cannot be overstated. Interpersonal problems are among the most common complaints reported in clinical interviews (Horowitz et al., 1993). Interpersonal relationships often are the focus of psychotherapy, and the work of psychotherapy occurs in an interpersonal environment through relational processes. The therapist can learn much about the patient’s interpersonal functioning in the context of the therapeutic relationship (i.e., through the manner of the patient’s relating to the therapist and through the therapist’s reactions to and feelings about the patient). From the way the patient relates to the therapist, particularly in the anxiety-provoking situation of crossing the boundary from everyday life to life in the consulting room, the therapist can see firsthand the developmental phase that predominates in the patient’s personality and interpersonal functioning (Scharff & Scharff, 2005). Ultimately, this firsthand experience may provide the best assessment data.

If, however, the therapist desires a more structured approach to assessing interpersonal functioning, perhaps for purposes of measuring psychotherapy outcomes, he or she can administer an instrument such as the Inventory of Interpersonal Problems (IIP) (Horowitz et al., 1988), which is a self-report inventory that has been used to identity dysfunctional patterns in interpersonal interactions. It describes different types of interpersonal problems and has been used to measure the level of distress associated with them before, during, and after psychotherapy (Horowitz et al., 1993). Each of its eight subscales describes a different interpersonal style (Box 3.17). This instrument can also be useful in clinic settings where the clinician completing the initial assessment is different from the eventual therapist. Although the IIP is not included in this chapter, Table 3.4 provides a fragment of it.

BOX 3.17

INTERPERSONAL STYLES

Domineering I try to change other people too much.

Intrusive It is hard for me to stay out of other people’s business.

Overly nurturing I put other people’s needs before my own too much.

Exploitable I let other people take advantage of me too much.

Nonassertive It is hard for me to be assertive with another person.

Socially avoidant It is hard for me to socialize with other people.

Cold I keep other people at a distance too much.

Vindictive I fight with other people too much.

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TABLE 3.4 A Fragment of the Inventory of Interpersonal Problems

ASSESSING ADULT ATTACHMENT

The quality of the client’s earliest interpersonal relationships with caregivers may influence the adult personality. In particular, attachment insecurity in infancy and early childhood has been shown to predict various forms of psychopathology in adolescence and adulthood (Shmueli-Goetz, Target, Fonagy, & Datta, 2008). When the therapist suspects that attachment issues may be complicating the client’s interpersonal functioning, he or she may want to assess the client’s attachment system in a more structured way (Box 3.18). Provided he or she has obtained training in administration procedure, the therapist may choose to utilize the Adult Attachment Interview (AAI) for the assessment. Numerous studies have established the reliability and validity of the AAI (Shmueli-Goetz et al., 2008). Although the AAI protocol is readily available online (see Box 3.19), the scoring manual is available only in conjunction with training courses; and the published protocol, too lengthy to append in full, is not considered a substitute for AAI training (Main, n.d.; Main & Goldwyn, 1998). In general, the AAI focuses on the adult client’s childhood relationships with parents, thus facilitating an overall assessment of the quality of the attachment to parents, starting with childhood experiences that may have affected the client’s adult personality, and moving through adolescence to present- day, adult experiences.

More specifically, in a series of 20 assessment questions, with suggestions for follow-up probes, the AAI orients the interviewer to the client’s family constellation. It encourages the client to remember and describe his or her earliest memories of relationships with parents and asks for descriptors of each parent that reflect the childhood relationships with them (Main, n.d.). The interview protocol covers areas with attachment implications, including the client’s childhood (and adult) experiences of separation, the person(s) to whom the client as a child felt most close, what the client did as a child when upset, how he or she coped with feelings of loss and/or rejection, whether or not the client as a child ever felt threatened by parents, and how the client understood and responded to such threats. The AAI protocol also explores other potentially traumatic experiences in both childhood and adulthood. It assesses the client’s experience of the impact of these events and explores the client’s wishes and hopes for his or her own children as well as the client’s present-day, adult relationships with living parents (Main, n.d.).

BOX 3.18

SAMPLE QUESTIONS TO ASSESS ATTACHMENT

How would you describe your relationship with your parents? As a child? Now? What words would you use to describe your mother/father? As a child? Now? With whom did you/do you now feel the closest?

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What did you/do you now do when you feel upset about something? Did your parents ever threaten or hurt you, even jokingly or to discipline you? Anyone else? What did you/do you now do with feelings of loss? Rejection? Threat? Were you ever separated from your parents as a child? Suffered a loss? How do you cope with losses/separations from significant others now? How do you think your overall experiences with your parents have affected your adult personality? What do you wish for your own children?

BOX 3.19

SCREENING/ASSESSMENT TOOLS

Toronto Alexithymia Scale (TAS-20)* Beck Depression Inventory (BDI) (copyright Psychological Corporation) Dissociative Experiences Scale (DES) (see Appendix 3.3) Impact of Events Scale (IES) (see Appendix 3.4); Zung Self-Rating Depression Scale (ZSRDS) (see Appendix 3.5) Geriatric Depression Scale (GDS) (see Appendix 3.6) Patient Health Questionnaire (PHQ-9) (see Appendix 3.7) Young Mania Rating Scale (YMRS) (see Appendix 3.8); Hamilton Anxiety Rating Scale (HAM-A) (see Appendix 3.9) Generalized Anxiety Disorder Questionnaire (GAD-7) (see Appendix 3.10) Yale-Brown Obsessive–Compulsive Scale (Y-BOCS) (see Appendix 3.11) Mini Mental State Examination (MMSE) (http://www.dhs.state.or.us/spd/tools/cm/aps/assessment/mini_mental.pdf) Global Assessment of Functioning (GAF) Quality of Life Scale (QOL) (see Appendix 3.12) CAGE Questionnaire (see Appendix 3.13) MAST Questionnaire (see Appendix 3.14) Adult Attachment Interview (AAI) (www.psychology.sunysb.edu/attachment/measures/content/aai_interview.pdf) Child Attachment Interview (CAI) (see Appendix 3.15) Strange Situation Procedure (SSP) (www.psychology.sunysb.edu/attachment/measures/content/ss_scoring.pdf) Adverse Childhood Experiences (ACE) Scale (see Appendix 3.16)

*The TAS-20 can be purchased directly from its developer, Dr. Graham J. Taylor, Department of Psychiatry, Mount Sinai Hospital, Toronto, Ontario, Canada.

ASSESSING CHILD ATTACHMENT

The Child Attachment Interview (CAI) (see Appendix 3.15) is similar in content to the AAI but focuses on the child-as-client’s current attachment relationships rather than the adult client’s memory of relationships in childhood (Shmueli-Goetz et al., 2008). Like the AAI, the CAI protocol elicits information about the family constellation but focuses on current and/or recent attachment-related events, including times of family conflict, distress, illness, hurt, separation, and loss (Target, n.d.). It includes interview items that elicit self- descriptions and caretaker descriptions, which may illuminate the child’s self-representations and representations of his or her primary caregivers as well as potentiate exploration of meaningful links between self-descriptions and attachment representations (Target, n.d.). Because the CAI is a narrative-based assessment that relies on a level of linguistic competence (i.e., verbal ability), it requires a developmentally appropriate interviewer stance with age-specific cues, or follow-up probes to help children remember and express attachment experiences (Shmueli-Goetz et al., 2008). Throughout the CAI, such probes are used to assist the child to tell his or her story. Verbal and nonverbal behavior is coded and scored. Although the CAI is a systematic, valid, and reliable assessment of the school-age child’s experience of parental availability (i.e., parent–child attachment), it cannot replace parental and teacher reports, nor is it appropriate for infants and toddlers for whom attachment is defined not by parental availability but rather by behavioral strategies to maintain proximity to attachment figures (Shmueli-Goetz et al., 2008).

For attachment assessment during very early childhood, a separation–reunion procedure such as the Strange Situation Procedure (SSP) (Ainsworth, Blehar, Waters, & Wall, 1978) may be appropriate (Box 3.19). The SSP is conducted in an unfamiliar, or strange environment by an unfamiliar person (a “stranger”) over a series of eight, brief, separation–reunion episodes that are designed to generate just enough stress to

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http://www.dhs.state.or.us/spd/tools/cm/aps/assessment/mini_mental.pdf

http://www.psychology.sunysb.edu/attachment/measures/content/aai_interview.pdf

http://www.psychology.sunysb.edu/attachment/measures/content/ss_scoring.pdf

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activate the infant’s or toddler’s behavioral attachment system. Separations are designed to be stressful but sufficiently manageable so that reunions become a reflection of the quality of the child–parent relationship (Ainsworth et al., 1978). Typically, the strange situation is videotaped and coded based on the child’s observed behaviors. Categories of observed behavior include proximity- and contact-seeking behavior, contact- maintaining behavior, resistant behavior, and avoidant behavior. Based on SSP scoring, attachment security is classified as secure, insecure avoidant, insecure resistant, or insecure disorganized. Scoring methods for the SSP are detailed and include considerable commentary to facilitate valid and reliable scoring; thus, training in coding the SSP is advised (Ainsworth et al., 1978).

Assessing Belief Systems

The disorders for which patients seek out psychotherapists lie on the boundary between the natural world and the constructed social world (Wakefield, 1992). Whether a patient construes a particular symptom as harmful or a particular constellation of symptoms as a disorder or an illness for which help is required has a lot to do with his or her values and beliefs. A disorder exists when a person’s internal psychological or physiologic mechanisms fail to perform their functions as designed by nature but only if this impinges on the person’s sense of well-being as defined by social values and meanings (Wakefield, 1992). Ultimately, the whole point of diagnosing a psychiatric disorder is to help a patient regain the ability to function effectively in social, occupational, and family roles. Most of the behaviors and feelings categorized in the Diagnostic and Statistical Manual of Mental Disorders (DSM) as symptoms of mental illness can be construed as what many people do or feel at various times without having a psychiatric disorder or suffering from a mental illness.

Belief systems, spiritual practices, religious affiliation, and other frameworks for meaning and purpose can have a profound impact on a person’s well-being, resilience, or ability to adaptively cope with adversity. An inventory of the person’s strengths is important to plan where to intervene in the treatment hierarchy (see Chapter 1). At other times, a patient’s symptoms may result from unrest in the person’s belief systems or from conflict in his or her religious, spiritual, philosophical, ethical, or existential frameworks (Shea, 1998). It is therefore crucial that a therapist assess a patient’s values, beliefs, and framework for meaning to identify problems and support important strengths. The information gleaned may suggest the utility of individual psychotherapy slanted toward existential concerns (Shea, 1998), or it may remind the therapist that patients sometimes find meaning and purpose in everyday, well-known processes such as caring for their families, engaging in community activity, or staying close to nature.

Although an understanding of the stages or processes of faith (Fowler, 1981) or spiritual development (Wink & Dillon, 2002) is not absolutely necessary to an understanding of how to assess belief systems (and is beyond the scope of this chapter), the therapist should consider that how people construct meaning in life is subject to developmental shifts (Fowler, 1981) and is the product of maturational processes that continue over the course of adult life (Wink & Dillon, 2002). Spiritual development is linked to other processes of development. It requires capacities for abstraction, ambiguity, and ambivalence (i.e., the ability to integrate paradox and disparate notions of self, other, and the world), which are some of the same capacities that constitute ego strength as earlier described. It involves going beyond the linear and strictly logical modes of apprehending reality described by Piaget’s model of cognitive development to an integrated cognitive– emotional view of the world that embraces paradox and incorporates feelings and context, as well as logic and reason in making judgments about the nature, meaning, and purpose of self, other, and the world (Wink & Dillon, 2002). Changes in or consolidation of belief systems, meaning frameworks, and other processes of making sense of life’s meaning and purpose occur more frequently during periods of adversity and crisis than during times of stability (Stokes, 1990). Such changes are more salient for women and older adults (Wink & Dillon, 2002), both of whom tend to experience more stress than other social groups (Mirowsky & Ross, 1992, 1995). The therapist assessing the quality, salience, and influence of his or her patients’ belief systems should keep these findings in mind and use the energy existing in crisis to promote positive change.

Practically speaking, assessing the values and beliefs of patients is a standard part of taking a history (see Box 3.1). As a matter of course, the therapist should inquire about the patient’s belief systems and values, both social and moral, including values about work, money, play, children, parents, friends, sex, community concerns, and cultural issues (Sadock et al., 2009). Much of this information is gleaned in the process of obtaining a patient’s developmental, family, and social history. Specific assessment questions are illustrated in Box 3.20 and in Table 3.5, which is an adapted portion of the World Health Organization’s (WHO) Quality of Life–Spirituality, Religiousness, and Personal Beliefs (WHOQOL–SRPB) field-test instrument. The

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WHOQOL–SRPB has been developed from an extensive pilot test of 105 questions in 18 centers around the world. The resulting 32-item instrument represents the finalized version currently in use in field trials (WHO, 2002).

BOX 3.20

SAMPLE QUESTIONS TO ASSESS BELIEF SYSTEMS

What helps you cope with adversity? What gives you a sense of meaning and purpose in life? What matters most to you in life? What are your beliefs about health/illness/therapy/seeking help? To what extent do your spiritual/religious beliefs comfort you? What enables you to stay healthy/get better/find comfort/continue living? What do those spiritual/religious practices bring to your life?

TABLE 3.5 A Portion of the World Health Organization’s Spirituality, Religiousness, and Personal Beliefs Field-Test Instrument

Adapted from the World Health Organization (2002).

ASSESSING FUNCTIONAL STATUS

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For several important reasons, the APPN must be able to competently assess a client’s functional status and degree of functional impairment. First, for most psychiatric disorders to meet diagnostic criteria, the most commonly used diagnostic system (the DSM) requires that individuals meet a clinical significance criterion, that is, that symptoms result in either clinically significant distress or impairment in social, occupational, or other important areas of functioning (McQuaid et al., 2012). Second, improved functioning in one or more domains is often a goal of psychotherapy. Thus, the means and methods by which the APPN assesses functional status are important to outcomes evaluation, that is, the process of determining the extent to which psychotherapy has been effective in targeting symptoms and improving the client’s health status and/or quality of life. Third, measures of functional status are important to clients for various reasons, including that degree of functional impairment has implications for compensation and pension procedures as well as decisions around the extent to which a psychiatric disorder is judged to have a military service connection (McQuaid et al., 2012). Fourth, functional status is often a better indicator of service needs and treatment outcomes than diagnosis alone (McQuaid et al., 2012). Thus, the APPN must be prepared to perform and document diagnostic evaluations that include competent functional assessments across the relevant domains of functioning.

Although this chapter addresses the assessment of mental health functioning broadly, its scope does not include detailed discussion of the many types, domains, and processes of assessing functional status. In some cases, the APPN may recommend a more comprehensive assessment of functional status from an occupational therapist or disability specialist. However, a number of screening instruments and rating scales are available to assess, measure, document, or monitor functioning in social, occupational, psychological, interpersonal, and other domains (Table 3.6). One of the most common and better known measures of functioning, included in Table 3.6 but no longer required by the DSM-5 diagnostic system, is the Global Assessment of Functioning (GAF) (APA, 2000), which is a clinician-rated, global measure of illness severity. Scores range from 0 to 100, with a higher score indicating better functioning. A GAF score is typically based on a client’s worst functioning within occupational, social, or psychological domains. It combines psychiatric symptomatology and social–occupational functioning into a single score even though they are distinct constructs, and even though research has found that GAF scores are most significantly associated with symptom ratings rather than social or occupational functioning (McQuaid et al., 2012). Table 3.6 lists several alternatives to the GAF. In addition, as an alternative to the GAF, McQuaid et al. (2012) offer a detailed description of the Inventory of Psychosocial Functioning (IPF), which is a newly developed, 80-item, self-report measure designed to assess functional impairment experienced by veterans and active-duty service personnel across multiple domains.

TABLE 3.6 Commonly Used Clinical Rating Scales Scale Reference Quality of Life Scales

Quality of Life Enjoyment and Satisfaction Questionnaire Q-LES-Q Endicott et al. (1993)

Quality of Well-Being Scale (QWB) Kaplan and Anderson (1988)

Quality of Life in Depression Scale (QLDS) Hunt and McKenna (1992)

Medical Outcome Survey (MOS) Ware and Sherbourne (1992)

Mental Health Status and Functioning Scales

Clinical Global Impression (CGI) NIMH (1970)

Endicott Work Productivity Scale Endicott and Nee (1997)

Global Assessment of Functioning (GAF) APA, 2000: DSM-IV-TR

Sheehan Disability Scale Leon et al. (1992)

Social and Occupational Functioning Assessment Scale (SOFAS) APA, 2000: DSM-IV-TR

Work and Social Adjustment Scale Mundt et al. (2002)

Adverse Effects Scales

Abnormal Involuntary Movement Scale (AIMS) Guy (1976)

Simpson–Angus Extrapyramidal Symptom Rating Scale Simpson and Angus (1970)

Cognitive Disorders Scales

Delirium Rating Scale Revised—98 (DRS—R98) Trzepacz et al. (2001)

Mini-Mental State Examination (MMSE) Folstein et al. (1975)

Alcohol Use Disorders Scales

CAGE Questionnaire Ewing (1984)

Michigan Alcoholism Screening Test (MAST) Selzer (1971)

Mood Disorders Scales

Beck Depression Inventory, 2nd Revision (BDI-II) Beck et al. (1961)

Hamilton Depression Rating Scale (HAM-D) Hamilton (1960)

Inventory of Depressive Symptomatology (IDS) Rush et al. (1996)

Quick Inventory of Depressive Symptomatology (QIDS) Rush et al. (2003)

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Patient Health Questionnaire (PHQ-9) www.pfizer.com

Geriatric Depression Scale (GDS) Yesavage et al. (1983)

Montgomery–Asberg Depression Rating Scale (MADRS) Montgomery and Asberg (1979)

Zung Self-Rating Depression Scale (ZSRDS) Zung (1965)

Young Mania Rating Scale (YMRS) Young et al. (1978)

Anxiety Disorders Scales

Hamilton Anxiety Rating Scale (HAM-A) Hamilton (1959)

Yale-Brown Obsessive–Compulsive Scale (Y-BOCS) Goodman et al. (1989)

Psychotic Disorders Scales

Brief Psychiatric Rating Scale (BPRS) Overall and Gorham (1962)

Positive and Negative Symptom Scale (PANSS) Kay et al. (1987)

Aggression and Agitation Scale

Overt Aggression Scale—Modified (OAS-M) Coccaro et al. (1991)

Sources: APA (2006); Bresee et al. (2009).

GENOGRAMS

The family genogram is a useful tool for the assessment of individuals, couples, and families; and it should be a routine part of any comprehensive patient or family assessment (Glick et al., 2000). Encouraging or assigning a patient the task of drawing his or her family genogram is an effective assessment and intervention strategy at different points in the therapy. It can yield significant assessment data and lead to important, new patient understandings and insights as multigenerational patterns take shape and assume new meaning. In essence, the genogram is a graphic sketch of the patient and several generations of his or her family. Occupational and social roles, major life events, significant illnesses, and important dates, for example, births, deaths, marriages, and separations, are mapped. The quality and longevity of significant relationships are noted. The graphic presentation of family events and relationships facilitates the linkage of current issues, concerns, or circumstances to the multigenerational family’s structure and evolving patterns of relationship (Glick et al., 2000). The family genogram has several purposes:

1. Provides the identified patient, family, and therapist with a graphic structure to explore past and present difficulties

2. Provides the therapist with background information to put current patient difficulties in context 3. Uses the assessment process as an opportunity for patient intervention, for example, as the patient begins

to see patterns emerge (Glick et al., 2000)

In addition, based on genomics research findings, emerging standards of care for psychiatric assessment and treatment now include a more detailed family history or pedigree (genogram), assessment of environmental risk factors, genetic screening and testing if indicated, and application of individualized therapies based on assessment data (Pestka et al., 2010). While genetics is the examination of specific genes and their effects, genomics considers all the genes in a human genome and their interactions with each other, which has relevance for psychiatric practice along pathways of prevention, screening, diagnostics, prognostics, treatment selection, and monitoring of treatment effectiveness (Pestka et al., 2010). Nationally endorsed genomics competencies include the following nursing genomic assessments:

1. Gathering and/or clarifying family history information 2. Updating or constructing a family genogram 3. Assessing environmental factors 4. Assessing genomic physical findings 5. Assessing genetics/genomics learning needs (Consensus Panel on Genetic/Genomic Nursing

Competencies, 2006, 2009; Pestka, Meisheid, & O’Neil, 2008; Pestka et al., 2010)

Figure 3.1 shows a genogram with the inclusion of demographic, occupational, and major life event information (Varcarolis et al., 2006). In Beth’s case, a family genogram was not done because of her limited knowledge of family history and her refusal to participate in a family session. Had it been done, the family genogram would have revealed a multigenerational pattern of affective disorder, substance abuse, and early parent loss. Beth might have seen in graphic form some of the factors relevant to her strained relationship with her mother, including her birth only 15 months after the birth of her older brother; a lengthy separation from her mother before age 3, precipitated by her mother’s psychiatric hospitalization; and the death of Beth’s

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maternal grandmother very early in Beth’s mother’s life, followed by a series of unstable living arrangements.

FIGURE 3.1 An elaborated genogram with demographic, occupational, and major life event information. Adapted from Varcarolis, Carson, and Shoemaker (2006).

ASSESSING SPECIAL POPULATIONS

The initial psychiatric assessment follows an established, comprehensive format but also homes in on the specific content domains most relevant to the client-identified problem and presentation. Some client populations, if not most clients, will require ongoing assessment of missed or emerging symptoms as the client becomes more comfortable disclosing them and/or the therapist better comprehends the clinical situation. For example, the client who presented initially as depressed and anxious might later disclose the full extent of his or her bulimia, substance use, suicide ideation, violent fantasy, confusion, cognitive impairment, disability, personality disorder, or any of dozens of other symptoms, syndromes, or conditions. The literature is replete with specialized information, which is beyond the scope of this chapter, about focal assessments within given clinical domains; and the APPN should be comfortable turning to the scholarly literature whenever he or she experiences a knowledge gap. The literature includes, for example, information on psychiatric violence risk assessment (Buchanan, Binder, Norko, & Swartz, 2012); suicide risk assessment (Aflague & Ferszt, 2010); disability and occupational assessment (Williams, 2010); assessment of personality disorders (Widiger & Samuel, 2009); psychiatric evaluation of the agitated patient (Stowell, Florence, Harman, & Glick, 2012); specialized assessment of eating disorders (Berg, Peterson, & Frazier, 2012); and specialized assessment of cognitive function in older populations (Milisen, Braes, & Foreman, 2012).

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SCREENING TOOLS

Screening tools can provide useful assessment data to supplement data obtained from the clinical interview. They can identify problem areas for psychotherapeutic focus and contribute to case formulation or to the determination of the differential diagnosis. For example, psychiatric rating scales can generate baseline measures of symptom severity, social and occupational functioning, or quality of life for purposes of monitoring changes over time or measuring psychotherapeutic outcomes. Although a single rating scale score at best provides only a snapshot of a complex clinical situation, repeated ratings can objectively describe longitudinal change over a defined treatment period and therefore provide some justification for the choice of treatment plan and some measure of its efficacy. Such ends are secondary to their overall purpose, which is to contribute to a deeper, more holistic, more empathic understanding of the person who presents for help and, in so doing, frequently risks so much.

Psychotherapists have long been challenged to quantify the impact on patients’ lives of both psychiatric illness and the therapies employed to treat psychiatric illness (Bresee, Gotto, & Rapaport, 2009). Early on, Barrell and colleagues (1997) encouraged APPNs to use assessment tools to measure patient outcomes and to evaluate the efficacy of practice. Currently, with the arrival of “pay for performance” standards, a more rigorous approach to assessment and treatment is no longer optional (Bresee et al., 2009). The concept of measurement-based care, which refers to the use of rating scales to measure the outcome of psychiatric treatment, has arrived (Zimmerman, Young, Chelminski, Dalrymple, & Galione, 2012). The practice of assessing psychiatric vital signs has also arrived: based on the prevalence of anxiety and depressive symptoms across diagnostic categories, Zimmerman et al. (2012) have recommended that anxiety and depression be regularly assessed and monitored in all psychiatric patients regardless of diagnosis. In addition, given the prevalence of childhood trauma and the long-term consequences, every adult should be screened with the Adverse Childhood Experiences (ACE) Scale. This is a 10-item scale that asks the person about disturbing events that occurred during childhood. A score of 4 or more indicates a highly significant increase in the development of chronic disease and mental illness (Felitti et al., 1998). See Appendix 3.16 for the ACE Scale.

The Practice Guideline for the Psychiatric Evaluation of Adults (APA, 2006) and the American Psychiatric Publishing Textbook of Psychopharmacology, 4th edition (Schatzberg & Nemeroff, 2009) both emphasize the utility of structured instruments for patient assessment and outcomes evaluation; and both list commonly used clinical rating scales, screening tools, and structured instruments (Table 3.6). Fifteen screening tools commonly used by APPNs to assess psychotherapy patients and measure treatment outcomes are included in this chapter as appendices or are proprietary and can be purchased from their publishers (Box 3.19). They include several of the rating scales listed in Table 3.6.

DIAGNOSIS AND CASE FORMULATION

For any patient, the last steps in the assessment process are to formulate the case and determine the diagnosis. It is important to understand the relationship between a screening tool, along with the data it generates, and a diagnosis. Screening instruments are commonly used in many areas of health care and are well accepted by the general public and health care professionals. They are helpful in that they suggest the presence or absence of one or more diagnoses. In essence, screening tools identify the presence and severity of symptoms and therefore the likelihood of a diagnosis, but their results do not produce a diagnosis. The results of screening instruments have to be interpreted and put in the context of the broader assessment.

There is an important distinction between the presence of symptoms and the diagnosis of psychiatric disorder. Symptoms do not generate a diagnosis unless their nature, number, duration, and context (e.g., impaired social and occupational functioning) meet the established criteria of a diagnostic taxonomy such as the DSM for the suspected diagnosis. The distinction between symptoms and diagnoses underscores the importance of using systematic criteria to make a formal diagnosis. The data generated by screening tools can contribute to the systematic process of determining a diagnosis, but no one can assume that a score of 38 on a Beck Depression Inventory (BDI), for example, determines a diagnosis of major depression. What it indicates is the likelihood of a major depression. Further investigation, including the rest of the assessment process, which continues throughout treatment as the therapist observes how the patient responds to interventions, and the integration of findings across assessment areas are required to make that determination.

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Diagnosis

Although a comprehensive assessment is essential to understanding a patient’s concerns and capacities and to developing an appropriate treatment plan, a diagnosis is not central to psychotherapy. It is possible to help a person regain the ability to function effectively in social, occupational, and family roles without one. Nevertheless, skills in differential diagnosis are useful. They are among the specified competencies for APPNs and a DSM diagnosis is required for purposes of insurance reimbursement. Some practice guidelines do specify the forms of psychotherapy to which research evidence points as most effective for certain diagnoses. Although it is beyond the scope of this chapter to address the development of skills in differential diagnosis, some discussion of the concept is warranted.

A diagnosis is an extraordinarily complex concept. To illustrate, consider some of the more interesting questions that arise in considering the nature of a diagnosis. What are we doing when we give someone a DSM diagnosis, and why are we doing it? Does diagnostic labeling serve any purpose other than to facilitate insurance reimbursement? What does it mean that with each new version of the DSM some diagnostic labels are discarded and new ones are added? Have certain illnesses disappeared and others emerged? Why do they disappear, and what gives birth to new ones? What does it mean that each subsequent version of the DSM has become significantly larger? Are we getting sicker, or are we socially constructing more and more disorders? In other words, are we construing more and more formerly normal aspects of everyday life as pathologic or just getting better at finding and isolating diseases that actually exist? In light of their complicated and controversial nature, perhaps diagnoses are best made, when they must be made at all, as a necessary evil and with an attitude of humility and profound respect for the complexity of human beings. Given the importance of DSM diagnoses for research purposes, their prominence within clinics and other medicalized practice sites, and their role in obtaining insurance reimbursement, diagnoses must also be made with a thorough understanding of the DSM, which is the most commonly used taxonomy of mental disorders in the United States and is now in its fifth edition.

The DSM-5 significantly changes current processes of assessment and diagnosis with the addition of dimensional and cross-cutting assessments to the DSM’s categorical diagnoses (Jones, 2012). A categorical diagnosis is either present or absent, and a categorical diagnostic system like the DSM assumes that psychiatric disorders are discrete entities with homogeneous populations that all display similar symptoms of a disorder (Jones, 2012). In reality, client populations are widely heterogeneous and do not fall neatly into diagnostic categories, just as psychiatric disorders are neither homogeneous nor divided by distinct boundaries (Jones, 2012). This reality has highlighted some of the significant shortcomings of the current diagnostic system, including excessive comorbidity (i.e., need for multiple diagnoses), irresolvable boundary disputes (with their corresponding conflicts among clinicians with different diagnostic views), and excessive use of the not otherwise specified (NOS) diagnostic category (Jones, 2012).

To address these shortcomings, the DSM-5 Task Force has proposed adding dimensional assessments to every diagnosis in the DSM. Dimensional assessments are rating scales with multiple (three or more) ordered values that measure the frequency, duration, severity, or other characteristics of a psychiatric disorder (Jones, 2012). A symptom cannot be either present or absent. Rather, it exists along a continuum of severity ranging from, for example, 0 = not at all, 1 = for several days, 2 = more than half the days, to 3 = nearly every day (Jones, 2012). In addition to including dimensional assessments for individual disorders, the DSM-5 may also include cross-cutting assessments to measure symptoms such as depression and anxiety that commonly occur across clients regardless of the presenting problem or eventual diagnosis (Jones, 2012). Such symptoms have been conceptualized as psychiatric vital signs, given the evidence for their occurrence across diagnostic categories (Zimmerman et al., 2012).

The DSM-IV-TR described psychiatric disorders in terms of clusters of symptoms and relied heavily (and necessarily) on phenomenological description, that is, the subjective interpretation of experience as opposed to objective, physiologic markers—of which there are very few in psychiatric illness. This edition attempted to reconcile multiple, competing theoretical notions about the cause of psychiatric illness in essence by avoiding the question of causality altogether, focusing only on symptom presentation. The DSM constitutes a consensus effort to achieve uniformity among mental health professionals with radically disparate theoretical orientations, ranging from the behavioral to the psychoanalytic (Mechanic, 2007). The DSM is a political document, albeit one with some clinical utility. It allows for greater precision in the use of psychiatric labels, which can facilitate clearer communication among mental health professionals with different disciplinary backgrounds; and it can define more clearly samples of patients for psychiatric research. Because the DSM is a tool for clustering symptoms and syndromes, a DSM diagnosis implies various therapeutic interventions. For clinicians, diagnosis serves only one major purpose—to guide the discovery of information

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that will lead to the most effective methods of helping people regain optimal functioning in social and occupational roles (Shea, 1998).

A diagnosis is probably best understood as a descriptive tool, subject to change over time that can assist in the identification of a current syndrome, or as a disorder for which a particular treatment is indicated. A diagnosis is a descriptive label that categorizes persons who evidence clusters of symptoms and behaviors considered clinically meaningful in terms of their course, outcome, and response to treatment—although no one agrees on the nature, significance, or utility of these designations (Mechanic, 2007). In some cases, a diagnostic label denotes an underlying condition with hereditary and physiologic antecedents (e.g., schizophrenia). In other cases, it refers to a pattern of response to various forms of stress not clearly connected to underlying physiologic phenomena (e.g., adjustment disorder). The diagnosis is not itself the thing it connotes, that is, a disorder. However systematically or carefully it is crafted, a diagnosis represents a snapshot in time. Diagnostic error is common, and diagnoses tend to be fluid—that is, subject to the irresolvable boundary disputes identified by Jones (2012)—which is what accounts for the reality that, for example, what looks like attention deficit hyperactivity disorder at age 5 years becomes oppositional defiant disorder at age 9 years, conduct disorder at age 12 years, antisocial personality disorder at age 18 years, and bipolar disorder at age 21 years. Here lies the need for diagnostic skill as well as humility and a lack of narcissistic investment in being “right” about the “correct” diagnosis.

Although DSM-5 has eliminated multiaxial diagnoses, it has retained diagnostic categories and supplemented them with the addition of one or more dimensional assessments. In Beth’s case, the diagnosis of major depression was determined from the fact she had the requisite number of designated DSM symptoms for the diagnostic category, including depressed mood and loss of interest or pleasure, in the 2-week period before her assessment. This represented a change from previous functioning, caused clinically significant distress and impairment in social and occupational functioning, and was not caused by the direct physiologic effects of a substance or a general medical condition (APA, 2010). The dimensional assessment for the categorical diagnosis of major depression used the Patient Health Questionnaire-9 (PHQ-9) (see Appendix 3.7), which assesses the severity of nine possible depressive symptoms over a 2-week period using a 4-point scale: 0 = not at all, 1 = for several days, 2 = more than half the days, 3 = nearly every day. Beth scored 16 out of a possible 27 points on the dimensional assessment, indicating a moderate level of major depression. Because she reported that some of these depressive symptoms had been present for longer than 2 years, there was a possibility that this major depressive episode was superimposed on a dysthymic disorder, so dysthymia was provisionally included in the differential diagnosis. However, more information will be needed to make that diagnosis, perhaps including some collateral information from people who know Beth.

Beth’s therapist also had concerns about a possible diagnosis of personality disorder given her history of intense and unstable relationships with her most significant others, the predominance of anger in her affective presentation, the apparent identity diffusion, her difficulty being alone, self-injurious behavior (i.e., wrist scratching), her inability to modulate interpersonal distance, and her apparent lack of object constancy (e.g., “If she [my mother] didn’t call me every night, I wouldn’t even think about her”). Nevertheless, a diagnosis of personality disorder was deferred because it was not clear on the basis of a single interview, especially in the middle of a major depressive episode, that the impairments in personality functioning (self and interpersonal) were relatively stable across time and consistent across situations (APA, 2010). In addition, it was not yet clear that Beth’s individual personality trait expression, which seemed at first glance to include at least one pathological trait domain (negative affectivity), could not be better understood as normative for her developmental stage (APA, 2010). Finally, it should be noted that Beth had no medical diagnoses to report and that the clinician’s assessment of her overall level of functioning employed the Global Assessment of Functioning (GAF) scale. Beth’s GAF was scored at 41 due to suicide ideation, self-injurious behavior, and serious impairment in academic and social functioning.

A psychiatric assessment is not the completion of a symptom checklist; and a diagnosis cannot express the clinician’s empathic understanding of the client, even though accurate, empathic understanding of the client may be essential to the diagnostic process (Silberman, 2010). Despite the comprehensiveness of the DSM diagnostic system, much is missing from this diagnostic picture. It has a flat, two-dimensional quality and does not really encapsulate the essence of Beth’s case. It does not tell us enough. It does not clarify the boundaries between normality and illness in her case, establish an etiology for the diagnostic entities, or convey any understanding of the psychological or neurophysiologic factors that might be contributing to her presentation (Silberman, 2010). It does not put Beth’s case into a theoretical perspective, prioritize her problems, predict any sort of outcome, or most important, paint a rounded picture of her uniqueness and humanity. For that, we need a case formulation.

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Case Formulation

Case formulation lies “at the intersection of etiology and description, theory and practice, and science and art” (Sim et al., 2005, p. 289). Case formulation fills the gap between the purely descriptive, atheoretical DSM criteria, which say nothing about the cause of a person’s problems, and the practical art of prescribing a particular treatment approach for a given patient. Accurate diagnoses and effective treatment plans are essential to helping people; but in the gap that lies between, we need a process to link the patient’s various complaints to one another, explain why these problems have emerged, and provide predictions about the person’s probable course (Sim et al., 2005). We need a process to capture the essence of a case. Case formulation does so by succinctly describing the essential features of a case—by encapsulating the complaints, problems, diagnosis, etiology, treatment options, and prognosis with enough sensitivity and specificity so that the uniqueness of the individual appears and a more complete picture emerges of what is required in the way of help. Box 3.21 illustrates a formulation of Beth’s case.

BOX 3.21

SAMPLE CASE FORMULATION

Beth is a 20-year-old college junior with no previously diagnosed psychiatric problems. She presents with symptoms that meet criteria for a diagnosis of major depression, single and moderate episode, no psychosis, possibly superimposed on an underlying dysthymic disorder. A 4- to 5-year history of family conflict, particularly with her mother, coincides with the experience of depressed mood. By Beth’s account, the family system is hostile enmeshed and not supportive of separation or individuation. For example, Beth reports that her mother pushes her to succeed in school but then sabotages her by withholding financial and emotional support, using those resources to enroll herself in school with the same major focus. Hostility and ambivalence also are apparent in the act of putting Beth’s dog to sleep on the day of a scheduled family celebration.

The current episode is largely precipitated by Beth’s moving away from home for the first time. Beth and her mother are having a difficult time with the separation, but that is largely unacknowledged. Instead, they stay close with angry, conflict- ridden phone conversations initiated each evening by her mother and from which Beth does not or cannot separate herself. Beth has considerable strengths: she has stayed in school despite her intense distress, has continued to work at a stressful fast-food job, and has not escalated her wrist-scratching behaviors. However, she might not be doing as well as she is but for the fact she has been living with a significant other since moving away from home. Of concern, that relationship is unstable, marked by some of the same intense conflict and abandonment anxiety that characterizes her relationship with her mother, and may not last much longer. In that case, I would expect to see an exacerbation of the self-injurious behaviors used previously to cope with stress. It is possible a low-level, chronic risk of passive suicide ideation may become transiently active and acute. An intense argument with her boyfriend, followed by his abandonment of her for an entire night, is the acute precipitant for the current therapy contact and evaluation. The vicissitudes of the therapeutic relationship are likely to precipitate similar responses.

To treat the major depression, I will start a selective serotonin reuptake inhibitor and order a thyroid-stimulating hormone test to rule out hypothyroidism. Because she gives a reliable history of birth control, I will not order a test for beta-human chorionic gonadotropin. The risks and benefits of an antidepressant have been thoroughly discussed. Beth has a good understanding of these, and she is in agreement with the treatment plan. Individual psychotherapy with a relational focus, starting at one session per week, begins next week. Ongoing assessment for a diagnosis of personality disorder, cluster B traits, will occur in the context of the therapeutic relationship. Given Beth’s successful engagement in the assessment process, I expect she will be able to form a therapeutic alliance despite some difficulties modulating distance in close relationships. Family therapy with a colleague has been recommended and refused, but Beth may be more open to this option as individual gains are made. Beth will continue to receive academic support services at the college, and I will suggest that she investigate options for student housing on campus. She may be able to maintain her relationship with her boyfriend for a time if she gets a reprieve from the increased intimacy demanded by their close living quarters. I will also suggest she open a dialogue with her father about financial support as she has an appropriately close and relatively conflict-free relationship with him. I will encourage her to continue to use her current support system and will work with her to expand and strengthen it as more pressing problems are addressed (e.g., as her depressed mood begins to lift, she is better able to modulate and tolerate contact with her mother, she achieves some stability in her living situation, and she is more able to negotiate the demands of work and school).

Sim and associates (2005) identify clear benefits to the therapist in having a case formulation. These are related to the following five aspects of any given case: integrative, explanatory, prescriptive, predictive, and therapist elements. Box 3.21 illustrates how a case formulation can attempt to integrate clinical data, including biologic, psychological, and sociocultural data; summarize the salient features of a case; identify important issues quickly in the context of an explanatory framework that provides insight into the intra-individual and inter-individual aspects of the case; prioritize the patient’s problems and the interventions that will address them; and identify the target symptoms by which interventions will be evaluated (Sim et al., 2005). At the prescriptive level, it demonstrates how the case formulation guides the therapy in choice of goals, including

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the point at which intervention will begin. It demonstrates how a case formulation sheds light on the prognosis of the case and makes predictions about the probable course of treatment. It illustrates how a case formulation helps the therapist recognize and organize the complex issues that lie beyond the presenting problems such that greater empathy with the patient is possible (Sim et al., 2005).

In sum, case formulation provides a context for the evolving therapeutic relationship. It allows the therapist to better understand the nature of the therapeutic relationship and to anticipate how to manage therapy-interfering events and resistance to change, including in Beth’s case the possibility of self- injurious behavior or the impulse to flee from any further closeness with the therapist. Case formulation begins a process of actualizing in practice the holistic model of healing discussed in Chapter 1. More than integrating the physiologic, emotional, spiritual, cognitive, and sociocultural data obtained through a comprehensive assessment process, it attempts to do so such that the person seeking help is more comprehensible as a complex, multidimensional being within specific cultural contexts. A particularly successful case formulation begins to actualize the practice treatment hierarchy discussed in Chapter 1 (Figure 1.6). A good case formulation identifies, or begins a process of identifying in an ongoing way, a hierarchy of treatment interventions that can promote the patient’s healing over time.

In Beth’s case, a treatment hierarchy would move from a period of stabilization, through processing of past and present feelings and events, and on to future visioning and an integration of past, present, and future. It would move from a focus on increasing external resources to a focus on developing internal resources (see Chapter 1, Figure 1.6). Beth’s treatment may start with concrete, supportive, case-management interventions designed to promote safety and stabilization in physiologic, emotional, and social spheres, such as medication to target her depressive symptoms, laboratory work to rule out complicating physiologic conditions, a schedule of psychotherapy sessions and academic support services contacts, a plan to seek financial and emotional support from her father, a new living situation, and a concrete plan to limit destabilizing phone calls with her mother. As therapy progressed, interventions would move up the treatment hierarchy to focus on building healthier relationships, improving communication and interpersonal effectiveness, processing thoughts and feelings, and developing internal resources, such as insightfulness; the ability to tolerate distress, unpleasant affect, and ambiguity; or the ability to integrate disparate feelings about her mother, herself, or other significant persons. Ultimately, integration is the goal, as defined by Beth within her own cultural context.

CONCLUDING COMMENTS

A comprehensive assessment of the patient who presents for psychotherapy is necessary to develop an appropriate treatment plan. In some practice settings, a comprehensive assessment is required in the initial session, and many tools are available to help the therapist. This assessment is a relational process that sets the tone for subsequent sessions. If sensitively crafted, an intake assessment can be a powerful therapeutic tool with the potential to further the therapeutic alliance, on which all good psychotherapy outcomes depend. Far from being a rote process with a simple question-and-answer format, a comprehensive intake assessment is a creative act (Havens, 1998). It begins the ongoing, essentially creative activity of two reciprocally influencing therapeutic partners in constructing the patient’s life story. The more powerfully engaged the patient and therapist are in the assessment process, the more valid are the data on which to base the diagnosis that will guide the choice of treatment plan.

In addition to taking a comprehensive biopsychosocial history of the patient who presents for psychotherapy, the therapist must assess the patient’s ego functioning, affective development, interpersonal relationships, and cultural belief systems. Genograms play an important role in the assessment process, as do the screening tools, diagnosis, and case formulation in the therapeutic process. Several rating scales, psychiatric databases, and other screening tools are commonly used to facilitate assessment and diagnosis or to measure psychotherapy outcomes. Although there is no substitute for experience, the assessment format and rating scales presented in this chapter provide a foundation that equips the novice nurse psychotherapist for the creative collaboration that lies ahead.

DISCUSSION EXERCISES

1. Discuss the ways in which a comprehensive clinical assessment presents a unique opportunity for

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intervention in the psychotherapeutic context. 2. How may an assessment interview in the psychotherapeutic context differ from conventional

medical history taking? 3. Discuss the relationship between the therapeutic alliance and the validity of clinical assessment

data. 4. Describe the major goals and tasks of assessment. 5. Describe the ways in which a psychotherapist facilitates and strengthens the therapeutic alliance

in the process of completing an assessment. 6. How would you describe the connections among ego functioning, affective development, sense of

self, and interpersonal functioning? 7. Think of a patient in your practice context with whom you have had a therapeutic relationship.

What specific questions would you ask to assess that patient’s ego functioning, affective development, and interpersonal functioning?

8. How does the therapeutic relationship with a psychotherapy patient serve as an assessment tool? Can you assess the areas of patient functioning mentioned in question 7 without asking specific questions? If so, how?

9. What are the similarities and differences among screening (i.e., employing a screening tool), diagnosing a disorder, and formulating a case?

10. Given what you have learned about Beth in this chapter, can you construct an alternate case formulation? Can there be multiple formulations of the same case? How so?

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Outline of the Comprehensive Psychiatric Database

I. Identifying data A. Age B. Sex/Gender preference C. Race/Ethnicity D. Marital status E. Children F. How arrived? G. Who referred? Why? H. Mental health providers? I. Sources of information J. Number of times seen in this setting

II. Client-identified problem A. What the client states he or she wants help with B. Verbatim statement 1. “I’m depressed.” 2. “My mother brought me. I don’t need help.”

III. History of current illness A. Onset, duration, or change in symptoms over time 1. Organized chronologically 2. Client’s perception of changes in himself or herself over time 3. Others’ perception of changes in the client (e.g., spouse, employer, and friend) B. Precipitating factors 1. Why now? C. Baseline functioning D. Last period of stability

IV. Psychiatric history A. Inpatient 1. Location, dates, and lengths of stay 2. Diagnoses 3. Previous episodes of current symptoms 4. Previous episodes of other disorders not described in history of current illness 5. Legal status 6. Use of medications or other treatments, including doses, blood levels, clinical response 7. Perception of helpfulness B. Outpatient 1. Dates, duration, and frequency of sessions 2. Location, type, and focus of treatment or therapy 3. Perception of helpfulness

V. Medical history

A. Past and current medical problems 1. Illnesses, operations, and hospitalizations, especially history of open or closed head injury, birth trauma, seizure disorder, and

encephalitis or meningitis B. Past and current medications 1. Dosages, blood levels, and clinical response 2. Adherence C. Primary care physician, specialists, and phone numbers D. Allergies (and reactions)

VI. History of substance use and abuse

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A. Episodes of alcohol abuse 1. What, how much, and consequences (e.g., charges for driving under the influence [DUI], other legal sequelae, and loss of

relationships, jobs, and opportunities) 2. Does the client or others think he or she has a problem? 3. Typical pattern of use 4. History of blackouts, seizures, complicated withdrawal, or delirium tremens 5. History of suicide ideation, gestures, or attempts while intoxicated or withdrawing 6. Longest period of sobriety 7. What facilitates sobriety? 8. Previous treatments (e.g., detoxification, rehabilitation, counseling, and Alcoholics Anonymous) B. Episodes of illicit or prescription drug abuse 1. What, amount, route of administration, and consequences (e.g., DUIs, other legal sequelae, and loss of relationships, jobs, and

opportunities) 2. Does the client or others think he or she has a problem? 3. Typical pattern of use 4. History of suicide ideation, gestures, or attempts while intoxicated or withdrawing 5. Longest period of sobriety 6. What facilitates sobriety? 7. Previous treatments (e.g., detoxification, rehabilitation, counseling, and Narcotics Anonymous) C. Tobacco 1. Number of cigarettes or packs per day 2. Years client has smoked 3. Cessation attempts D. Caffeine 1. Form (coffee, cola, tea, and pills) 2. Amount consumed per day 3. Cessation attempts E. Over-the-counter drugs or “herbal” medications 1. What, how much, purpose, frequency, side effects, and interactions with prescribed medications 2. Perceptions of helpfulness or efficacy VII. Developmental history

A. Developmental milestones and family of origin 1. Information about mother’s pregnancy and delivery 2. Were developmental milestones reached as expected? 3. Childhood temperament and important family events (e.g., death, separation, and divorce) 4. Information about early experiences and relationships (e.g., school experiences, academic performance, delinquency, family of

origin relationships, family stability, early sexual experiences, and history of abuse or neglect) 5. Important cultural or religious influences 6. Values, beliefs, or framework for meaning B. Educational history C. Occupational and military history 1. Number and types of jobs; reasons for termination 2. Highest rank attained; conditions of discharge 3. History of disciplinary problems or combat D. Legal history VIII. Family history A. Psychiatric or substance use disorders 1. Have any family members undergone psychiatric or substance abuse treatment (inpatient or outpatient), attempted or completed a

suicide, had problems with drugs or alcohol, and behaved strangely? 2. Have any family members successfully used any psychotropic medications for the same or similar symptoms? 3. Family attitudes toward mental illness B. Pertinent medical disorders in blood relatives (e.g., seizure disorder or thyroid disease)

IX. Social history A. Current social situation 1. Living arrangements (e.g., where, with whom, for how long, how stable, and how satisfactory or desirable) 2. Employment (e.g., where, for how long, how stable, and how satisfactory or desirable) 3. Financial (e.g., current sources of income, how stable, and how adequate) 4. Insurance coverage B. Breadth of client’s social life

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1. Is he or she a loner or involved in an intimate relationship? 2. How difficult is it to get into and out of relationships? C. Past and present levels of functioning 1. Marriage, parenting, and work 2. Client strengths and strategies used to manage stress, resources, or positive memories (draw a line and place important positive

memories and events) 3. Current functional deficits (e.g., activities of daily living, task performance, and relationships)

X. Trauma history A. Ten most significant disturbing events in life B. Violence 1. To self a. What, when, where, how, why; warning signs or symptoms, triggers, and consequences b. How intense, specific, and controllable is current ideation 2. To others or property a. What, when, where, how, why; warning signs or symptoms, triggers, and consequences b. How intense, specific, and controllable is current ideation 3. Current access to weapons a. What, where, why; plan for use; plan for disposition of weapon b. How will disposition of weapons be verified?

XI. Psychiatric review of systems (ROS)

A. Includes all symptoms not part of the current episode or presentation B. May have to ask specific questions about the presence or absence of these symptoms 1. “Are you now or have you ever had any of the following …” C. Anxiety symptoms 1. Shortness of breath, heart palpitations, panic attacks, sweating, flushing, hyperventilation, sense of doom, fear of death

or collapse, cold or clammy skin, and tingling sensations in extremities D. Mood symptoms 1. Sadness, irritability, anergia, fatigue, lethargy, tearfulness, increased or decreased appetite or energy, changes in sleep or libido, suicide

ideation, homicide ideation, hypomania (e.g., spending sprees, increased energy, and religious preoccupation beyond baseline), and feelings of hopelessness, helplessness, or worthlessness

E. Psychotic or cognitive symptoms 1. Hallucinations, delusions, thought insertion, thought blocking, thought broadcasting, flight of ideas, hyper-religiosity, tangentiality,

looseness of associations, and circumstantiality XII. Mental status examination (MSE)

A. Informal: begins immediately on contact with the client and includes an informal assessment of the client’s characteristics 1. Appearance 2. Manner of relating 3. Use of language 4. Mood and affect 5. Content of speech 6. Perceptions 7. Abstracting ability 8. Judgment 9. Insight B. Formal: focused, structured assessment of the client’s characteristics 1. Appearance: overall appearance, dress, grooming 2. Attitude: attitude toward examiner (e.g., hostile, cooperative, evasive) 3. Behavior and psychomotor activity: gait, carriage, posture, activity level 4. Speech a. Rate, amount, tone, impairment, aphasia 5. Mood and affect a. Mood (i.e., how the client reports feeling) in relation to affect (i.e., emotional expression observed by the therapist) b. Depth and range of emotional expression 6. Perception a. Hallucinations i. Auditory ii. Visual iii. Gustatory: taste (temporal lobe dysfunction?) iv. Olfactory: smell (temporal lobe dysfunction?) v. Tactile: Skin sensations (alcohol withdrawal and intoxication?)

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vi. Kinesthetic: feeling movement when none occurs vii. Hypnagogic: occurs while falling asleep viii. Hypnopompic: occurs while waking up b. Illusions: misinterpretations of actual sensory stimuli

c. Depersonalization: feels detached and views self as unreal d. Derealization: experiences objects and persons outside of self as unreal 7. Thought process a. The pattern of a client’s speech allows the therapist to observe the quality of the thought process, including its flow, logic, and

associations. Abnormalities include the following: i. Loose associations (LOAs) ii. Tangentiality iii. Circumstantiality iv. Thought blocking (TB) v. Thought insertion (TI) vi. Flight of ideas (FOAs) vii. Perseveration viii. Echolalia 8. Content of thought a. Delusions i. Paranoid or persecutory ii. Grandiose iii. Nihilistic iv. Somatic v. Bizarre b. Ideas of reference c. Obsessions d. Suicidal thoughts e. Homicidal thoughts 9. Judgment a. An assessment of social judgment involves determining whether a client understands the consequences of his or her actions b. Must recognize differences in cultural values when assessing judgment c. “What would you do if you found a sealed, stamped, addressed envelope on the sidewalk?” 10. Insight a. Must assess whether a person is aware of a problem, the cause of the problem, and what type of help is needed to address the

problem 11. Cognition a. A formal mental status examination measures the ability of the brain to function by assessing the following cognitive functions: i. Consciousness: alert, confused, drowsy, somnolent, obtunded, delirious, stuporous, and comatose ii. Orientation: knows who he or she is, where he or she is, and what day it is iii. Memory: can remember what was eaten for breakfast today; has remote memory for long-past events iv. Recall: can recall three objects after 5 minutes v. Registration: can name three objects immediately vi. Attention: can spell world forward and backward vii. Calculation: can do serial 7’s or count backward from 20 viii. Language: can name items, repeat a phrase, follow simple commands, read, write, and copy a design

XIII. Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) differential diagnosis

A. On a single axis, lists the principal psychiatric, neurodevelopmental, neurocognitive, and other disorders requiring further assessment, along with the corresponding ICD code(s)

B. Includes so-called “rule-out” and/or “provisional” diagnoses C. ICD-9 codes are listed before each disorder name, followed by ICD-10 codes in parentheses D. ICD-9 codes will be used in the United States through September 30, 2014. IDC-10 codes will be used starting October 1, 2014. XIV. Case formulation A. Presents a brief summary of the client and rationalizes the diagnoses 1. Minimal identifying data, including past diagnosis 2. Abbreviated recapitulation of presenting symptoms, onset, and course 3. Draws from all sections of the database as needed B. Outlines the contributing factors, precipitants, and stressors

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C. Summarizes the logic behind the differential diagnoses D. Identifies information still needed to confirm the diagnoses XV. Treatment plan

A. Biologic 1. Medications (e.g., name, dose, route, for what purpose, and client’s level of understanding of medication education) 2. Diagnostic tests (e.g., where, when, and who will administer) 3. Referrals for primary care B. Psychological 1. Therapeutic modalities to be used and with what focus a. Individual psychotherapy? b. Group psychotherapy? c. Family therapy? d. Case management? C. Social 1. Support or self-help groups 2. Mobilization of family resources 3. Vocational rehabilitation 4. Financial planning D. Strengths 1. Overt identification of client strengths, values, and beliefs to support or draw from in implementing the identified treatment plan

Data from APA (2006); Gordon and Goroll (2003); Marken, Schneiderhan, and Munro (2005); Morrison (2008); Sadock, Sadock, and Ruiz (2009); Scully and Thornhill (2012); Shea (1998).

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Sample Assessment Form

INITIAL CLINICAL ASSESSMENT

Identifying Data

Client-Identified Problem (Client’s Own Words) and Referral Source

1. History of current illness A. Stressors and symptoms: include current stressors and detailed chronologic history of symptoms for

each diagnosis on axes I and II. Detail current substance abuse and the amount and pattern of use. B. Recent suicide or homicide ideation or behavior: include all ideation, gestures, attempts, presence or

absence of hopelessness, and extent of actions or plans in the past month. 2. Psychiatric history

A. Episodes and treatment: describe previous episodes of current disorder and all other disorders, including treatment modalities such as hospitalization, psychotherapy, and medications and their dosages.

B. History of trauma: list the 10 most significant traumas. Do a timeline, and rate the disturbance for each event on a scale of 0 to 10; you can also ask for significant positive and negative events in the person’s life. Administer the Impact of Events Scale and Dissociative Experiences Scale if trauma is suspected or reported.

C. History of violence To self: To others: To property:

3. Psychiatric review of systems: circle all relevant symptoms, and add any not listed A. Mood: sadness, tearfulness, depressed mood, irritability, fatigue, lethargy, anergia, anhedonia, sleep

changes, appetite changes, decreased libido, hopelessness, helplessness, worthlessness, suicide ideation, homicide ideation, spending sprees, increased energy or activity, decreased need for sleep, increased libido, pressured speech, tangentiality, and flight of ideas.

B. Anxiety: anxious mood, excessive worry, shortness of breath, heart palpitations, panic attacks, sweating, flushing, hyperventilation, sense of impending doom, fear of death or collapse, cold/clammy skin, and tingling sensations in extremities.

C. Thought disorder: auditory or visual hallucinations, other hallucinations, ideas of reference, paranoia, delusions, thought insertion, thought blocking, thought broadcasting, flight of ideas, hyper-religiosity,

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tangentiality, looseness of associations, and bizarre behavior. 4. Drug and alcohol history

B. Substance abuse profile:

5. Medical history: List significant past illnesses, surgeries, or hospitalizations A. Primary care physician: ______________________________________________ B. Allergies: ______________________________________________ C. Medications: use the table to document:

6. Psychosocial history A. Education: B. Family relationships, social relationships, and abuse history: C. Employment record and military history: D. Religious background, belief system, or meaning framework: E. Client’s strengths: include client resources and how client self-soothes and manages stress.

7. Family history A. Genogram:

CASE FORMULATION

Assessment of suicide or violence risk:________________________________________ Treatment recommendations:________________________________________ Admit to:________________________________________ One-time consultation:________________________________________ Refer to:________________________________________ Referred for: ____________________ Physical examination ____________________ Individual psychotherapy ____________________ Psychological testing ____________________ Group psychotherapy ____________________ Hospitalization ____________________ Medications

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____________________ Support group ____________________ Community support program services Diagnostic summary:

Clinician’s signature:________________________________________ Date:________________________________________ Location of assessment:________________________________________ Adapted from Shea (1998).

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Dissociative Experiences Scale (DES)

Name ____________ Date ____________ Age ____________ Sex ____________

Directions: This questionnaire consists of 28 questions about experiences that you may have in your daily life. We are interested in how often you have these experiences. It is important, however, that your answers show how often these experiences happen to you when you are not under the influence of alcohol or drugs. To answer the questions, please determine to what degree the experience described in the question applies to you and circle the number to show what percentage of the time you have the experience.

Example: 0% 10 20 30 40 50 60 70 80 90 100% (never) (always)

1. Some people have the experience of driving a car and suddenly realizing that they don’t remember what has happened during all or part of the trip. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

2. Some people find that sometimes they are listening to someone talk and they suddenly realize that they did not hear all or part of what was said. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

3. Some people have the experience of finding themselves in a place and having no idea how they got there. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

4. Some people have the experience of finding themselves dressed in clothes that they don’t remember putting on. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

5. Some people have the experience of finding new things among their belongings that they do not remember buying. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

6. Some people sometimes find that they are approached by people that they do not know who call them by another name or insist that they have met them before. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

7. Some people sometimes have the experience of feeling as though they are standing next to themselves or watching themselves do something as if they were looking at another person. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

8. Some people are told that they sometimes do not recognize friends or family members. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

9. Some people find that they have no memory for some important events in their lives (for example, a wedding or graduation). Circle a number to show what percentage of the time this happens to you.

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0% 10 20 30 40 50 60 70 80 90 100% 10. Some people have the experience of being accused of lying when they do not think that they have lied.

Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

11. Some people have the experience of looking in a mirror and not recognizing themselves. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

12. Some people sometimes have the experience of feeling that other people, objects, and the world around them are not real. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

13. Some people sometimes have the experience of feeling that their body does not belong to them. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

14. Some people have the experience of sometimes remembering a past event so vividly that they feel as if they were reliving that event. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

15. Some people have the experience of not being sure whether things that they remember happening really did happen or whether they just dreamed them. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

16. Some people have the experience of being in a familiar place but finding it strange and unfamiliar. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

17. Some people find that when they are watching television or a movie they become so absorbed in the story that they are unaware of other events happening around them. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

18. Some people sometimes find that they become so involved in a fantasy or daydream that it feels as though it were really happening to them. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

19. Some people find that they are sometimes able to ignore pain. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

20. Some people find that they sometimes sit staring off into space, thinking of nothing, and are not aware of the passage of time. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

21. Some people sometimes find that when they are alone they talk out loud to themselves. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

22. Some people find that in one situation they may act so differently compared with another situation that they feel almost as if they were different people. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

23. Some people sometimes find that in certain situations they are able to do things with amazing ease and spontaneity that would usually be difficult for them (for example, sports, work, social situations, and so

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on). Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

24. Some people sometimes find that they cannot remember whether they have done something or have just thought about doing that thing (for example, not knowing whether they have just mailed a letter or have just thought about mailing it). Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

25. Some people find evidence that they have done things that they do not remember doing. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

26. Some people sometimes find writings, drawings, or notes among their belongings that they must have done but cannot remember doing. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

27. Some people find that they sometimes hear voices inside their head that tell them to do things or comment on things that they are doing. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

28. Some people sometimes feel as if they are looking at the world through a fog so that people or objects appear far away or unclear. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100%

Adapted from Carlson and Putnam (1993).

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150APPENDIX 3.4

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The Impact of Event Scale (IES)

The table contains comments made by people after stressful life events. Using the scale, please indicate how frequently each of these comments was true for you during the past 7 days.

Adapted from Horowitz, Wilner, and Alvarez (1979); Weiss and Marmar (1997).

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Zung Self-Rating Depression Scale (ZSRDS)

Please read each sentence carefully. For each of the 20 statements, place a check mark in the column that best describes how often you have felt that way during the past two weeks.

Adapted from Zung (1965).

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Geriatric Depression Scale (GDS) (Short Form)

Circle the appropriate answer.

Adapted from Yesavage et al. (1983).

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153APPENDIX 3.7

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Patient Health Questionnaire-9 (PHQ-9)

Over the past 2 weeks, how often have you been bothered by any of the following problems?

If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Total Score:________________

Developed by Drs. Robert L. Spitzer, Janet B. W. Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display, or distribute. Available at www.pfizer.com

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Young Mania Rating Scale (YMRS)

Elevated Mood: 0 Absent 1 Mildly, or possibly elevated on questioning 2 Definite subjective elevation: optimistic, cheerful, self-confident; appropriate to content 3 Elevated; inappropriate to content; humorous 4 Euphoric; inappropriate laughter; singing Increased Motor Activity/Energy: 0 Absent 1 Subjectively increased 2 Animated; gestures increased 3 Excessive energy; hyperactive at times; can be calmed 4 Motor excitement; continuous hyperactivity; cannot be calmed Sexual Interest: 0 Normal; not increased 1 Mildly, or possibly increased 2 Definitive subjective increase on questioning 3 Spontaneous sexual content; elaborates on sexual matters; hypersexual by self-report 4 Overt sexual acts (toward interviewer, staff, patients) Sleep: 0 Reports no decrease in sleep 1 Sleeping less than normal by up to 1 hour 2 Sleeping less than normal by more than 1 hour 3 Reports decreased need for sleep 4 Denies need for sleep Language/Thought Disorder: 0 Absent 1 Circumstantial; mild distractibility; quick thoughts 2 Distractible; loses goal of thought; changes topics frequently; racing thoughts 3 Flight of ideas; tangentiality; difficult to follow 4 Incoherent; communication impossible Content: 0 Normal 2 Questionable plans; new interests 4 Special projects; hyper-religious 6 Grandiose or paranoid; ideas of reference 8 Delusions; hallucinations Disruptive/Aggressive Behavior: 0 Absent; cooperative 2 Sarcastic; loud at times; guarded 4 Demanding; threats on ward 6 Threatens interviewer; shouting; interview difficult 8 Assaultive; destructive; interview impossible Appearance: 0 Appropriate dress and grooming 1 Minimally unkempt 2 Poorly groomed; moderately disheveled; overdressed

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3 Disheveled; partly clothed; garish makeup 4 Completely unkempt; decorated; bizarre garb Irritability: 0 Absent 1 Subjective increased 2 Irritable at times during interview; recent episodes of anger or annoyance on ward 3 Frequently irritable during interview; short and curt throughout interview 4 Hostile; uncooperative; interview impossible Insight: 0 Present; admits illness; agrees with need for treatment 1 Possibly ill 2 Admits behavior change, but denies illness 3 Admits possible behavior change, but denies illness 4 Denies any behavior change

Speech (Rate and Amount): 0 No increase 2 Feels talkative 4 Increased rate or amount at times; verbose 6 Push; consistently increased rate or amount; difficult to interrupt 8 Pressured; uninterruptible; continuous speech

Guide for scoring items—the purpose of each item is to rate the severity of the abnormality in the patient. When several keys are given for a particular grade of severity, the presence of only one is required to qualify for that rating.

The Young Mania Rating Scale © 1978 The Royal College of Psychiatrists may be photocopied by individual researchers or clinicians for their use without seeking permission from the publishers. The scale must be copied in full, and all copies must acknowledge the following source: Young, R. C., Biggs, J. T., Ziegler, V. E., & Meyer, D. A. (1978). A rating scale for mania: Reliability, validity, and sensitivity. British Journal of Psychiatry, 133, 429–435. Written permission must be obtained from the Royal College of Psychiatrists for copying and distribution to others or for republication (in print, online, or by any other medium).

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Hamilton Anxiety Rating Scale (HAM-A)

0 = None 1 = Mild 2 = Moderate 3 = Severe 4 = Grossly disabling

Adapted from Hamilton (1959).

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Generalized Anxiety Disorder Questionnaire (GAD-7)

Over the past 2 weeks, how often have you been bothered by any of the following problems?

If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Total Score:________________________________________

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Yale-Brown Obsessive–Compulsive Scale (Y-BOCS)

Circle the average occurrence of each item during the prior week up to and including the time of interview.

Obsession Rating Scales

1. Time spent on obsessions 0 = 0 hr/day 1 = 0–1 hr/day 2 = 1–3 hr/day 3 = 3–8 hr/day 4 = > 8 hr/day

2. Interference from obsessions 0 = None 1 = Mild 2 = Definite but manageable 3 = Substantial impairment 4 = Incapacitating

3. Distress from obsessions 0 = None 1 = Mild 2 = Moderate but manageable 3 = Severe 4 = Near constant/disabling

4. Resistance to obsessions 0 = Always resists 1 = Much resistance 2 = Some resistance 3 = Often yields 4 = Completely yields

5. Control over obsessions 0 = Complete control 1 = Much control 2 = Some control 3 = Little control 4 = No control Compulsion Rating Scale

6. Time spent on compulsions 0 = 0 hr/day 1 = 0–1 hr/day 2 = 1–3 hr/day 3 = 3–8 hr/day 4 = > 8 hr/day

7. Interference from compulsions 0 = None 1 = Mild 2 = Definite but manageable 3 = Substantial impairment

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4 = Incapacitating

8. Distress from compulsions 0 = None 1 = Mild 2 = Moderate but manageable 3 = Severe 4 = Near constant/disabling

9. Resistance to compulsions 0 = Always resists 1 = Much resistance 2 = Some resistance 3 = Often yields 4 = Completely yields

10. Control over compulsions 0 = Complete control 1 = Much control 2 = Some control 3 = Little control 4 = No control

Obsession subtotal (add items 1–5): ______________________ Compulsion subtotal (add items 6–10): _____________________ Y-BOCS total score (add items 1–10): ______________________ Range of severity (scores for clients who have both obsessions and compulsions): Subclinical: 0–7 Mild: 9–15 Moderate: 16–23 Severe: 24–31 Extreme: 32–40

Adapted from Goodman et al. (1989).

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Quality-of-Life Scale (QOL)

Please read each item and circle the number that best describes how satisfied you are at this time. Answer each item even if you do not currently participate in an activity or have a relationship. You can be satisfied or dissatisfied with not doing the activity or having the relationship.

Scoring 7 = Delighted 6 = Pleased 5 = Mostly satisfied 4 = Mixed 3 = Mostly dissatisfied 2 = Unhappy 1 = Terrible

Adapted from Flanagan (1982); Burckhardt, Woods, Schultz, and Ziebarth (1989).

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CAGE Questionnaire

Name:________________________________________ Date:________________________________________ CAGE score:________________________________________

Scoring: Assign 1 point for each “Yes” answer. A score of 1 to 3 should alert the examiner and warrants further evaluation.

Score of 1: 80% are alcohol dependent Score of 2: 89% are alcohol dependent Score of 3: 99% are alcohol dependent Score of 4: 100% are alcohol dependent

Adapted from Ewing (1984).

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Michigan Alcohol Screening Test (MAST)–Revised

Circle the response to each item that best describes how you have felt over the past 12 months.

Scoring: Allocate 1 point to each “Yes” answer, except for questions 1 and 4, to which 1 point is allocated for each “No” answer. Total the responses. Adapted from Selzer (1971). Tool available at www2.uchsc.edu/pharm/arc_misc/mast.asp

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Child Attachment Interview (CAI) Protocol

Introduction: This is an interview not a test; want to know what things are like in your family; want to understand your point of view.

1. Can you tell me about the people in your family? – The people living together in your house? – Extended family?

2. Tell me three words that describe you, that is, what sort of person you are. – Examples.

3. Can you tell me three words to describe your relationship with your Mom, that is, what it is like to be with your Mom? – Examples for each.

4. What happens when your Mom gets cross with you or tells you off? – Story. (Questions 3 and 4 repeated for Dad or other main caregivers)

5. Can you tell me about a time when you were really upset and wanted help? – Story.

6. Do you ever feel that your parents don’t really love you? – When? Do they know you feel that?

7. What happens when you are ill? – Example.

8. What happens when you get hurt? – Example.

9. Have you ever been hit or hurt by an older child or a grown-up in your family? – Story. – Have you been badly hurt by someone outside your family?

10. (Elementary school-age children:) Have you ever been touched in the private parts of your body by someone much older than you? (For older children:) Have you ever been touched sexually by someone when you did not want him or her to do it? – Story.

11. Has anything (else) really big happened to you that upset, scared, or confused you? – Story.

12. Has anyone important to you ever died? Has a pet you cared about died? – Story. What did you feel? What did others feel?

13. Is there anyone whom you cared about who is not around anymore? – Story.

14. Have you been away from your parents for longer than a day? (If child is not living with parents [e.g., is in foster care], ask about a time when he or she left parents.) – Story. How did you and your parents feel? What was it like when you saw them again?

15. Do your parents sometimes argue? – Story. How do you feel?

16. In what ways would you like/not like to be like your Mom/Dad? 17. If you could make three wishes when you are older, what would they be?

Shmueli-Goetz, Target, Fonagy, and Datta (2008). Adapted with permission from the publisher: American Psychological Association.

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Adverse Childhood Experiences Scale

While you were growing up, during your first 18 years of life: 1. Did a parent or other adult in the household often or very often …

Swear at you, insult you, put you down, or humiliate you?

Act in a way that made you afraid that you might be physically hurt? Yes No If yes enter 1 _____________

2. Did a parent or other adult in the household often or very often … Push, grab, slap, or throw something at you?

Ever hit you so hard that you had marks or were injured? Yes No If yes enter 1 _____________

3. Did an adult or person at least 5 years older than you ever … Touch or fondle you or have you touch their body in a sexual way?

Attempt or actually have oral, anal, or vaginal intercourse with you? Yes No If yes enter 1 _____________

4. Did you often or very often feel that … No one in your family loved you or thought you were important or special?

Your family didn’t look out for each other, feel close to each other, or support each other? Yes No If yes enter 1 _____________

5. Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?

Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? Yes No If yes enter 1 _____________

6. Were your parents ever separated or divorced? Yes No If yes enter 1 _____________

7. Was your mother or stepmother:

Often or very often pushed, grabbed, slapped, or had something thrown at her?

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Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard?

Ever repeatedly hit at least a few minutes or threatened with a gun or knife? Yes No If yes enter 1 _____________

8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? Yes No If yes enter 1 _____________

9. Was a household member depressed or mentally ill, or did a household member attempt suicide? Yes No If yes enter 1 _____________

10. Did a household member go to prison? Yes No If yes enter 1 _____________

Now add up your “Yes” answers: _______. This is your ACE Score.

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The Initial Contact and Maintaining the Frame KATHLEEN WHEELER

he two most important goals of the first session are to initiate a therapeutic alliance and to assess safety. Both are foundational to the treatment hierarchy described in Chapter 1, and they provide the basis for

the psychotherapeutic process. The psychobiologic underpinnings of the therapeutic alliance are discussed in Chapter 2. This chapter discusses strategies for developing the therapeutic alliance. The therapeutic alliance cultivates a healing environment for emotional safety and allows the patient to continue psychotherapy and to benefit from treatment. Safety issues include assessment of how safe the patient is from himself or herself and from others. The first contact with the patient is described along with issues germane to the first session, such as making practical arrangements, setting goals, how to end a session, and what records to keep. Therapeutic communication techniques are reviewed.

The other important dimension to psychotherapy is maintaining the frame of the session. The frame refers to the parameters of the psychotherapeutic relationship and includes maintaining appropriate boundaries and safeguarding the rules of therapy. Maintaining the frame is relevant for all models of psychotherapy and ensures that the patient is in a safe environment for the emotional intensity that often accompanies the therapy process. Although the rules may seem strange and arbitrary to the novice psychotherapist, they are of paramount importance in safeguarding the integrity, structure, consistency, and objectivity of the relationship. Attention to the frame of traditional psychotherapy facilitates the best possibility of clinical improvement and personal growth. The therapist is responsible for keeping the frame of the sessions.

The frame provides guidelines for the parameters of therapy, such as adherence to a schedule, fees, confidentiality, therapeutic relationship boundaries, and for minor but important issues during sessions, such as whether eating or smoking or interruptions are allowed during sessions, phone calls between sessions, and starting or stopping on time. By being consistent and trustworthy, punctual, unconditionally accepting, keeping commitments, maintaining boundaries while at the same time being caring, warm, and available, the advanced practice psychiatric nurse (APPN) facilitates neural integration. This chapter begins with a discussion of boundaries and countertransference, self-disclosure, fees, and how to deal with patients who are late or who do not show up for sessions. Change is always fraught with anxiety, and understanding violations of the frame as manifestations of anxiety is key to developing communication strategies that meet this challenge.

DEVELOPING A THERAPEUTIC ALLIANCE

The therapeutic alliance is initiated in the first contact with the patient, and the first several sessions are crucial for laying the foundation for the therapist’s connection with the patient. A meta-analytic review of research studies found that the therapeutic alliance is itself therapeutic and essential for the successful outcome of treatment no matter what model of therapy is used (Horvath et al., 2011; Safran, Muran, & Eubanks- Carter, 2011).

A challenge for the therapist is to engage the patient so that he or she will continue. A meta-analysis of 669 studies shows that the dropout rate after the initial session is 20%, that is, one out of five patients terminated treatment before meeting the goals of the proposed treatment (Swift et al., 2012). A further meta- analysis of psychotherapy dropout and the therapeutic alliance indicates a moderately strong relationship between dropout and therapeutic alliance, that is, the weaker the alliance, the more likely the person will be to drop out of treatment (Sharf, Primavera, & Diener, 2010). The therapeutic alliance is necessary to help the patient, and the first session lays the foundation for the alliance, enabling the patient to continue treatment.

Psychotherapy outcome research confirms the importance of the therapeutic alliance based on decades of research and an exhaustive review of these studies (Horvath et al., 2011; Swift et al., 2012). The percentage of

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improvement in psychotherapy patients is a function of various therapeutic factors and includes patient’s expectancy (i.e., the placebo effect), technique, extratherapeutic change (e.g., friends, family, self-help, group participation, and clergy), and common factors (e.g., therapist empathy, warmth, acceptance, encouragement of risk taking, confidentiality of relationship, and the therapeutic alliance). In other words, what the therapist does is less important than how the therapist does it. The process is more important than the technique, because the latter only accounts for 15% of change in psychotherapy outcome.

The ideal is to develop a basic level of trust and a shared agenda with the patient, which includes the collaborative goals of therapy. Three elements of the therapeutic alliance that most theorists agree with are the collaborative nature of the relationship, the affective bond between the patient and therapist, and the agreement between the therapist and patient on the goals of treatment (Martin et al., 2000). Competencies that reflect the therapist’s ability to develop a therapeutic alliance include the ability to establish rapport, enable the patient to actively participate in the process, establish a treatment focus, provide a healing environment, and recognize and attempt to repair the alliance if needed. Cultivating the therapeutic alliance is an ongoing process throughout the therapy.

Horvath elaborates on the therapeutic alliance:

Developing the alliance takes precedence over technical interventions in the beginning of therapy. Therapists need to be sensitive to the risk that their own estimate of the status of the relationship, particularly in the opening phases of therapeutic work, can be at odds with the patients and such misjudgment may have costly consequences. Thus it seems prudent to actively solicit from patients their perspective on various aspects of the alliance and to negotiate flexibly the goals of treatment and even the content of therapy to secure their active collaboration and engagement. Particularly close attention is warranted in the early phases of work with the patient who is diagnosed with relational problems … these patients not only find it difficult to engage in an intimate relationship such as the one between therapist and patient, but they also are likely to solicit negative or rejecting therapist responses. The value of an open, flexible stance as opposed to relational control or rigid expectations on the part of the therapist is a consistent theme across much of the literature. The therapists who can complement the patient’s relational style and are able to demonstrate a capacity to collaborate (e.g., adopt the patient’s ideas; using the patient’s ideas or expressions) seem to have a better chance of guiding good alliances. On the other hand, therapists who were seen by patients as rigid or cold; were rated as less effective and had poorer alliances. Negative or rejecting transactions seem to have a particularly insidious impact on the alliance, and there are preliminary indications that such hostile therapist responses may be related to the therapist’s own negative introject. (Horvath, 2001, pp. 369–370)

Although numerous tools are available to measure the alliance, most therapists test the waters of the therapeutic alliance without the use of elaborate tools. One way is to ask the patient at the end of the first session: “How do you feel about working with me?” or “How did you feel about talking to me today?” or “How did you feel about coming here today?” Alternatively, the therapist can question the patient at the beginning of the next session: “How did you feel after the last session?” Patients may respond positively, or they may say something negative, such as: “My last therapist always was very involved, and I’m not sure you will be.” It is important to explore all negative feelings that the person brings up. Often, novice psychotherapists are hesitant to open up any suggestion of negative feelings with the patient for fear that the person will be more likely to leave treatment. The exact opposite is true; exploring the person’s negative feelings makes it much more likely that the person will stay in treatment (Norcross & Wampold, 2011).

Additionally, besides not exploring the patient’s negative feelings or thoughts about the therapist or therapy, ineffective qualities of the therapeutic relationship have been identified and include: the use of confrontation; therapist’s comments that are critical, rejecting, or blaming; therapists who assume they know what their patient is feeling or thinking without asking; and the therapist’s rigidity to a treatment method without adapting it to the person (Norcross & Wampold, 2011). Thus, balancing fidelity to the treatment protocol with flexibility to the person is essential. The more knowledgeable the therapist about various treatment approaches, the better able the therapist will be in accommodating the approach to the patient rather than allegiance to a particular therapy.

What is most important for the beginning psychotherapist is learning how to develop the therapeutic alliance. Strategies for initiating and maintaining the therapeutic alliance include asking detailed questions about the patient’s main concern, validating affect, explaining the therapy process as it unfolds, listening empathically without minimizing or offering “fix it” statements, and goal consensus and collaboration (Tryon

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& Winograd, 2011). Matching the therapist’s style to the patient’s needs (i.e., the therapist’s ability to be an “authentic chameleon”) facilitates the alliance (Lazarus, 1993). This requires the therapist to have facility in a range of techniques and a flexible repertoire of relationship styles to suit different patients’ needs and expectations. Essential relationship building skills have been identified by Perraud and colleagues in order to assess APPN students’ ability and are included in Box 4.1.

A search of the nursing literature on the therapeutic nurse relationship from 1996 to 2008 found 31 research studies that identified core attributes of the therapeutic relationship. The investigators found that a nurse–patient relationship in advanced psychiatric/mental health nursing could be deconstructed into nine main constructs: conveying understanding and empathy, accepting individuality, providing support, being there/being available, being genuine, promoting equality, demonstrating respect, maintaining clear boundaries, and having self-awareness (Dziopa & Ahern, 2009).

For some patients, physical safety is an issue, whether real or imagined. For the psychotic patient, fears of fragmentation and annihilation may be the norm (McWilliams, 2011). Even though psychotic patients may be compliant, it does not mean that they trust the therapist; they may adhere only out of fear of retribution if they do not. Clinicians who work with psychotic patients use various strategies to reduce the overwhelming anxiety experienced by these patients. Strategies include sitting farther away from the patient than usual, leaving the door open, taking as few notes as possible, giving information, communicating with emotional honesty and judicious self-disclosure, providing education, applying normalization, asking the person what would make him or her feel safe, assuming a more authoritative role, using simple communications, and creating opportunities for the person to demonstrate personal competency.

BOX 4.1

ESSENTIAL RELATIONSHIP-BUILDING SKILLS

Therapist Contributions to the Therapeutic Alliance Make the development of the alliance the highest priority early in therapy. Enter a collaborative partnership. Listen to the patient’s theory of illness and avoid reinterpreting it to match your own theory. Allow the patient to direct therapeutic choices. Attend to and address what the patient considers is important and relevant. Agree on interventions—only use those that you feel confident will work. Find out what the patient thinks would represent improvement. Tailor interventions and homework to accomplish goals set by the patient. Recognize attitudes and behaviors that cause patients to react negatively and avoid them. Explore patient hostility when it is directed toward you. Engage in supervision to explore relational difficulties. Be in touch with own experience of the patient. Respond honestly and sincerely.

Goal Consensus and Collaboration Skills

Use your clinical expertise to help patients clarify problems. Address topics of importance to patients that fit with why they feel they have these problems. Be an understanding and sympathetic listener. Discuss and agree upon goals frequently. Check on homework if given.

Modified and adapted from Perraud et al. (2006).

ASSESSING SAFETY

Assessing safety is of paramount importance in the initial contact. Every patient should be asked about suicidal or homicidal thoughts in the initial session. Although the patient with major depressive disorder usually is considered to be at particularly high risk, research has found that suicide is a risk for all persons with psychiatric disorders. Individuals with borderline personality disorder, substance use, eating disorders, or bipolar disorder have an equal or higher level of risk for suicide compared with those with major depression

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(National Institute of Mental Health [NIMH], 2013). A 10-year prospective study found that the total number of psychiatric disorders was more predictive of suicidal behaviors than any one psychiatric diagnosis by itself (Borges et al., 2008). The strongest risk factor for those who die from suicide is a history of previous attempts (Fowler, 2012). Other lesser but significant risk factors include a family history of suicide, interpersonal violence, relationship difficulties, recent discharge from psychiatric hospital, and social alienation. Demographic risk factors include males, single, elderly, adolescent and young adults, and Caucasian (Fowler, 2012).

Safety can be assessed with questionnaires such as the self-report Beck Depression Inventory (BDI), which has a question about suicidality, or a rating scale such as the Columbia-Suicide Severity Rating Scale available at http://cssrs.columbia.edu/docs/C-SSRS_1_14_09_Baseline.pdf, which has good normative data (Posner et al., 2011). In addition, an assessment tool, the Suicide Assessment Five- step Evaluation and Triage (SAFE-T) developed by SAMHSA (2012) and derived from the American Psychiatric Association Practice Guidelines, can be downloaded for free from http://store.samhsa.gov/product/SMA09-4432. The SAFE-T offers comprehensive guidelines that include an assessment of risk factors, protective factors that can be enhanced, and a scale to determine the level of risk and possible interventions. See Box 4.2 for the SAFE-T. If an assessment tool is used, open interview questions should follow up on all positive items.

Research indicates that using both self-report and interview methods may be the best way to ensure accuracy, because some patients are thought to prefer the anonymity of a self-report form and the interviewer may get a negative response even though the patient is suicidal. Several questions can be asked: “Do you ever experience hopelessness or suicidal thinking?” “Do you ever think of hurting yourself?” Asking about suicide ideation does not give the person the idea or increase suicide risk. Most people are relieved to be able to discuss openly the painful feelings they have been struggling with in private. If the patient answers in the affirmative, the therapist can ask follow-up questions: “Do you have a plan?” or “How would you carry out a suicide?” This information is pursued because the more specific the plan, the more likely the person is to hurt himself or herself. Asking for specificity helps to determine the seriousness of intent.

Even so-called parasuicidal behaviors, such as cutting and self-mutilation, should be taken seriously. Understanding the person’s underlying motivation for self-harm is important. Briere (1996) makes a distinction between those who self-mutilate in an attempt to stay alive and those who attempt suicide and consider death a solution. Parasuicidal behaviors may reflect a reenactment of abuse dynamics with a physiologic basis associated with poor attachment and early abuse (van der Kolk et al., 1996). Chapter 2 describes the neurophysiology associated with reenactment of early trauma. These reenactments may be experienced as normal because they mirror early experiences. The person with borderline personality disorder may want attention in the context of an abandonment crisis and may escalate the threat and self-destruct in a desperate bid for attention. Because these individuals may be suicidal in the context of an abandonment crisis, talking about the loss sometimes may be enough to assuage the suicidal feelings.

The therapist must openly and honestly express concern and engage in problem solving with the patient so that a written plan can be developed. This collaborative plan should explicitly address the friends and community resources that would be available in an emergency so that the patient can be safe. A safety plan should be developed for all patients who are thought to be at high risk for self-harm. Guidelines developed by the International Society of Study for Dissociative Disorders (ISSD) with respect to suicidal behaviors can be applied to all patients who are at risk for self-harm. These guidelines include developing a safety plan that consists of a hierarchy of alternative behaviors, such as contacting friends, self-hypnosis, grounding techniques, medications as needed, and calling the therapist and waiting for a return call and/or going to the emergency department if the patient feels imminently unable to maintain safety (ISSD, 2011). Although a safety plan and attention to protecting the life of the patient are paramount, it is important that the APPN is careful to avoid chronic crisis management as the purpose of the treatment. For example, one well-intended recent graduate adopted the role of constant savior and asked her patient to call her every morning to ensure her safety. This backfired because the patient ultimately viewed this as a strategy to relieve the therapist’s anxiety and many frantic moments were spent on the part of the APPN attempting to call the patient when she had “forgotten” to call.

From a clinical and legal perspective, a written safety plan or a no-suicide contract, even if signed by the patient, is not a substitute for clinical judgment. Accurate assessment is imperative because the typical no- suicide contract may not be effective in a crisis situation, whether the patient is in the hospital or the community (Garvey et al., 2009). A safety contract is only as good as the therapeutic alliance. Safety may be especially compromised if the patient is inebriated or psychotic. Although nurses are used to dealing with life and death situations, they usually do not occur in private practice or without others around to help. The

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therapist is often in just that situation and must make decisions independently. It is safest to err on the side of caution and believe the intuition that tells you the person may hurt himself or herself. Suicidal patients should be hospitalized immediately if the family or significant others cannot guarantee safety and the safety plan cannot be adhered to. The clinician must ensure that the patient is safe and may need to personally escort the patient to the emergency department if needed.

BOX 4.2

SAFE-T

1. RISK FACTORS Suicidal behavior: history of prior suicide attempts, aborted suicide attempts, or self-injurious behavior Current/past psychiatric disorders: especially mood disorders, psychotic disorders, alcohol/substance abuse, attention deficit hyperactivity disorder (ADHD), TBI, PTSD, Cluster B personality disorders, conduct disorders (antisocial behavior, aggression, impulsivity)

Co-morbidity and recent onset of illness increase risk Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, global insomnia, command hallucinations Family history: of suicide, attempts, or Axis I psychiatric disorders requiring hospitalization Precipitants/Stressors/Interpersonal: triggering events leading to humiliation, shame, or despair (e.g. loss of relationship, financial or health status—real or anticipated). Ongoing medical illness (esp. CNS disorders, pain), intoxication. Family turmoil/chaos. History of physical or sexual abuse. Social isolation

Change in treatment: discharge from psychiatric hospital, provider or treatment change

2. PROTECTIVE FACTORS Protective factors, even if present, may not counteract significant acute risk Internal: ability to cope with stress, religious beliefs, frustration, frustration tolerance External: responsibility to children or beloved pets, positive therapeutic relationships, social supports

3. SUICIDE INQUIRY Specific questioning about thoughts, plans, behaviors, intent Ideation: frequency, intensity, duration—in the past 48 hours, past month, and worst ever Plan: timing, location, lethality, availability, preparatory acts Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun) vs. non-suicidal self injurious actions Intent: extent to which the patient (1) expects to carry out the plan and (2) believes the plan/act to be lethal vs. self- injurious. Explore ambivalence: reasons to die vs. reasons to live

4. RISK LEVEL/INTERVENTION Assessment of risk level is based on clinical judgment, after completing steps 1 through 3 Reassess as patient or environmental circumstances change

5. DOCUMENT Risk level and rationale; treatment plan to address/reduce current risk (e.g., medication, setting, psychotherapy, ECT, contact with significant others, consultation), firearms instructions, if relevant; follow-up plan. For youths treatment plan should include roles for parent/guardian.

For Youths: ask parent/guardian about evidence of suicidal thoughts, plans, or behaviors, and changes in mood, behaviors, or disposition. Homicide Inquiry: when indicated, especially in character disordered or paranoid males dealing with loss or humiliation. Inquire in four areas listed above.

Other safety issues may need consideration, including the anorexic patient who is severely underweight (20% below the expected weight for the patient’s height) (Sadock & Sadock, 2007); substance abuse patients who may overdose or pose a threat to others if inebriated and driving; actively self- mutilating patients; sexually promiscuous patients; and angry patients who want to hurt others. Each of these situations must be the first order of business in any treatment setting. Any acute mood disorder or psychosis, out-of-control substance abuse, or eating disorder may need to be treated in an inpatient program before traditional psychotherapy begins. If the patient comes to the session inebriated or high, the session should not be held, and the patient may need to be escorted to a safe place by the therapist, sent home in a taxi, or have a

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friend or family member called to escort the person home. The therapist’s safety must also be assessed. Some patients may be threatening, and the best predictor of

violence has been found to be previous violent episodes (McWilliams, 2004). Often, intuition can tell you whether the patient may be violent, and it is better to err on the side of safety than to dismiss your feelings. Leaving your office door open and making sure that you are near the door may be warranted when working with hostile, unpredictable people, or it may be prudent to interview patients with a security guard nearby or with a colleague if you are working in a dangerous setting. One patient came to his session with a gun, which he told the APPN about. He was asked to leave the gun at home for future sessions, which he agreed to, and psychotherapy proceeded as planned.

THE FIRST CONTACT

APPNs work in varied public and private situations, such as inpatient psychiatric settings, inpatient medical settings, outpatient community mental health centers and mental health clinics, residential care facilities, integrated behavioral care settings, intermediate and skilled nursing facilities, juvenile and criminal justice settings, private practice, primary care and medical outpatient settings, home care, managed care, homeless shelters, substance abuse units and programs, emergency or crisis settings, partial hospital settings, medical homes, and in rural, suburban, and urban areas. The unique practice setting determines how the initial contact with the patient unfolds, and the specifics of each cannot all be covered in this chapter. Guidelines and policies for the particular practice setting should be followed. Aspects of the suggestions offered here may be incorporated into specific settings, if applicable. However, the following discussion is probably most relevant for therapists in outpatient settings where psychotherapy is practiced.

The initial phone call is most likely from the patient seeking help, but it occasionally may be from a friend, family member, or professional colleague. It is important to speak to the patient directly, even if someone else has made the first phone call. To avoid telephone tag, it is helpful to leave a message with several times of the day and a number where you can be reached, as well as requesting that the person leave a message with a telephone number and the times when he or she can be reached if he or she has trouble reaching you. It is better to leave your first and last name when returning a call because the person may not want others who live in the house to know that he or she is seeking help. Recording a “Dr. Wheeler called” message on the patient’s answering machine may leave the person in the uncomfortable situation of explaining to others when he or she does not wish to.

During the initial phone call, the therapist is already gathering information and begins the therapeutic alliance. Keeping the initial phone call as brief as possible is advised unless there are special circumstances. Occasionally, someone may ask whether you specialize in a particular problem or have had experience in a certain area, such as eating disorders or trauma. Answer the question factually, and refer the person elsewhere if that is warranted. Although at first you may not know what your areas of expertise are and feel you have none, it is probably best for you and the patients to start with populations and approaches with which you feel most comfortable. Knowing your own limits is essential, as is not using modalities with which you have little expertise, such as hypnosis, guided imagery, eye movement desensitization and reprocessing (EMDR), or expressive therapies, because in incompetent hands, patient regression may be triggered, and the blurring of fantasy and reality may occur.

If the person launches into a detailed description of the problem over the phone, it is appropriate to say that it would benefit the prospective patient to come in and set up a mutually agreeable time for the first session. Most therapists do not ask about insurance or other specifics on the phone unless the patient asks for information regarding insurance or asks about fees or unless the therapist’s agency requires that specific information ahead of the appointment. Others feel that it is important to discuss financial issues before committing to see the patient, because clarification of how the therapy will be paid for saves time for the patient and the therapist. Patients may not understand the terms of their insurance and may need to call the insurance company before setting up an appointment. Issues regarding which providers are covered, the number of sessions, co-pays, parity diagnoses, and preauthorization, may need to be explained first to allow the person to ask appropriate questions. Some APPNs make the phone call to the patient’s insurance to ensure that the terms of reimbursement are clear before agreeing to see the patient. Another decision that needs to be made is whether to charge for the initial consultation. Some therapists do not charge for consultations, and the patient should be told whether you do or do not charge for the first session. Tell the person the times you have available, and end the conversation by giving directions to your office after an

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agreeable time to meet has been decided. The patient comes to the first session with expectations, even if the person has never been in

psychotherapy before. Some of these expectations are conscious and some are not. Expectations can tell you about the person’s developmental level and what may be going on in the person’s relationships. For example, some patients with magical thinking fully expect to have their problems solved in a few sessions; those with dependency needs may expect to be taken care of or to be given advice; those who have been criticized expect to be disapproved of or judged; and those who eroticize relationships may expect the therapist to have sex with them. Sometimes, asking the person how he or she feels about coming to the session can help to elicit some idea of expectations. Asking if the patient has ever known anyone who was in therapy can also give valuable information about expectations. The patient may have known someone who was greatly helped by psychotherapy or may associate treatment with Woody Allen and endless, self-absorbed neurosis. Some therapists elicit this information by giving the patient an intake form, such as the Multimodal Life History Inventory (Lazarus & Lazarus, 1991). This questionnaire contains questions that address patients’ expectations regarding therapy. What do you think therapy is all about? How long do you think therapy should last? What personal qualities do you think the ideal therapist should possess?

If your office shares a waiting room, and you have not met the patient before, it is best to ask those in the room “Are you waiting for Kate Wheeler?” Doing so ensures that you will not be divulging the person’s name to all those sitting there. In that way, the person can say yes without a breach of identity disclosure. Even the simple gesture of shaking hands is important to think about. If it is the therapist’s custom to shake hands, and she naturally extends her hand to the patient, the patient may feel uncomfortable. It is better to take the lead from the patient. For patients who extend a hand, by all means shake hands. For a patient who does not offer, following his or her lead may allow the person control and to feel more comfortable. After the patient enters your office, asking what he or she would like to be called is a courtesy that sets a collaborative tone at the very beginning.

The therapist’s office and seating arrangements are considered with respect to keeping the patient’s best interests in the foreground. Seating arrangements may be constrained if you are seeing patients in a clinic setting, but it is usually best not to sit behind a desk because this puts a barrier between you and the patient. However, sitting at the desk with the person on one side of the desk may be conducive to conversation. Ideally chairs are set at approximately 3 to 4 feet away from each other and arranged so that the person is not directly across from you but at a 45-degree angle. In this way, the patient does not feel scrutinized and compelled to make eye contact and can look away if he or she wishes.

It is not appropriate to have your family pictures visibly displayed in the office. They may be comforting to you, but they may be distracting to the person seeking help and do not serve a therapeutic purpose for the patient. A clock can be placed across from the therapist’s chair, so it can be easily seen unobtrusively by the therapist, or it can be placed where both the patient and therapist can monitor how much time is left in the session. Phone calls are not taken during sessions, and all phones and beepers are turned off. This is the patient’s time, and it is courteous to ensure that the patient is the center of attention for the entire session. On the rare occasion when you are working with a professional or personal emergency, it is advisable to tell the person at the beginning of the session that you may be interrupted and to apologize. In most instances, a quiet, confidential setting where you will not be interrupted is imperative.

There are several ways to begin the session. “What brings you here?” usually gets the ball rolling, although for a very concrete-thinking patient, the answer may be “the bus.” “What is going on that you are seeking help now?” or “How would you like to start?” may also be an effective way to begin. “How can I help?” may feel patronizing to the patient and implies something less than a collaboration. Small talk for a moment, such as asking if the person had any trouble finding the office, can be appropriate to put the person at ease because the last contact most likely was on the phone when directions were given. When the person is in the office and the APPN is ready to begin, the type of setting will determine how best to proceed.

The intake or first session for the patient may last for the usual 45 to 50 minutes to 1.5 hours, depending on the clinical site. In some settings, a different therapist does the intake, and the patient then may be assigned to another therapist, or sometimes, the same therapist may do the intake and continue with the person in therapy. If you are serving as the intake therapist in a setting in which forms must be completed by the patient, it may expedite the process to leave the forms with the receptionist so that as much information as possible is obtained before your meeting. Much of the information needs to be gathered initially, and if you do not have a receptionist, perhaps some of the assessment and intake forms can be mailed to the person ahead of time before the first session. Some APPNs give the patient forms to take home at the end of the first session and ask the person to bring them back the next week. In that case, the first session is used to gather only preliminary information and assess safety. Many therapists in private practice leave the first session less

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structured because this allows the person to tell his or her story in an unstructured way, and it can be invaluable in accomplishing one of the most important tasks of the first session: initiating a therapeutic alliance.

For those who work in settings in which a comprehensive assessment is required in the initial session, Chapter 3 provides guidelines on how to accomplish this while effectively initiating a therapeutic alliance. For those who are in settings in which the assessment can be conducted over several sessions, Chapter 3 provides excellent resources and screening tools to incorporate to ensure a thorough and accurate assessment. If you are the prescribing advanced practice nurse only, guidelines for assessment on how to combine medication management with or without psychotherapy are discussed in Chapter 15. No matter what type of setting you are working in and how you proceed, practical arrangements for continuing the work, establishing goals, ending the session, and keeping records must be considered.

Making Practical Arrangements

Practical arrangements must be made regarding the frequency and length of the sessions. Weekly sessions of 45 to 50 minutes are usually scheduled unless there is a significant reason to deviate from this standard plan. The session begins and ends at predetermined times. Meeting less often usually is not as effective and interferes with the momentum of treatment, unless the goal of treatment is maintenance of the status quo or the APPN is prescribing only and another person is conducting the psychotherapy. It may be best to see the patient more often initially if you are concerned about safety or the person is in crisis. However, starting several times a week often is too intense for most people and may be threatening and counterproductive. The number of sessions per week may be increased after a solid therapeutic alliance is formed and the patient wishes to intensify the work for faster resolution.

Some brief and cognitive psychotherapists advocate setting a termination date at the beginning of treatment, because it is thought that if the ending time is known, the goals and work may proceed faster. Toward the end of the time set, there can be renegotiation if more time is needed. Guidelines and principles for short-term psychotherapy are further discussed in Chapters 5 and 10. Sometimes, therapists prefer to allow the process to unfold and leave the termination date open-ended unless there is a specified number of sessions that the person is allowed by the insurance company or there are agency constraints. Frequently, what the person initially came to therapy for evolves into something somewhat different as the process unfolds, and goals are revised periodically. For example, one man came into treatment because he felt depressed and unhappy with his work. As this was explored, he began to examine his long-standing dysthymia and how this related to a childhood traumatic experience that had violated his trust and impacted all dimensions of his life. The goals then focused on resolving his early trauma in light of his deepening awareness of its significance.

A Health Insurance Portability and Accountability Act (HIPAA)–type form explaining confidentiality and a contract delineating the terms of the psychotherapy can be given to the patient (see Appendices 4.1 and 4.2), along with the packet of screening and assessment tools and can be signed and brought back to the next session. Some therapists also have a policy statement, posted in the waiting room, which describes consumer rights, confidentiality, missed sessions, and fees. A sample is available at www.guidetopsychology.com/compol.htm. Confidentiality is discussed, and whether you will be discussing information about the person to a supervisor or other health care providers is disclosed. Permission for these discussions is authorized with a written release of information form, and care is taken to use discretion and reveal only what is necessary for medical care. If a treatment report requesting more sessions is to be sent to an insurance company, the form may be shared with the patient before sending it. In discussing patients with colleagues or in a professional forum such as a conference or paper, use a pseudonym or initial, and disguise identifying information to protect the person’s identity. Even though the person’s identity is kept confidential, permission should be obtained from the patient unless the information shared is an amalgam of cases and is not specifically about the patient. Permissions can also be explicitly stated in the initial treatment contract so that additional permissions are not needed. A formal Informed Consent is required in some states; however, keep in mind that a written document signed by the patient does not demonstrate that informed consent has been obtained because it does not demonstrate the patient’s comprehension. General risks and benefits should be discussed with the person and documented in the patient’s records that such a conversation took place. Informed Consent specifically for nurse psychotherapists has not been addressed by our professional organizations but Ken Pope’s website provides guidelines from other organizations about requirements. See http://kspope.com/consent/index.php and the sample of a practice contract in Appendix

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4.2. Confidentiality should be respected in all situations. That is, the APPN should not discuss the patient to

the person’s family members or spouse. If a family member calls and is concerned and wishes to tell the APPN something about the patient, the APPN can listen but is obligated to explain that therapy is confidential. The patient should also be informed of the family’s concerns and call so that transparency between the therapist and patient is preserved. Of course, if the patient is a minor, this may change depending on the circumstances and the state law. If the APPN sees the patient in a public setting, it is best to not acknowledge the person’s presence unless the patient says hello first. When asked by anyone for information about the patient, it is best to consult with an attorney experienced in mental health law before complying. Confidentiality should never be broken unless the patient is a danger to himself or herself. If you are concerned that the patient is a threat to others, it is important to document your assessment of the patient and to follow through if the risk is high. Every state has statutes about the duty to report when a patient is a risk to others, and it is important to be aware of your state’s laws about how to manage these patients safely. The APPN is legally bound to report patients she suspects are abusing children to child protective service agencies, those who abuse the elderly to adult protective service agencies, and those threatening violence to the police. Familiarity with state statutes and services is essential, and the novice APPN should seek legal advice and consultation from the state board and professional associations before releasing any confidential records or filing a report with any agency.

Practical arrangement and issues relating to ethics, confidentiality, and scope of practice have become more complex with the advent of telepsychiatry for APPNs who wish to use technology to conduct psychotherapy or prescribe medications. For an overview of the use of Skype in tele–mental health, see www.zurinstitute.com/skype_telehealth.xhtml#top. Prescribing and conducting psychotherapy for those who live out of state must be in compliance with the state regulations in which the patient resides and it is prudent to check with the respective state board of nursing before teleconferencing, skyping, or prescribing. In addition, other issues are important considerations and are included in Box 4.3.

Fees

Fees should be discussed during the first session. Novice nurse psychotherapists often feel conflicted about charging a fee for their services when they do not feel knowledgeable about what they are doing. Fees should reflect the level of education, the degree of expertise, and the going rate in the community for such services. Sometimes, beginning therapists overlook the extensive education and training required to do psychotherapy and the fact that to take care of the patient’s emotional needs, it is necessary to get paid for their professional services. You may decide to offer a certain percentage of your patients a reduced fee, but having a pro bono practice in which you are paid by most of your patients less than others in your area is a recipe for resentment. Each therapist should decide on the basis of her finances whether a certain number of patients can be offered a lower fee and then fill that number of hours with low-fee or sliding-scale patients and refer others who cannot afford the standard fee to a low-cost clinic.

BOX 4.3

TELEPSYCHIATRY

There are three major issues associated with Skype or any form of videoconferencing that are not well understood. The difference is between public media videoconferencing and professional media videoconferencing.

I. All health care professional use videoconferencing must be HIPAA compliant, which requires that access to the system/software requires a unique identifier (user name) and a password for protection. Almost all videoconferencing systems do this.

What is not done is related to the Federal Information Processing Standards 140-2, sometimes referred to as CMS (Medicare Rule) 140-2. This can be found at www.hhs.gov/ocr/privacy/hipaa/enforcement/cmscompliancerev08.pdf

This set of regulations required that all professional use meet the HITECH Act regulations. These can be found at www.emrandhipaa.com/tag/fips-140

Although at first glance, these regulations appear intimidating, they are really quite simple. The rules for use are:

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1. Is the software videoconferencing HIPAA compliant? 2. Is the software FIP 140-2 or CMS compliant?

II. The 140-2 rules are a standard of encryption beyond the AES (Advanced Encryption Standard). The new 140-2 regulations require an internal program that mathematically encrypts the transmission of all sensitive information, including patient records, and patient information at one of four levels… which is based on the system used by the Pentagon. Although daunting, one only has to check and see whether the software uses the 140-2 standard as it should run smoothly within the background. This requirement is one of the major problems associated with noninstitutional use of videoconferencing for psychiatric mental health issues. Most institutional IT departments run these programs in the background and users are seldom aware of the presence of the security features. This is not true with the public social media based videoconferencing, which although convenient, is not secure and violates the regulations. There are significant federal fines for breaking these rules.

These rules are incorporated into all states’ regulations on reimbursement for telehealth services. So it is wise to check with the state regulations on telehealth and what can and cannot be reimbursed within a state.

An additional concern is the terms and agreements of the public videoconferencing platforms. If the terms and agreements state that the company stores information and shares it with business partners, then it is not owned by the care providers any longer.

III. A final issue is the use of clinical standards of care. These are outlined in the American Telehealth Association for Videoconferencing. These can be found at www.americantelemed.org/practice/standards/ata-standards- guidelines/videoconferencing-based-telemental-health

In summary, although this may seem daunting, it is just a set of simple checks.

1. Is the system HIPAA compliant? 2. Is the software 140-2 encrypted? 3. Does the state allow reimbursement for this service under the state telehealth act? 4. Are the clinical guidelines followed? 5. Does the software provider store the information or allow it to be erased once the session is completed?

Contributed with permission from Michael Rice, PhD, APRN-NP, FAAN from American Psychiatric Nurses Association Discussion Forum, May 17, 2013.

In agency settings, collecting fees is often taken care of by others, and it is not until the therapist is in private practice that collecting fees becomes an issue. In either setting, being clear about the fee and when payment is expected is part of the frame and should be discussed in the initial session. If you are in private practice or a setting that requires that you discuss fees with the person during the initial visit, information about the patient’s insurance may need to be obtained by you. Usually, a limited number of sessions are authorized, sometimes after the deductible is met, and an outpatient treatment report (OTR) is required after the allotted number of sessions. This should be discussed with the patient, because many therapists believe that the OTR violates patient confidentiality and that the person should know what information will be provided to the insurance company. Sometimes, a creative solution can be worked out if the person already has a high co-pay with a managed care company that you are not a provider for. For example, seeing the person 30 minutes instead of the usual 45 to 50 minutes and charging one half of your usual fee may allow the person to pay about the same fee as he or she would if using the managed care company. In that way, the person can be seen for a shorter session and reduced fee, and confidentiality is preserved.

If the therapist is on the provider panel for a managed care company, the provider is contracted to charge a particular fee, and the patient pays a specified co-pay. Most therapists require payment at the end of the month for that month or the first session of the next month for the previous month. Other therapists expect payment at the end of each session. The provider submits the balance to the insurance company on an HCFA form and then gets paid by the managed care company or insurance company usually a month or more later. Psychotherapy sessions are given Current Procedural Terminology (CPT) codes that designate the type of service given for billing and documentation for all insurers. These codes were revised as of 2013 in an effort to better reflect the complexity and level of care for patients. See Chapter 19 for how to use these codes for reimbursement.

For those patients who do not have insurance or where the therapist is not a provider on the panel for the insurance they have, the fee may need to be paid by the patient out-of-pocket. In these cases, usually the patient pays the provider directly. The patient then is responsible for submitting the bill to the insurance company so that he or she can get reimbursed. Most therapists prefer this method of payment as it helps to avoid tracking down claims, wasting time on the phone with managed care companies, and trying to get paid for services already rendered. Whatever method you decide to use for payment, it is best to keep when and how you get paid consistent for everyone to avoid confusion for yourself.

Whether you charge for missed sessions is important information to share during the first session. A

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cursory survey of colleagues reveals that most APPNs in private practice do charge for missed sessions; some charge only for those who do not call and do not show up, whereas others charge if they do not receive 24 or 48 hours’ notice and cannot reschedule for later that week. The idea behind charging for missed sessions is that the session time is rented much as a person would pay money for classes even if the person does not attend. The therapist has saved this time for the patient and should not be penalized financially for the patient’s absence. Paying for missed sessions also emphasizes the importance of psychotherapy. Just as a person should not arbitrarily decide to not take a medication that was prescribed, psychotherapy is a prescribed treatment modality and, as such, is valuable. Some therapists feel that charging for missed sessions conveys to the patient the importance and value of their work together.

If the person cancels or does not come because of weather problems or significant illness, many therapists do not charge for the missed session. Most insurance companies do not allow reimbursement for missed sessions. If you are charging, be sure to state the specifics in the contract with the patient, and do not charge the insurance company because this violates the policy of most provider agreements. Many agencies do not have a cancellation policy and do not charge for missed sessions, and this may explain the high number of absences in such settings. Policies about attendance, missed appointments, and fees in the form of a contract should be provided to the patient at intake and should be signed by the patient.

Establishing Goals and Ending the Session

About 10 minutes before the end of the session, it is a good idea to ask the person whether he or she has any questions. Then give the patient a brief idea without psychiatric jargon about what you think may be going on and what may help. For example: “From what you have told me, you have suffered several significant losses in the past year, and this could account for the difficulty concentrating, the sadness, and the trouble sleeping that you have been having. I think it would be helpful to come and talk about what has been going on for you. I would like you to take some forms home with you to fill out this week, and over the next few sessions, I will be asking you additional questions so I can get to know you better. This will help me to determine what is the best way to help you.” Conveying hope is also important, for example: “As you talk about some of these losses and begin to feel better, I have a hunch your sleeping will improve too.”

The therapist then discusses the goals of treatment by asking the person: “What you would like to get out of this?” or “How would you like your life to improve?” or “What would you like your life to be like?” These are all open-ended questions that assist the person in formulating goals. Patients passively receiving suggestions fare far worse than patients who are actively involved in goal setting. Arriving at some consensus on therapy goals at intake helps the therapeutic alliance and engagement, which increases the probability that the patient will return after the initial session and will continue treatment. If the patient wants behavioral exercises between therapy sessions and the therapist is psychodynamically oriented, it will be apparent that there is a disagreement about therapy tasks at the outset, and these differences need to be explicitly negotiated. The therapist and patient need to jointly decide goals and reevaluate them together throughout therapy. Reflecting on your understanding of what the patient said helps to strengthen the alliance, and the person knows that you are listening and that you are on the same wavelength.

Although establishing goals is important, Gabbard (2010) cautions against the therapist being too wedded to goals, because the patient may begin to feel that the emphasis on attaining goals is the therapist’s agenda and comply to please the therapist. Alternatively, the therapist who is too eager to achieve goals may elicit a stubborn resistance by the patient, who wishes to defeat the therapist by not changing. As a wise supervisor once told me: “The therapist should not be the most motivated person in the room.” The therapist should not be too eager and respect the patient’s ambivalence. Safran and Muran (2000) concur and place change in a framework of mindfulness. They state, “… change merges out of nonjudgmental awareness, rather than through trying to force things to be different” (p. 116). A basic tenet of communication is to emphasize awareness rather than change.

Keeping Records

Taking notes during a session is a matter of individual preference. Sometimes, novice therapists take verbatim session notes and go over everything with a supervisor so that nothing will be missed that may be important

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because everything seems potentially important. This can be very distracting and distancing from the person sitting across from you. It is better to listen attentively, perhaps writing occasionally a word or two to pique your memory for constructing process notes that are more elaborate after the session. It is important to keep two sets of notes:

1. Process notes that include what you think is going on in terms of transference and countertransference, topics discussed, questions about your own intuition, issues for discussion during supervision, or verbatim notes, particularly about a difficult or problematic interaction.

2. A more formal record of the treatment progress with the diagnosis, level of care, history of present illness, review of symptoms, past, family, and social history, examination components, medication reactions, suicidal thoughts, treatment decisions, and a description of the session for that particular session. These should be brief and respectful of the person’s confidentiality. See Chapter 19 for an explanation of these components based on the 2013 CPT codes.

The formal progress notes are kept for legal purposes or for review if mandated by a managed care or insurance company for quality auditing while the process notes do not need to be delivered if there is a legal action or a medical record is requested. Examples of process and progress notes can be found in Appendices 4.3 and 4.4.

THERAPEUTIC COMMUNICATION

Psychotherapy is considered the talking cure, and therapeutic communication skills are the hallmark of good psychotherapy. Nurses have learned communication skills as undergraduates and most likely have been talking to patients for years. However, as with any new role, the novice APPN psychotherapist may be anxious and forget what she or he already knows, and a review of therapeutic communication may be helpful. Therapeutic communication is embedded in the holistic model of nursing, with the overall aim of promoting integration toward the goals of wholeness and healing. This is accomplished by assisting the person in experiencing and expanding thoughts, feelings, and actions that enhance resources or processing. Therapeutic communication can be accomplished through the use of open-ended therapeutic communication techniques with the specific aims of promoting self-understanding and self-acceptance and of enhancing strengths. There is a vast literature on humanistic therapies such as Gestalt, patient-centered, and existential approaches to helping people become more connected with their feelings and more comfortable with expressing themselves directly (Wachtel, 2011) (see Chapter 10). Most therapies encourage the patient to talk nondefensively about his or her emotional experiences, and through the ambient environment of a supportive, nurturing relationship, a narrative of the person’s life unfolds.

The elements of psychotherapy as described in Chapter 1—caring, connection, narrative, and anxiety management—provide the parameters for communication. Good communication is all about context and relationship. Therapeutic communication competency is based on the ability to listen nonjudgmentally, facilitate the patient to talk openly, and respond appropriately to what the person says. The psychotherapist assists the person in clarifying feelings and meanings and guides the person into areas that may not be fully conscious to enhance coping skills, deepen self-understanding, and improve the ability to make decisions. The patient does most of the talking, and the focus is on the patient’s concerns. One criterion of effective communication is whether what you say enables the patient to speak more freely. If you are talking more than 10% to 20% of the time, it becomes your session, not the patient’s. When you begin to feel concerned about what you are going to say, remember that less is best. During sessions, the therapist typically uses short sentences rather than long-winded explanations. Lengthy explanations have the potential for increasing the anxiety level of patients, especially during the initial session.

Barriers to listening include an emphasis on gathering information or getting the facts, giving information, and the therapist’s bias and judgmental attitudes. For example, suppose you are listening to someone talk about an abortion with a cavalier attitude and you are pro-life. How would you hear what the person said? Alternatively, suppose you are an atheist, and the patient talks about reading scriptures every day and the solace that this brings him or her. Would you judge the person as being too religious? Everyone has prejudices and attitudes, and it is important for therapists, through supervision or their own therapy, to be aware of their attitudes and how they may interfere with their work with the different people encountered in practice. A respectful, nonjudgmental stance is essential for the development of rapport and connection.

Gabbard (2010) says that therapeutic communication interventions exist on a continuum from expressive

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to supportive. Those communication techniques that are most expressive are used by psychodynamic therapists to provide understanding and insight for processing while supportive interventions are less emotionally laden. This conceptualization is useful and applicable to the treatment hierarchy triangle described in Chapter 1. Some interventions, such as focusing, observation, immediacy, and interpretation may be emotionally arousing and are more likely to be employed for patients who are higher on the treatment hierarchy triangle, whereas patients needing stabilization are more likely to require more supportive techniques, such as broad openings, information giving, giving recognition, restating, clarification, and reflection. However, techniques considered more supportive and needed for stabilization are also used for processing, but the expressive techniques higher on the treatment triangle are most often used for processing, not stabilization.

Communication techniques used for processing may trigger implicit neural networks, and without the proper resources, may be experienced as overwhelming, unmanageable feelings. The supportive techniques are more likely to be resource building and less anxiety provoking. Cozolino (2002) speculates that supportive communication optimizes cortical executive functioning as the patient is invited and supported to experience a wide range of emotions. He states, “This simultaneous activation of cognition, emotion, enhanced perspective, and the emotional regulation offered by the relationship may provide an optimal environment for neural change” (p. 53). Figure 4.1 shows the treatment hierarchy triangle as outlined in Chapter 1 with the continuum of therapeutic communication.

It is not important to know the names of these techniques or to memorize each one, but a review and discussion may help the beginning psychotherapist to identify which skills he or she uses now and how to expand this repertoire of communication skills to include others. Each of us must find words that feel genuine so that we do not sound stilted and mechanical. The examples listed in Table 4.1 assist in advancing the psychotherapeutic process and are embedded in the context of attending and listening, empathy, and exploration. Selected techniques are discussed as they relate to these processes of therapeutic communication. All techniques are included in the following discussion; however, those higher on the treatment triangle are most likely not used in the initial session.

Attending and Listening

The APPN psychotherapist attends and listens by paying close attention to what the patient is saying verbally and nonverbally. Therapists think of the manifest content as what patients are actually saying, whereas the latent content is what they mean by what they say, or the process. This dichotomy has also been referred to as explicit versus implicit communication. Often, a session or a series of sessions has a latent theme in the foreground, such as issues relating to trust, loneliness, abandonment, feelings of helplessness or inadequacy, or anger toward authority or about the carelessness of others. The therapist listens and hears the central issues and themes. Even though there may be manifest and latent content, the therapist most often does not directly address latent themes with the patient, but hearing and attempting to deepen understanding of the issues that the person is struggling with are relevant no matter what orientation or model of psychotherapy the therapist subscribes to. For example, a patient came to his session railing against authority figures he felt were controlling and unreasonable. This is the manifest content, whereas the latent content may relate to his feeling, perhaps unconsciously, that the therapist is authoritarian and controlling. It does not necessarily mean that the therapist is authoritarian and controlling, but for this person who is in a dependent position at this time, state-dependent neural networks of anger and resentment about helplessness or dependency from a past relationship are activated. The emotional arousal and novel sensory experience inherent in the psychotherapeutic process trigger implicit memory networks, or transference.

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185FIGURE 4.1 Treatment hierarchy and continuum of therapeutic communication.

TABLE 4.1 Selected Therapeutic Communication Techniques Technique Example Broad opening Where shall we begin?

Information giving I recommend that you take this medication at bedtime because it may make you feel tired.

Giving recognition You were able to do well this week with the goals we set last week.

Restating You cannot study and have trouble concentrating.

Suggestion It may help to keep a journal of your thoughts this week.

Clarification Would you tell me more about what you mean by “upset”?

Reflection You are asking me what to do about your wife’s drinking and are very frustrated by the situation.

Exploring How did you feel when your friend said that to you?

Focusing Yes, your relationship with your mother is important, and it may help you understand better what goes on for you in other relationships by discussing this further.

Observation It seems that whenever you begin to talk about your mother, you change the subject.

Immediacy Perhaps you are feeling that I am not giving you what you need here. Interpretation From what you have told me, it seems that when you get close in a relationship, you become anxious

and then protect yourself by finding fault with the other person.

Transference refers to the patient’s thoughts, feelings, and behaviors that are associated with early important relationships with caretakers and significant others and that are felt toward the therapist. Transference reflects state-dependent memories of specific physiologic states of consciousness from the past. These neural networks are activated by the therapeutic relationship. Transference is ubiquitous and reflected in the way the patient acts, talks, and feels about the therapist. For example, a patient who is attending sessions regularly on time and is eager to share experiences and feelings most likely has a positive transference, and a person who is late, is reluctant to talk, and sits guardedly in sessions most likely has a negative transference. These are polarized extremes to illustrate vivid examples of transference, but most transference manifestations are much more subtle and complex.

There may be many different transference constellations and nuances over the course of treatment. The patient most likely is unaware of these feelings as transferential, especially at first, and it is often difficult for the novice therapist to identify them as well. Listening and responding empathically is usually the best strategy for any negative feelings that may arise. For example, one patient came to his initial session sullen and with arms crossed and informed the therapist that he did not trust her. Because the therapist had never seen this person before, the therapist first explored his feelings about coming. It is important to ascertain first whether the patient was forced to come, was responded to in a timely way when he called, or has any other reality-based reasons for the sullenness. If there seems to be no reality-based reason that needs to be addressed first, the therapist may understand his attitude as transferential. This can provide important information about the dynamics of this person. The therapist may empathically comment: “It may be hard to trust someone whom you do not know, and it makes sense to not trust me until you get to know me better.”

If the transference is positive, it does not need to be addressed with the patient no matter what psychotherapy approach is used. Only if the therapeutic alliance is threatened or the transference is negative does the therapist explore with the person his or her feelings. Once the patient feels understood and validated, an adverse transference or alliance rupture is often dissipated. In some psychotherapy approaches such as

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psychodynamic, negative transference is addressed as an alliance rupture and that is the primary work in the treatment (Safran, Muran, & Eubanks-Carter, 2011) while in other types of psychotherapy such as cognitive behavioral, goals or tasks of treatment may be changed without addressing the transference. Listening for such themes and providing feedback in the form of a question, if appropriate, deepen the process and enhance self- understanding and empowerment. The therapist assists the patient in his or her healing journey with the humbling knowledge that the therapist’s understanding may or may not be correct and that all observations require verification by the patient in terms of their probability. The therapist is not the authority on the patient’s unconscious; the patient is. These observations are best delivered by emphasizing the therapist’s subjectivity and nondefensive communication through the use of phrases such as “It seems to me …” or “I’m thinking that …” or “As I see it …”

Body language speaks volumes about the patient, and the astute therapist is observant of how the patient sits, walks, speaks, and moves. The therapist listens to what the person is saying and considers the meaning of the body language. Where and how does the person sit, and what posture does the patient assume? Does the patient leave his or her coat on? The therapist needs to be aware of the patient’s nonverbal behavior and its meaning. Following the patient’s body language and mimicking the person’s posture or breathing may signal the patient’s unconscious that you are on the same wavelength and can deepen your understanding of the person. Students are sometimes hesitant to try this exercise because of concerns that the patient may notice, but informal reports from APPN students have not found this to be true, and shadowing the patient in this way often serves as an insightful exercise for both the novice and the experienced therapist.

The therapist assumes an open, receptive posture without fidgeting and with arms not crossed. Good eye contact without staring is important, although this is somewhat culturally determined; some people from Asian or aboriginal cultures prefer indirect eye contact. A neutral, expectant look is important, because smiling and friendliness may be experienced as a social interaction or as threatening, or it may imply that the therapist is not serious about the person’s problems. Changes in the physiology of the therapist and the patient are important to observe to detect subtle or obvious dissociative shifts of consciousness in the patient (Schore, 2012). The therapist monitors his or her own body language and somatic experiences. These include changes in body position, shifts in facial expression or eye gaze, breathing, eye closing, yawning, swallowing, skin flushing, and tears that well up or flow.

In addition to following the patient’s body language and your own, a rule of thumb for skillful communication is to use the patient’s verbal language and to follow the affect. By following the affect, the therapist is attentive and listening to the emotions the person is expressing, whether verbal or nonverbal. Sometimes, there are discrepancies in what the person says, the manifest content, and how something is said. For example, if a person is recounting a tragic loss in a monotone that belies the seriousness of the situation, the therapist may point it out to the patient in the form of an observation: “You have had this horrible loss, but you do not look or sound sad about it.” The person may laugh inappropriately when discussing an unloving marriage, and the therapist may offer this comment: “I am thinking that perhaps it is easier to laugh when feeling so unloved than to feel sad about your wife’s neglect.” Observations are made in a collaborative attempt at understanding and out of genuine uncertainty, not as objective truth (Safran, Muran, & Eubanks-Carter, 2011).

Ralph Greenson (1967) discusses the use of language in his seminal text on technique:

My language is simple, clear, and direct. I use words that cannot be misunderstood, that are not vague or evasive. When I am trying to pin down the particular affect the patient might be struggling with, I try to be as specific and exact as possible. I select the word which seems to portray what is going on in the patient, the word which reflects the patient’s situation of the moment. If the patient seems to be experiencing an affect as though she were a child, for example, if the patient seems anxious like a child, I would say, “You seem scared” because that is the childhood word. I would never say, “You seem apprehensive” because that would not fit, that is a grown-up word. Furthermore, “scared” is evocative, it stirs up pictures and associations, while “apprehensive” is drab. I will use words like bashful, shy, or ashamed, if the patient seems to be struggling with feelings of shame from the past. I would not say humiliation or abasement or meekness. In addition, I also try to gauge the intensity of the affect as accurately as possible. If the patient is very angry, I don’t say: “You seem annoyed” but I would say: “You seem furious.” I use the ordinary and vivid word to express the quantity and quality of the affect I think is going on. I will say things like: You seem irritable, or edgy, or grouchy, or sulky, or grim, or quarrelsome, or furious, to describe different kinds of hostility. How different are the associations to grouchy as compared with hostile?

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In trying to uncover and clarify the painful affect and the memories associated to that specific affect, the word one uses should be right in time, quality, quantity, and tone. (pp. 108–109)

Following the person’s affect and staying emotionally close to the patient’s experience enhance connection and the therapeutic alliance while assisting the person in labeling his or her emotions. Expanding the patient’s repertoire and emotional vocabulary and awareness is largely the work of psychotherapy. There are many nuances of feelings, and the therapist needs to know the language of emotions. For example, when hurt, a person may feel forsaken, crushed, devastated, destroyed, pained, wounded, disgraced, humiliated, anguished, or rejected. Unless the therapist is aware of his or her own nuances of emotion, it is not possible to convey the knowledge to others. Therapists must know themselves as much as the words for emotions, and even experienced therapists do not always have a rich vocabulary to describe feelings.

Giving information is customary for nurses and includes psychoeducation. Information giving normalizes the situation, provides hope, helps to set goals, identifies options, helps deal with obstacles, corrects misinformation, provides new perspectives, provides feedback, and helps to reframe the situation. However, therapists must be careful to not overload patients with information and should consider timing. Often, the person needs an empathic response and may not be ready to hear any information. Any information given should be clear, specific, and concise. Giving information is not giving advice or telling the person what to do. Giving advice is not compatible with promoting empowerment. If helpful comments and suggestions worked, the patient would not be sitting in your office. Moreover, advice that does not work may be blamed on the therapist, and even if the advice is successful, it is a reminder of the patient’s inadequacy and can ultimately be demoralizing. A better strategy is to offer the person various options and explore each so that the patient can choose what to do. In my experience in teaching psychotherapy to nurses, being nondirective and not offering fix it statements are difficult for novice APPNs, because most nurses are used to telling patients what to do, particularly in inpatient settings.

Educating the person about the psychotherapy process is an important component of the initial contact and the ongoing sessions. Often, the psychotherapeutic process seems strange to patients, even if they have had previous treatment. For example, it is common practice and therapeutic for therapists to ask questions about how patients feel about them or about coming to see them, but patients may think therapists want reassurance rather than an honest answer. Patients should be told at the outset that they sometimes may not want to come to their sessions and that is okay to not want to come, but that it may mean that important issues are surfacing and that it is important to come anyway and to be honest about how they are feeling. This is important information, particularly for patients who are in treatment for the first time. It is also important to tell patients that psychotherapy is a relationship and that the feelings elicited sometimes are similar to those experienced in past relationships. For example, if a patient has generally felt vulnerable in relationships and distanced from these feelings by avoiding others in the past, this reaction is likely to occur in the relationship with the therapist. Instruct the patient to tell the therapist when he or she begins to feel this way, because the information is important to the continuing work of psychotherapy. As therapy progresses, there are many opportunities to educate patients about the process of psychotherapy, and they are discussed throughout this textbook.

Giving recognition is a form of attending. It means that the therapist notices what the person has done and validates dimensions that are successful, which helps to build on strengths already in place. This is different from praise, because indiscriminate praise can backfire. Although praise may make the therapist and patient feel better temporarily, it can also leave the patient wondering about the therapist’s sincerity and the reality of the person’s strengths. If everything is wonderful, perhaps nothing is wonderful. Being a cheerleader implies that the therapist has judged that certain actions are desirable, and this does not foster the patient’s empowerment and decision making. A better reply to positive change would be: “How did you feel about being able to say no and set limits on your own behalf?” Another caveat about cheerleading is that the patient may try to please the therapist, often unconsciously; nonetheless, the therapy process is hijacked and turned into what the person senses the therapist wants without advancing the patient’s self-direction and empowerment.

Empathy

Perhaps the most important element of therapeutic communication is empathy. Cozolino (2002) speculates that empathic connectedness stimulates the biochemical changes in the brain that increase brain plasticity and

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enhance learning. This makes sense in light of Schore’s work (2012), which demonstrates that social interactions early in life result in the stimulation of neurotransmitters and neural growth hormones that shape brain development. Research in mirror neurons provides a scientific explanation for the development of empathy through attachment relationships (see Chapter 2). The attachment arousal of the therapeutic relationship provides the interpersonal context for integration and regulation of neural networks, with empathy serving as the vehicle for this connection. Empathic resonance is a physiologic state of consciousness that helps the therapist connect, attune, and coregulate with the patient (Dworkin, 2005).

Historically, there has been a considerable amount of research on empathy in nursing (LaMonica et al., 1987; Layton & Wykle, 1990; Määttä, 2006; Morse et al., 1992; Wheeler et al., 1996). Empathy is a complex concept, and three phases have been delineated. In phase 1, empathy reflects the individual’s empathic potential or ability; in phase 2, empathy is expressed; and in phase 3, empathy is received. Research does not support that a high degree of the nurse’s empathy ability results in the patient receiving that empathy. The most accurate measure of empathy for patient outcome is phase 3, empathy received (Wheeler, 2003). This is important because therapists may feel very empathic toward patients, but it is conveying this understanding to patients and their hearing it as such that count. The most accurate definition for empathy is “a process of understanding whereby the nurse enters the patient’s perceptual world, the patient perceives this understanding, and confirmation of self occurs as part of this process” (Wheeler, 2003, p. 207). Confirmation of self is reflected in the patient feeling more worthwhile, energetic, confident, hopeful, and comforted. This physiologic state results from the attunement and empathic resonance that are cultivated through empathic communication techniques.

How does the therapist convey empathy and ensure that it is heard by the patient? The therapist’s empathy is only as helpful as it is accurate. For example, one patient came to his session looking very stony faced. The therapist misunderstood the patient’s silence as anger rather than fear and said: “Perhaps you are angry at me because I had to cancel our session last week.” The reality was that the patient was afraid that he had made a big mistake with his girlfriend and that she was going to break up with him. This kind of breach of empathy can be harmful to the therapeutic alliance. A better response for the therapist would be to observe and ask for clarification: “You look unhappy. What is going on?” To deepen the perception of what others are feeling, it is sometimes useful to ask, “What would someone be feeling who experienced this? What is the implicit communication in this situation?” Empathy is about trying to understand the key elements of what the person’s experiences, behaviors, decisions, values, and feelings are and about communicating these elements back to the person to see whether the perceptions were correct. It is responding to the context or implicit communication, not just to the words. Often, the person is unaware of what his or her feeling is, and it is the therapist’s job to perceive the emotion and to convey the perception to help the person expand awareness (i.e., to make the implicit explicit).

A related concept to empathy but a barrier to effective listening is being overly sympathetic. Feeling sorry for the patient can reinforce self-pity, does not help problem solving, and can weaken the patient because the therapist is not emphasizing strengths. One patient reported fleeing treatment from a therapist because she experienced the former therapist as “too kind.” If the therapist feels too sympathetic toward the patient, it is most likely about the therapist’s feelings, not the patient’s. For example, one student nurse cared for a young woman about her own age who had just lost her father. The student’s own father had died after a protracted illness several years earlier. Unable to hide her sadness, the student began to cry and was less than effective in being present and objective for her patient.

Egan (2006) provides a basic empathy formula that is worth practicing: You feel… (naming the correct emotion expressed by the patient), followed by because… (indicating the patient’s correct thoughts, experiences, and behaviors). Posing the response in a tentative manner allows the patient to agree or correct you. However, empathy is more than parroting the patient’s words. Empathy picks up on implied feelings and can be invaluable in deepening the process. For example, one patient complained about being charged for a session she had missed and for which she had not given 24 hours’ notice. The patient said: “All you care about is money. You don’t care that I was sick and couldn’t come!” The therapist answered empathically, reflecting “You feel angry because you believe that you are not cared about?” This response was less threatening than “You feel angry because you think that I do not care about you.” Even though the latter response was not said and was undoubtedly the more empathic statement, this is an example of being empathic by not expressing empathy, because the therapist understood that the patient would have been humiliated and would have experienced the latter response as threatening and intrusive. The patient went on to discuss how unfair it was that the therapist could cancel sessions without repercussions, whereas she had to come or would be charged anyway. The power imbalance of the relationship revived how she felt in her relationship with her mother, who was cold and controlling. Being able to express her feelings in a supportive relationship allowed her to

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remain in therapy and feel understood, even though the framework of the therapy contract, which involved paying for missed sessions, remained the same.

Reflection is a form of empathic validation. It helps to provide direction, shows the patient that the therapist understands the person’s perspective, helps to develop insight into problems, and encourages the patient to continue discussion. “You feel so hopeless …” encourages the patient to expand on his hopelessness. The therapist uses the same language as the patient but does so by paraphrasing and summarizing, not by restating what the person has said. Summarizing pulls together the main themes of the patient’s conversation and can be done at the beginning of a conversation, when a conversation is disjointed, when the patient is “stuck,” when the patient needs a new perspective, and at the end of a conversation. For example, the therapist may say, “You seem to feel very angry but feel that you are not supposed to be?”

Contributions from both the therapist and patient influence the degree of empathy the patient perceives from the therapist. In a review of the literature on the therapist-mediating factors, Elliott and associates (2011) found that similarity between the therapist and patient, a nonjudgmental attitude on the part of the therapist, attentiveness, openness to discussing any topic including countertransference, ability to regulate and awareness of one’s own emotions, ability to encourage exploration using emotion words, ability to take others’ perspective, abstract ability, in addition to the therapist’s posture, and vocal quality. Conversely, therapist behaviors seen as less empathic include talking too much, advice giving, interrupting, failing to maintain eye contact, and dismissing the patient’s ideas. Client contributions include the patient’s self-esteem, less patient pathology, and the patient’s intelligence that all predicted the patient’s perception of the therapist’s empathy. By enhancing self-awareness and continual work on improving communication skills using the therapeutic skill-building exercises described previously, empathy can be enhanced.

If the therapist’s empathic statement is correct, the response of the patient is often one of endorsement and opening up further about what is being discussed, sometimes with an enthusiastic “That’s exactly how I feel” or at least with a nod and further thoughtful comments about what is being discussed. Empathy advances the conversation. However, if the therapist is off base, the patient may pause, and the conversation may flounder, or the person may try to help the therapist get back on track. For example, one woman whose husband insisted she see a therapist because she criticized him constantly complained, “This is such a waste of time! I wouldn’t be here if my husband didn’t want me to come. He has all the problems. I don’t know what I am doing here!” The therapist responded with what was thought to be a reflective statement: “You are angry that he thinks you have mental health problems.” The patient angrily responded, “No, that is not what I am angry about. I am being forced to come here and am resentful that he is unfairly blaming me for his problems!” The therapist obviously misunderstood, and after the patient explained further, the conversation focused on her feelings of being dominated in her marriage and how she criticized her husband as a response to her hurt about his total disregard of her feelings.

Empathy is an important element of anxiety management in psychotherapy. Because anxiety often occurs when the patient changes, it is an important dimension for the therapist to be aware of, especially when the patient begins to feel anxious after a significant therapeutic gain. Any new behavior, feeling, or thought increases arousal in the brain and creates some anxiety, even if it is a change for the better. Change does not feel natural in the beginning, and it may take many tries or much time before it becomes integrated into the patient’s brain and way of being. It is helpful for the therapist to educate the patient to expect anxiety when change occurs. For example, one patient who had been able to make significant changes in boundaries in her relationship with her boyfriend came to her session and commented about how anxious she had felt during the past week for no apparent reason. The therapist made this interpretation: “Perhaps the anxiety you are feeling now is not so much about being stuck as about being able to do things differently from before and your newfound ability to say no when it is not something you want to do.” In psychotherapy, there are always two steps forward and one step back. Knowing this and watching for therapeutic regressions as a normal part of the therapeutic process are essential to assist patients in healing. The therapist can then reframe the situation as a transition time and as a temporary response to change, explore with the patient anxiety management techniques that have been helpful for this person in the past, and assist with learning new resources, if needed. Box 4.4 identifies skills and techniques that help to enhance empathy.

Exploration

Exploring or investigative questions encourage the person to clarify, expand, elaborate, and focus, moving the patient from the general to the specific. Listen carefully to the patient so that your questions follow from what

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the person is saying, have a therapeutic purpose, and are clear, concise, simple, and judicious. Asking a question to which you think you know the answer but which the person is busy denying most often alienates the person and increases defensiveness. For example, a therapist may suspect that a person is having anxiety because of angry feelings toward his mother who neglected him, but the person may not be ready to examine this idea and instead be aware only of feeling disturbed about a friend’s negligence. A premature statement by the therapist (“Perhaps you are really angry at your mother, who was not there for you”) may be met with silence or vehement denial, further strengthening defenses. A better clarification type of question may be “What is the worst part about feeling neglected?” Gently leading the person to examine his or her feelings helps the patient to engage and can be an appropriate therapeutic intervention because through the inquiry, the person’s self-understanding is deepened.

BOX 4.4

SKILLS AND TECHNIQUES TO INCREASE POSITIVE RECEPTION OF EMPATHIC OVERTURES

Accept and appreciate the patient’s world but make sure that your understanding fits with the patient’s ability to tolerate it.

If you suspect that the patient would rather not hear your empathic statements, do not share them.

Add to or carry forward the meaning in the patient’s communication.

Listen beyond the words. Attempt to capture the nuances and implications and reflect back your understanding.

Focus on patients’ feelings, perceptions, meanings, values, assumptions, and their views of the other people and situations.

Be nonjudgmental, attentive, and open to discussing any topic. Avoid interrupting, talking too much, and advice giving.

Modified and adapted from Perraud et al. (2006).

A caveat is that asking questions centers the control in the therapist because the conversation is directed to an area the therapist wants to explore, and questions should therefore be used judiciously. Too many questions yield negative results and can be a barrier to listening. All questions should be patient centered, and only one question should be asked at a time. Sometimes, therapists ask multiple questions because they are uncomfortable, and this can leave the patient feeling overwhelmed or confused. Another problem is that asking many informational questions collects facts but often misses the point about the psychotherapy process and what is happening for the patient. Restating or paraphrasing may be less threatening and allows more space for the patient to pursue what he or she feels is relevant. For example, “What I hear you saying is that you have been having a great deal of trouble getting to sleep but, once asleep, you can sleep through the night.”

Egan (2006) advises to listen to the person contextually by focusing on key themes and messages. For example, a man who came into therapy recounted a number of unfortunate events in his life, explaining that “bad stuff always finds me. I will never be happy, and I never get a break.” Rather than asking questions about each instance, it is beneficial for the therapist to identify the themes of hopelessness and helplessness and to explore other dimensions, such as genetic roots (when in the past did he feel this way?) or other more adaptive situations (has there been any time when he did not feel this way?) or future potential (what would he like to feel in the future?).

Exploring can be verbal or nonverbal; shaking the head yes or saying “I see” encourages the patient to continue with the story. It can be particularly helpful to use open questions that encourage the patient to be active in the conversation: “How did you feel when your friend told you that he did not want to see you?” Open questions begin with who, what, how, when, and where, and they invite the patient to elaborate and provide factual information. Open questions are preferable in therapy, but they should not be so broad that the person is confused. For example, rather than asking “What kind of person are you?” it may be more helpful to ask “How are you like your mother?” Hypothetical questions such as “What do you think would happen if you quit taking your medications?” or “What would being assertive in that situation be like for you?” help the person imagine future consequences or possibilities.

Avoid “why” questions because they tend to have a critical tone, are likely to make patients feel defensive

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and may be associated with disapproval. For example, “Why did you say that to your son?” most likely will cause anxiety, leaving the person feeling put on the spot and explaining unnecessarily. Usually, why questions can be rephrased with “how” exploring-type questions that ask the person to give his or her perspective on the situation. For example, “How did you feel when you said that to your son?” or “What was going on with you when you said that to your son?” may lead to deepening the patient’s understanding of her feelings.

Closed questions such as “Are you still feeling depressed?” usually elicit one syllable answers such as “No” without elaboration and may be used to clarify information, but if they are used too much, the therapist begins to feel as if she is conducting an interrogation and the patient is passive. However, it is sometimes appropriate to ask a closed question to obtain specific information and then follow with an open question that elicits more information from the patient. Closed questions tend to be less arousing than open questions and sometimes can be interspersed with open questions that may be more anxiety provoking to assist the person who is hyperaroused. The therapist should not ask leading questions that imply how the patient should answer, such as “Do you think that your depression affects your relationship with your family?” or “You do believe that abortion is acceptable, don’t you?”

Observation, focusing, immediacy, and interpretation are higher on the treatment hierarchy continuum and are usually not used in the initial session, but they are employed later as therapy progresses. Making an observation is verbalizing what is perceived or observed, and this encourages the patient to recognize specific behaviors and compare his or her perception with those of others. Observation can be extremely helpful to the person. For example, a pattern of relating may contribute to the person’s problem, and the therapist may point out the pattern by making an observation: “I’ve been noticing that you joke a lot whenever I mention how devoted you are to your husband” or “You seem tense today?” The patient then can elaborate on the therapist’s comments. Observation can also involve pointing out discrepancies and distortions between verbal and nonverbal behavior in a nonjudgmental, tentative way. These types of observations are best delivered using I statements such as “I wonder whether you are thinking that you are not really drinking if you only have two beers?”

Focusing is drawing attention to a potentially anxiety-provoking issue for further exploration. It can help the patient become more specific, move from vagueness to clarity, and further understanding about an issue. In addition to the example in Table 4.1, another form of focusing is to polarize the two parts of the patient that are in conflict by asking the person to examine each part. For example, “A part of you may feel like coming here to work on your problems while another part of you feels hesitant to share so many important feelings with me.” Alternatively, the therapist may say: “It seems that a part of you would really like to stop drinking but another part of you feels afraid to consider this.” The therapist can then explore each part with the patient in a way that assists in understanding relevant implicit issues through the matter-of-fact manner that the therapist accepts the two parts of the person: “Please tell me about the part that is afraid to stop.” This type of comment can deepen the patient’s understanding about implicit barriers to change, and it reframes resistance as anxiety. This type of communication points to the importance of the therapist’s empathy in recognizing the emerging inclination of the patient to change.

Immediacy and interpretation are probably the most anxiety-provoking therapeutic communication skills for any therapist. Immediacy is a type of confrontation that is challenging and requires self-awareness by the therapist. Often, the patient is not aware of how he is affecting others and that the same pattern is occurring in the therapeutic relationship. Immediacy involves exploring what is occurring currently in the therapeutic relationship, and it can help with problem resolution. The therapist can address a change in the process. For example, if the patient is suddenly withdrawn or hostile, the therapist may say: “What are you feeling at this moment?” or “What do you want to say right now?”

Egan (2006) identifies three types of immediacy: exploring what is occurring in the relationship in general; assessing what is happening at the moment between the patient and therapist; and giving present tense feedback to the patient. Examples for each type include “It is hard for you when you feel so misunderstood?” “What do you want to say right now?” and “It is hard for me when you cut me off while I am talking.” Immediacy may be used in situations in which factors impact the relationship, such as when trust is a concern, when the patient is “stuck,” when boundaries are violated, or when tension or dependency is an issue. The patient’s acknowledgment of dependence can be invaluable. Assertiveness, self-awareness, and courage are prerequisites for using this skill.

Interpretation can take the form of pointing out to the patient what the therapist hears him or her saying regarding conflicts that he or she is struggling with (i.e., making the implicit explicit). An interpretation is a statement that explains how a feeling, thought, behavior, or symptom is related to its unconscious origin. Repeated attention to unconscious material results in gradually expanding awareness and the integration of top-down and right-left neural networks (Cozolino, 2002).

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Interpretations are largely the work of psychodynamic psychotherapy, and they serve to defuse the potency of defenses as coping strategies. Cozolino (2002) says, “Conscious awareness of the defenses often leads to experiencing the feelings against which the patient has been defending. The networks containing the negative emotions become disinhibited and activated. For example, if intellectualization is being used to avoid the shame and depression related to early criticism, recognition of the defense will bring these feeling memories to awareness” (p. 51). For example, a patient who may be warding off feelings of abandonment is angry and critical of her boyfriend, and the therapist offered this interpretation: “It seems that you feel so angry when you feel dependent on Dan.”

All communication techniques are only as good as the therapist’s understanding of the patient and the therapist’s sensitivity to nuances. How you understand your patient will inform what you say, and your understanding will deepen as you gently explore with your patient and expand your knowledge about human behavior and development. What is said is informed by the theoretical approach the therapist is using. For example, interpretations are largely used in psychodynamic or interpersonal psychotherapy, whereas suggestion is used most often in cognitive behavioral therapy (CBT) or supportive psychotherapy. Communication depends on your theoretical understanding of the patient, the approach used, the phase of therapy, the context, your relationship with the patient, and your own self-awareness.

Situations in which interpretations can be particularly helpful are when patients engage in negative statements about themselves, constant excuses, complacency, rationalization, procrastination, and passing the buck. Interpretations can increase the patient’s awareness, but because interpretations can be threatening, the therapist should allow time for the comment to be heard and should offer support with empathic statements. Interpretations often are most effective if delivered in two parts, with empathy offered first and with the second part containing the interpretation with but or however linking the two parts (Wachtel, 2011). For example, Wachtel provides an example of such an interpretation for an adolescent who refused to clean her room and who kept her mother in a constant state of agitation. The therapist stated: “It is hard to keep your room clean and neat, and I could be wrong about this, but from what you say, it sounds as if your mom gives you a lot of attention when your room is a mess.”

Therapeutic communication is a set of skills that can be improved for both experienced and novice APPNs. Expanding one’s repertoire of skills can be accomplished through practice and by enhancing self- awareness. Therapists can gain understanding through their own psychotherapy and through reflection and mindfulness exercises. These include audio taping, clinical studies, assignments, clinical supervision, discussion, journaling, critical incident techniques, learning diaries, process recordings, literature or vignettes, montage, painting, poetry, role playing, videotaping, and reading books that help to develop self-awareness and reflective thinking. Although time consuming to write, process recordings provide an invaluable opportunity to scrutinize communication skills and require no special equipment. An example of a format and directions for a process recording are provided in Appendix 4.5. More information on selected exercises designed to enhance reflection can be found at www.nursingsociety.org/about/resource_reflective.doc. Mindfulness exercises are also helpful in deepening self-awareness and are included in Chapter 13.

MAINTAINING THE FRAME

Boundaries

The term boundaries in psychotherapy refers to the therapist’s ability to establish and maintain a treatment frame, set a schedule, and honor times; maintain a professional relationship; and protect the patient from intrusions into privacy and confidentiality. The frame of treatment is the APPN’s responsibility, and it is important in creating a safe environment for both the patient and the therapist. For patients with dysfunctional, out-of-control behaviors, adherence to limits and boundaries may be a major focus of the treatment. Most therapists do not allow eating, drinking, or smoking during sessions or any type of interruption during the session. All phones and beepers should be turned off. This is the patient’s time, and distractions from the business at hand are counterproductive to good psychotherapy.

Therapists’ violations of the frame, such as extending sessions longer than usual, being late for sessions, forgetting the session, not following the standard protocol for all patients for any reason, making special allowances for a particular patient, feeling the patient is special having social contact with the patient, and violating confidentiality, are all breaches of boundaries and can alert the therapist to countertransference issues that he or she needs to address. The therapist is often not aware initially of feelings toward the patient and

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becomes aware only by taking note of his or her own behavior and the signs of countertransference (Box 4.5). Countertransference reflects feelings that the therapist has toward the patient and is similar in some

respects to transference. Countertransference involves past significant relationships and includes attitudes, feelings, and thoughts about another person. Contemporary theorists believe that countertransference is a response to the patient’s transference, and as such, it can be used to understand the patient. Countertransference can serve as a barometer in the relationship with the patient for the self-aware therapist. Although countertransference is usually associated with breaches of boundaries or problems in relationship, such as those listed in Box 4.5, like transference, countertransference can also be positive, such as idealizing feelings or empathic resonance with the patient.

Countertransference involves activation of the therapist’s state-dependent memories in the relationship with the patient. As occurs in transference, countertransference reflects a particular physiologic state of consciousness triggered by the relationship, and therapists’ bodies can inform them about what is occurring. For example, one therapist reported that narcissistic patients triggered her to become exceedingly tired in sessions, so much so that she often struggled to stay awake. For another therapist, the same patient may elicit tension in the chest. This is because state-dependent memories are idiosyncratic biochemical profiles that depend on each therapist’s experiences and development and on the interaction with the patient’s contributions in the co-construction of the relationship.

BOX 4.5

SIGNS OF COUNTERTRANSFERENCE

Extending sessions longer than usual Being late for sessions Forgetting the session Seeing the person socially Violating confidentiality Dreams about the patient Difficulty staying awake during sessions Anger at the patient’s inability to change Arguing or irritability that occurs in sessions Sexual or aggressive fantasies about the patient Rescue fantasies and offering advice and “fix it” statements Anxiety or guilt about what you did or did not say Thinking a lot about or being preoccupied with the patient outside of sessions Dreading the session Postponing confrontations or questions about lateness or absence Unnecessary reassurances and oversolicitousness Denying the pathology, conflict, or resistance Allowing the person to run up a high unpaid bill Ignoring the therapist’s errors and the subsequent effect on the patient’s behaviors Therapist’s body feelings, images, and thoughts during the session

Images and thoughts during the session can also alert the receptive therapist to what may be going on during the psychotherapeutic process. For example, one therapist had an image come to mind during a session with a patient from a movie scene he had seen that depicted a forbidden sexual encounter. This was a cue to the therapist about the erotic transference developing in the relationship, even though the manifest content of the session was seemingly about an unrelated topic. The astute therapist is aware of all emerging thoughts, images, and sensations, without judgment or censorship, as manifestations of countertransference. They are considered important data about the therapeutic relationship and deepen the therapist’s understanding about the unfolding process.

A therapist using his or her feelings as a clue to what may be going on for a patient is referred to as autognosis, and this can be very helpful in understanding the patient. Autognosis is similar but different from the nursing concept of therapeutic use of self, originally described by Travelbee (1971). Therapeutic use of self is the ability to use one’s personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions (Travelbee, 1971). In contrast, autognosis is using one’s feelings to deepen understanding of the patient and use of oneself to diagnose the nature of the patient’s problems. Often, these feelings are more implicit and not fully conscious.

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Two types of countertransference identified are concordant and complementary (Racker, 1968). Concordant identification is a process in which the therapist takes on the experience of a patient’s personality as if it were his or her own. For example, when interacting with a sad patient, the therapist begins to feel sad. Complementary identification occurs when the therapist is treated transferentially by the patient as if the feelings were true. For example, one patient who had a critical father began to feel criticized and judged by the therapist, and the therapist did feel induced to act punitively toward the patient. Often, these types of countertransferential responses are transitory and serve to deepen the therapist’s understanding of the patient. The therapist who is able to monitor his or her own emotional reactions, thoughts, and fantasies throughout a session can deepen the process in a way that otherwise may not be possible.

Although we often think of countertransference feelings as strong sexual or hostile feelings or boredom, often the therapist’s feelings toward the patient are more nuanced and may include judgments or unconscious stigmatizing beliefs. For example, one graduate nursing student working with a patient who decided he wanted to go back to school and become a nurse created an uneasy feeling in the student who told him that he needed to not take on too many stressors (Buck & Lysaker, 2010). Responses such as these that are not enthusiastic or perhaps overly enthusiastic may reveal deeply held stigmatizing beliefs about mentally ill adults and be barriers to treatment. All feelings—the good, the bad, and the ugly—occur and can be used in the service of the therapeutic process by self-aware therapists. Strategies to enhance self-awareness are included in Chapter 1.

The relational-psychodynamic therapist may address or interpret the cocreated countertransference, whereas the cognitive behavioral therapist is more likely to notice but not address it directly. Chapter 5 on supportive and psychodynamic psychotherapy discusses countertransference further. Even if the therapist decides it is best not to address what is going on with the person, the work is enhanced. For example, one patient seemed so vulnerable and childlike that the therapist would often have fantasies of protecting and rescuing her. Even though this was not directly addressed with the patient in treatment, knowing this allowed the therapist to contain these feelings so that support could be provided without infantilizing the patient. Occasionally, feelings can be so intense about a patient that they may be difficult to contain and be therapeutic. “Strong countertransference feelings can be invoked when working closely with patients who are resistant to change” (Jones, 2004, p. 18).

Supervision and one’s own therapy can help to process emotional reactions. Lifelong supervision is always a good idea, but extra consultation with an experienced therapist can help in managing countertransference. Supervision consists of meeting regularly, much like therapy sessions, and discussing issues germane to the work of psychotherapy that the therapist needs help with. Often, supervision is a mixture of the patient’s issues and the therapist’s issues, because the latter impacts the treatment process in significant, often unconscious ways. For example, one young woman who came for therapy was extremely demanding and devaluing to the point that the therapist was defensive and dreaded her appointment each week. Discussing this patient in supervision helped the therapist to be more objective and understand how her own issues were triggered by the patient’s devaluation. The therapist then was able to be more empathic and understand how the patient must have felt in her relationship with her devaluing mother.

Empirical and clinical studies on countertransference have found five interrelated factors that are important for management of countertransference. These include therapist qualities of self-insight (aware of one’s own feelings), self-integration (ability to set boundaries and manage internal reactions), empathy, therapist’s ability to admit a mistake, and conceptualizing ability (i.e., therapist understands the patient’s dynamics theoretically) (Hayes, Gelso, & Hummel, 2011). Therapists who possess these characteristics are seen as excellent by peers and can control countertransference acting out, and it is thought that these qualities are positively related to treatment outcome. In contrast, the therapist may have personality characteristics that are called chronic countertransference, such as a tendency toward rescuing the patient, being overly supportive or solicitous, or being authoritarian or antiauthoritarian and frequently violating the rules or frame of treatment. These attitudes can create chaos in the therapeutic relationship, and the therapist may need psychotherapy in addition to a consultation to ameliorate such traits. It is essential to monitor countertransferential feelings throughout therapy because these feelings are implicit and state dependent, and they may come to awareness only through ongoing self-reflection. Countertransference can significantly enhance or inhibit the therapeutic process. Seeking consultation and keeping documentation in clinical notes are essential to protect the therapeutic relationship and patient from therapist boundary problems. Theory and personal awareness are key to managing countertransference.

The most egregious violation of boundaries is that of a sexual relationship with the patient. Sexual misconduct ranks as one of the highest causes of malpractice actions against mental health providers (Norris, Gutheil, & Strasburger, 2003). Often, patients express wishes to be closer to the therapist, occasionally

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sexually or as a friend. It is the therapist’s job to assist the person in understanding the wish for closeness and not to gratify it, no matter how well intended. Even a slight boundary violation sends the wrong signal and may lead to more serious violations. In discussing why the therapist should not hug the patient, even if requested, McWilliams (2004) says, “physical contact of this sort collapses the ‘space’ between the two parties —the area of symbolization, play, and ‘as-if’ relating—that has been so carefully constructed over the course of the therapeutic work. Such a collapse reduces to a concrete physical act the complex metaphorical meanings of the longing to be held, and it creates unconscious anxiety that other strivings—ones that are not so attractive (such as the wish to attack physically or exploit sexually)—may also be acted out” (pp. 190–191).

Nurses are used to touching their patients, and the emphasis in some psychiatric nurse practitioner roles as primary mental health care practitioner may leave the nurse psychotherapist on a slippery slope. The blurring of boundaries in advanced practice nursing is only beginning to be addressed in the literature (McCabe & Burnett, 2006). Relatively few studies on touching patients in psychiatric settings have been conducted, and none has addressed touching in the role of APPN psychotherapist. Gleeson and Timmins (2004) studied caring touch, in contrast to task touch, in a long-term setting for older patients who suffer from dementia. They conclude with the caution against the widespread adoption of caring touch as an intervention for ethical reasons. Another qualitative study of seven outpatients, who had previously been hospitalized for psychosis, found that some of the informants felt violated and oppressed when touched by someone with whom they did not have an established relationship (Salzmann-Erikson & Erikson, 2005). However, positive results were found for an inpatient adolescent population when therapeutic touch was utilized (Hughes et al., 1996).

Although some forms of therapeutic touch do not involve actually touching the patient (i.e., the nurse may keep hands an inch or two away from the patient’s body), use of this or any kind of touch significantly changes the parameters of the psychotherapy frame. The setting, situation, patient population, and other factors dictate boundaries for the APPN role. The blurring of boundaries mandates that each APPN set limits based on the patient’s welfare. Because research on the APPN relationship with the patient and the integration of touch and psychotherapy has not been conducted, it is prudent to regard touch as a boundary violation. If the APPN conducts a physical assessment at intake or admission, it is not appropriate to continue with that person in ongoing psychotherapy. Erring on the side of caution ensures a judicious and ethical practice.

Chapter 16 further discusses maintaining the therapeutic frame and boundaries for those who have problems with addictions. However, the transference and therapeutic issues identified for this population are relevant in working with all patients, and the reader is referred to that chapter for a fuller discussion on how to work with those who have an idealized or erotic transference.

Self-Disclosure

Minimal self-disclosure is part of maintaining a professional relationship. Self-disclosure is defined as the therapist revealing something personal. However, the therapeutic technique of immediacy is a type of self- disclosure, in which the therapist reveals feelings about himself or herself in relation to the patient or the therapeutic relationship and immediacy is considered therapeutic communication. Therapists must be aware of their own motives and thoughts relating to self-disclosure. Gabbard says: “Because we cannot be sure what we are up to when we are disclosing our own feelings to the patient, self-disclosure should be thought about carefully before using it” (2010, p. 159). Self-disclosure should not be used to meet the therapist’s own narcissistic or intimacy needs in that the focus is shifted from the patient. This can interfere with the flow of the session and may confuse or burden the patient. It is essential for APPNs to be aware of patients with whom they would be more likely to confide, because this may herald a potential boundary issue.

Based on an extensive review of the research on self-disclosure, Hill and Knox (2002) suggest the following practice guidelines for therapists:

1. Therapists should disclose infrequently. 2. The most appropriate topic involves the therapist’s professional background. 3. Use such disclosure to validate reality, normalize, model, strengthen the alliance, or offer alternative ways

to think or act. 4. Use such disclosure in response to similar patient self-disclosure. 5. Monitor how patients respond by asking about their feelings about the self-disclosure.

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6. Disclosure depends on the patient’s needs.

Regarding the last point, the less self-disclosure by the therapist, the more the transference is thought to be heightened. Less self-disclosure may be more helpful for some patients who are higher functioning so that through discussion of the transference, profound learning and change may occur.

However, for those who use more immature defenses, such as projection, it may be better if the therapist is judiciously self-disclosing and more real so that less implicit feelings, thoughts, and state-dependent memories from the past are transferred onto the therapist, resulting in less distortion. Patients who are paranoid especially may need the therapist to be candid because they may project so much that it is important to inform them what aspects of their observations are accurate and what is being misinterpreted. Answering nondefensively and without evasion is usually warranted. For example, one patient who was schizophrenic asked the therapist why she dressed like a hippie. The therapist responded good-naturedly, “I kind of like these 60s outfits; I think I look groovy.” The inherent inequity in the therapeutic relationship creates a climate in which dependency and some distortion are inevitable, with one vulnerable person requesting caretaking from another. The dependency triggered by psychotherapy can be particularly problematic for those needing stabilization and for those who have been chronically disempowered.

Questions about one’s credentials and qualifications should be answered. The patient has a right to know the APPN’s general therapy orientation and the amount of experience with the type of problem the patient has. A thornier issue related to self-disclosure and maintaining boundaries is how to answer patients who ask personal questions. If the patient asks the therapist personal questions, the therapist can say, “I’ll be glad to answer that, but first I’m wondering what your thoughts are about that and how is it that you are asking?” If the patient persists in asking personal questions that the therapist does not want to answer (e.g., “Are you divorced?” or “How many children do you have?”) the therapist should listen for the latent content and explore what the patient is really asking for. For example, “Are you married?” may mean “Are you available?” or “Are you gay?” Often, the question is really about the person wondering whether the therapist can be trusted and reflects concerns about whether the therapist likes him or her, can understand his or her culture, and can relate to the patient. The patient may be unsure about the intimacy of therapy versus the intimacy of a personal relationship. The therapist can say: “You are very curious about me. Can you tell me more about that?” or “This is your time to talk about you.” If the person persists, and the therapist does not want to answer the question, it is best to say this honestly, “I am not comfortable answering personal questions about myself, but I am interested in how this information is important to you.” It is possible to spend the whole session on the meaning of the person’s question by reflecting: “It sounds as if you are feeling that if I am not married like you, I will not be able to understand how you feel.” The therapist and patient then explore the context for this belief. It is only through inviting the patient to express his or her reservations about therapy and about you that the process can proceed. Being curious, interested, and open to all communication are essential skills for all therapists.

Cancellations, Fees, and Lateness

Even though the patient has signed a contract about the cancellation policy and fees were discussed during the initial session, the policy may need to be revisited as therapy proceeds. Undoubtedly, the patient will cancel and forget that he will be charged for missed sessions as the policy proscribes. Understanding money issues in psychotherapy is essential. For example, paying late may be a signal that the patient unconsciously expects to be taken care of or forgetting to pay may be a passive aggressive act, and there may be any number of other unconscious reasons that the patient may deviate from the agreed fee structure and cancellation policy. Addressing and exploring the behavior to clarify the psychological meanings and to reiterate the frame for payment is imperative. Often, forgetting to pay reflects deeper meanings than at first glance.

It is not good practice for the patient or the therapist to allow a large outstanding bill to accumulate. A better alternative is to explore the meaning of not paying and help the person deepen his or her understanding while maintaining the frame of the contract. Higher-functioning patients usually honor the therapist’s fee structure and are easier to work with when exploring money issues than those who are lower functioning. For example, one patient who was a therapist herself expected a reduced fee after her insurance company changed and she no longer had good coverage for outpatient psychotherapy. In exploring this subject with her, deep feelings of sadness and abandonment surfaced from her childhood related to the caretaking role she had played with her mother, who had significant financial problems. Implicit neural networks associated with

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dependency and entitlement were triggered in therapy when she was asked to take care of the therapist by paying more out-of-pocket fees for her sessions. As the therapist explored these issues and reworked them in the present, the patient was able to make new neural connections that allowed her to continue in treatment and pay the charged fee. This awareness reverberated to other areas of her life, and she benefited financially in her own practice as a consequence of her work on this issue. Often, money issues in treatment reflect similar difficulties for the person outside the therapy.

Essential to maintaining the frame is the therapist’s reliability and consistency of sessions. The therapist must be on time for sessions. It is important to keep the time of the session the same each week because changing appointment times often creates chaos, and the patient may not honor the commitment if the therapist is a poor example. Informing the patient well ahead of time when you will be gone and trying to reschedule, if possible, are common courtesies and essential for integrity of the frame. The patient’s lateness and not showing up for appointments are likely to be forms of resistance, but it is important to understand that tardiness and absence may be caused by an unforeseen circumstance. Emergencies, such as illness, lack of childcare, transportation problems, or whether problems do occur. It is important to determine whether this is an isolated event or whether a pattern is developing. If the lateness is a one-time event, you can open a discussion by observing: “I notice you were late today.” However, if the person has been late two or three times in a row, the cause is most likely resistance, which should be addressed, or the person may leave treatment altogether. It may be better to wait until an opening in the session presents itself or the person’s defenses may increase. If an opening does not present itself, the therapist can say: “You have been 10 minutes late for the past two weeks, and it seems hard for you to get here on time.” The person may launch into the real reasons for the tardiness. The therapist can then ask, “Do you have any other feelings about coming here lately?” Approaching with curiosity and understanding conveys caring and allows the patient to explore what is going on. It is important for the therapist to adhere to the established time for the session and not extend the time another 10 minutes if the patient is 10 minutes late.

If the person does not show up for a scheduled session and does not call, most therapists assume that the patient will come to the next session and do not contact the person. However, if two sessions are missed, the person is usually called, and a message is left that states: “I had in my appointment book that you were coming yesterday at 3, and you did not come. I hope everything is okay. Please call if you would like to schedule an appointment. I look forward to hearing from you.” Adding the last sentence is helpful, because the person may feel that the therapist is angry if he or she has missed several times. If the person calls, confirms, comes the following week, and has not missed before, the therapist must explore what is going on with the person, because the resistance must be addressed if the patient is to continue. If the person does not address the absence, the therapist can ask: “How did you feel about missing the past few weeks?” If this is the first time a session was missed, the therapist can reiterate the policy about paying for missed sessions once before instituting it the next time. If the patient calls and says he or she wants to end treatment, the therapist should suggest that the person come in to discuss the issue first.

Even when issues are discussed and the patient still wants to terminate against the therapist’s best judgment, it can still be helpful to the patient to meet for a final session. The therapist can use this opportunity to explore what is going on and leave the door open for future work when the patient is ready. However, if the person does not call or come to the next confirmed appointment and has missed three sessions in a row, a termination of treatment letter (see Appendix 4.6) should be sent to the person. This official termination letter protects the therapist from legal liability if the person has difficulties later. Chapter 20 provides further discussion of termination.

Telephone Calls and E-mails

Being responsible for patients 24 hours a day is often a new experience for most new APPNs, and it is essential that emergency coverage is in place. It is important to state explicitly whether you will be available for phone calls between sessions and adhere to clear limits. How the patient contacts you between sessions and in emergencies is included in the contract given to the patient during the initial session. Although you need not be available around the clock, suitable arrangements should be made. Reasonable examples include having a pager or cell phone and providing patients with a number so that they may contact you if needed, hiring an answering service that contacts you when contacted by a patient, and sharing coverage with colleagues who are each on call every few days, provides uninterrupted coverage throughout the week and weekend. Checking messages at least once each day and calling back within 24 hours are good practice habits that are

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relevant for legal and ethical professional responsibility. Some therapists leave a message on their answering machine that states that he or she will call back as soon as possible and that if this is an emergency, the patient should go to the emergency room or call a crisis hotline. In this way, you are not serving as the emergency room liaison and setting appropriate limits on your availability. Asking a colleague to cover is essential for vacations and time off, in addition to discussing fragile patients who may call while you are gone. It is helpful to write notes for the covering person with details about the patient’s name, address, phone number, and narrative about issues that may arise. This is a courtesy to your colleague and your patient.

Occasionally a patient may call between sessions to hear their therapist’s voice, and this can be quite soothing to those needing stabilization. E-mails can also connect with patients and be helpful between sessions. However, this can create problems if the patient expects a timely response for lengthy journal entries. This puts an unnecessary burden on the therapist and complicates boundaries and the frame. Phone calls from patients between sessions should be discouraged by assessing quickly whether the call is truly an emergency and, if not, gently saying: “This sounds important, and we need to talk more about it when you come next week.” However, sometimes a phone call from a patient who has been averse to seeking help or afraid to trust can signify that a positive shift has occurred in the therapeutic relationship. In other cases, a phone call may mean increasing desperation and loneliness. It may be necessary to strengthen affect management strategies for those who have difficulties in this area.

No matter what the reason, it is important to limit conversations, because giving away free sessions over the phone violates the frame and cultivates an unhealthy dependency. If the APPN is receiving several urgent phone calls each week, the possibility exists that such calls are inadvertently being encouraged, and consultation with an experienced therapist is indicated. Conducting phone sessions in lieu of office sessions is not routinely advised, but it may be necessary on occasion or in addition to a regularly scheduled weekly appointment. Fees for phone sessions are the same as for regular sessions. Phone sessions also may serve as a way to wean the patient from psychotherapy during termination. This topic is covered in Chapter 20.

WORKING WITH RESISTANCE

Resistance has traditionally been viewed as an inevitable and unfortunate occurrence in the psychotherapeutic process. Historically, resistance was thought to reflect the unconscious forces of the patient that inhibit change but more recently resistance is thought of as an opportunity to increase understanding of the patient (Gabbard, 2010). Resistance is seen primarily as a defense that shows the therapist that the patient’s anxiety has increased and that defenses are near the surface, indicating an opportunity for insight. Despite this idea about resistance, research suggests that psychotherapy works best if the therapist induces as little resistance as possible while moving the client toward his or her goals (Beutler et al., 2011). This is easier said than done, because change is always fraught with anxiety and resistance is a manifestation of anxiety. Resistance can be thought of as implicit memory networks created through earlier dysfunctional situations and relationships that serve a self-protective function. Resistances manifest in psychotherapy as aspects or issues in treatment that challenge the person’s ability to change. It is these implicit neural patterns and ways of being that have brought the person into therapy in the first place. These defenses or resistances have been helpful and were functional for the person in the past, and for this reason, understanding resistances can be valuable to the work of therapy. Chapter 5 on supportive and psychodynamic psychotherapy discusses further how to work with resistance.

Often, a parallel process occurs, and the therapist’s defenses are also triggered when the patient manifests resistance. Resistance is not always easy to recognize, and if the issue is not addressed, the patient may not return. Traditionally, resistances are thought to be caused by anxieties about the unknown, loss of control, rejection, loss of meaning, physical pain, isolation, and self-loathing (Gabbard, 2010). These manifest as agitation, demanding behaviors, silence, noncompliance, chronic lateness, not coming to sessions, anger, eagerness to leave treatment, superficial chit chat, paranoia, irritability, lack of progress, requests for special favors, eating or drinking during sessions, homework not done, nonpayment or late payment of bills, sexual interest in the therapist, frequent requests for personal information from the therapist, and doorknob disclosures (i.e., bringing up important material or intense emotion at the end of the session). When patients introduce new information as they are on the way out, this ensures that there will not be enough time to deal with the issues. This represents resistance in the form of ambivalence. It may be helpful to bring up the issue at the beginning of the next session if this occurs to open up exploration.

A more contemporary view of resistance posits that the patient’s failure to respond favorably with therapy

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is a problem of reactance and reflects a failure of the therapist to fit the treatment to the receptivity of the patient and further that expert therapists tailor interventions to meet the person’s needs. For example, for those patients who are highly resistant, less directive models of therapy are used that allow more control for the patient. For example, directive therapies such as CBT may be better for patients who are less resistant, and nondirective forms such as psychodynamic therapy and interpersonal therapy may be better for highly resistant patients. A meta-analysis of 12 studies supports that nondirective techniques predict better treatment outcomes for highly resistant patients (Beutler et al., 2011). Clinically, it is important to identify those who are the low- or high-resistant patients. Several groups of likely to be high resisters include adolescents, paranoid or distrustful patients, and those who are forced to come to treatment by the court, a spouse, a job, or a family member.

The therapist’s competency in dealing with resistance includes identifying problems in collaboration, recognizing defenses and obstacles to change, and understanding ways to address resistance. Three responses by the therapist to the patient have been identified as helpful: acknowledging and reflecting the patient’s concern, discussing the therapeutic relationship, renegotiating the contract and goals, listening versus talking should shift more toward the patient, and using fewer instructions (Beutler & Harwood, 2000; Beutler et al., 2011). The therapist first observes and points out the behavior: “I notice that you have been pretty quiet the past couple of weeks during our sessions” or “You seem angry today” or “It is so hard for you to be here when you don’t want to be here.” Interventions that discuss the therapeutic relationship are called process comments and include questions such as “How did you feel when you left the last session?” or “How do you think things are going here?” These questions invite the patient’s response. Sometimes, questions engender a limited or no response, but often such inquiries open up the process in a way that allows the patient to share feelings. The ensuing conversation may be surprising, because the person often responds quite honestly with feelings that are enlightening. If the person says that something is a problem or that things are not going so well, the therapist can explore further what would help to make it better. This can be very helpful for collaboration. On the other hand, the person may not know how he or she is feeling and may deny any negative feelings. The therapist can then explore with another question: “How did you feel when I asked you that?” These types of process questions encourage self-exploration and may enable the person to deepen self-awareness so that acting out can be minimized.

BOX 4.6

MOVING WITH RESISTANCE AND RENEGOTIATING THE CONTRACT

Ms. A is a 28-year-old woman, who initially sought help for panic attacks. A major theme in her treatment was her intense neediness and struggle for love and safety. Asking for help was fraught with anxiety because she was ridiculed in her family for asking for anything, and this was compounded by the fact that on some level she felt that others should know what she wanted without telling them. The following process was from a session that addressed her leaving her last session seemingly angry (i.e., her face appeared angry, and she slammed the door as she left). The therapist had a cold during the session and had to struggle to stay awake.

APPN: How did you feel when you left the last session?

Ms. A:

Angry; I wanted to shake you apart.

APPN: Tell me more about how you felt.

Ms. A:

I felt lost; you don’t talk to me enough. You weren’t really with me.

APPN: Thank you for telling me how you felt. I’m sorry. I was not feeling well and really was not there for you. I understand how angry you must feel about being here and not being heard.

Ms. A:

Yes, this is a waste of time, and I don’t want to come here anymore.

APPN: You have been feeling that you are not getting better and that this is a waste of time?

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Ms. A:

I’m not that much better. I haven’t had anymore panic attacks, but maybe they are just going away on their own.

APPN: When you first came here, that was what you wanted to work on, and it seems that the panic attacks have lessened and are not such a problem for you anymore. Perhaps it would be helpful to discuss whether there are any other areas of your life in which you would like things to be different.

Ms. A:

Well, can you find me a boyfriend? Jim [her boyfriend] is AWOL.

APPN: What do you mean by AWOL?

Ms. A:

Jim wants his space and just wants to be by himself. [She then recounted numerous instances of his inattention to her needs and rude behavior toward her.]

APPN: How hurtful it is to feel so rejected and devalued. From what you have told me, you are feeling so vulnerable with Jim right now that it might be helpful to talk about some resources to help you feel stronger in situations in which you feel dependent and needy. Would it be okay to continue for a few more sessions and see if we can come up with a plan that will help you and then reevaluate whether this is the best time for you to stop?

Ms. A:

Okay, I suppose, but only for a few more sessions.

Renegotiating the contract and goals may not be feasible, but discussion and flexibility may be indicated if content and process comments are not working. Maintaining firm limits may be the focus of therapy for some patients, such as those who have borderline personality traits and who desperately need structure and consistency. Others may be better served by flexibility and the APPN moving with the resistance. Box 4.6 provides an example of moving with the resistance and renegotiating the contract for a client who suffered an alliance rupture. Two things are important to remember about resistance. If resistance is increasing and not addressed, the patient may never return; and once articulated by the patient and heard by a curious, nonjudgmental therapist, the resistance can be defused, often allowing the patient to continue with the work of therapy. Perhaps it is the empathic connectedness of the therapeutic relationship that allows new expectations and learning to occur.

During the session, Ms. A’s anger and hurt are acknowledged and validated empathically, and the therapist apologizes. This session illustrates an example of moving with resistance based on a real issue that the therapist acknowledges, not on the patient’s distortions, which is what we frequently think of as resistance. This is important in that the therapist needs to be prepared to take responsibility for mistakes. The therapist moves with the resistance by inviting Ms. A to talk about how she felt, even though she suspected that the patient would criticize her, and the therapist then thanks Ms. A for telling her how she felt. This patient risked criticizing the therapist, and the therapist was glad that Ms. A was able to trust the relationship enough to be honest about her feelings. Ms. A’s feelings toward the therapist and Jim, her boyfriend, are similar and reflect current feelings and thoughts that are associated with implicit memories of being ignored and not responded to. Although not explicitly linked by the therapist, this issue is addressed by the renegotiating of goals. Setting new goals is another example of moving with the resistance, and although the therapist does think that the therapy has been helpful in decreasing Ms. A’s panic attacks, she does not disagree with her about that because it will not serve to advance the process at this point. This also illustrates how the therapist moved with the resistance. This was a much different experience for Ms. A from what she remembers in her family when she asked for help. After a few more sessions, the therapist again asked Ms. A how she was feeling, how things were going, and whether they were on track with her goal of enhancing resources.

This example illustrates what is called an alliance rupture, that is, tension or breakdown in the collaborative relationship between the patient and the therapist (Safran, Muran, & Eubanks-Carter, 2011). Such a rupture can occur at the beginning of treatment or anytime over the course of treatment. Unlike this example, sometimes patients may be only vaguely aware of their dissatisfaction and it is up to the APPN to help the person express negative feelings. An extensive review of the literature and research found a number of

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therapeutic strategies helpful to repair alliance ruptures (2011). Please see Box 4.7.

Paradoxical Interventions

Paradoxical interventions are used for patients who are said to be highly resistant and experiencing much conflict about change. These communication strategies assist in looking at the problem in a new way and are paradoxical because they ask the person to embrace the behavior that the therapy is aiming to diminish (Wachtel, 2011). This approach often helps the person to become unstuck through bypassing the resistance and overloading the conscious mind with confusion. The problem that was thought to be uncontrollable becomes volitional and purposeful. Neurophysiologically, this may be arousing, particularly in the frontal and parietal lobes, which become activated during novel stimuli, and this allows a window of opportunity for new learning to occur. This parallels brain development in that repeated exposure to new stimuli in a supportive interpersonal context results in the brain’s increased ability to tolerate increasing levels of arousal and permit ongoing neural integration (Cozolino, 2002). Paradoxical interventions challenge the established neural networks in the context of guidance and support that underlies all forms of successful therapy.

BOX 4.7

THERAPEUTIC STRATEGIES FOR ALLIANCE REPAIR

Be aware of subtle indications of ruptures in the relationship and explore the patient’s negative feelings Respond nondefensively and accept responsibility for your contribution to the interaction Emphasize with patient’s experience and validate the patient for bringing it up Consider changing the goals of treatment Explore the alliance rupture further if therapy is psychodynamic Do not generalize to other relationships even if true

Paradoxical interventions are most appropriately used for patients who cannot see any other possibilities and are consistently self-defeating. The therapist connects with the person through understanding and empathy, agrees with the person, and then prescribes the problem behavior or may ask the patient to observe the behavior. One strategy is to ask the patient to not try to change the behavior but instead to observe it and keep track of it throughout the week. This changes the relation of the person to the behavior so that the behavior is no longer the enemy and becomes a curiosity because an antagonistic attitude often accompanies what should be changed. This also increases the therapeutic distance of the problem, and the person develops the capacity for an observing ego whereby the person is not the problem. For example, the insomniac who is battling to go to sleep dreads going to bed and may benefit from being told to try to stay awake and resist going to sleep. An analysis of two studies of treatment for chronic insomnia confirmed that paradoxical intention reported greater benefit compared to placebo (Morin et al., 1999). Another example of a paradoxical intervention is the therapist telling the person who is paranoid and highly distrustful, “It is probably a good idea not to trust me and wait until later to make sure that it is safe.” For patients who are locked into being helpless, hopeless, and self-defeating, a useful paradoxical communication may be “I can understand believing that nothing will ever be better would make everything seem pretty impossible. Please continue this week to notice all the negative thoughts that come up for you without trying to make anything better.”

These interventions have been used and are embedded in various psychotherapy approaches such as family, behavioral, solution focused, and psychodynamic therapies (Wachtel, 2011). Erickson, the master of paradox and metaphor, developed elaborate interventions designed to intentionally confuse the patient through contradictory commands during trance (Lankton, & Lankton, 1991). Westerman and colleagues (1987) found that brief paradoxical treatment was more effective for resistant patients than brief behavioral treatment. A meta-analysis of 15 studies supports the idea that paradoxical treatments are more effective than nonparadoxical treatments for various behavioral problems (Hill, 1987). Motivational interviewing is an especially effective therapeutic approach designed to change behavioral problems. See Chapter 7.

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Paradoxical interventions may be inappropriate for the beginning therapist because if not used sparingly and sensitively, the therapist may be experienced as sarcastic. For example, a patient who is plagued by distressing, negative thoughts may be advised to take 5 minutes of every hour to worry. Suggesting this without proper empathy may serve to humiliate and further alienate the person from his or her therapist. Prefacing such a suggestion with “I can see how having such negative thoughts would make things look pretty impossible” conveys an appreciation of the person’s experience. There are a wide range of applications for paradoxical interventions such as smoking cessation, binge eating, anxiety disorders, behavioral problems, depressive thinking, or any problem where the person is entrenched in a self-defeating pattern of behavior that creates pain for the person.

Secondary gain means that the person develops an illness or perpetuates a behavior that results in favorable environmental, interpersonal, monetary, or situational benefits. Sometimes, these gains are explicit (i.e., in the person’s awareness), and other times they are implicit and can be brought to consciousness through exploration. For example, for a depressed patient who was asked to list the pros and cons of being depressed, the person identified and clarified the secondary gains received from being depressed, which the person may only have been dimly aware of before. The areas identified included avoiding confrontation and possible abandonment by his partner, sex with his partner, and work in an area he did not like. Once identified, these underlying issues could then be explored. Open-ended exploration of what would happen if the person changed and asking how this change would affect his or her life and important relationships are relevant questions to ask at the beginning of any treatment to examine whether there are secondary gain issues. Often, secondary gains are more apparent to others than to the patient. Skillfully leading the person to his or her own discovery can potentiate significant, long-lasting change.

CONCLUDING COMMENTS

In the initial session, caring, connecting, and goal consensus begin the psychotherapeutic process through the use of open-ended therapeutic communication. This applies to all models of psychotherapy and practice settings. Engagement of the patient is essential to ensure that the person returns after the intake process is complete. Early research on the initial session suggests that therapists who have a higher percentage of patients who return after the first session also saw a higher percentage of people for more than 10 sessions (Tryon, 1986). Despite managed care and the emphasis on brief treatment, keeping people in treatment until their goals are met is a hallmark of successful therapy. Although in some settings a comprehensive assessment is required in the initial session, the first priority must always be initiating a therapeutic alliance, and assessment is a priority only in terms of safety. After the person has been engaged, a more thorough assessment, diagnosis, and case formulation are in order. As you increase your skills in engagement and assessment, you will be able to achieve competency in assessment in a shorter period.

Both patients and therapists need to have the security of boundaries and a frame for practice to be comfortable with the anxiety-provoking work of psychotherapy. Early in the therapy process, it is thought that most patients consciously or unconsciously test the frame of the treatment. A person may forget to come or to pay, may be late, or continue to talk beyond the scheduled session time even when reminded that it is time to stop. It is always best to err on the side of conservatism and consistency when setting boundaries. Both patients and therapists may have problems adhering to the frame. For example, ending the session and adhering to the timeframe may be difficult for a variety of reasons. The therapist may feel inadequate and extend the session, thinking perhaps that listening longer will make the person feel better or that it is okay to make up the time the person missed if he or she is late. It is important for the APPN to maintain the frame and start the session on time and end on time so that if the person has an appointment at 12 and comes at 12:30, the session that is scheduled for 45 minutes will still stop at 12:45 as previously planned. Patients may have separation issues and not want to leave. The person may linger while writing a check, talk about a scheduling problem, ask for a referral for a friend, or bring up an issue that seems important to address sooner rather than later (i.e., doorknob disclosure). Other patients may get intensely emotional during the last 5 minutes of the session. Offering the person a few extra minutes may be appropriate but difficult, particularly when other patients are waiting. The therapist can gently say something such as: “I’m sorry, but we do have to stop now. You have touched on some very sad feelings that would be important to talk more about. Would you like to wait in the waiting room until you feel better?” Ending the session on time is an area that well-intended therapists often struggle with in maintaining the frame.

For the novice APPN psychotherapist, the frame of treatment, payments, session times, phone calls,

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emergencies, and other factors are usually decided by the setting in which the therapist accepts employment, and have little to do with the therapist’s preferences. Although these rules of the agency may not be what the therapist would choose, it is best for the patient if the therapist adheres to the policies. In opening a practice, the therapist is faced with a multitude of issues about the frame, such as setting fees, collecting money, availability, session times, cancellations, and records, that must be decided. The process of psychotherapy encourages powerful attachments for both participants, and these feelings may undermine the APPN’s confidence about limits and sometimes obscure the importance of maintaining the frame. Boundaries, working with resistance, and setting limits are areas that challenge even experienced therapists. Errors will be made at times, but it is important to be able to recognize situations when boundary or resistance issues arise, to regain balance, and to follow the frame for treatment as closely as possible. This is what the work of psychotherapy is about, no matter what approach or model is used.

DISCUSSION EXCERCISES

1. Discuss transference, and give a clinical example from your practice. Describe how your understanding of transference affects your response as a therapist.

2. Develop specific goals for how and what therapeutic communication skills you would like to integrate and further develop in your practice.

3. Generate a list of words for the various nuances that can be used to describe the feeling of anger, and generate another list for the feeling of sadness.

4. Discuss the goals of the first session. 5. Discuss why the therapeutic alliance is important, and identify psychotherapeutic strategies that

can help in developing this alliance. 6. Is empathy always a good thing? Give some examples of when it may be a problem. 7. Using the example of a practice contract from the appendix or from the website cited in the

chapter, develop a one-page contract or office policy that you could give to patients. 8. Identify from your clinical practice an example of complementary or concordant

countertransference, and explain how your feelings might have helped you in understanding your patient.

9. Describe a clinical situation in which paradoxical interventions may be useful, and develop a plan to use this strategy.

10. Discuss communication techniques for dealing with specific instances of resistance, and give examples for each.

11. Examine your own areas of chronic countertransference and what may be helpful to you in your future APPN practice.

12. What is meant by the slippery slope and what problems may arise as a result of integrating therapeutic touch and Reiki in your APPN practice? Discuss strategies for how you could address these issues.

13. A patient who has been depressed most of her life comes to therapy complaining that she is hopeless, helpless, and will never have a good life. Discuss your gut reaction with someone with this characterological issue and how this could impact frame issues such as money, time, and therapist availability.

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Research, 3(1), 281–289.

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Notice of Privacy Practices

This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

I may use or disclose your protected health information (PHI), for treatment, payment, and health care operation purposes with your consent. To help clarify these terms, here are some definitions:

“PHI” refers to information in your health record that could identify you. “Treatment, payment, and health care operations” – Treatment is when I provide, coordinate, or manage your health care and other services related to your

health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another psychologist.

– Payment is when I obtain reimbursement for your health care. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

– Health care operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

“Use” applies only to activities within my (office, clinic, practice group, and so on) such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

“Disclosure” applies to activities outside of my (office, clinic, practice group, and so on), such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment, and health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures With Neither Consent nor Authorization

I may use or disclose PHI without your consent or authorization in the following circumstances:

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Child abuse: When in my professional capacity, I have received information which gives me reason to believe that a child’s physical or mental health or welfare has been or may be adversely affected by abuse or neglect, I must report such to the county Department of Social Services, or to a law enforcement agency in the county where the child resides or is found. If I have received information in my professional capacity which gives me reason to believe that a child’s physical or mental health or welfare has been or may be adversely affected by acts or omissions that would be child abuse or neglect if committed by a parent, guardian, or other persons responsible for the child’s welfare, but I believe that the act or omission was committed by a person other than the parent, guardian, or other persons responsible for the child’s welfare, I must make a report to the appropriate law enforcement agency.

Adult and domestic abuse: If I have reason to believe that a vulnerable adult has been or is likely to be abused, neglected, or exploited, I must report the incident within 24 hours or the next business day to the Adult Protective Services Program. I may also report directly to law enforcement personnel.

Health oversight: The State Board of Examiners has the power, if necessary, to subpoena my records. I am then required to submit to them those records relevant to their inquiry.

Judicial or administrative proceedings: If you are involved in a court proceeding and a request is made about the professional services I provided you or the records thereof, such information is privileged under state law, and I will not release information without your written consent or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

Serious threat to health or safety: If you communicate to me the intention to commit a crime or harm yourself, I may disclose confidential information when I judge that disclosure is necessary to protect against a clear and substantial risk of imminent serious harm being inflicted by you on yourself or another person. In this situation, I must limit disclosure of the otherwise confidential information to only those persons and only that content which would be consistent with the standards of the profession in addressing such problems.

Workers’ compensation: If you file a workers’ compensation claim, I am required by law to provide all existing information compiled by me pertaining to the claim to your employer, the insurance carrier, their attorneys, the South Carolina Workers’ Compensation Commission, or you.

IV. Patient’s Rights and Psychologist’s Duties

PATIENT’S RIGHTS

Right to request restrictions: You have the right to request restrictions on certain uses and disclosures of PHI about you. However, I am not required to agree to a restriction you request.

Right to receive confidential communications by alternative means and at alternative locations: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. On your request, I will send your bills to another address.)

Right to inspect and copy: You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.

Right to amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.

Right to an accounting: You generally have the right to receive an accounting of disclosures of PHI regarding you. On your request, I will discuss with you the details of the accounting process.

Right to a paper copy: You have the right to obtain a paper copy of the notice from me on request, even if you have agreed to receive the notice electronically.

NURSE PSYCHOTHERAPIST’S DUTIES

I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and

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privacy practices with respect to PHI. I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.

If I revise my policies and procedures, I will mail you a copy of the new notice.

V. Questions and Complaints

If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, you may ____________. If you believe that your privacy rights have been violated and wish to file a complaint with our office, you may send your written complaint ____________. You may also send a written complaint to the secretary of the U.S. Department of Health and Human Services.

You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.

VI. Effective Date, Restrictions, and Changes to Privacy Policy

This notice will go into effect on April 14, 2004.

I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice by mail.

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Contract

Welcome to my practice. The following includes some essential information regarding psychotherapy. Please read and sign at the bottom to indicate that you have reviewed this information.

Length and Frequency of Treatment

Psychotherapy typically involves regular sessions, usually 45 minutes in length. Duration and frequency vary depending on the nature of your problem and your individual needs.

Confidentiality

Information you share with me will be kept strictly confidential and will not be disclosed without your written consent. By law, however, confidentiality is not guaranteed in life-threatening situations involving yourself or others, or in situation in which children are put at risk (such as by sexual or physical abuse or neglect). If I need to discuss your treatment with a colleague, I will take pains to disguise identifying information, including using a pseudonym.

Fee Policies

My fee for an individual therapy session is ___________ per session. If you need to cancel an appointment, please tell me at least 24 hours ahead of time; otherwise, you will be charged for the missed session. Please be aware that insurance carriers will not cover cancellation charges.

If you carry Anthem Blue Cross insurance coverage where I am a provider, I will bill your carrier and assist with insurance reimbursement. In this circumstance, the insurance carrier limits the fee charged for the session and you will not be charged for the difference between my ordinary fee and the cap placed by insurance. Any copayment necessary should be made at the time of the office visit. Unless we make another explicit arrangement, you are responsible for filing insurance claims for all other carriers where I am not a provider. I will give you a bill at the beginning of the month for the previous month and would like to receive payment at that time or at the next session.

Phone and Emergency Contact

If you need to contact me by phone, do not hesitate. When I am not available, my answering machine will take a message. I am usually able to return calls the same day. You will not be charged for phone calls unless we have a scheduled conversation of an information-exchanging or problem-solving nature that lasts more than 10 minutes. If you cannot reach me in an emergency, you can find help at the Emergency Services number of the local hospital: Norwalk Hospital, 203-852-2000.

Physician Contact

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Physical and psychological symptoms often interact. I encourage you to seek medical consultation if warranted. It may benefit your treatment for me to speak to your primary care provider, in which case, I will ask your permission first.

Freedom to Withdraw

You have the right to end therapy at any time. If you wish, I will give you the names of other qualified psychotherapists.

Informed Consent

I have read and understood the preceding statements. I have had an opportunity to ask questions about them, and I agree to enter a professional psychotherapy relationship with Dr. Kathleen Wheeler.

Notice of Privacy Practices

I have read the NOTICE OF PRIVACY PRACTICES given to me by Kathleen Wheeler PhD, APRN. I have been given a copy to keep. I understand my rights and responsibilities and know that I may ask questions about my personal health information and its safekeeping at any time.

Signed: _____________________________ Date: ____________

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Process Note

This page is a psychotherapy process note under the Health Insurance Portability and Accountability Act (HIPAA) regulations. It must not be included in or attached to any other part of the client’s health care records except with other psychotherapy notes. Clients may request access to these notes only under exceptional circumstances and access may be denied if it is deemed harmful to the client. Releasing these notes requires a special authorization.

Client name:

(for each entry, date code, time, and signature)

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Progress Note

Kathleen Wheeler, PhD, PMHCNS-BC, PMHNP-BC, APRN, FAAN 3 Cedar Pond Road Westport, CT 06880 203-919-1984

Client name: ___________________

Diagnoses (DSM-5): ________________

Date: _________________

CPT code: _____________

Prognosis: ____________

Signature: ______________

Visit time: ____________

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Process Recording

Purpose

The process recording is a written account of a session between a client and therapist. Through the reconstruction of the interaction, the student is provided with an opportunity to retrospectively examine and analyze your facilitative communication skills and therapeutic use of self and the client’s contribution to the interaction. Through an analysis of what is said (the content of the interaction) and the flow of the interaction (the process of the interaction), awareness is increased of your own feelings, values, attitudes, expectations, assumptions, and verbal responses and how all influence the interaction with the client. The analysis also helps you to distinguish between your own thoughts and feelings and gain insight into how this influences the perception of the client, the client’s situation, and how the client is coping.

The therapist analyzes what is said (the content) and the flow of the interaction (the process of the interaction). This analysis is then used to increase self-awareness of your own feelings, values, attitudes, and beliefs and how they influenced the interaction with the client. This analysis also helps to distinguish between your own thoughts and feelings, and gain insight about how each influences your perception of the client. The process recording also provides you with an opportunity to retrospectively examine and analyze a client’s behavior. Through this analysis, inconsistencies or consistencies between what the client says and does can be identified and used to help clients gain insight about their problems and function more effectively.

Directions

There should be four columns, the first designated as Therapist Said, the second, Client Said, the third, Therapist Thought/Feeling column, and the fourth, the Analysis column plus a Summary page. See criteria on the next page regarding what should be in each column and form for how to set up. At the end of the session, write down everything you can remember that the person said in the Client Said column, then go back and fill in what you think you said in the Therapist Said column, then fill out the Therapist Thought/Feeling column, and the Analysis column last. After reading over, write a summary of the interaction on a separate page.

If you have gaps in your memory or cannot recall the exact flow of the interaction, indicate this in the Analysis column and examine why you think you might have “forgotten” (e.g., “I wonder whether the topic was anxiety provoking to me?”). Don’t write while talking with the person. The process recording is an efficient way to provide students with help with their communication skills; therefore, choose an interaction that was difficult or problematic (e.g., you were stuck, speechless, and overwhelmed). You will probably think of alternative ways of dealing with the situation after reading it over. Openness about problems encountered during the interaction will facilitate helpful feedback that will enhance both your communication skills and therapeutic use of self.

Some of the clients that you will encounter come from very different cultural and socioeconomic backgrounds, and have very different values, expectations, perceptions, and behavior. An important part of the learning experience is to identify those differences and how they influence your ability to be sensitive, empathetic, nonjudgmental, accepting, and therapeutic.

CRITERIA FOR EVALUATION OF PROCESS RECORDING

Therapist ________________ Client’s initials ________________ Date ________________

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In Therapist Said Column

Reconstruct an interaction with a client using the assigned format.

Document, in the “student said” column, verbatim statements (what you said as closely as you can remember) during the interaction.

In Client Said Column

Document, in the “client said” column, verbatim statements (what the client said as closely as you can recall) during the interaction.

In Therapist Thought/Feeling Column

Separate out your thoughts and feelings and indicate by a T for Thought or F for Feeling at the end of each sentence.

Document the cognitive responses (what you thought) during the interaction. (T)

Document your affective response (your feelings and emotions such as anxiety and sadness) in response to what occurred during the interaction. (F)

In Analysis Column

Identify how thoughts and feelings influence own behavior. Identify own values, beliefs, attitudes, expectations, and assumptions, and how they influence perceptions and responses to the client.

Identify own expectations and how they influence perceptions and responses to the client. Identify inconsistencies between what the client is saying and doing, or between the client’s situation and efforts to function effectively.

Identify discrepancies between verbal and nonverbal behavior. Identify discrepancies between the client’s perception of potential or existing problems and the reality of these problems.

On Summary Page

Identify client resistances to disclosing and examining potential or existing problems. Identify nonverbal behavior that indicates resistance to dealing with existing or potential problems. Identify verbal behavior that indicates resistance to dealing with existing or potential problems. Identify any defenses that you thought the client manifested. Identify responses to the client that were ineffective or nontherapeutic. Identify the verbal input that was a barrier to facilitating the relationship with client. Label the barrier to facilitating the relationship with the client. Identify alternative effective responses that would have facilitated the interaction with the client. Identify examples of latent communication.

Use the attached format to document the interaction.

When documenting the interaction, set up the columns so that the reader can see the flow by staggering what

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is documented in the “therapist” and “client” columns.

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Sample Termination Letter

Date ________________

Dear ________________,

The last session we had was on ________ (date) and you have missed two scheduled appointments since then. I did leave you two telephone messages but you have not responded. I hope you are okay and will contact me in the near future to resume treatment. As the contract you signed stated when you initially came to therapy, regular appointments are important in order to continue to make progress. I believe it is not in your best interests to terminate now. I would like to continue to work with you but if you would like a referral elsewhere, please call me and I can help make some suggestions for ongoing treatment. If I do not hear from you by _________ (date 2 weeks away), I will consider your treatment under my care to be terminated. If you have any difficulties, please go to your nearest emergency room. I hope to hear from you soon.

Best Regards, Kathleen Wheeler, PhD, PMHCNS-BC, PMHNP-BC, APRN, FAAN

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Psychotherapy Approaches

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Supportive and Psychodynamic Psychotherapy KATHLEEN WHEELER

his chapter begins with an overview of the underlying assumptions of psychodynamic psychotherapy, the history, and evidence-based research. Psychodynamic psychotherapy is discussed as on a continuum,

with supportive, expressive, and psychoanalytic approaches considered. Rationale is provided for choice of approach based on developmental considerations for clinical decision making. How to develop a case formulation and the working through phase of treatment is examined, as is working with alliance ruptures and dreams. Guidelines for brief psychodynamic psychotherapy are provided with case studies illustrating concepts and techniques throughout the chapter. Those skilled in psychodynamic psychotherapy recognize the difficulties in suggesting specific standardized techniques, because technique is driven by the context of the interaction.

In the current environment of managed care, in which a course of psychotherapy is often three to six sessions, practicing any meaningful relationship-based work is difficult, if not impossible. With these limitations in mind, an overview of relevant concepts and technical considerations is presented. The chapter ends with information about postmaster’s training and certification requirements for psychodynamic psychotherapy. Chapter 4 reviews the basic concepts of transference, countertransference, and resistance, which are foundational to understanding psychodynamic psychotherapy.

With the American Psychiatric Association’s (2008) mandate that all psychiatric residency training programs teach long-term psychodynamic psychotherapy to meet standards of accreditation, the relevance and importance of this type of therapy were affirmed by the psychiatric establishment (Gabbard, 2010). Knowledge about psychodynamic psychotherapy is essential for all advanced practice psychiatric nurses (APPNs) to deepen understanding about development and how the patient’s history is reenacted in the nurse– patient relationship in therapy and in life. Even if the APPN is using another approach, it is still important to understand the person’s dynamics to inform decisions about treatment. The patient does not necessarily need to achieve dynamic insights to experience symptom reduction and personal growth, but developmental considerations, anxiety, transference, countertransference, implicit memory (unconscious), defenses, motivation, and resistance are relevant in any therapeutic encounter. Knowledge about psychodynamic theory is also important for APPNs to communicate with other mental health disciplines. The literature in nursing reiterates the importance of psychodynamic theory for understanding the psychodynamics in the nurse– patient relationship and the inner world of both the nurse and the patient (Gallop & O’Brien, 2003). These authors stress that without knowledge of psychodynamic psychotherapy, nurses are at a tremendous disadvantage and at risk for acting inappropriately and not in the patient’s best interests.

Psychodynamic psychotherapy requires intensive teaching and experience to attain competency. This chapter lays the foundation for the APPN who wishes to understand the basics of this approach. Competencies in psychodynamic psychotherapy include using developmental models to understand personality and psychopathology, formulating a psychodynamic explanation and plan treatment, tracking the issue that is the focus of treatment, implementing the process of therapy, and managing the relationship (Binder, 2004).

UNDERLYING ASSUMPTIONS OF PSYCHODYNAMIC PSYCHOTHERAPY

Psychodynamic psychotherapy is derived from psychoanalytic psychotherapy, which was developed by Sigmund Freud at the end of the 19th century. This type of therapy is also referred to as insight-oriented, intensive, exploratory, expressive, and depth psychotherapy. Underpinnings of psychodynamics are rooted in developmental theory, with the basic premise that what has happened in the past determines what we are doing today. It is thought that through understanding these factors, the person is empowered and then free to

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make more conscious decisions and consequently live a more satisfying and useful life. Blagys and Hilsenroth (2000), in an extensive review of the literature, identify factors that distinguish

psychodynamic from cognitive behavioral therapy (CBT). These include emphasis on the past; focus on expression of emotion; identification of patterns in actions, thoughts, feelings, experiences, and relationships; emphasis on past relationships; exploration of and working with resistances that impede treatment; exploration of intrapsychic issues through asking about wishes, dreams, and fantasies; and emphasis on the transference and the working alliance. Gabbard (2010) identifies seven key concepts of psychodynamic psychotherapy: the unconscious, a developmental perspective, transference, countertransference, resistance, psychic determinism, and unique subjectivity. Gabbard explains unique subjectivity as the therapist’s challenge to pursue the patient’s subjective truth and true self, which most likely has been thwarted by parents who cannot recognize, validate, and appreciate this self. This is based on the underlying premise that we do not really know ourselves and that much of what determines our behavior is governed by unconscious memories.

Most psychodynamic schools emphasize the centrality of conflict among powerful desires, wishes, and fears. Psychodynamic clinicians believe that to help the person, it is essential to understand how these conflicts are enacted in the present. Psychodynamic theorists agree that understanding unconscious psychological structures and patterns in daily life, as well as how they interact and maintain each other, are essential ingredients to understanding the person (McWilliams, 2011; Wachtel, 2011). Wachtel points out that a key characteristic of this pattern is irony; the person ends up in the very position that he or she was trying hard to avoid. For example, the person who is fearful of feelings of anger may act overly nice, unassertive, and maintain a passive stance toward others. This allows others to ignore his or her needs and, consequently, he or she begins to feel frustrated and devalued, which leads to more anger and more anxiety, and the pattern is repeated. Another example is a person who fears hostility from others and interprets every interaction as potentially hostile, preemptively acting in self-protective hostility toward others, which evokes hostility from others, which leads to more anxiety, and so on (Figure 5.1).

Anxiety is central to understanding these difficulties, and even if the person does not feel particularly anxious, defenses and characterological personality traits embedded in implicit memory systems bind the person to a life that is restrictive as compromises are made to keep anxiety at bay. Specific anxieties arise at every level of development, with various theorists positing different tasks based on various theoretical models (Tables 5.1 through 5.3). For each developmental stage, anxiety revolving around a specific issue is negotiated, and if successful, the fear surrounding that phase is assuaged so that the person is then able to proceed to the next stage without being preoccupied by that threat (McWilliams, 1999). For example, in early infancy, a major preoccupation is security, with annihilation the threat if the attachment to the mother is threatened or not present; for early childhood, the issue is autonomy, with the concomitant anxiety revolving around separation (i.e., how to be an independent agent and still maintain a relationship with the caregiver); for later childhood, issues of identity must be resolved, with fears of punishment, injury, and loss of control important to resolve. To regulate the anxiety associated with each stage and other painful affects, defense mechanisms develop in implicit memory networks through interaction with caregivers and interpersonal experiences.

FIGURE 5.1 Cyclical psychodynamics.

The job of the psychodynamic therapist is to help the person understand how fears and inhibitions in

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early life have led him or her to react to healthy feelings as if they were a threat and how this plays an active role in generating his or her difficulties in the present. The person inadvertently and consistently brings about consequences that are not consciously intended. The psychodynamic therapist uses interpretations to expose the person to previously avoided experiences combined with empathy in a safe therapeutic environment. Chapter 4 discusses interpretation. The focus of the interpretation depends on the school of psychodynamic thought the therapist subscribes to. This exposure is not just aimed toward intellectual understanding but emotional experiencing at a gradual pace. Re-experiencing painful affects allows adaptive processing so that dissociated or disconnected memory networks can be integrated with other, more adaptive neural networks (Cozolino, 2010).

HISTORY

The history and theory of psychodynamic psychotherapy since Freud’s time are complex, and his ideas have undergone numerous permutations and iterations. This evolution has paralleled paradigm shifts in science in the 20th century, which emphasize interconnections, mutual interactions, and subjectivity of phenomenon (Curtis & Hirsch, 2003). Each psychodynamic model evolved from the others before establishing a new perspective placing different emphases on human development and motivation for behavior. New perspectives addressed what was seen as the failure of Freud’s theory (Mitchell, 1988). These competing schools of thought—Freudian, ego, self, existential, Lacanian, analytic, object relations, interpersonal, relational, and intersubjective—are somewhat insular and fragmented in that each seems to take little notice of the others. Each school developed its own theoretical constructs and techniques. The following overview highlights selected theorists and does not do justice to the complexity, richness, and nuances of psychoanalytic theory.

TABLE 5.1 Freud’s Psychosexual Stages

Adapted from Sadock, Sadock, and Ruiz (2009).

Sigmund Freud’s classic model of psychoanalytic psychotherapy is based on drive theory; that is, all behavior is determined by unconscious forces or instincts, either sexual or aggressive. Freud’s structural model of the id, ego, and superego explains the idea of psychic conflict. Symptoms are thought to develop through a conflict between an instinctual wish (id) and the defense against the wish (ego). The superego is part of the unconscious that is formed through internalization of moral standards of parents and society, and the superego acts to censor and restrain the ego. The concept of psychic determinism is embedded within this model and refers to the idea that nothing happens by chance and that everything on a person’s mind and all behavior, pathological and nonpathological, has a cause and is multiply determined. Freud delineated the psychosexual stages of development based on the idea that libidinal energy shifts from various erogenous zones in each stage. Freud posited that if a person had not successfully negotiated the previous stage, specific problematic character traits or psychopathology would continue throughout life (see Table 5.1).

In the 1960s, the scope of psychoanalysis was widened by interpersonal theorists such as Harry Stack Sullivan, Karen Horney, and Eric Fromm, who stressed the importance of relationship. Sullivan believed that the details of the patient’s interactions with others provided insight into what would help resolve intrapsychic

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difficulties. Using Sullivan’s framework, Hildegard Peplau developed the psychodynamic interpersonal model for psychiatric nursing. Sullivan’s perspective of the therapist as participant–observer expanded the prevailing paradigm. Sullivan believed that the therapist was not just a passive observer of what was going on in the patient but was a participant in the process of psychotherapy.

TABLE 5.2 Mahler’s Stages of Separation–Individuation

Adapted from Mahler, Pine, and Bergman (1975).

Ego psychology and object relation theorists such as Margaret Mahler followed with increased emphasis on relationship in producing change. Mahler’s object relation theory evolved from her observations of infants and children and analysis of this qualitative data (Mahler et al., 1975). Stages of development based on separation–individuation were described and explanations were offered about how children develop a sense of identity separate from their mothers (see Table 5.2). The infant is described as being totally dependent, with relatively little self–other differentiation, and the child develops through a relationship into a separate person with a high degree of differentiation.

Klein and Fairburn combined intrapsychic theory and drive theory with the idea that the primary motivation of the child is to seek objects (Curtis & Hirsch, 2003). Object means the internalization of experiences with other people. Object relation theorists posit that people are primarily motivated to seek other people and that this is the central motivating force in development rather than drive gratification (Winnicott, 1976). Winnicott (1976) speculated that for a child to develop a healthy, genuine self, as opposed to a false self, the mother must be a good enough mother, who relates to the child with primary maternal preoccupation. The child then can grow and explore without overwhelming anxiety feeling that the world is safe. The child develops a sense of me and those aspects that are not part of him or her create a potential space between himself or herself and the mother. This is the area of play and is an important dimension of the developing self. Winnicott (1976) said that the therapist’s chief task is to provide a holding environment for the patient so that the patient can have the opportunity to meet neglected ego needs and allow the true self to emerge. In contrast to the good enough mother, the not good enough mother is thought to create a dynamic in subsequent relationships in adult life, in which the person feels never good enough. Alice Miller (1981) in her widely recognized book, The Drama of the Gifted Child, describes eloquently the adverse effects of certain types of parenting on the development of the child’s true self.

Building on Freud’s ideas about intrapsychic conflict, Erik Erikson, a lay psychoanalyst, expanded the theory of development to encompass the entire life cycle. He conceptualized life as a struggle of conflicting needs in the quest toward self-actualization (Erikson, 1964). These conflicting needs revolved around the need for stability versus the need for growth at each stage of development. Table 5.3 shows Erikson’s stages of development. As we move from infancy to old age, Erikson posited that we face a stage-specific conflict that involves themes of inhibition versus desire. Although similar symptoms may be experienced in each stage, each of the eight stage-specific conflicts may have a different meaning, depending on unique issues and emotions for that particular stage, and success at resolution depends on how successfully the person has negotiated the previous stages.

TABLE 5.3 Erikson’s Psychosocial Stages

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Adapted from Erikson (1964, 1968).

For example, a 21-year-old woman came to therapy after being raped in college. She had become significantly depressed and attempted suicide shortly after the rape. Her depression reflected a loss of identity that was shattered beyond repair. She had previously functioned as her parents expected her to and was generally motivated to meet others’ expectations. Her depression precipitated an exploration of her own values and who she really was, a process that gradually allowed her to rebel against the need to conform. Finding her own voice was integral to the treatment, and she eventually was able to articulate the differences between her opinions and those of her parents. Her depressive symptoms represented the conflicting need for stability and conformity versus the need for self-awareness and growth.

Significantly departing from the idea of intrapsychic conflict, Heinz Kohut developed self psychology based on a deficit model of development. Kohut posited that the self was the central organizing frame of reference and that the self seeks out responses from others to maintain self-cohesion (Kohut & Wolf, 1978). Contrary to Freud’s conception of the individual as primarily being driven by the quest for pleasure, Kohut’s self strives for competence, self-esteem, and order, and these are the sine qua non motivators of behavior. Others serve self-object functions for the individual, and these include mirroring, idealizing, and alter-ego experiences. Individuals never lose the need for self-object experiences throughout life. However, if self-object experiences are less than adequate in early life, the person may later in life have difficulty with self-soothing, self-regulation, and maintenance of self-cohesion. Kohut based this idea on the clinical observation that a certain subgroup of patients developed an idiosyncratic transference in therapy, which he called the narcissistic transference. These patients, unlike the typical analytic patient, needed mirroring and idealized the analyst. Those with this type of self-pathology formed attachments based on these needs. Kohut posited that empathy played a central role in the psychotherapy of those with narcissistic psychopathology.

The relational model evolved in the 1980s from object relations, self, interpersonal, existential, and feminist models. This significant shift in the psychoanalytic paradigm changed what was called a one-person psychology to a two-person psychology (Gabbard, 2010). This awareness of two separate minds interacting with one another is also referred to as intersubjectivity. The therapist is considered a coparticipant in the co- construction of the relationship, not an outside observer. It is only in the present moment as the process is unfolding that both participants’ understanding is deepened. The need for relationship derives from the physical closeness to the mother and is thought to be the prime motivator for behavior. The presence of the other is necessary and inescapable in human development and in the therapeutic relationship. Self-regulation results from mutually regulatory interactions with caretakers and evolves within the mother– infant dyad. Relational psychodynamic theory heightens our understanding about the need for attachments for psychophysiologic stability.

Schore’s (2012) neurobiologic research and theory on attachment provides a scientific basis for the importance of relationship to therapeutic action in psychotherapy. The growing capacity to self-regulate is contingent on transformations of underdeveloped functions that exist in the infant through early attachment experiences that assist the developing psychobiologic, homeostatic regulatory processes. Cumulative early attachment problems are thought to produce chronic dysregulation in central and autonomic arousal, with deficits in mind and body. Chapter 2 discusses the neurophysiology underlying this dysregulation. Problems in self-regulation include difficulties in tension regulation, such as in addictive disorders, eating disorders, personality disorders, anxiety disorders, attention deficit hyperactivity disorder, and mood disorders.

A basic tenet of the contemporary relational model is that the therapist and patient are always participating in a relational configuration and that understanding this process is how change occurs. Before relational theory, much discussion ensued about the differences between the transference relationship and the

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real relationship between the therapist and patient. The transference and the patient’s feelings toward the therapist were artifacts of the past, whereas the real relationship was what was going on in the present. In the relational model, however, this is irrelevant because there are multiple truths and there is no real relationship, only a co-constructed interaction that is at best subjective (Gabbard, 2010). This interaction coupled with mindfulness is the agent of change, and developing and repairing problems in the therapeutic alliance are considered the work of relational psychodynamic psychotherapy.

Embedded in this idea of multiple truths is the concept of multiple selves; there is no unitary true self, but each person is constructed with many self-states. Different self-states are based on the various states of consciousness that we flicker in and out of throughout the day. Chapter 2 discusses the neurophysiology supporting this idea. These shifting, multiple self-states elicit complementary self-states in others through relationship. Dissociated self-states that are experienced as potentially dangerous are kept from the person’s awareness. By potentially dangerous, Safran and Muran (2000) explain that these states are associated with actual traumatic experiences or disruptions of relatedness to significant others. Assisting the patient to experience and accept the various dimensions of the self through enhanced awareness of these traumatic states is considered crucial to the relational psychodynamic therapy process.

A synthesis of the literature on the relational model reveals significant differences between Freudian psychodynamic psychotherapy and relational psychodynamic therapy. Table 5.4 compares and contrasts these models.

EVIDENCE-BASED RESEARCH

Studies of the efficacy of psychodynamic psychotherapy began in earnest only within the past 10 years because this type of therapy developed outside of universities and the academic world (Shedler, 2010, 2011). Education and training in psychoanalysis took place in institutes that were open only to medical doctors and excluded psychologists who are trained in research methodology. However, several compendiums of psychoanalytic research published within the past 10 years have attempted to address this deficiency by presenting reviews of psychodynamic research (Fonagy 2002; Levy & Ablon, 2009). These volumes report positive results for psychoanalytic psychotherapy.

TABLE 5.4 Comparison of Classical Psychodynamic Therapy With Relational Psychodynamic Therapy

The late start for research on psychodynamic therapy does not demonstrate that this approach is not effective, but it may more accurately reflect the difficulties in experimental controlled design for this approach. Numerous methodological problems for research on psychodynamic psychotherapy have been identified,

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because psychodynamic techniques do not lend themselves to the precision required for a clinical trial (Curtis & Hirsch, 2003; Gabbard, 2010). The problems cited in the literature include the following:

1. Manualized, structured protocols, such as CBT and interpersonal psychotherapy (IPT), are easier to systematically evaluate.

2. There is great difficulty in randomizing subjects, which is the gold standard of experimental design. Patients who want to engage in psychodynamic psychotherapy must be motivated to engage in the self- reflected exploration needed and are self-selected.

3. If the treatment is long term, which some psychodynamic therapies are, the costs would be too great to follow patients over time.

4. Funding is lacking for studies in psychodynamic psychotherapy. 5. The complexity and variety of psychodynamic approaches and technique make adherence to a specific

model for intervention in an experimental design difficult. 6. Because subjectivity and context are embedded in the psychodynamic process, it is not possible to study by

traditional objective scientific inquiry. 7. Most psychodynamic research consists of case studies, which limits the ability to generalize to other

situations and populations. 8. Outcomes involve internal change for psychodynamic psychotherapy, which is difficult to quantify. 9. Randomized clinical trials focus on patients with one specific diagnosis and symptom measurement.

Patients treated with psychodynamic therapy present with complex problems that usually are not limited to one disorder.

Despite the above limitations, many randomized clinical trials in the literature report positive results. The most compelling evidence includes meta-analytic studies of randomized clinical trials which are considered the most effective statistical method for synthesizing the findings of many studies through using effect size as a comparison. Effect size is the difference between the control and experimental groups with a 0.8 indicating a large effect size, 0.5 a moderate effect size, and 0.2 a small effect size. A review of meta-analytic studies of psychodynamic studies reveals overall large effect sizes for pretreatment to post-treatment outcomes. See Table 5.5 for selected meta-analytic studies. The large effect sizes for psychodynamic psychotherapy 0.69 to 1.46 are impressive but even more so when compared with studies of the U.S. Food and Drug Administration (FDA) research, which found effect sizes for fluoxetine (Prozac) of 0.26, for sertraline (Zoloft) of 0.26, citalopram (Celexa) at 0.24, and escitalopram (Lexapro) at 0.31 (Turner et al., 2008).

In addition, larger effect sizes are reported for follow-up outcomes than immediate post-tests after treatment for those studies that included this measure (Shedler, 2010). What this suggests is that the patient continues to change for the better after leaving therapy. This indicates that the changes are enduring and extend beyond symptom remission. As a result of this research, numerous practice guidelines include psychodynamic psychotherapy as a treatment for various psychiatric disorders (see Table 5.6).

PSYCHODYNAMIC CONTINUUM

Psychodynamic psychotherapy can be seen as a continuum from supportive psychotherapy to expressive to psychoanalysis using the practice treatment hierarchy from Chapter 1, Figure 1.6, as an overall framework for practice. The goals and focus of each type of psychodynamic psychotherapy differ, with the supportive end of the continuum aimed toward stabilization through restoring functioning, reducing anxiety, strengthening defenses, and more effective problem solving, whereas the psychoanalytic end of the continuum is aimed toward processing through interpreting unconscious conflict and gaining insight (Gabbard, 2010).

Expressive and psychoanalytic therapies involve more emotional processing than supportive psychotherapy with periods of stabilization alternating with processing, and therapy often shifts back and forth along this continuum. Chapter 1 (Figure 1.8) addresses the treatment process spiral that illustrates the process of psychotherapy. The degree to which the therapy is supportive versus psychoanalytic is based on the focus on transference issues and the frequency of sessions (Gabbard, 2010). In moving toward the psychoanalytic end of the continuum, the transference interpretations increase, as does the number of sessions per week. Through transference, unconscious conflicts are illuminated and then worked through. By increasing the number of sessions per week, it is thought that the transference intensifies, which is desired in psychoanalytic psychotherapy.

Along this continuum, some therapeutic communication techniques may be more appropriate for

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stabilization and others aid in processing. See Figure 5.2 on treatment hierarchy, psychodynamic continuum, and communication. Briere and Scott (2013) describe the therapeutic window of emotional processing and say that activation of emotion must accompany the narrative to process the trauma. The APPN helps the patient to modulate experience through questions that increase or decrease activation. As described in Chapter 4, the communication techniques considered to be more supportive are less emotionally laden and appropriate for stabilization, whereas those higher on the treatment triangle may trigger processing and implicit neural networks. Without the proper resources, this may be experienced as overwhelming accompanied by unmanageable feelings. The supportive techniques are considered to be resource building and less anxiety provoking. Thus, for patients who require primarily stabilization through supportive psychodynamic psychotherapy, the communication techniques toward the lower level of the treatment hierarchy are most often used. Supportive communication alternating with those communication techniques higher on the treatment hierarchy are appropriate for the emotional processing that occurs in expressive and psychoanalytic psychotherapies.

TABLE 5.5 Selected Meta-Analytic Studies of Psychodynamic Psychotherapy

Adapted from Shedler (2010). BT, behavior therapy; CBT, cognitive behavioral therapy; PT, psychodynamic psychotherapy; sx, symptoms; tx, treatment.

TABLE 5.6 Practice Guidelines for Psychiatric Disorders

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FIGURE 5.2 Psychodynamic case formulation.

Using communication techniques that are expressive to increase arousal may be needed for avoidant patients. These techniques may include immediacy, interpretation, observation, and focusing, depending on the psychotherapy approach being used. Another strategy to increase activation is to ask the person to go over the memory slowly in detail using the present tense. The amygdala is thought to hold memory in the present tense because it has not yet been processed. The narrative naturally shifts from what is happening to what did happen after processing has occurred. The greater the detail of the event narrated in the present tense, the greater the activation and the processing of traumatic material (Briere & Scott, 2013).

Processing involves exposure to the trauma and assisting the person in constructing a narrative through the exploration of the meaning of significant small and large traumas that impair functioning. The emotional dimension of the memory is essential for full processing to occur. Emotions are embedded in body sensations so that both in tandem are experienced during processing. Talking about the event without the attending emotions or body sensations may be an intellectual exercise only and preclude total processing. Briere and Scott (2013) emphasize that much of trauma activation and processing occurs at implicit, nonverbal, often relational levels.

Abreactions are intense emotional reactions to painful experiences that have been repressed. Chu (2011) delineates common phases that occur during abreactions: increased symptoms; intense internal conflict; acceptance and mourning; and mobilization and empowerment. Patients who do not have the capacity to withstand the intense feelings that occur during abreaction may instead use dissociation, substance abuse, distraction, and other avoidance responses (Chu, 2011). Avoidance responses may take the form of missing sessions, lateness to sessions, increased distress, or self-injurious or impulsive behaviors after sessions. Therapists not skilled in working with abreactions should heed these signs as indicators that the therapeutic window for processing has been exceeded.

When overactivation or abreaction occurs, suggestions include shifting the focus away from the trauma with breathing exercises or relaxation techniques; directing the person’s attention to less disturbing material; focusing on only one aspect or dimension of the experience such as the sounds or body sensations; distraction; using supportive communication techniques that are dearousing and supportive (see Figure 5.2) emphasizing intensity of emotion as doing good work; explaining activation before and after processing to normalize the person’s reactions; problem solving with the person to help mediate hyperarousal; using the safe place or container exercises (see Appendices 1.7 and 1.8); conveying optimism; and stabilizing with other affect management strategies (Briere & Scott, 2013). If the person is abreacting, do not touch the person or make any sudden moves, and allow for personal space.

Periods of processing are often followed by periods of destabilization. The APPN paces and structures treatment so that work on traumatic material alternates with resources, such as grounding and containment. “Trauma should not be the focus of session after session. Instead, as material is retrieved, it is much more important to process that material in a manner that allows the patient to remain stable than it is to move on to

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find and/or deal with more material” (Kluft, 1999, p. 15). As Kluft points out, slower is faster because the overall therapy time is reduced if treatment is relatively stable. Periods after processing may include feelings of increased sadness, anxiety, loss of control, or confusion. Sometimes, normal functioning is impaired, and the person may become suicidal or unable to function, especially if there are memories of childhood abuse. More sessions per week sometimes offer more support, and the person then can have the opportunity to move beyond crisis intervention to address deeper underlying difficulties (Kluft, 1999).

The APPN emphasizes the importance of maintaining supportive relationships and regular activities because these provide a positive sense of self and allow the work to continue. If the crisis is not averted quickly, this is an indication that the patient is not ready to continue with emotional processing. Hospitalizing the person to process trauma only furthers regression and is counterproductive unless needed to ensure patient safety. As illustrated in Figure 1.8 in Chapter 1, the treatment process often looks more like a spiral alternating interventions aimed at stabilization and then processing leading toward integration and future visioning. As life happens and job loss, serious illness, and other events may lead to destabilization, it may be necessary to stop processing and move to stabilizing again in the course of treatment.

Siegel (2012) posits that coherent narratives facilitate processing and interhemispheric integration. The left brain, which is language based, interprets the emotion-based autobiographical content of the right brain. Chapter 2 discusses right- and left-brain functions. The narrative in psychotherapy as told to an empathic other links self-states that have become dissociated due to trauma (Howell, 2005). This integration is considered the heart of mental health, with the successful resolution of trauma creating a deep sense of coherence (Siegel, 2012). The narrative helps the person to reconstruct a chronology to make sense of the experience by providing a context for time with a beginning, middle, and end. Research supports that through the reconstruction of the narrative, posttraumatic symptoms are reduced (Amir et al., 1998). Because the disturbing experience is disconnected from other dimensions of the person’s experience, it is important that the person integrate the event into his or her life and create meaning, allowing for closure. The literal recall is not as important as the meaning of the event to the person and how his or her sense of self or identity has been impacted.

As patients begin to accept what has happened, new perspectives about long held assumptions begin to shatter. Those who have suffered abuse typically have conflicts in many areas of life. For example, one young woman who had been sexually abused by her father as a child felt intense shame about not having been good enough to stop the abuse. She had both love and hate for her father and, consequently, for herself. Her ambivalence was reflected in many areas: “I was loved/I was hated; I was powerless/it was my fault.” These intense ambivalent feelings were extremely painful, repressed, and reflected entrenched neural networks of thought, emotion, and sensations. As she began to see her father more realistically, she was able to reformulate a more accurate view of herself. Over time, she began to see herself as a survivor instead of a victim. The reworking of traumatic material occurs over time in different ways. The person begins to understand the various elements of what happened and then understands the same event and sense of self in a different way at a later date.

Another patient, a man who suffered horrific physical abuse from his sadistic father, examined various aspects of this situation. First, he understood and experienced the betrayal and pain he felt because of his father and, subsequently, he also understood the event as betrayal and humiliation by his neglectful mother, who did not intercede and passively witnessed his abuse. He then examined how this reverberated into all areas of his life, such as his feelings about himself in relationships, difficulty setting boundaries, inability to make decisions, lost job opportunities, self-esteem issues, somatic symptoms, difficulty managing feelings and self-soothing, and poor coping skills. Changes in physical and emotional responses occurred as the fragments of the traumatic memory from the past were integrated with other more adaptive networks. The emotions elicited from the retelling are likely to be intense, and this expression is encouraged. Eventually, the events no longer increase emotional arousal after they are fully processed. Over time, memories are woven into a narrative reflecting the integration of neural networks as new information is learned.

Educating the person about relapse prevention is important. The patient may always be vulnerable to symptoms when re-exposed to stress because high states of arousal may promote retrieval of state-dependent memories, sensory information, or behaviors associated with prior disturbing experiences if the memories have not been fully processed. A plan for how to manage these times should be discussed, and this includes reviewing resource materials to enhance coping skills and booster sessions at vulnerable times. Explain to the patient that these high-risk periods may include developmental changes, periods of elevated stress, or reminders of partially processed traumas. Traumas that have not been previously identified may also be triggered at these vulnerable times. Resources should be increased prophylactically during these times.

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Supportive Psychotherapy

Frequently, supportive psychotherapy is recommended, and it is assumed that the therapist knows what this entails without training. Supportive psychotherapy is psychodynamic in that it is based on a knowledge of the patient’s psychodynamics, which shapes the approach, but the goals of treatment differ considerably. Whereas psychoanalytic psychotherapy aims to restructure defenses and change personality organization through interpreting feelings, fantasies, and beliefs, supportive psychotherapy aims to strengthen defenses, promote problem solving, restore adaptive functioning, and provide symptom relief. Left-brain frontal cortex problem-solving abilities are greatly impaired in some patients because of personality organization structure or current life stressors that have precipitated regression to an earlier stage of functioning. Supportive psychotherapy is indicated to assist the person in stabilization, as illustrated by the treatment hierarchy in Figure 1.6 in Chapter 1. This involves increasing external and internal resources.

In A Primer of Supportive Psychotherapy, Pinkster (1997) says that the supportive model is the preferred model for most patients and that it is only when the goals of treatment cannot be met through this model that more expressive therapies should be employed. Although Figure 5.3 indicates that supportive therapy is for those who are on the psychotic end of the continuum, it is the treatment of choice for healthier patients too. Most clinicians believe that the decision about whether to use supportive psychodynamic psychotherapy should be based on the person’s ego strength and weaknesses, coping skills present, highest level of functioning previously achieved, recent losses, and other life stresses and circumstances (Hollender & Ford, 2000). In a seminal article, 16 basic strategies are identified as supportive (Misch, 2000) (see Table 5.7).

In assessing ego strength, it is important to identify the primary defenses the person uses to ward off anxiety. McWilliams (2011) lists the types of defenses most commonly associated with those in the psychotic level of personality organization and says these defenses are preverbal. These include denial, projection, splitting, primitive idealization and devaluation, withdrawal, omnipotent control, and dissociation. These defenses protect the person who is terrified of annihilation, lacks a basic security in the world, and is vulnerable to psychotic disorganization. Those in this end of the developmental continuum struggle with identity issues and confusion about who they are. Even if not overtly psychotic, the person is thought to be functioning at the symbiotic level of development, with little self–other differentiation. Some relational psychodynamic psychotherapists, such as Searles, Sullivan, and Fromm-Reichmann, advocate working with severe psychiatric disturbances such as schizophrenia using this model (Curtis & Hirsch, 2003).

Attachment research provides additional data for determining whether to use supportive or expressive interventions based on the person’s attachment style (Levy et al., 2011). See Table 2.1 in Chapter 2. Attachment style describes the person’s fear of rejection, yearning for intimacy, and preference of interpersonal distance in relationships. Determining the person’s attachment style assists the APPN in understanding about where to intervene on the psychodynamic continuum. The Adult Attachment Interview (AAI) is a semistructured interview that measures attachment style by analyzing how the patient describes childhood experiences (see Chapter 3). Those who are characterized as unresolved/disorganized are unable to form a coherent narrative about their life, due to lapses in memory or reasoning; those with preoccupied attachment styles seem overwhelmed with early relationship experiences and are unable to elaborate a coherent narrative without being flooded with emotion; while securely attached individuals are able to communicate with coherence and emotional genuineness about difficult childhood experiences.

An unresolved/disorganized attachment style may need more active interventions that facilitate emotional expression and connection, whereas a preoccupied style may need more supportive interventions that help the person contain overwhelming emotions; those with a secure attachment are able to work productively anywhere on the continuum without customizing psychotherapy interventions. Preoccupied attachment has been strongly correlated with borderline personality disorder (BPD; Fonagy et al., 1996). Not surprisingly, the patient’s attachment style predicts the nature of therapeutic alliance and the outcomes of treatment. The therapist’s attachment style also influences treatment. One study found that therapists who measured as insecure on attachment tools tended to worry more about rejection and were less empathic with patients (Rubino et al., 2000).

TABLE 5.7 Basic Strategies of Dynamic Supportive Therapy Strategy #1: Formulate the case Serves as a roadmap for future interventions; why does this person have this problem now; evolves as more information becomes available;

involves a developmental assessment

Strategy #2: Be a good parent “…to the extent that the patient is functioning at a childlike level in significant domains of life, the supportive therapist assumes a parental role” (p. 175)

Strategy #3: Foster and protect the therapeutic alliance First and primary goal throughout the therapy; respect the patient with compassion, empathy, and commitment; align with the healthy parts of

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the person; collaboratively set goals and strategies to attain these; interpersonally active treating the patient as the therapist would want to be treated

Strategy #4: Manage the transference Do need to explore the childhood experiences that underlie negative transference feelings but they must be corrected or the person may leave treatment; therapist acknowledges openly, explicitly, and nondefensively and/or apologizes

Strategy #5: Hold and contain the patient Provide empathy, understanding, soothing, helping the person to modulate affect, set limits when necessary, restrict acting out and impulsivity; may require medication and/or hospitalization; securing social services and so on while protecting the person’s autonomy

Strategy #6: Lend psychic structure Help as needed with reality testing, problem solving, impulse control, affect modulation, interpersonal awareness, social skills, and empathy

Strategy #7: Maximize adaptive coping mechanisms Support high level of defenses such as humor, altruism, sublimation, rationalization, and intellectualization and decrease use of denial, splitting, projection, and acting out; enhance coping skills such as mindfulness, dialectical behavior therapy and cognitive behavioral strategies to build distress tolerance skills and emotional regulation

Strategy #8: Provide a role model for identification Use judicious self-disclosure; be present, available, and real

Strategy #9: Decrease alexithymia Help the person to identify and name feelings; focus on somatic sensations associated with particular emotions; encourage use of metaphor to describe feelings

Strategy # 10: Make connections Make associations between an event or situation and the person’s feelings such as how false negative beliefs about himself or herself have undermined self-esteem and prevented the person from setting and/or achieving goals, seeking out healthy relationships, and so on

Strategy #11: Raise self-esteem Foster competency in real skills; role play skills; correct cognitive distortions; unravel unconscious guilt; normalize thoughts, feelings, and behaviors; explain why counterproductive behavior in the present may have been adaptive attempts to deal with earlier adverse life situations

Strategy #12: Ameliorate hopelessness Use CBT, reframing, case management such as helping the person to obtain disability, housing, job, transportation, community resources

Strategy # 13: Focus on the here and now Address primary issues: (1) safety, (2) therapy interfering behaviors, (3) future-foreclosing events or plans, (4) treatment noncompliance, (5) negative transference

Strategy #14: Encourage patient activity Help the person to take action through setting concrete behavioral goals, devising a plan of action, behavioral rehearsal, role playing, relaxation, visualization, imagery, graded exposure, and serving as cheerleader for patient efforts

Strategy #15: Educate the patient and family Teach about medication(s) side effects and so on, diagnosis/illness, relapse symptoms, specific tasks or functions that the person cannot do on his or her own

Strategy #16: Manipulate the environment Intervene as appropriate with agencies or persons in order to advocate for the person; do for the person what he or she cannot do for himself or herself always with an aim toward maximum independence and growth

In supportive psychodynamic psychotherapy, the content of sessions most often focuses on feelings, life stresses, and problem solving, rather than on defenses. The therapeutic techniques most helpful in supportive psychotherapy are on the lower end of the continuum of therapeutic communication. Although giving advice is not on the continuum, it is sometimes prudent to offer a suggestion when the person cannot problem solve. Suggesting that someone see an attorney if it is apparent that there is an impending legal problem and suggesting that a patient see a medical specialist if those services are necessary are two examples of situations in which it is appropriate and necessary to offer a strong suggestion. It would be remiss in these situations to not offer this type of advice. In contrast, the therapist should not offer suggestions in some cases: suggesting that someone go to church, take a vacation, join a singles club, go back to school, or try online dating. These types of suggestions are imposing the APPN’s values on the patient, and shifting the responsibility away from the patient to the therapist, which also encourages dependency and regression. Another way to help the person problem solve without giving advice is to explore alternatives of action, expanding the possibility of choices with the person.

Often, supportive psychotherapy is most useful for people who need clarification and help in sorting out issues that they would be able to do under other circumstances. Patients may need to discuss situations, sort out the alternatives, and express feelings. Supportive psychotherapy focuses on safety, education, and assisting with enhancing coping skills. For example, Mrs. J came to therapy on the suggestion of her friend because of a crisis in her marriage. She recently found out her husband was having an affair and was quite despondent. She felt lonely, isolated, and useless. The therapist listened attentively as Mrs. J described her 30 years of marriage, the early years of their relationship, and her inability to forgive her husband. She felt stuck in her grief and anger and could not decide what course of action, if any, to take. The therapist suggested that it is sometimes better to wait to make decisions until feelings are clearer and that they would together explore the possible consequences of various courses of action. Through expressing her anger toward her husband in therapy, she felt somewhat better and was only then able to begin to examine other dimensions of disappointment that had been present in their relationship for a long time.

Sometimes, catharsis is all the person wants or needs from the therapy, without resolution of conflict. This is true especially in grief and the mourning process. Expression of feelings can be the first step in acknowledging other, more painful affects. For example, anger often masks underlying hurt, and anxiety often masks underlying anger. Through empathic exploring and open-ended questions, the person is gently guided to a full expression of the nuances of emotion. One caveat is warranted: With patients who are histrionic or overly emotional, emotion may need to be contained rather than freely expressed, and affect regulation strategies may be needed before encouraging emotional expression. Chapters 13 and 14 discuss specific affect management strategies. The objective for supportive psychotherapy is to restore emotional equilibrium as quickly as possible.

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Expressive Psychotherapy

The psychodynamic treatment of choice for those with borderline character structure is expressive psychotherapy (McWilliams, 2011). The American Psychiatric Association (APA) guidelines for BPD state that psychodynamic psychotherapy is the psychotherapy of choice, along with dialectical behavior therapy (APA, 2010). Oldham (2005) reaffirms in a Guideline Watch that psychotherapy represents the core or primary treatment for BPD, with symptom-targeted psychopharmacology a secondary helpful adjunct. Those with borderline character structure as defined by McWilliams do not necessarily have a DSM-IV-TR diagnosis of BPD but may encompass BPD and a wider diversity of diagnostic categories that rely on primitive and immature defenses and include those with BPD. These individuals are not consistently in the mature spectrum of healthy defenses, and under stress, they may even appear psychotic; hence, the term borderline is used. Defenses predominately include projection, acting out, and splitting when under stress, but higher-level defenses may also be used.

Some theorists speculate that the genesis of difficulties occurs around 18 months of age in the rapprochement phase of separation–individuation (Masterson, 1976). It is thought that the child who still needs reassurance about his or her budding autonomy is thwarted developmentally by an unavailable caretaker or one who discourages separation. The child learns that independence equals loss of love (i.e., abandonment) and that closeness is associated with dependence and therefore fears of loss of control (i.e., engulfment). These early attachment issues can lead to a variety of adult relational problems and reflect unresolved attachment trauma. The ability to form and sustain reciprocal interpersonal relationships is notably disrupted in individuals who have experienced early traumatic attachment patterns (Schore, 2012). This essential dilemma gets played out in all subsequent relationships, including the psychotherapeutic relationship, creating chaos and unstable ego states.

Attachment trauma produces chronic problems in relationships, and processing relational trauma occurs largely through the therapeutic relationship. These individuals have difficulty in determining their own needs or sense of self and engaging in introspection. The relationally traumatized person has had to be hypervigilant, other directed, and accommodating to survive. This focus on other precludes the inner work needed to develop a coherent sense of self (Briere & Scott, 2013). The child who has been emotionally or physically abused or neglected in early life learns that he or she is not worth it and, due to cognitive immaturity, arrives at the conclusion that he or she must deserve such treatment. Consequently, the person views himself or herself as weak, helpless, and inadequate, existing at the whims of an inherently rejecting, unavailable, and hurtful other. These implicit schemas of worthlessness and helplessness become powerful organizing determinants of personality. Sometimes, an exaggerated façade of independence, willfulness, and self-sufficiency develops to counter these vulnerable feelings.

Most often, those with borderline personality structure are anxious, depressed, self-harm in crisis, and unable to tolerate ambivalence or defer gratification. These are individuals who are notoriously difficult to engage in treatment. Often, the precipitant for treatment is not because the person wants to change his or her personality, but because others have urged the person to seek help. These patients come to therapy with anxiety, depression, and dissatisfaction with their relationships. The challenge for the novice APPN is sorting out what to address first and what will be the focus of treatment. Because the person with borderline personality structure can appear to be high functioning and reality functioning seems intact, the nature of the underlying difficulties may not be readily apparent at intake.

As the transference evolves, it may take the form of idealizing or devaluing. The therapeutic relationship itself becomes a source of interpersonal triggers for implicit memories as the caring, empathic therapist often activates fears of abandonment. The growing feeling of emotional attachment to the therapist activates emotional responses from earlier childhood neglect or abuse experiences. These responses are often intense and may seem irrational and inappropriate. The therapist’s first clue of a rupture in the therapeutic alliance may be the person’s reaction to a comment that is intended to be helpful but the patient reacts as if attacked. For example, a man who is describing how angry he is that his boss is critical of him is asked by his therapist, “Does your boss remind you of anyone?” A higher functioning patient would most likely consider the question and answer, whereas the person with borderline personality structure may hear this as an accusation or criticism and feel angry at the therapist’s perceived lack of attunement and “judgmental” comment.

However, it is important to note that processing may be on an implicit level and may not always occur in words (Briere & Scott, 2013). Emotional processing can occur without higher processing systems of the brain that involve explicit memory. For example, conditioned responses of shame or anger associated with abandonment and/or self-hatred present in implicit memory as a consequence of relationship or attachment trauma are triggered through relationships in the present with the therapist as well

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as with significant others. Within the safety of the therapeutic relationship, counterconditioning occurs so that over time these schemas are not reinforced and the positive feelings of the therapeutic relationship allow new learning to occur.

Expressive psychodynamic therapy provides a vehicle for processing relational trauma through an ongoing therapeutic relationship over time. Briere and Scott (2013) identify healing components inherent in this approach:

1. The therapist offers consistent support for introspection through exploration, which allows the patient to develop an articulated and accessible sense of self.

2. The relationship itself provides a safe forum for activating and providing exposure to relational trauma. 3. The disparity between the therapeutic relationship and the expectation of abuse or neglect is demonstrated

and experienced. 4. Counterconditioning occurs when the patient perceives safety, nurturance, and acceptance in the session

and, consequently, fear is diminished. 5. Desensitization occurs as relationships are no longer perceived as dangerous, and triggers of fear, anger,

distrust, and avoidant behaviors are changed so that relationships are seen as a source of support rather than pain.

As the therapeutic relationship deepens over time, the inevitable dependency of the patient provides an opportunity to rework these implicit memories so that new learning can occur. The therapist does not encourage dependency but does provide support and caring in a nurturing environment so that the patient can safely re-experience childhood implicit relational memories.

McWilliams (2011) says that the overall goal for expressive psychodynamic psychotherapy is the development of an integrated, complex, and positively valued self. This means that the person is able to tolerate ambivalent feelings and self-regulate emotions. Although there is no universal agreement about how to work with patients who have borderline character structure, several general principles of working in expressive psychodynamic psychotherapy with these individuals have been delineated: establishing consistent boundaries, using empathy before all interpretations, focusing on the here and now, asking the patient for help, rewarding assertiveness, discouraging regression and dependency, decreasing arousal levels so that communication can be heard, and understanding countertransference.

Countertransference is particularly challenging in working with those with borderline character organization. Even experienced therapists seek supervision when working with these individuals. It is thought that powerful unconscious communication occurs with these patients, even more so than with those psychotically or neurotically organized. The right-brain-to-right-brain communication often is more helpful in understanding the patient than what is actually said. Psychodynamic therapists call projective identification a specific type of countertransference that deepens the therapist’s understanding of the patient.

Projective identification is considered a defense mechanism and a countertransference constellation. It essentially involves behaving in such a way that subtle interpersonal pressure is placed on the therapist to take on dimensions of an experience or unconsciously identify with aspects of the patient (Gabbard, 2010). Projective identification is a type of concordant countertransference, as described in Chapter 4, in which the therapist identifies with an aspect of the patient’s experience (empathy). For example, a therapist may begin to feel afraid of the patient as the person is talking, which does not seem related to what the person is talking about. This out of the blue feeling may reflect the patient’s own fear being projected onto the therapist, and the patient does not have the feeling, but the therapist does. Not only fear can be projected, but also anger, boredom, intrusiveness, passivity, and other feelings.

Or the therapist may identify with an experience that has been projected, which is known as complementary countertransference. For example, the therapist begins to behave, think, and feel whatever the patient is projecting and as significant others felt when with the person. The therapist can identify whether this is occurring if the therapist begins to feel or act unlike herself. For example, the therapist begins to feel angry or is verbally abusive toward the patient. The challenge is for the APPN to identify the powerful feelings that occur during the session.

Although projective identification has been touted as a useful tool to deepen therapists’ understanding of patients, savvy therapists know that any feeling that may come up during a session may be from their own unconscious and not from a patient. Therapists should trust their own instincts but only after taking emotional inventory and responsibility for their own dynamics. Sometimes, projective identification is so powerful that the therapist may feel confused, and on reflection between sessions or with supervision, the therapist begins to sort out her contributions from that of the patient. Contemporary psychoanalysts feel that countertransference and transference are co-constructed, and as such, the therapist uses her own feelings as a

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barometer to understand the patient’s internal world only after considerable self-reflection. Relational psychodynamic psychotherapists believe that all transference–countertransference phenomena are forms of projective identification, in that the therapist unwittingly always lives out the reciprocal role of the significant other in the patient’s early life.

Psychoanalytic Psychotherapy

Patients who are considered ideal candidates for psychoanalytic psychotherapy are those with neurotic-to- healthy personality organization, who primarily rely on mature defenses. Some primitive defenses may be present, but along with these, mature defenses are also evident. These individuals have a sense of who they are, generally are in touch with reality, and have achieved object constancy. Object constancy refers to the capacity to be alone. When asked to describe others, they are able to give a fairly detailed account of the other person so that the APPN can get a clear picture of the person’s characteristics. The patient with a neurotic- level personality most likely has had some satisfying relationships and is experienced by the therapist as able to engage in a therapeutic alliance. These persons may come to treatment because of obstacles in love or work that they are uncomfortable about. Usually, they are the people who seek help without being forced. Problems for individuals with neurotic-level personality organization are often experienced as ego dystonic (i.e., alien to how they experience themselves). For example, patients may be troubled by disturbing thoughts about harm coming to them or loved ones. These experiences are felt as different from themselves, as ego alien. In contrast, persons with psychotically organized personality may be more likely to experience their problems as ego syntonic. This means that the problem is compatible with who they are, and these individuals often feel that it is others who have the problem, and they want reassurance, for example, that they have good reason to be paranoid or acting out.

If the person wants to understand himself or herself deeply and significantly change, psychoanalysis may be indicated. Psychoanalysis is more intense than psychoanalytic psychotherapy in that session frequency is increased and the transference is intensified. Sometimes, the person comes to treatment and has some initial psychotherapy and then decides to deepen the work and undergo psychoanalysis. Psychoanalysis generally takes three to five sessions each week and requires the amount of time for natural or normal maturational change (3–7 years). Many of the candidates for psychoanalysis are those in training programs to become psychoanalysts. Therapists who want to work in a deeper way with patients and understand that knowing themselves is a prerequisite to this work sometimes seek their own psychoanalysis without the structure of a formal training program. Traditionally, the basic methods of psychoanalysis involve free association by the patient lying on the couch, with the therapist sitting in back of the patient while listening and interpreting resistance and transference as these elements are manifested in dreams and considering what the patient says or does in and outside of sessions.

The development and facilitation of what is called the transference neurosis are integral to the process of Freudian psychoanalysis. The transference neurosis is a rerun of the developmental process through an intense relationship with the therapist. The patient feels toward the analyst feelings that were similarly expressed toward significant others in early development. This enactment and resolution of the transference are the work of psychoanalysis. The deep analysis of the relationship with the therapist distinguishes psychoanalytic therapy from other types of therapies. The transference is intensified with the increased frequency of sessions and the neutrality of the analyst. The analyst listens with evenly hovering attention, which means without preconceptions, absorbing what the person says with an attitude of nonjudgmental, empathic neutrality designed to create a safe environment. As the transference unfolds, the patient and analyst work together in understanding unconscious processes that are triggered in the therapeutic relationship.

CASE FORMULATION

In order for the APPN to decide on a relevant therapeutic focus, realistic expectations of treatment, and the appropriate type of psychodynamic psychotherapy to use, a dynamic case formulation is essential. In general, the shorter the length of the psychotherapy, the more intense the pressure to determine a therapeutic focus, and this is done through a psychodynamic formulation. Safran and Muran (2000) state: “It is the establishment of a dynamic focus and the consistent interpretation of that focus over time, as it emerges in a

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variety of different contexts that facilitates the working through process and allows the client to integrate treatment changes into his/her everyday life” (p. 178). As addressed in Chapter 1, Figure 1.6, the hierarchy of treatment aims is helpful in this regard, but a more sophisticated psychodynamic understanding of development and defenses further refines treatment choice and informs the work of psychodynamic psychotherapy. The case formulation identifies a central issue that underlies the person’s presenting problem that is related to the person’s early developmental history. This involves conceptualizing presenting issues developmentally and understanding intrapsychic conflict. Three personality organization levels have been identified—neurotic to healthy, borderline, and psychotic—based on a synthesis of major developmental theories (McWilliams, 2011) (Figure 5.3).

These developmental levels may be thought of as a continuum ranging from neurotic to psychotic and that cuts across all diagnostic categories, because virtually all diagnoses are represented at each level. Some diagnostic categories are more heavily represented on one end of the continuum or the other, depending on the primary category of the defense used: primitive, immature, neurotic, or mature. Chapter 2 lists defenses in each category. In general, the person who uses primarily primitive defenses is more likely in the psychotic range of the continuum, and the person who primarily relies more on mature, higher-level defenses more likely is in the neurotic-to-healthy range. However, given enough stress, anyone can veer toward the psychotic end of the continuum. For example, the person with narcissistic traits can be primarily in the neurotic-to- healthy range, but with enough stress, the individual can slip into the psychotic end of the continuum. Under stress, we revert to methods of coping from earlier levels of development that feel similar to the current situation. Implicit memory networks of defenses are triggered by biochemical states reflecting state-dependent learning.

FIGURE 5.3 Case formulation and psychodynamic therapy.

McWilliams (1994) says that dynamically oriented therapists make an assessment based on the following: “People with a vulnerability to psychosis may be understood as fixated on the issues of the early symbiotic phase; people with borderline personality organization are comprehensible in terms of their preoccupation with separation–individuation themes; and those with neurotic structure can be usefully construed in more

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oedipal terms” (p. 53). The importance of determining the primary defenses of the patient and assessing ego functions in light of these developmental levels is to determine a dynamic case formulation and what type of treatment can be most helpful for the person at this time. Chapter 3 explains how to assess ego development. The core conflicts of the patient inform how to proceed psychodynamically with treatment more than a formal Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis.

A summary of the dynamic formulation should be shared with the patient and should be tentative, with some idea about how the therapist sees the nature of the work to be accomplished. For example, Michele, a 27-year-old French woman, came to therapy because she felt “confused, depressed, and was losing control.” She had several recent panic attacks accompanied by paranoid ideation, fearing that she might be attacked and possibly raped. At the end of the first session after taking her history, the therapist said: “The recent loss of your boyfriend has contributed to you feeling increasingly sad and panicky. We need to work on shoring up your resources so you can feel more in control when bad things happen. How does that sound to you?” The APPN felt that relational psychodynamic psychotherapy would be helpful but was careful to not overwhelm Michele with too much information in the first session. Later in treatment, after an alliance was more firmly established, the APPN fleshed out the dynamic formulation to Michele by suggesting: “Most likely, the absence of your mother’s presence in your early life and your father’s anger made you feel unsafe and prevented you from learning and developing the coping skills you need to stay on an even keel. It would be helpful to deepen your understanding of how you seem to end up in relationships that are not good for you.”

WORKING THROUGH

Working through is considered the heart of the therapeutic work. Freudian psychoanalysts see the working- through process as observing, clarifying, and interpreting defenses as manifested by the resistances and transferences again and again. However, relational psychodynamic psychotherapists emphasize working through as restructuring the person’s relational schemas through working with therapeutic impasses or ruptures in the therapeutic alliance. This “involves a recognition of how the relationship with the therapist reflects relationships from childhood and current extratransference relationships” (Gabbard, 2010, p. 170). Working through is the consistent interpretation of this dynamic focus over time. Rarely is there one insightful comment or interpretation that changes things dramatically. Rather, it is the repeated, consistent interpretation of the same themes and patterns as they are manifested in myriad situations and relationships. Both Freudian and relational psychodynamic therapists conceive that change occurs gradually and includes changing internal and external representations. Patterns of interactions are significantly changed with other people, and this is accompanied by changes in the patient’s internal representations or how the person perceives himself or herself and others. This change reflects adaptive information processing of memory networks that have been dysregulated or dissociated in implicit memory systems.

Emphasis in relational psychodynamic psychotherapy in the working-through process is on facilitating the development of the capacity for mindfulness (Safran & Muran, 2000). Mindfulness is the ability to observe internal processes and actions in relation to other people. This goal is conveyed to the patient at the outset of therapy. The APPN explains to the patient that how he or she feels with the therapist can also occur outside of therapy in other relationships. The patient is asked to monitor what dimensions of this situation are true or occur for him or her. The relational psychodynamic psychotherapist points out to the patient that with the therapist and with those outside of therapy, patterns of relating are similar and that these are fueled by the person’s early experiences. The therapist observes characteristic patterns of implicit relatedness and shares these observations with the patient, providing a new perspective that is different from the person’s own subjective impressions. Pointing out the person’s tendency to be controlling, demanding, dependent, or passive increases awareness of implicit modes of relatedness and the impact of these behaviors on others (Gabbard, 2010). This awareness often brings the patient a much greater sense of mastery, so that patterns of behavior can be reflected on before enacted in future relationships.

However, more than interpretations about relationships create change. The psychotherapeutic relationship itself provides a different relationship experience for the person so that new neural connections can be made. This inevitably leads to disillusionment as the person comes to accept his or her own separateness and that of the therapist, and it involves a mourning process in that the patient gives up an old way of being. Curtis and Hirsch (2003) state, “Salubrious new experience can only develop in a context in which old experience is first repeated, perhaps mourned, and let go of” (p. 81). Mourning the loss of possibilities and unhealthy relationships with significant others is considered curative because more energy is

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freed for current relationships. Unfulfilled desires are identified, tolerated, and then relinquished in a safe relationship.

The working-through process assists the person in recovering split off and dissociated aspects of the self that developed to maintain a relationship with parents. The person who has not been attuned to or who suffered trauma in early life has had to comply to survive, and a false self is thought to have developed. This false self lacks spontaneity and may result in a pervasive sense of unreality, futility, and lack of vitality (Safran & Muran, 2000). Relational theorists posit that there is not one false self, but multiple selves that need to be re-appropriated for the person to feel real and alive. These ways of being are embedded in important early relationships and templates of neural networks that at one time were adaptive. For example, the patient who was connected to her mother through chaos and unpredictability will experience sadness at giving up this state of consciousness, because this way of being is embedded in the fundamental attachment to the caretaker that ensured survival.

Various exploratory communication techniques assist in the working-through process. These include asking patients about their fantasies, daydreams, dreams, early memories, and ideas about what they perceive others are thinking, including what they imagine the therapist to be thinking. One way to help patients reflect on interactions outside of therapy involves helping them to experience situations fully by comments such as: “Imagine being there right now” (Curtis & Hirsch, 2003). Another exploratory technique is to observe and reflect what seems to be happening for the patient. For example: “You sound very angry today. I wonder what this is about?” Gabbard says this increases mentalization (i.e., mindfulness), which is the person’s ability to think about his or her own experiences and feelings, which invites further differentiation of emotions (2010). In a similar vein, if the patient reports an impulsive act, the therapist may ask what was going on just before that happened. Using open-ended, exploring communication allows patients to deepen their capacity for reflection. As a patient integrates emotional information that has been dissociated, a more robust sense of self develops that is grounded in the person’s own experience.

In contrast to cognitive therapy, in which there is a structured agenda for each session, psychodynamic psychotherapy is based on psychic determinism (Binder, 2004). This means that the patient’s spontaneous verbalizations will reveal affectively charged themes and that the person does not need to have a specific topic in mind but talks about whatever is on his or her mind that is relevant to the agreed problem focus. Those that are the most emotionally arousing and meaningful are current problematic relationships or past ones. This free association is thought to allow space so that the person’s own experience and ways of interacting can emerge. The therapist listens with the idea of discerning latent themes related to the person’s underlying conflicts and issues. The therapist asks herself: “What is the central issue here? What is going on now?” It is the therapist’s job to track salient themes and goals that were set at the outset of the treatment. Each session then is a continuation of the one before. What this means is that themes reverberate, threading throughout sessions, and what is talked about in the current session reflects issues that were salient at the end of the previous session. Taking good process notes at the end of each session helps in tracking these themes.

Integral to the working-through process is pointing out positive change and supporting the person’s strengths. The therapist points out positive changes to the patient and reframes experiences. For example, one patient who was struggling with rejection, neediness, and failed relationships was told by her therapist: “It is sad that things did not work out with Jim, but it seems that unlike past situations, you were able to see much sooner that your needs were not being met and to say what you wanted, rather than just hanging in there, hoping that things would change.” Encouraging risk taking and tolerating anxiety-producing situations through such comments provides the support needed and points toward positive change. Tempered comments without cheerleading are most effective; making the therapist happy is not the point of therapeutic gains. The idea that the patient changes to please the therapist is known as transference cure, and the therapist needs to be vigilant to ensure that the patient’s autonomy and self-actualization are the goal (Curtis & Hirsch, 2003).

Structuring challenging situations through gradual tolerance of anxiety-provoking situations can be done through psychoeducation, role playing, imagery, rehearsal, and modeling. For example, a man who came to treatment for marital problems was extremely passive in his relationship with his wife and often expected her to know what he wanted without articulating his needs. He grew up the youngest of six children with an angry father and depressed mother, and he spent much time alone in his room, withdrawing passively from the chaos around him. This typical response to conflict, coupled with his fear of rejection and his wife’s anger, paralyzed him in addressing anything with her that he was unhappy about. The therapist role-played a typical scenario, with the patient playing the role of his wife and the therapist playing his role. This exercise provided a new way of responding that he eventually was able to try at home. The role playing helped to build his confidence, see new ways of relating, and enabled him to deepen his understanding about his anxiety in a safe

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context. Because problems in relating to others are a core focus in relational psychodynamic psychotherapy, the

therapist helps the person to understand his impact on others, deepening understanding of other people, too (Wachtel, 2011). Flexibility in relationships is considered a sign of health, with healing defined as the ability to assimilate new experiences and to transcend the unhealthy identifications with others and constraints of the past (Curtis & Hirsch, 2003). For example, in the previous situation, the therapist pointed out to the patient “Given what you have told me about your wife, she seems to strike out and get angry when she is feeling neglected, and she likely feels neglected when you withdraw and do not communicate.” This type of comment enables the patient to see the cyclical nature of the patterns of relating that perpetuate the difficulties that the person is experiencing. In this situation, the patient’s passivity created the very situation that he was trying to avoid: his wife’s rejection and anger.

REPAIRING ALLIANCE RUPTURES

Many relational psychodynamic theorists believe that alliance ruptures are inevitable in therapy and that resolving these ruptures creates positive change (Binder, 2004; Safran et al., 2011). Any psychotherapy that goes too smoothly is thought to be an accommodation of the person’s false self to the therapist and is likely to remain superficial without really changing anything. In general, the therapeutic alliance may be stable from session to session, but there may be instances of strained interpersonal interactions between the therapist and patient. If the therapy is particularly brief, alliance ruptures may not develop because of the limitations of the treatment. The key to resolution lies in the experience for the patient of a collaborative conflict resolution with an emotionally significant other that is different from what the person expects (Binder, 2004). This is accomplished with the consistency and empathic attunement of the therapist.

Immediacy, a therapeutic communication technique described in Chapter 4, is useful in relational psychodynamic psychotherapy, especially in the throes of an alliance rupture. For example, one patient, a 46- year-old woman named Susan, came to therapy for depression because of a series of failed relationships. Her history revealed early deprivation with both parents, who were extremely self-involved and neglectful of their children. Her experience was one of chronically feeling devalued, which reinforced her schema that she was not lovable and not worth it. This theme played out in all her relationships in that no one could ever meet her needs or be there in the way she needed them to be. Chronic dissatisfaction and feelings of deprivation permeated every situation as she upped the ante, no matter what was offered to her. Whatever was given was not enough, providing proof of the person’s neglect or ill intentions. She presented an unpaid bill demanding to be paid in every interpersonal encounter. This was repeated in therapy, with Susan wanting more time, continuing to talk at the end of sessions, making frequent demands for changes of appointment times, and offering relentless criticisms of others. The therapist began to feel demoralized and tense up before each session, almost as if to shore up in order to withstand the barrage of negativity. The therapist felt hopeless and helpless, caught in the throes of a negative transference–countertransference enactment. After discussing the situation in supervision, the therapist understood that she was feeling as Susan must have felt, devalued in her family and hopeless, and the therapist offered this interpretation in the next session: “Perhaps you are feeling that I am not giving you what you need here.” This helped bring the process into the here and now, focusing on the therapeutic relationship, which allowed Susan to explore the reasonableness of her needs and her inevitable disappointment and hurt when she felt slighted. An interpretation is considered timely and relevant if it opens a productive avenue of therapeutic inquiry. The therapist encouraged and explored, listening empathically and nondefensively. She stated: “It is so hard to be here and feel so vulnerable and not get what you want or need.”

Negative Therapeutic Reaction

A negative therapeutic reaction is a specific type of therapeutic impasse in which the patient gets worse and becomes entrenched in maintaining his or her problems despite the help of the therapist. Gabbard (2010) says that these reactions likely result from revenge fantasies, in that the therapist serving as parent in the transference is defeated by the patient by not getting better. This reaction is usually unconscious. The patient is often not aware of ill intentions, only that he or she is stuck or unhappy in treatment. In relational

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psychotherapy, this situation is not one-sided. The therapist may have too much invested in helping the person and begin to feel demoralized because nothing seems to be helpful. It is often necessary for the therapist engaged in the throes of a negative therapeutic reaction with a patient to seek supervision and consultation to sort out the situation. Evaluating the relational dynamics with a colleague can be helpful, but sometimes even then, the only solution is to refer the patient to someone else. The patient sometimes makes significant improvements only after treatment is terminated.

WORKING WITH DREAMS

Research on dreams has confirmed the importance and relevance of dreams for understanding the unconscious and implicit memory (Solms & Turnbull, 2002). Dreams are the brain’s attempt to process information and to integrate the day’s residue into the existing memory networks. Dreams represent current conflicts, and work on dreams focuses on the here and now, rather than the past, although current conflicts usually have roots in the past. Many psychodynamic psychotherapists consider dream work a useful tool to assist patients in deepening their understanding about themselves. A basic tenet of dream work is that dreams represent wishes, fears, and conflicts, as well as the person’s attempt to master unresolved issues and process traumatic experiences. Dreams are fertile ground for work in psychodynamic psychotherapy.

As in communication, there is the manifest content and the latent content. The manifest content is what the dreamer says the dream is about, and the latent content is the meaning of the dream. The latent content is disguised by defenses so that the person will not awaken. Although dream symbol books are interesting, they are not particularly useful in interpreting dreams, because all meaning and symbols in dreams are highly idiosyncratic and not universal. Dreams have multiple levels of meaning, and the symbols represented in the dream are unique for that person. Two people may have the same exact dream, and it may mean completely different things to each individual. However, dreaming about a house or type of house may symbolize the person and feeling about himself or herself. The other theme that seems to appear for many people is going someplace in a car or train, which sometimes heralds movement or change in therapy or in people’s lives. There are often transferential dimensions to the dream; the dream may reflect feelings the dreamer has about the therapist, albeit in disguised form. Dreams can reveal feelings that have arisen in the therapeutic relationship that have not been addressed (Curtis & Hirsch, 2003).

Dream interpretation is a little like trying to understand a poem or a work of art. It is undoubtedly a right-brain endeavor, and it is helpful to use right-brain functions when working with dreams. This can sometimes be accomplished through a mindful state, whereby the APPN attends by suspending usual left- brain problem-solving thinking by listening with empathic receptivity and resonance. Dreams are not linear in that time and space are suspended. To understand the patient’s dream, it is important to know the basic mechanisms associated with dreams. These include secondary revision, symbolic representation, condensation, and displacement (Gabbard, 2010). Secondary revision refers to the right-brain implicit message being translated into a coherent story. Symbolic representation refers to an image that represents a complex set of emotions that may be highly charged. Condensation is a mechanism that combines more than one wish, feeling, or impulse into one image. Displacement is similar to defense in that feelings for one person are displaced onto another person in the patient’s life.

Working with dreams can be introduced to the patient by asking in the assessment about recurring dreams, memorable childhood dreams, and recent dreams. It is helpful to suggest that the patient keep a dream log next to the bed so that he or she can jot down significant dreams on wakening. These dreams can be helpful in gaining insight. Even if patients do not usually remember their dreams, they can be trained to do so by beginning to keep track of their dreams in this way. After discussing the idea of working with dreams with patients, it is better to not bring up the subject again and to allow patients to report dreams when they are ready. Not all patients are able to remember their dreams. Alexithymic patients in particular have great difficulty in remembering their dreams because of their impoverished ability to symbolize (Hollender & Ford, 2000).

Bringing in the first dream often heralds a deepening of the therapeutic alliance and should be positively acknowledged by the APPN. The first dream often illustrates the dynamic focus for the work of treatment. For example, one woman, who came to treatment with significant long-term depression but who was fairly high functioning, had suffered significant attachment trauma from her early relationship with her mother, who had BPD. The patient reported her first dream in the sixth session: “My daughter and I are taking care of a baby, a baby girl, about 2 years old. She is dead and in parts, and we can’t seem to

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get her back together. I am trying to call the funeral home but can’t get through, and for some reason, I have only 45 minutes. That is not enough time. I wake up thinking that I won’t be able to put her together in such a short time.” Her thoughts about the dream were that the baby was her and the 45 minutes was the length of our session time. This was a graphic illustration of how the patient felt about herself and the work that needed to be accomplished in therapy.

Although dreams can advance the work of therapy, they can also serve as a resistance. If the patient comes in with several dreams and floods the session with dream material, it may not be possible to examine any dimension of the dream in the detail needed to be helpful. As with all therapy, the process or context should be dealt with first. What is going on in the process of psychotherapy that causes the person to overwhelm the therapist with so much material now? If a dream is reported in a session, the whole session’s latent content usually is about the dream, even if the dream content itself is not the topic of conversation. Asking the person: “What are your thoughts about the dream?” is often a good way to start getting the patient’s associations about the dream. Another way to work is to ask the person what stands out the most about the dream or what was the worst part of the dream. If the dream is readily understood and the manifest content is obvious, it is considered transparent, which may sound like a derogatory term, but it means that the content is not highly disguised or defended against. In contrast, the dream that is difficult to understand may reflect the strength of the defense against this implicit material coming to consciousness. Sometimes, novice therapists are hesitant to do dream work because they feel they must come up with a grand interpretation at the end. Often, however, the therapist gets only the person’s thoughts on the dream without much comment. It is thought that relating the dream is therapeutic because this translates right-brain material into left-brain information, which is integrative in and of itself. It is not incumbent on the therapist to make sense of the dream; after all, it is the patient’s dream, and it is his or her thoughts about it that count. The following example illustrates the concepts and how to work with dreams.

Sarah, a 22-year-old English woman from an orthodox Jewish family, was seen for depression and low self-esteem. She described her mother as depressed, sometimes staying in bed for weeks, and her father as hypersensitive, depressed, tense, and domineering. Sarah moved to the United States to go to school the previous year. Sarah began her 15th psychotherapy session by saying that she was too hard on herself and that she always feels she is going to be judged because she sees others as superior to her and wonders how they will perceive her. She wanted to be different but was anxious about changing. Her parents always implied that they knew the real Sarah and that she was too introspective. Her older sister was always down on everything and saw Sarah as emotional, selfish, and a troublemaker, and Sarah tended to agree with her. She then reported the following dream: “I was at home in my parents’ house in London. Dad died in the dream and was out in the front yard without his head. Blood was pouring out of his neck, but he was still talking. I was crying ‘no, no, no.’ I felt awful that he had died.”

When the therapist asked what she thought about this dream, Sarah said she thought that she was trying to kill off parts of herself that were like her dad. She thought that the dream was telling her that she loved her father and did not really hate him and that she could love him after she was in control of herself and did not feel as if he controlled her. The therapist responded: “You care a great deal about your father, but you have issues to work out about yourself before you can improve your relationship with him.” In understanding the session in light of the dream, Sarah had started the session being concerned about being judged and perhaps wondered what the therapist would think of such a murderous dream. This is the latent transferential part of the session. By listening nonjudgmentally and accepting her thoughts about the dream, the therapist provided a different experience for her from the one she had in her family. The therapist offered no new interpretation but agreed and reflected what Sarah said about the dream. The following illustrates the basic mechanisms in Sarah’s dream:

Secondary revision: Sarah recounts the dream in story form. Symbolic representation: The house in London may represent her childhood experiences. Condensation: She sees her anger at her father and her own murderous impulses toward him on the one hand; his death brings freedom from his tyranny. On the other hand, he is still talking, and this may reflect the embedded wish that she can still maintain a relationship with him despite her anger or that his words would continue to influence her even though he is dead. Perhaps his talking head reflects her wish that her anger would not kill him and he would still be alive. Displacement: Sarah is in part displacing her own anger about herself toward her father. She focuses on her father as the source of her unhappiness in the dream, but in her associations to the dream, she says that she wants to kill off parts of herself that are like her dad, which illustrates the utility of the dream in illuminating her displacement.

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BRIEF PSYCHODYNAMIC PSYCHOTHERAPY

In contrast to psychoanalysis, brief psychodynamic psychotherapy takes place in fewer days per week and lasts for a shorter duration. Although techniques are similar, less regression is encouraged, and the patient is not encouraged to use the couch but to sit facing the therapist. For those wishing to work on a particular issue or conflict, shorter-term psychodynamic psychotherapy may be indicated. This approach is sometimes called focal psychodynamic psychotherapy. Although psychodynamic psychotherapy is frequently thought of as long-term therapy, brief psychodynamic psychotherapy is probably most often practiced given the current climate of managed care.

How many sessions constitute brief therapy? It could be one session, although we might question what this one session would consist of and how helpful it would be. Most often, 20 to 30 sessions are considered brief therapy. Even if brief, psychodynamic assumptions and techniques are the same as if longer-term treatment was conducted. There is no qualitative difference between brief and long-term psychodynamic psychotherapy. “There are not specific techniques that hold the key to the practice of brief therapy. Instead, the most expeditious means to achieve efficient and effective therapeutic outcomes is to practice ‘good’ psychotherapy, regardless of the anticipated or planned length” (Binder, 2004, p. 22). Wolberg (1977) developed general guidelines for conducting brief psychodynamic psychotherapy. A slightly modified version is provided in Box 5.1.

Proponents of brief psychodynamic psychotherapy believe that setting a termination date at the beginning of treatment assists in the progress and resolution of the patient’s problems. Setting the termination date is thought to provide a focus that can link or thread unrelated experiences together for the therapist and the patient. A termination date is thought to be integral to the treatment in that the patient is helped to work through the meaning of termination. This central issue in the therapy parallels the separation–individuation developmental issue of life. Loss is a central theme for everyone, along with the tension of connecting through relationship while at the same time being a self-agent. Termination in psychotherapy can be a forum for addressing and exploring these central dilemmas in life. Specific issues related to termination that frequently arise in therapy are abandonment fears, disappointments, and anger about not getting what a person hoped for. The therapist listens empathically, and this noncritical acceptance of the patient’s needs and wants helps the patient to accept the limitations of others. This approach is thought to help the person access dissociated wishes and needs that have been split off due to early relationships. Through the process of acknowledging and relinquishing the pursuit of an idealized, unattainable goal, the limitations and realities of relationships are accepted. However, there may not be enough time for transference to develop sufficiently, so the therapist can use the relationship to work through as just described. The focus of therapy then is on interpersonal relationships outside of the therapeutic relationship.

BOX 5.1

GENERAL PRINCIPLES FOR CONDUCTING BRIEF PSYCHODYNAMIC PSYCHOTHERAPY

Establish a therapeutic alliance Set a termination date (within 30 sessions) Deal with initial resistances Gather historical and other data What is the most important problem? Why now? What has been done so far? What does the patient think caused the problem? What does the patient want from therapy? Select the symptoms (focus) most amenable to treatment within the first three sessions Define the precipitating event Identify developmental issues and defenses to understand how to proceed Share the case formulation with the patient Enlist the patient as an active participant through a verbal contract Use the most effective techniques to help the patient Identify resistances or alliance ruptures, and address them with the patient Be sensitive to how the past is influencing the present Examine countertransference feelings Give homework (optional) Stress the need for continuing work

Adapted from Wolberg (1977).

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CASE EXAMPLE

Ms. S is a 32-year-old, intelligent, attractive woman who is very successful in her career. Her reason for seeking treatment is related to her dissatisfaction with her chronic tendency to choose men who eventually abuse her emotionally. Ms. S stated that her father had abused her sexually as well as other female relatives in the family. When Ms. S got older and objected to his advances, her father accused her of being uptight and compared her unfavorably to her younger and more compliant sister, who obviously had no problem because she willingly accepted his behavior. Ms. S had a good early relationship with her mother. The sexual abuse left Ms. S with a profound mistrust of men. She was active and controlling in relationships with men (e.g., she was always the one who initiated sex). When her partner expressed an interest in sex, it felt analogous to her father’s sexually controlling, intrusive, and abusive behavior. In addition to initiating sex, she was giving in other ways (e.g., gifts, dinners, and arranging activities for her and her boyfriend to enjoy). The unfortunate side of this behavior was that it obscured the essentially narcissistic character structure of these men. In other words, they were fine as long as they were on the receiving end. Inevitably, the relationship would founder when she risked expressing needs of her own.

Developmentally, her anxiety and conflict seemed to lie in the area of identity and loss of control in that she experienced much anxiety in relationships with men if she did not control what happened. Ms. S had good object constancy and could be alone without much separation anxiety, could self-soothe, was self-directed, and was fairly autonomous even though controlling in relationships. In Erikson’s framework, issues of intimacy versus isolation were apparent in that the crux of her problems was in establishing an intimate relationship. Neurotic-level defenses of displacement and rationalization were evident, as well as denial, which is considered a primitive defense. Her displacement took the form of an inability to recognize her own deep feelings of worthlessness, and she became a compulsive giver and cared about the needs of others to avoid the fact that she was being exploited in her relationships with men. She rationalized whenever she was not treated well in a relationship that she was needed and that only she could help her boyfriend feel better about himself. She should care for men and was plagued with guilt if she did not give more. The should often indicates oedipal issues in that a harsh superego predisposes the person to be overly hard on himself or herself. This, coupled with her denial about the selfish, exploitive characteristics in the men she chose to date, corresponded to her denial on some level of her father’s motives. Her high level of functioning with use of the defenses of humor and sublimation led her male therapist to conclude that she was probably a candidate for psychoanalytically oriented psychotherapy. Twice-weekly psychotherapy was conducted over a 2-year period.

Ms. S initially related to the therapist in a guarded, hypervigilant state, which sometimes made the therapist feel uneasy and constricted. At other times, she was quite seductive and incredulous that the therapist would not have sex with her. The following excerpt from a session illustrates the exploration of the importance of her sexual quest. She arrived characteristically late for her session and alluded to the previous session, which involved her declaring her sexual feelings for the therapist.

Ms. S: I finally understand why you won’t have sex with me, and although it’s frustrating, at least I understand why you are doing this.

Therapist: What is it that you understand?

Ms. S: It’s your goddamn ethics, your code.

Therapist: My code of ethics prevents me from having sex with you?

Ms. S: Yes.

Therapist: Anything else about me that may contribute to my not having sex with you?

Ms. S: [after a long pause] Well maybe, just maybe you feel it would hurt me.

Therapist: So, on the one hand, I want to have sex with you but don’t because of my ethical code, and on the other hand, I may care enough about you to not want to hurt you, as you have in the past been hurt.

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Ms. S: Perhaps I’m trying here to create a situation that is familiar to me.

Therapist: Perhaps, but you also consider that I may have different, more caring motives, and that is very new for you.

This session highlights the use of the relational model of psychodynamic psychotherapy. Relational psychodynamic psychotherapy is based on the idea that problems are caused by disturbances in relationships with early caretakers that pattern subsequent relationships. The therapist’s understanding emerged over time as the relationship unfolded. The therapist initially explained to Ms. S the importance of mindfulness and observing her own thoughts and feelings in the therapy relationship as it is taking place in the present moment. In exploring other aspects of a relationship in the here and now with the therapist, Ms. S was able to consider that the therapist cared about her, which introduced a new hypothesis about what ingredients there are in relationships. She spent numerous sessions struggling with a shift in her thinking that someone would care about her and not want to exploit her. As she mourned the loss of the illusion of a loving father and saw her father more realistically, she was able to see men in her life more realistically, too. Over time, she developed better object choices in that she looked for indicators that the men who she dated overtly cared about her, and she was able to make a better assessment of their intentions. Her defenses were modified, and she no longer had to compulsively control and give in intimate relationships. New, more adaptive information in implicit memory networks was learned through the processing that took place in her relationship with the therapist.

POSTMASTER’S PSYCHODYNAMIC PSYCHOTHERAPY TRAINING AND CERTIFICATION REQUIREMENTS

Although there is no one certifying body or national certification in psychodynamic psychotherapy, there are many psychodynamic training programs in most major cities in the United States that offer certification. Psychodynamic training is most often offered at an analytic institute and requires the therapist’s own analysis, coursework, and supervised psychoanalytic treatment of a requisite number of patients, culminating in a written case presentation and an oral defense, much like an oral dissertation defense. There are a number of 2- year programs with a focus on psychodynamic psychotherapy and 4-year programs in traditional psychoanalysis. In the past, programs affiliated with the American Psychoanalytic Association limited training to doctors of medicine (MDs), but most of these programs now allow APPNs, social workers, and psychologists to matriculate into their programs.

The American Psychoanalytic Association (2008) sets standards for candidates eligible for admission and includes: doctors of osteopathic medicine, medical doctors, mental health professionals with a doctorate as well as those with a clinical master’s degree. The many institutes of psychodynamic psychotherapy represent the various schools of psychodynamic thought and their respective curricula reflect their orientation. These include ego psychology, self psychology, traditional Freudian psychoanalysis, intersubjectivity approaches, interpersonal therapy, and relational therapy. APPNs who wish to pursue this type of training are advised to obtain information about the institute’s orientation before matriculation, because the theoretical foundation and practice approach may differ greatly.

CONCLUDING COMMENTS

Psychodynamic psychotherapy is forging new connections with neurobiology to validate existing clinical practice as new knowledge about implicit unconscious processes continues to be generated. It is this meeting of psychology with physiology that Freud envisioned more than 100 years ago. The contemporary model of relational psychodynamic psychotherapy builds on the important contributions of interpersonal psychodynamic theory and is consistent with the centrality of relationship that nursing espouses. The interpersonal psychodynamic model of psychotherapy has been the dominant paradigm for psychiatric nursing for the past 3 decades, since Hildegard Peplau based her framework of psychiatric nursing on the work of Harry Stack Sullivan. The contemporary psychoanalytic theory discussed here for APPN psychotherapy

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practice is moored in the one-to-one relationship, which builds on that model. The evolving, expanding knowledge of psychodynamic psychotherapy is based on a developmental, neurophysiologic model that deepens the understanding of others and offers the APPN relevant principles important for clinical practice.

DISCUSSION EXERCISES

1. Diagram (as in Figure 5.1) and discuss the cyclical dynamics of a patient you are currently working with or have worked with in the past.

2. Identify at least five reasons why evidence-based research is difficult to conduct in psychodynamic psychotherapy.

3. Compare and contrast the developmental models (i.e., Freud, Mahler, and Erikson) presented in this chapter.

4. Discuss the evolution of psychoanalytic thought. 5. What is the relational psychodynamic model of psychotherapy, and how can you integrate the

concepts and techniques described in this chapter in your work with patients? 6. Using the diagram in Figure 5.3, present a case formulation for a specific patient, covering all the

dimensions (e.g., anxiety, developmental issue, attachment schema, defenses, and developmental level), and then discuss what type of psychodynamic therapy you think would be appropriate and why.

7. Describe supportive psychodynamic psychotherapy, and discuss the various techniques for this type of therapy.

8. Discuss the dynamics of borderline personality organization, and describe general principles for how to work with patients with this character structure.

9. A patient comes to you for brief psychotherapy, and you believe that psychodynamic psychotherapy would be helpful. Discuss the beginning steps of treatment, and elaborate on how you would go about establishing a therapeutic alliance.

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Eye Movement Desensitization and Reprocessing Therapy KATHLEEN WHEELER

ecent research and theory support that processed experiences are the basis of mental health functioning and that unprocessed experiential contributors are the basis of most psychopathology (Bergmann, 2012;

Cozolino, 2010; Shapiro, 2001, 2006, 2007; Siegel, 2012; van der Kolk, McFarlane, & Weisaeth, 1996). Genetic vulnerabilities, insults to the central nervous system, medical and neurologic disorders, structural defects, and prenatal viruses can also affect mental health. However, it is the unprocessed fragments of memories of adverse life experiences and traumas that significantly impact the neurophysiology of the brain that are amenable to psychotherapy. Chapter 2 is foundational for understanding the neurophysiology of the trauma response.

This chapter discusses eye movement desensitization and reprocessing (EMDR) therapy, the only major evidence-based psychotherapy that has emerged with the explicit goal of neural network integration. Although other therapies, such as psychodynamic or humanistic existential therapy, can involve processing because implicit memories are accessed and new information is learned, EMDR has been developed specifically for the purpose of processing adverse life experiences and traumatic events. EMDR is both a psychotherapy approach on its own as well as a psychotherapy that can be integrated into other psychotherapy models such as cognitive behavioral, transpersonal, family, psychodynamic, experiential, feminist, hypnosis, schema-focused, and behavioral therapies (Shapiro, 2002) as an adjunct to treatment. This chapter begins with an introduction to EMDR and presents evidence-based research. Stabilization and processing are discussed along with general guidelines for processing. The eight-phase protocol for EMDR is described and a case example illustrates the use of EMDR. The chapter ends with information about postmaster’s EMDR certification.

WHAT IS EMDR?

EMDR has emerged in the past two decades as one of the most innovative and effective approaches to treat symptoms of adverse life experiences and trauma. Dr. Francine Shapiro (2001) developed eye movement desensitization (EMD) in the late 1980s as a behavioral technique to treat posttraumatic stress disorder (PTSD) and subsequently EMDR evolved, as it became apparent that more than desensitization occurred and that dysfunctional memories were actually being reprocessed. EMDR is now viewed as an integrative eight- phase psychotherapy based on a comprehensive three-pronged approach that includes earlier life experience, present-day stressor (i.e., triggers), and desired thoughts and actions for the future. The therapist guides the patient in processing affective, cognitive, and somatic material with procedures and protocols that include some form of bilateral stimulation (BLS) during a session. The BLS may take the form of eyes moving horizontally back and forth, sounds alternating in each ear, or alternate tapping on each hand or knee. The goal is to bring the trauma to an adaptive resolution.

Research indicates that trauma involves right-brain processing and most psychotherapy is a left-brain endeavor, so there may be areas that talk therapy does not reach. Processing in EMDR seems to rapidly connect left-brain ways of processing information with emotional right-brain information. Both limbic and prefrontal changes have been found in brain scans after EMDR treatment; that is, the prefrontal cortex shows increased activation with increased inhibition of the amygdala so that patients with PTSD are less hyperaroused and have fewer symptoms of flashbacks and hallucinations (Pagani, Hogberg, Fernandez, & Siracusano, 2013). In addition, functional magnetic resonance imaging studies have found an increase in hippocampal volume after PTSD patients are treated with EMDR (Bossini et al., 2012). These neurobiological changes correspond with significant clinical improvement in PTSD symptoms. EMDR is the only evidence-based therapeutic modality that includes a somatic component that provides therapists the ability to access all dimensions of memory.

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Evidence-Based Research

EMDR has a solid research base demonstrating effectiveness in treating PTSD with over 27 randomized clinical trials to date. See Table 6.1 for selected meta-analysis and randomized clinical trials. EMDR is included in many practice guidelines for the treatment and processing of trauma (American Psychiatric Association, 2009; Bisson & Andrew, 2007; Bleich et al., 2002; CREST, 2003; DVA/DoD, 2010; Foa et al., 2009; INSERM, 2004; NICE, 2005; SAMHSA, 2011; WHO, 2013). Researchers and clinicians have developed and researched EMDR protocols for a wide variety of clinical problems and diagnoses such as combat trauma, anxiety disorders, depression, unresolved grief, medical trauma, dissociative disorders, chemical dependency, eating disorders, and somatic problems. Please see Table 6.2. EMDR protocols for many specific problems are available in two manuals by Luber (2009a, 2009b).

Studies of single trauma, in contrast to complex multiple trauma, indicate a 77% to 100% remission of PTSD after three to six EMDR sessions (Lee et al., 2002). When comparing trauma-focused cognitive behavioral therapy (TF-CBT), the other Level A treatment for PSTD, with EMDR, both are considered effective. “Like CBT with a trauma focus, EMDR aims to reduce subjective distress and strengthen adaptive beliefs related to the traumatic event. Unlike CBT with a trauma focus, EMDR does not involve (a) spontaneous associations of the event, (b) direct challenging of beliefs, (c) extended exposure, or (d) homework” (WHO, 2013, p. 1). EMDR is less time intensive (Ironson et al., 2002, Lee et al., 2002; Power et al., 2002; Rothbaum et al., 2005; Taylor et al., 2003), treatment effects are long lasting (Carlson et al., 1998; van der Kolk et al., 2007; Wilson, Becker, & Tinker, 1997), and dropout rates are significantly lower for EMDR than for TF-CBT (Carlson et al., 1998; CBO, 2012).

Mechanism of Action

The exact mechanism of action is unclear just as any other psychotherapy’s action is unclear. However, because EMDR is such an unusual and powerful therapy, there has been much speculation about how it works. It is thought that the dual attention stimulation that is required during EMDR facilitates interhemispheric connection, jump-starting the natural information processing system. Accessing adaptive information and integration of memory networks have been linked to the processes of rapid eye movement (REM) sleep, and there is some empirical support for this explanation for EMDR (Shapiro, 2001; Stickgold, 2008). The BLS promotes the dual attention to internal and external stimulation. This is thought to disarm arousal by coupling attention to the disturbing dimensions of the memory (internal stimulation) with attendant relaxation that occurs with BLS (external stimulation) allowing the linkage of dysfunctional material with more adaptive memory networks. Siegel (2002) speculates that the orienting response is crucial, along with the comprehensive protocol that accesses all dimensions of the experience. Cozolino (2010) posits that activation in both temporal lobes with the BLS enhances neural network connectivity and the integration of traumatic memories into normal information processing.

TABLE 6.1 EMDR Research: Selected Randomized Clinical Trials and Meta-Analyses

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Adapted from handout Shapiro (2012). EMDRIA Conference, Arlington, VA.

TABLE 6.2 EMDR Clinical Applications Population Research Studies Combat veterans Blore (1997a); Carlson et al. (1996); Carlson et al. (1998); Daniels et al. (1992); Lipke (2000); Lipke & Botkin (1992); Russell (2008a, 2008b);

Russell et al. (2007); Shapiro (1989); Silver & Rogers (2001); Silver, Rogers, & Russell (2008); Thomas & Gafner (1993); Wesson & Gould (2009); White (1998); Young (1995); Zimmermann et al. (2005)

Phobias, panic disorder, obsessive–compulsive disorder, and generalized anxiety disorder

Böhm & Voderholzer (2010); De Jongh (2012); De Jongh et al. (2010); De Jongh & Ten Broeke (1998); De Jongh, Ten Broeke, & Renssen (1999); De Jongh, van den Oord, & Ten Broeke (2002); de Roos & de Jongh (2008); de Roos, Veenstra, et al. (2010); Doctor (1994); Fernandez & Feretta (2007); Feske & Goldstein (1997); Gattinara (2009); Gauvreau & Bouchard (2008); Goldstein (1992); Goldstein & Feske (1994); Grey (2011); Gros & Antony (2006); Howard & Cox (2006); Kleinknecht (1993); Marr (2012); Muris & Merckelbach (1997); Muris, Merckelbach, Holdrinet, & Sijenaar (1998); Nadler (1996); Nazari et al. (2011); Newgent, Paladino, & Reynolds (2006); O’Brien (1993); Protinsky, Sparks, & Flemke (2001a); Schurmans (2007)

Crime victims, police officers, fire fighters, and field workers Baker & McBride (1991); Dyregrov (1993); Goldstein, deBeurs, Chambless, & Wilson (2000); Jensma (1999); Kitchiner (2004); Kitchiner & Aylard (2002); Kleinknecht & Morgan (1992); Lansing et al. (2005); McNally & Solomon (1999); Page & Crino (1993); Rost, Hofmann, & Wheeler (2009); Shapiro & Solomon (1995); Solomon (1995, 1998); Solomon & Dyregrov (2000); Wilson et al. (2001)

Unresolved grief Gattinara (2009); Lazrove et al. (1998); Puk (1991a); Shapiro & Solomon (1995); Solomon (1995, 1998); Solomon & Kaufman (2002); Solomon & Rando (2007); Solomon & Shapiro (1997); Sprang (2001)

Sexual assault victims Ahmad et al. (2007); Bae, Kim, & Park (2008); Beer & Bronner (2010); Bronner et al. (2009); Chemtob et al. (2002); Cocco & Sharpe (1993); Datta & Wallace (1994, 1996); Edmond, Rubin, & Wambach (1999); Fernandez (2007); Fernandez, Gallinari, & Lorenzetti (2004); Greenwald (1994, 1998, 1999, 2000, 2002); Hensel (2006, 2009); Jaberghaderi et al. (2004); Jarero, Artigas, & Hartung (2006); Johnson (1998); Korkmazler-Oral & Pamuk (2002); Lovett (1999); Maxfield (2007); Oras et al. (2004); Pellicer (1993); Posmontier, Dovydaitis, & Lipman (2010); Puffer, Greenwald, & Elrod (1998); Rodenburg et al. (2009); Russell & O’Connor (2002); Scheck, Schaeffer, & Gillette (1998); Shapiro (1991); Soberman, Greenwald, & Rule (2002); Stewart & Bramson (2000); Taylor (2002); Tinker & Wilson (1999); Tufnell (2005); Wadaa, Zaharim, & Alqashan (2010); Wanders, Serra, & de Jongh (2008); Zaghrout-Hodali, Alissa, & Dodgson (2008)

Victims of natural and manmade disasters Aduriz, Bluthgen, & Knopfler (2009); Chemtob et al. (2002); Colelli & Patterson (2008); Farrell et al. (2011); Fernandez (2008); Fernandez et al. (2004); Gelbach (2008); Grainger et al. (1997); Jarero & Artigas (2010); Jarero et al. (1999); Jayatunge (2008); Knipe et al. (2003); Konuk et al. (2006); Shapiro & Laub (2008); Shusta-Hochberg (2003); Silver, Rogers, Knipe, & Colelli (2005)

Accident, surgery, and burn victims Blore (1997b); Broad & Wheeler (2006); Hassard (1993); McCann (1992); Puk (1992); Softic (2009): Solomon & Kaufman (1994)

Victims of family, marital, and sexual dysfunction Bardin (2004); Capps (2006); Chu et al. (2009); Errebo & Sommers-Flanagan (2007); Gattinara (2009); Keenan & Farrell (2000); Kaslow, Nurse, & Thompson (2002); Knudsen (2007); Koedam (2007); Levin (1993); Madrid, Skolek, & Shapiro (2006); Moses (2007); Phillips et al. (2009); Protinsky, Sparks, & Flemke (2001b); Reicherzer (2011); Shapiro, Kaslow, & Maxfield (2007); Snyder (1996); Stowasser (2007); Talan (2007); Wernik (1993); Wesselmann & Potter (2009)

Chemical dependency, sexual deviation/addiction, and pathological gamblers

Abel & O’Brien (2010); Amundsen & Kârstad (2006); Besson et al. (2006); Cox & Howard (2007); Hase, Schallmayer, & Sack (2008); Henry (1996); Marich (2009); Popky (2005); Ricci (2006); Ricci et al. (2006); Shapiro & Forrest (1997); Shapiro, Vogelmann-Sine, & Sine (1994); Vogelmann-Sine et al. (1998); Zweben & Yeary (2006)

Dissociative disorders Cohen (2009); Fine (1994); Fine & Berkowitz (2001); Lazrove (1994); Lazrove & Fine (1996); Marquis & Puk (1994); Paulsen (1995); Rouanzoin (1994); Twombly (2000, 2005); Young (1994)

Performance anxiety or deficits in school, business, arts, and sports

Barker & Barker (2007); Crabbe (1996); Foster & Lendl (1995, 1996); Graham (2004); Maxfield & Melnyk (2000); Silverman (2011)

Somatic problems (migraines, chronic pain, phantom limb pain, chronic eczema, GI problems, CFS, psychogenic seizures, EDO and negative body image)

Bloomgarden & Calogero (2008); Brown, McGoldrick, & Buchanan (1997); Chemali & Meadows (2004); de Roos, Veenstra, et al. (2010); Dziegielewski & Wolfe (2000); Gattinara (2009); Grant (1999); Grant & Threlfo (2002); Gupta & Gupta (2002); Kelley & Selim (2007); Kneff & Krebs (2004); Konuk et al. (2011); Kowal (2005); Marcus (2008); Mazzola et al. (2009); McGoldrick, Begum, & Brown (2008); Ray & Zbik (2001); Royle (2008); Russell (2008a, 2008b); Schneider et al. (2007, 2008); Silver, Rogers, & Russell (2008); Tinker & Wilson (2006); Torun (2010); Van Loey & Van Son (2003); Wilensky (2006); Wilson et al. (2000)

Depression Bae, Kim, & Park (2008); Broad & Wheeler (2006); Gomez (2008); Grey (2011); Hogan (2001); Manfield (1998b); Protinsky, Sparks, & Flemke (2001a); Srivastava & Mukhopadhyay (2008); Tanaka & Inoue (1999); Uribe & Ramirez (2006)

Acute trauma/PTSD/personality (trauma-based issues) Allen & Lewis (1996); Barol & Seubert (2010); Bisson et al. (2007); Brown & Shapiro (2006); Carbone (2008); Cohn (1993); Farrell et al. (2010); Fensterheim (1996); Forbes, Creamer, & Rycroft (1994); Gelinas (2003); Hogberg & Pagani et al. (2007); Inoue (2009); Kim & Choi (2004); Kutz, Resnik, & Dekel (2008); Hyer (1995); Ironson et al. (2002); Kitchiner (1999, 2000); Korn & Leeds (2002); Laub & Weiner (2011); Lee et al. (2002); Manfield (1998a); Manfield & Shapiro (2003); Marcus, Marquis, & Saki (1997); Marquis (1991); Maxwell (2003); McCullough (2002); McLaughlin et al. (2008); Mevissen & de Jongh (2010); Mevissen, Lievegoed, & de Jongh (2010); Mevissen et al. (2011); Parnell (1996, 1997); Pollock (2000); Power et al. (2002); Protinsky, Sparks, & Flemke (2001a); Puk (1991b); Raboni, Tufik, & Suchecki (2006); Renfrey & Spates (1994); Rittenhouse (2000); Sandstrom et al. (2008); Schneider, Nabavi, & Heuft (2005); Seidler & Wagner (2006); Shapiro (2012); Shapiro & Forrest (1997); Shapiro & Laub (2008); Spates & Burnette (1995); Spector & Huthwaite (1993); Sprang (2001); van der Kolk et al. (2007); Tofani & Wheeler (2011); van den Berg & van den Gaag (2012); Vaughan et al. (1994); Vaughan, Wiese, Gold, & Tarrier (1994); Wilson, Becker, & Tinker (1995, 1997); Wolpe & Abrams (1991); Zabukovec, Lazrove, & Shapiro (2000)

Adapted from handout Shapiro (2012). EMDRIA Conference, Arlington, VA.

There may be both right and left hemisphere stimulation of attention that triggers the integration of affect with cognition, sensations, and emotion in the brain along with top-down cortical–hippocampal circuits and bottom-up amygdala–cortical activation with subsequent processing. The activation of emotion and the right hemisphere along with the simultaneous activation of the language-based left hemisphere may aid in integration of these functions, thus enhancing the person’s ability to gain cognitive perspective and emotional regulation. This multilayered process produces a new information-processing matrix in the brain that is essential for the resolution of trauma and integration of the left hemisphere, which is language based, with the right hemisphere, which contains the somatic and autobiographic components of the self.

Although EMDR contains aspects of numerous psychotherapy approaches, the BLS and the unique components of the EMDR protocol are crucial ingredients for the efficacy of this approach. A recent meta- analysis of 14 EMDR studies comparing eye movement with no eye movement evaluated the efficacy of eye movements in processing emotional memories with eye movements averaging a significant medium effect size with respect to outcomes over those studies with no eye movements (Lee & Cuijpers, 2012). Thus, contrary to some early classifications as EMDR as a type of CBT, eye movements are essential for the efficacy of EMDR. The mechanism of action for TF-CBT and exposure is different than for EMDR. EMDR strategies include frequent brief exposure to the disturbing memory, interrupted exposure, and free association while CBT relies on habituation and prolonged exposure, which often creates high levels of anxiety. A meta-analysis of EMDR studies found larger effect sizes for studies that cited use of a treatment manual and that adhered to the EMDR protocol (Maxfield & Hyer, 2002). These studies support the use of eye movements and fidelity to

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the treatment protocol for best results.

STABILIZATION

Specific stabilization strategies are the focus of Chapters 13 and 14 as well as inherent in other approaches in this book including CBT, supportive therapy, solution-focused, group, family therapy, and motivational interviewing. Stabilization and resourcing the patient are integral to EMDR especially in Phase 2, the preparation phase. The therapeutic relationship and attunement serve as resources and help to stabilize the person. Patient collaboration and empowerment are integral to all phases of the EMDR protocol. It is crucial to explain to the patient that their current symptoms may be driven by experiences from the past, how the present serves as a trigger for these past experiences, and how the therapy can help.

Three general types of resources used in stabilization are identified by Shapiro (2001) and include mastery resources such as patient’s memories of past coping, relational resources such as memories of positive role models or supportive others, or symbolic resources from dreams, nature, religion, music, and future positive image(s). EMDR has specific protocols for stabilization and these usually combine imagery, safe place, therapeutic interweaves, and/or containment exercises with BLS. The person is taught the safe place in the preparation phase in addition to other resource strategies if needed. See Appendix 1.7 for the safe place exercise, Appendix 1.8 for the container exercise, Appendix 6.1 for the lightstream exercise, and Appendix 6.2 for the circle of strength exercise.

One particular soothing resource originated by an EMDR therapist using dual attention stimulation is the “butterfly hug.” This self-soothing treatment intervention was developed for use with children but has been expanded to calm adult patients as well. The technique involves the person crossing their arms so that each hand rests on the opposite biceps muscles. Then each hand taps alternately on the opposite bicep. This can be combined with positive affirmations and/or to an exercise to anchor a safe place (Jarero et al., 2006). See Chapter 13 for stabilization strategies, many of which can be combined with or without BLS.

Although EMDR has been most researched for processing trauma, extension of the EMDR protocol for resource development and installation (RDI) has been found to increase stabilization in a series of cases (Korn & Leeds, 2002). RDI is usually used to prepare the patient so that positive resources increase affect regulation and coping skills prior to trauma processing. See Box 6.1 for the steps in RDI. If the person has had a paucity of positive experiences in his or her life, there may need to be a longer period for resourcing. In general, patients who have suffered complex early trauma need a longer period of stabilization because adaptive memory networks may need to be strengthened and/or created in order to tolerate processing. However, it should be noted that most patients presenting with PTSD do not need RDI (Leeds, 2006). RDI exercises can be used with or without BLS and should be practiced in the session with the patient as well as at home so that they can be used to assist the person in decreasing hyperarousal at the end of disturbing sessions, as well as other times outside of sessions when disturbing memories may be re-experienced.

BOX 6.1

RESOURCE DEVELOPMENT AND INSTALLATION PROCEDURE

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Adapted from Shapiro (2001).

Signs that the person is stabilized include no current life crisis, acceptance of the diagnosis, an ability to set and adhere to limits, the ability to identify triggers, ability to self-soothe and to reach out to supportive people, and the ability to communicate honestly with the clinician. In terms of mood stability, the person’s mood may be depressed but not labile (Davis & Weiss, 2004). The stabilization checklist provided in Appendix 1.5 is a general guideline, and not all of these parameters must be met before processing. Clinical judgment is essential in assessing the patient’s ability to tolerate processing. Because of the intensity of the experience, the patient must have the ability to maintain a dual awareness during processing and sustain increased arousal with little or no dissociating or avoidance of the content. The person needs to be in the here and now of the therapy session while also in the then and there of the traumatic event. After stabilization has been achieved, the person is ready to move to the next stage, processing.

PROCESSING

Processing involves acquiring new learning and connecting adaptive neural networks with dysfunctionally stored information by activating emotions associated with traumatic memories or adverse experiences in tandem with the relaxation induced through BLS. Processing, represented toward the top of the Treatment Hierarchy Triangle (see Chapter 1, Figure 1.6), reflects accessing of all dimensions of memory: behaviors, affect, sensations, cognitions, and beliefs associated with the experience (Shapiro, 2001). Current situations activate or trigger unprocessed memories, and the person feels the attending emotions and sensations of the stored memory. The memory that informs the basis of the current problem is called the touchstone memory or event. This may be one event, a Criterion A event for PTSD, or a situation that represents or reflects the origin of the problem. For example, a patient who has an early attachment trauma history may repeatedly be triggered by her relationship with the therapist and expects to be emotionally abused and criticized. In this situation, there is not one specific event but most likely many implicit memories that get activated. Because the therapist is consistently caring and nonjudgmental, this expectation is eventually diminished through counterconditioning through the therapeutic relationship without the person being explicitly aware that this has happened. Chapter 5 describes how to work with and process this type of attachment trauma using psychodynamic psychotherapy, but when EMDR is used, often the results are much faster.

Processing promotes neural integration and association of dysregulated memory fragments, removing blocks to the flow of information and energy. This is a basic tenet of the adaptive information processing

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(AIP) model (Shapiro, 2001). AIP posits that dysfunctional information is blocked from adaptive resolution and connection to other memory networks. The other important tenet of AIP is that this integration can occur much faster than previously thought possible with appropriate accessing of information. Nonadaptive self-beliefs, negative emotions, bodily sensations, and intrusive images that contribute to psychopathology can be positively integrated as fast as these elements were disturbed in the first place.

In psychopathology, dimensions of memory are improperly stored, fragmented, and dissociated from one another and are not linked to adaptive memory networks. As discussed in Chapter 2, high levels of emotion with the resulting physiologic changes contribute to traumatic memories being stored in dysfunctional memory networks (Shapiro, 2001, 2006). The person may experience anxiety without the attending context for the anxiety or experience a body sensation, and these feelings and sensations may be disconnected from other, more adaptive memory networks. For example, one man came to psychotherapy for depression and subsequently had a panic attack after undergoing sinus surgery. On exploration in psychotherapy, he discovered that the panic attack was triggered by an earlier body memory of swallowing blood after a tonsillectomy in which he had almost died as a child. He had no memory of this incident as particularly disturbing prior to the EMDR processing of his panic attack (Broad & Wheeler, 2006).

Another patient heard only sounds without understanding the context but knew that these sounds were associated with disturbing memories that occurred when she was a child. These dissociated memory networks may also manifest as behaviors or personality traits that are compartmentalized and triggered in specific situations or contexts. For example, in intimate relationships at home, a woman is emotionally and physically abused by her husband; but at work, she is decisive and assertive. All these examples reflect state-dependent memories or states of consciousness that are physiologically based and triggered by stimuli in the present. The latter example illustrates that resources, like trauma, may be stored in one state of consciousness and not available in another state.

Transforming traumatic memories through processing opens up access to positive emotions and thoughts as the negative event is integrated into the larger networks where positive memories are stored (Shapiro, 2001). The traumatized person may be numb to both positive and negative emotions because we cannot numb emotions selectively; that is, we cannot numb negative emotions without numbing the positive emotions as well. As emotional awareness increases and the attending anger, sadness, and hurt are experienced, the person will also be able to access more positive feelings.

When processing in EMDR, dysfunctionally stored implicit memories are accessed, and this occurs in the context of a safe therapeutic relationship with adequate resources in place. This is important so that the person’s experience is safe, because activating the disturbing memory has the potential to further entrench the negative memory network. The more the dysfunctional memory network is activated, the more likely it is that this template is reinforced and the connection and pattern formed between neurons and networks of neurons are strengthened (i.e., long-term potentiation). Chapter 2 describes the neurophysiology supporting this phenomenon. This explains why the traumatized person is prone to reenact the experience. To counter this, adaptive memory networks need to be linked to the trauma memory during the arousal generated by the event so that processing and new learning can occur. This speaks to the importance of preparing the person so that positive neural networks exist that can be accessed spontaneously during processing so that state changes are possible. The reparative process begins when catharsis and abreaction are possible in a supportive relationship.

Indicators that the person is processing during EMDR include changes in facial expression, body movements and sensations, sighing, changes in feelings, changes in cognitions, the memory becomes either more distant or more clear, and the incident or image of the event changes (Dodgson, 2009). The experience and memories are not held in isolation and are connected or linked to other memory networks so that during processing, there are emotional or body sensation associations to other related memories. Each person processes information differently and a unique dimension of EMDR processing is that the therapist allows and facilitates the process to unfold without being too directive.

The Therapeutic Window of Processing

In processing, the hypothalamic–pituitary–adrenal (HPA) axis needs to modulate sympathetic arousal so that the person can regulate affect while accessing arousing memories that must be activated for neural reintegration to occur. This activation must occur in the therapeutic window (see Figure 1.3); the person must not be too overwhelmed and hyperaroused (i.e., sympathetic dominant) but not be too underaroused (i.e., parasympathetic dominant) to engage the emotional memory. Research has shown that high levels of

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arousal interfere with frontal lobe functioning. It is thought that trauma is relegated to the right posterior hemisphere and to its hormonal counterpart, the HPA axis. EMDR works best if the person is in the therapeutic window of arousal so that the skillful APPN needs to assess whether the person is avoiding the material, is dissociating, and has too little activation; or is hyperaroused with too much activation.

Some patients may need activation decreased, especially if they are hyperventilating, overwhelmed with emotion, and in a highly anxious state. Hyperarousal sometimes manifests as REMs, increased respirations, and increasing levels of anxiety. During processing, an abreaction, which is the intensive discharge of emotions related to the trauma, may occur. During abreaction, the person experiences some or all of the same sensations, thoughts, and emotions that occurred during the time of the trauma and becomes immersed in the event (Sadock & Sadock, 2007).

Abreactions indicate that the person has accessed the memory with all the attending emotions of the original event. The abreaction may be necessary but should be titrated and monitored so that the person does not re-experience the trauma with overwhelming negative affect, identity fragmentation, or feelings of loss of control (Briere & Scott, 2012). The key to re-experiencing the trauma with manageable affect is maintaining dual awareness so that the person knows they are in the present with one foot in the traumatic memory. Dual awareness is cultivated during EMDR processing through the use of BLS in tandem with explaining to the person prior to processing to just note what comes up as if the person is on a train and watching out the window as the memories and experiences come up, much as scenery passes while on a moving train (Shapiro, 2001).

Shapiro (2001) differentiates abreactions that occur with EMDR from those that occur with hypnosis or other therapies. In EMDR, abreactions occur more rapidly as processing is accelerated, and abreactions can be an indicator of movement toward healing. Helpful strategies during abreactions include a calm voice, detached compassion, changing the rate or direction of BLS, allowing the process to unfold without judgment, grounding techniques (see Chapter 13), calling the person by name, and orienting the person: “It’s okay, Jeanne. You are at my office and can hear my voice. It is old stuff; let it go. You are right here with me, and you are safe.”

For a significant subgroup of patients, dissociation presents a barrier to processing trauma, especially for those who have suffered complex trauma. Dissociation is a right-brain phenomenon and therefore may not be linked to declarative memory networks (see Chapter 13). For those who are victims of complex trauma, there may not be a felt sense of their whole body. Accessing procedural somatic memories through words and left- brain activities may not be possible. For those who are mildly dissociating (see Chapter 13, Boxes 13.1 and 13.2 for signs of dissociation), the therapist may be able to bring the person back by asking questions and observing that the person seems to be away. Grounding techniques as described in Chapter 13 may be needed to bring the person back to the present. For an avoidant patient, asking detailed information about the specifics can increase activation and encourage comments if the patient is processing: “Stay with that. You’re doing well.”

General Guidelines for Processing

Processing in EMDR involves accelerated learning as the targeted memory is accessed and brought to a successful resolution so that trait changes can occur (Shapiro, 2006). A trait change refers to a permanent personality change, whereas a state change is a temporary change of emotions. For example, a person who is anxious driving over a bridge may learn deep breathing, distraction, safe place, and/or container exercises so that he or she could manage to get across the bridge. Trait change, on the other hand, would be total removal of anxiety about driving over a bridge without the need to use any anxiety relieving strategies to accomplish this. The person would just not feel anxious about that anymore. The therapist’s role in EMDR is to facilitate the patient’s own natural healing ability to deal with stored, unprocessed experiences, which manifest as dysfunctional symptoms.

In EMDR, processing occurs according to procedures that track the progress through memory networks. As part of the protocol all dimensions of the memory—the image, the thoughts, the emotion, and the body sensations—are accessed with the therapist administering the BLS in the form of eye movements, auditory tones, or tapping, while at the same time the patient pays attention to the disturbing memory. This dual attention to the here and now with the then and there is foundational to EMDR. During the bilateral sets of stimulation, the patient free-associates according to protocols to elicit information and associated memories. Through EMDR, patients follow their own associative memory networks to process painful memories and

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integrate new information. The goal of treatment is to link dysfunctional memory networks to other, more adaptive networks.

In processing, the trauma recounted is often connected to other dysfunctional memory networks and can trigger other traumas, so that there is not a discrete, coherent account of one specific memory but a collage of traumatic memories. For example, one patient was focusing on a recollection of an abusive relationship with a boyfriend and then had another memory triggered that reminded her of being bullied by her brother. This led to a memory of an earlier abusive relationship with her father. Following the narrative with empathic attunement and allowing the person to go where he or she needs to go is a good principle for all therapies but of paramount importance for the significantly traumatized patient. It is especially important when working with a patient with significant trauma to honor feelings, go slowly, and give the person as much control as possible. The APPN empowers the patient by planning interventions collaboratively, allowing the process to unfold by staying out of the way so that the person’s natural healing ability can be accessed. The person’s ability to follow through with trauma processing depends on his or her affect regulation skills, support from others, and life stress at the time as well as on the safety of the therapeutic relationship.

Most people are not eager to re-experience upsetting material, and this is essentially what we are asking the traumatized person to do. Trauma survivors have spent considerable effort avoiding thinking about the traumatic event(s) and naturally question the wisdom of this idea. It is essential for the therapist to educate the person about how the flashbacks, symptoms, and intrusive memories are the brain’s effort to heal and how the avoidance serves to keep the trauma alive. The memories need to be integrated with other memory networks to dissipate. Reassure patients that you will teach them methods of managing arousal so that they will not be overwhelmed and assure them that they can stop or take a time out anytime they wish. However, it is more than the therapist’s reassurance that enables the patient to trust that processing trauma will be helpful. It is the psychoeducation in tandem with the safety and trust that has been cultivated in the therapeutic relationship that allows the person to process traumatic material.

Processing only in the middle of the session and helping the person to leave in a calm state are essential (Briere & Scott, 2013). Patients who have been processing need special closure at the end of the session so that they can leave in a comfortable state. Immediately after processing, sometimes patients report that they feel scattered or spacey. The APPN might suggest that the patient walk around first or sit quietly before driving home. It is important to inform the patient that processing may continue between sessions. Summing up the session at the end and telling the person the date of the next session helps to provide closure. Reframing the emotional distress with a statement such as, “You did some good processing today,” or returning to the safe place or using the container exercise for negative feelings, visualizing a healing image, or using art to draw a new belief or feeling are ways to soothe and contain at the end of processing.

Suggestions for assisting patients in managing emotions between sessions include offering to be available by phone if needed, journaling, walks in nature, artwork, meditation, stress-reduction strategies, group work, exercise, eating well, and other resource enhancing skills. These are all skills that have been learned before processing in the stabilization phase. Sometimes, patients report a deep sleep after a processing session, and perhaps this heralds the healing that is taking place. Ask the person to keep track between sessions of any increase in flashbacks, nightmares, and disturbing feelings or memories and to bring this information to the next session. It can also help patients if the APPN makes tapes for relaxation and guided imagery in one’s own voice so that the patient can play these audiotapes in between sessions to reinforce stabilization outside of sessions. These strategies help the person to stay connected and feel supported between sessions by providing a link to the holding environment of the therapeutic relationship.

Clinically, processing has been achieved once the SUD is 0 and there is no reported bodily disturbances when thinking about the event. Shapiro (2006) says that the clinician can tell that processing has occurred by positive somatic, behavioral, and cognitive trait changes that occur after treatment. These changes are not temporary state changes, but enduring trait changes with the person able to talk about the event without the attending hyperarousal that was present before processing (Shapiro, 2006). The patient will not feel the trauma in the body after it has been processed. Asking the patient near the end of processing to scan his or her body is useful to determine whether processing has occurred. Significant body changes will be noticed after trauma is processed and the dysfunctional memory is integrated. Appendix 1.6 provides a processing checklist to assist the therapist in determining whether processing has led to adaptive change. The traumatic memory should be re-accessed at the next session after processing and again before termination to determine whether the changes reflect trait changes (Shapiro, 2006). Asking the person to rate the SUD on a 0 to 10 scale of the memory assists the therapist and patient in determining the degree of processing that has been accomplished.

Overall, successful processing has occurred after relationships are adaptive, work is productive, self- references are positive, there are no significant affect changes on exposure to trauma triggers, affect is

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proportionate to events, and there is congruence among behavior, thoughts, and affect (Davis & Weiss, 2004). As the trauma loses its arousal capacity and losses are mourned, the person is able to be more future oriented and may decide to pursue life goals, such as relationships, education, or professional goals, that previously were not thought about. Remediation of life skills that were missed during crucial developmental periods because of trauma may be needed. For example, one patient who suffered incest as a child processed this trauma in psychotherapy, and only then began to envision a future for herself with a partner. The therapist taught her basic skills about dating and how to develop, pace, and deepen a relationship safely.

PROTOCOL FOR EYE MOVEMENT DESENSITIZATION AND REPROCESSING

EMDR therapy for most traumas involves three stages: targeting the original traumatic memory, targeting the present trigger, and incorporating a positive template for the future (Shapiro, 2001). The theoretical assumption is that the present dysfunctional emotions are related to past events that feed or keep alive the present problems. Current situations serve as triggers that activate implicit or episodic memories, and these unprocessed memories contain the emotions, thoughts, and sensations from the original event. Interventions for processing involve targeting the specific trauma with an eight-phase protocol that guides the person through a description of the disturbing event related to the presenting problem (Shapiro, 2001). The current triggers are also processed in order to address the possible effects of conditioning. Table 6.3 describes the eight phases of EMDR.

TABLE 6.3 Eight-Phase Protocol for Eye Movement Desensitization and Reprocessing One Patient History and Treatment Planning—assessment of stability and current life constraints; evaluation of clinical symptoms (affect tolerance and dissociation);

screening for use of EMDR; identification of targets including small traumas and big traumas; developing a treatment plan

Two Preparation—establish therapeutic alliance; educate the person about adaptive information processing (AIP) and EMDR; evaluate secondary gains; practice relaxation and safe place; resource development if needed

Three Assessment—identify components of the target (see Figure 6.1); patient identifies: an image that represents the experience or worst part of it; a negative cognition (NC) associated with the incident or image and a positive cognition (PC) that represents what the person would like to feel about himself or herself now; the patient then rates the PC on a 1 to 7 validity of cognition (VOC) scale that represents how true the PC feels now; then the emotions associated with the event are identified with a SUD on a 0 to 10 rated scale; finally, the person is asked where they feel this in their body

Four Desensitization—begin sets of bilateral stimulation with eye movements, sound, and/or tapping and continue until the SUD is 0 or 1

Five Installation—install PC with bilateral stimulation

Six Body Scan—note tension and sensations in body for any residual

Seven Closure—instruct about keeping a log and educate about disturbances that may occur postsession

Eight Re-evaluation—reassess and review targets that were processed at the beginning of the next session

Adapted from Shapiro (2001).

In the first phase, screening for dissociation and identification of targets begins the initial assessment. Assessing the person’s readiness for EMDR includes the person’s ability to manage intense emotions. The Dissociative Experiences Scale (DES) (Carlson & Putnam, 1993) is usually given as a screening tool for a dissociative disorder. If the total score is above 30, which indicates significant dissociation, the APPN should proceed with caution in that EMDR may be destabilizing because dissociative barriers and defenses are dissolved in EMDR processing. See Chapter 3 for the DES. A history of seizures and/or eye pain is a contraindication for using eye movements.

If a significant single incident trauma is apparent, the Impact of Events Scale is administered. Chapters 3 and 13 describe assessment tools and how to take a history for trauma. To further identify significant traumas, the patient is asked to identify his or her 5 to 10 most disturbing memories or events that are stressful or upsetting in his or her life. Some clinicians use this opportunity to construct a timeline of negative and positive memories or events so that the positive memories can be used later as resources and negative events are rated as to their level of disturbance. See Chapter 13 for how to construct a trauma history timeline.

Sometimes, patients minimize traumas and/or may not remember anything. This does not necessarily mean that this is the rare person who is trauma free; more likely, this information may not be remembered at this time. If any disturbing memories or traumas are recounted, ask the person to rate each on the 0 to 10 SUD scale. This is a good indicator for current arousal levels for the trauma. This scale is used later in the assessment phase of EMDR, with 0 reflecting no distress at all and 10 indicating the worst disturbance imaginable. These levels may change after the incident is accessed in treatment. It is important to identify the memory of the event, any related flashbacks, nightmares, and triggers that are associated with the event (Shapiro, 2001). Nightmares may represent unprocessed trauma and can also be targeted with EMDR.

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The memory or target that is chosen to process first is usually that which the person has identified as the first and worst with the idea that once this event is processed, there will be generalization to other disturbing similar memories. Components of the identified target are developed (Phase 3). The following is a summary as developed by Shapiro (2001). Asking the patient what was the worst part helps to home in on the specific image or incident. For example, a patient who suffered from injuries in an automobile accident reported that the worst part was being alone, not the injuries sustained. After an image or picture of the worst part is clearly identified, the person is asked to think about that and to identify the negative cognition (NC) associated with the event. This can sometimes be challenging for patients, and the person can be helped in focusing by asking: “What words best go with the picture that express your negative belief about yourself now?” The patient may then offer: “I am powerless” or “I am not lovable.” Often, the NC is not readily apparent to the patient, and the APPN helps the person in exploring the most accurate words that capture the self-referencing thoughts. After the NC is identified, the patient is asked to develop a positive cognition (PC) by the therapist, who asks: “When you bring up that picture or incident, what would you like to believe about yourself now?” This is important to do at this point to plant the seed for future adaptive associations. Examples might include “I am competent” or “I am lovable.” After the PC is identified, the patient is asked to rate how true the PC feels on a 1-to-7 scale, with 1 being completely false and 7 being completely true. This is called the validity of cognition (VOC) scale.

The next components of the target, which are all parts of Phase 3, are identifying the emotion, the SUD, and the body sensations. After the emotion is identified, the patient is asked to rate the disturbance on the SUD scale of 0 to 10. This gives a baseline so that the patient and clinician can monitor the processing as it unfolds. This then leads to the last question in fleshing out the target, which is to identify the body sensations: “Where do you feel it in your body?” Some patients who are particularly shut off from their bodies may have difficulty accessing this dimension of the memory, and the APPN may need to coach the person. “Becoming conscious of one’s body is a prerequisite for naming emotion and experiencing affect. Otherwise, the body says what the mouth cannot” (Chefetz, 1997, p. 205). This can be done with sensate focusing exercises, such as asking the person to feel a feather on his or her skin, an ice cube on the arm, or any touch sensation to heighten awareness of sensations. These exercises require time before true processing can be accomplished and may be included during stabilization if needed. Asking patients to close their eyes and think of a person or place they love and to notice where they feel this in their body may help to discriminate between the body sensations of the trauma memory and other bodily feelings. Asking patients where they feel blocked can help to focus their attention on their body.

After these components are identified, the person has accessed all dimensions of the memory and may already be processing. The patient focuses on all these aspects together and the clinician begins BLS. Sets of approximately 28 BLS are interspersed with the person noticing changes in thoughts, images, and sensations related to the targeted event. The clinician guides the patient to concentrate on various aspects of the associations, and at times asks the client to return to the memory of the event in order to make sure that the entire memory network is accessed and processed. After the SUD reaches 0, the person is asked if their PC is still correct and, if yes, the person is asked to think about this while thinking of the event during BLS. The person is asked to scan his or her body to check for any residual body sensations and if any disturbance is reported, the therapist continues with BLS until it dissipates. The session is closed with a safe place exercise and instructions to observe any distress between sessions. The SUD level is reevaluated at the beginning of the next session. See www.emdria.org/associations/12049/files/EMDRIA%20Definition%20of%20EMDR.pdf for the official definition of EMDR and delineation of the protocol. The following case example illustrates the use of EMDR to process trauma.

CASE EXAMPLE

Mr. S, a 32-year-old, successful, single man was referred for treatment because he felt stuck in his grief and had obsessive thoughts, guilt, and difficulty concentrating. Five months earlier, he had found his roommate, J, dead from an apparent overdose. An initial assessment was completed, and his trauma history revealed that he had worked near the World Trade Center during the 9/11 attack. Mr. S said he felt guilty when he thought about others who had suffered so much. He also reported his childhood was “rocky” with many arguments occurring between his parents in front of him when he was quite young. These events were not disturbing at the time of assessment and reported only as facts. After several sessions, the therapist felt that Mr. S

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was adequately stabilized, and EMDR was offered in order to process the trauma of finding his roommate dead. Mr. S was given information about the EMDR procedure, the potentially intense nature of the treatment, and a safe place practice session. Mr. S reported that the worst part of the trauma at this point was his difficulty with calling J’s father after the funeral. After this target for processing was accessed, relevant components were identified (Figure 6.1). Mr. S said that when he thought about calling J’s father, he became grief stricken, and the image of his roommate’s body flashed before his mind. The following is a verbatim session using EMDR to process this traumatic incident:

Therapist: What words best go with that image that expresses your negative belief about yourself now?

Patient: I’m helpless. I should have known (NC).

Therapist: When you think of that image, what would you like to believe about yourself now?

Patient: I did okay.

Therapist: When you think of that image, how true do those words I did okay feel to you now on a scale of 1 to 7 (validity of cognition [VOC]), where 1 feels completely false and 7 feels totally true?

Patient: Two.

Therapist: When you bring up that image and those words I’m helpless. I should have known what emotion do you feel now?

Patient: Grief, sadness.

Therapist: On a scale of 0 to 10, where 0 is no disturbance and 10 is the highest disturbance you can imagine SUD, how disturbing does it feel now?

Patient: Eight or nine.

Therapist: Where do you feel it in your body?

Patient: All over my head and eyes.

Therapist: Okay. Now bring up that image and your words I’m helpless. I should have known and notice where you feel it in your body. Follow my fingers with your eyes (eye movement 1). [Therapist holds two fingers upright, about 12 to 14 inches from the patient’s gaze, and slowly moves the fingers horizontally from the left to the right of the patient’s visual field while the patient follows with his eyes for approximately 28 bidirectional movements.]

Patient: I feel the door whacking his head as I open the door. I get a picture of his dad and the brother a couple of days later.

Therapist: Go with that (eye movement 2).

Patient: There are different angles on his body. I asked someone not to cover him. There is blood on the floor under his nose … shock and grief, crying, calling, telling J’s friends. I talked to my other roommate, and I said we have to talk more.

Therapist: Go with that (eye movement 3).

Patient: I had your fingers in mind. I feel more at peace. The funeral, the wake was sad but necessary … lot less trauma … feel more relaxed now.

Therapist: Go with that (eye movement 4).

Patient: The first part was weird. J is alive, hanging out at a Christmas party …. then 9/11 … an image of towers falling … moments when I was on the roof.

Therapist: Go with that (eye movement 5).

Patient: 9/11 some more … saw the second plane hit … big ball of flame … fuel line fire … talking with people … people running and jumping … hear people hitting the ground … then walked uptown to a friend’s place.

Therapist: Go with that (eye movement 6).

Patient: Kind of moved past 9/11 … younger … childhood … seeing dead grandparents in the coffin … my parents … the big fight … now I am really mad. I was six. My mom calls me in and asks how would you feel if we split up? Later, I wondered why are you asking me?

Therapist: Go with that (eye movement 7).

Patient: Really angry … tense all over.

Therapist: Go with that (eye movement 8).

Patient: There was a total shit storm when dad came home … he didn’t know. She started yelling at him … words exchanged … I was in the living room … dad was in his robe … he had to explain his whereabouts … dad cried … weird … he was held up and got a ticket and produced the ticket. Clearly there were larger issues at play. Somebody said you are going to burn in hell for what you are doing. I couldn’t believe it. They made up, and I said promise that you won’t break up.

Therapist: Go with that (eye movement 9).

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Patient: Mixed emotions … anger … relaxing … feeling of understanding between mom and me … she knows … she is sorry.

The session ended with Mr. S down to a 3 or 4 SUD, which indicated incomplete processing because 0 means that there is no subjective distress and that processing is complete. In the next session, Mr. S said he felt much better and wanted to work on some disturbing memories he had over the week about his childhood. He said: “EMDR was amazing and 9/11 was done.” This indicated that he had continued to process after the last session because his SUD level was now 0 when he thought about his roommate’s death. He said: “I never felt that kind of rage before; my whole body felt it.” The disturbing memory he wanted to work on in the session was the fight his parents had when he was younger that he had described in the previous session. When asked for the worst part about that situation, he reported that it was his parents crying and saying bad things to each other.

Therapist: What words go best with that incident that express your negative belief about yourself now?

Patient: I’m a troublemaker (NC).

Therapist: When you think of that image, what would you like to believe about yourself now? (PC)

Patient: I’m okay, a good person.

Therapist: When you think of that image, how true do those words I’m okay, a good person feel to you now on a scale of 1 to 7 (SUD), where 1 feels completely false and 7 feels totally true? (VOC)

Patient: I guess a 3 or 4, sometimes.

Therapist: When you bring up that incident and those words I’m a troublemaker what emotion do you feel now?

Patient: Anger for being exposed to it.

Therapist: On a scale of 0 to 10, where 0 is no disturbance and 10 is the highest disturbance you can imagine, how disturbing does it feel now? (SUD)

Patient: Probably a 6.

Therapist: Where do you feel it in your body?

Patient: My stomach.

Therapist: Now, bring up that incident and your words I’m a troublemaker and notice where you feel it in your body and follow my fingers (eye movement 1).

Patient: Parents crying … saying bad things to each other … my family unit shattering. Is there anything to do to put it back together? I’ve moved onto episodes of getting hurt … mundane … getting hit for knocking some curlers over. Mom would hit me for trivial reasons … Spanked … pissed at my folks … the fight … the rage … anger subsided … witnessing how painful marriage can be. I don’t want to be an instrument of pain.

Therapist: Go with that (eye movement 2).

Patient: Mixed emotions … happy memories with parents … home in Boston … baby-sister … regret that it happened … tired of carrying this around.

Therapist: Go with that (eye movement 3).

Patient: None of the same scenes … feeling crampy in my stomach … There’s nothing you can do about it.

Therapist: Go with that (eye movement 4).

Patient: Moving away from the pain … feeling of absolution.

Therapist: Go with that (eye movement 5).

Patient: I was a kid … not doing anything abnormal … she washed my mouth out for just doing kid shit … came back to J’s dad, and I’m feeling better about that whole situation … coping better.

Therapist: Go with that (eye movement 6).

Patient: Stomach … always an acid stomach … started thinking about good things … hanging out with J … feels good to not feel guilty … absolving myself … a feeling of liberation.

Therapist: Go with that (eye movement 7).

Patient: Thought back at age 14 about getting grounded … Parents going to my little league games … I’m happier … going about things the right way.

Therapist: Go with that (eye movement 8).

Mr. S ended the session with an SUD level down to 0. He was instructed to keep a log over the course of the next week and told that other feelings or disturbing thoughts might occur. At

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the beginning of the next session, Mr. S was asked to return to the disturbing memory he had discussed the week before, and when asked how he felt now on a 0 to 10 scale, he reported that the incident remained a 0. The PC I’m okay, a good person was installed with short sets of eye movements, and a body scan revealed no residual tension. After a total of five sessions, Mr. S terminated treatment successfully.

The trauma of the roommate’s death had reactivated guilt and responsibility schemas from long ago, when Mr. S felt responsible for his family’s difficulties. He reported after EMDR that he felt freer and not so guilt ridden and responsible. His belief that he had created the conflict in the family was processed, and he was able to normalize his childhood transgressions as normal kid stuff that his parents had reacted to with punishments that were inappropriately severe. He had always felt that he had to make up for something and was overly giving in relationships. With the processing of J’s death, he was able to resolve other associated memory networks. Mr. S said that he was less giving in friendships after EMDR in that he was looking out for himself and his own needs more. He realized that he did not have to make up for anything. The resolution of his guilt allowed him to increase his sense of worth and self-esteem.

This case was included because it is a simple demonstration of the successful use of EMDR, and it illustrates how memory networks are accessed and connected. Until Mr. S had processed his grief and early adverse childhood experiences, he did not have access to positive emotions of his childhood. This then resulted in significant trait changes in his personality because he was able to be in a relationship without the attending guilt feelings that he needed to make up for something. EMDR is a powerful therapeutic approach and perhaps the best way to understand this type of therapy is to experience an EMDR session. A certified EMDR therapist can be found on the website EMDRIA.org. Often dramatic outcomes occur after only a few sessions of EMDR therapy, particularly with simple PTSD or symptom-focused EMDR.

FIGURE 6.1 Components of EMDR.

POSTMASTER’S EMDR TRAINING AND CERTIFICATION REQUIREMENTS

Although EMDR may seem at first glance to be a simple technique, it is a complex psychotherapy approach that requires a high degree of clinical skill. Certification is needed to practice EMDR effectively and safely. EMDR certification is available for licensed mental health clinicians who have 2 years of clinical experience in their field through EMDR International Association (EMDRIA). EMDR training is offered by private trainers, the EMDR Institute, or the EMDR Humanitarian Assistance Program (HAP). The latter training is offered at half price for those who work 30 hours or more per week at a not-for-profit, are a student or university faculty. See the HAP website at www.emdrhap.org for schedule and location of future training. Training must be approved by EMDRIA, which sets the standards for training programs. Approved EMDRIA training programs through the institute or with private trainers are listed on the website www.emdria.org. The Basic Training usually consists of two weekend EMDR workshops (20 academic didactic and 20 supervised hours) plus 10 additional consultation hours. In order to receive EMDR certification, additionally a minimum of 50 sessions with a minimum of 25 patients, 12 continuing education

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units (CEUs), and 20 hours of consultation from an approved EMDRIA consultant are required. It usually takes a year to complete all the requirements for EMDR basic training and certification.

CONCLUDING COMMENTS

During the past 10 years, our understanding of trauma and effective psychotherapy for trauma has increased due to the development of brain imaging techniques and biochemical research studies of the physiology and sequelae of trauma. We now understand that trauma causes short- and long-term effects on the body. This expanding knowledge has inspired new approaches to treatment and new ways to consider what happens in the brain when trauma occurs. The AIP Model evolved as a result of this work. AIP posits that trauma is any information that cannot be processed to an adaptive conclusion, based on the idea that the brain has an inherent ability to process information and integrate with other memory networks (Shapiro, 2001). AIP provides the underpinnings for how to conduct psychotherapy with the person who has suffered adverse life experiences as well as significant trauma.

EMDR is a comprehensive psychotherapy approach used to treat depression, anxiety, phobias, pain, addictions, behavioral and personality disorders, trauma-related disorders, relationship and sexual problems, and other mental health and somatic problems due to adverse life experiences. It is used for those with complex and attachment disorders with special considerations and advanced training. Complex trauma often involves more resource installation and longer treatment than a few sessions. It is important to keep in mind that the APPN must be skilled in working with the type of issue or problem that is presented. For example, in working with a patient with a dissociative disorder, skills and knowledge about this population are imperative prior to using EMDR. Because EMDR breaks down dissociative barriers, the APPN should seek consultation and advanced training in treating those who are highly dissociative.

EMDR is highly congruent with nursing’s holistic model of care and recovery principles. The process and protocol is patient centered with the therapist facilitating and following the person’s lead. The EMDR trained APPN will be richly rewarded as brain changes are literally witnessed during processing with profound changes occurring in a short amount of time. Not only does the patient experience deep feelings of gratitude, the therapist too feels grateful and moved by the power and miracle of this remarkable healing therapy.

DISCUSSION EXERCISES

1. Discuss your understanding of processing and how you would know whether a patient was ready for processing.

2. What is an abreaction, and how would you handle this if it occurred in an EMDR session? 3. Identify strategies to pace treatment and mediate arousal levels. 4. Discuss a patient you have cared for and describe how you would conceptualize the problem and

treatment based on the AIP model. 5. Identify some strategies that may be helpful in closing a session when the person has processed

some traumatic material. 6. How would you support the person who has processed trauma between sessions? 7. What are the components of the EMDR protocol? 8. Although EMDR training is required before using the protocol, Phases 1 and 2 can be integrated

into your practice before training. Discuss specifically using a case example how you could include components of these phases in your work with your patient.

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Lightstream Exercise

This exercise can be used for any problem, such as obsessive compulsive disorder, pain, and so on. The therapist can ask the patient to draw what the problem or pain would look like on a piece of paper with colors or else to use the following without the drawing and to visualize:

“Concentrate on the feeling in your body … if the feeling had a shape: what would it be? If it had a size … what would it be? If it had a color … what would it be? If it had a sound … would it be high pitched or low?

Which of your favorite colors might you associate with healing?

Imagine that this favorite colored light is coming in through the top of your head and directing itself at the shape in your body. Let’s pretend that the source of the light is the cosmos; the more you use, the more you have available. … The light directs itself at the shape, and permeates and penetrates it … resonating and vibrating in and around it. As it does, what happens to the shape, size, or color?

As the light continues to direct itself to that area, you can allow the light to come in and gently and easily fill your entire head, easily and gently. … Now allow it to descend through your neck into your shoulders, and flow down your arms into your hands and out through your fingertips. Now allow it to come down your neck and into the trunk of your body easily and gently. Now allow it to descend down through your trunk and into your legs, streaming down your legs and flowing out your feet. …”

Give peaceful and calm suggestions until the next session.

An audiotape version is available from EMDR-HAP.

Adapted with permission from Shapiro (2001).

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Circle of Strength

This exercise is designed to assist the person in developing an internal resource for support. This exercise is most helpful if used with those who have positive relationships and memories and may not be appropriate for attachment and relationship trauma. It may create distress for those whose relationships are not working so well. “If it is okay, close your eyes, leaving them open is okay too. Take a nice deep breath and imagine yourself in the center of a wheel with people surrounding you like spokes in a wheel who are resources for you. Each person is a person who you like who has been there for you and who you feel comforted by and represents a source of strength for you. It could be someone you know from the past or a current person. As you think of each person, tell me who they are (say the name after each person is named to strengthen the image). Make the image of you surrounded by your resource people as vivid as you can with each person’s image as clear as you can make it with faces, colors. Just notice as you are surrounded by (name the people again who they named) and how you feel in your body … taking a nice deep breath as you feel the strength and comfort of your resources surrounding you with caring and comfort, those who like you for you and have been there for you. Feel their love around you supporting you and notice where you feel this in your body … let me know where this is. Now, as you breathe in, notice your ___________ (body part mentioned by client) and memorize that feeling and notice how calm and strong you feel as you image your circle of strength with you in the middle. Continue for a few minutes enjoying your circle of special people. Take a nice deep breath knowing that you can return to this image anytime you need.” (Ask the person to practice the image during the week several times a day. The more this is practiced, the easier it is to bring to mind when needed.)

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Motivational Interviewing EDNA HAMERA

otivational interviewing is a collaborative person-centered communication process designed to help individuals resolve ambivalence and plan for change. It can be used alone to increase motivation for

engaging in psychotherapy or in combination with other forms of therapy when resistance is encountered. This chapter begins with an overview of the guiding principles, the history, and evidence-based research for motivational interviewing. Application of motivation interviewing is discussed within the phases of change outlined by Miller and Rollnick (2013). Motivational interviewing is closely aligned with the Transtheoretical Model developed around the same time (Prochaska, DiClemente, & Norcross, 1992). Although both models concern changing behavior, motivational interviewing puts greater emphasis on getting ready to change. The two approaches are integrated in an evidence-based substance abuse treatment program (Center for Substance Abuse Treatment, 1999), which is discussed in the section on modifications of motivational interviewing. Process recordings from two cases, one in an integrated primary care setting and one during medication services at a community mental health center, illustrate the application of motivational interviewing.

GUIDING PRINCIPLES

The origins of motivational interviewing emerged from Miller’s clinical practice in addictions (1983) and research on therapists’ behaviors that elicit motivation. In the latest edition of their book, Miller and Rollnick (2013) elaborate on the values and philosophy of motivational interviewing. The “spirit” of motivational interviewing embodies a partnership with clients incorporating the principles of acceptance, belief in individual autonomy, and acknowledgment of the individual’s strengths and efforts with empathy and affirmation. The principles of acceptance, conveying accurate empathy, honoring the worth of individuals, affirming their strengths, and respecting their autonomy are adapted from Carl Rogers’s person-centered therapy (1965). Miller and Rollnick (2013) added the principles of compassion and evocation. Compassion means therapists give priority to the well-being of clients over their own needs. Evocation is accepting that individuals have within themselves what they need to change and it is the practitioner’s job to “draw it out” (Miller & Rollnick, 2013, p. 21).

Motivational interviewing contains elements of other theories that underlie the change process. Festinger’s Cognitive Dissonance Theory (Festinger, 1957) focuses on prejudice, asserting that awareness of discrepancies among beliefs and goals and behavior is an incentive for people to reconcile their inconsistencies. Motivational interviewing highlights dissonance between unhealthy behaviors and the person’s values and goals. Bem’s (1967) Self-Perception Theory is a refinement of Cognitive Dissonance Theory proposing that hearing oneself argue for change increases desire to change. In motivational interviewing it is important for individuals to voice the change they desire, which reinforces motivation for change (Amrhein, Miller, Yahne, Palmer, & Fulcher, 2003). Because motivational interviewing deals with ambivalence and resistance, it resembles Reactance Theory (Brehm & Brehm, 1981), the belief that some individuals are more defensive when persuasion or coercion is used because their sense of freedom is threatened. Miller and Rollnick (2013) prefer to use the word discord and believe that discord or differences arise in the context of the relationship and are not an individual trait. However, they concur that taking a directive role and using persuasion to encourage change is the antithesis of their philosophy.

HISTORY

W. R. Miller reviewed addiction studies and conducted research that led him to dismiss the idea that denial

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was a predominant trait of individuals with alcoholism and to question the belief that confrontation was effective (Miller, 1983, 1985; Miller, Benefield, & Tonigan, 1993; Miller et al., 1998).

The development of motivational interviewing paralleled that of Transtheoretical Model of Change, which proposed that people go through stages in the process of change (Prochaska & DiClemente, 1983). Miller and Rollnick have continued to define and elaborate motivational interviewing over time (Miller & Rollnick, 1991, 2002, 2013). As a practice theory it follows a bottom-up approach to theory development, emerging from clinical practice and clinical research. A few studies have examined the elements in the process of motivational interviewing that are related to outcomes. They indicate that a high frequency of behaviors inconsistent with motivational interviewing is linked to client resistance and worse outcomes, whereas the reverse, that is, a lower frequency of behaviors inconsistent with motivational interviewing is related to client engagement and better outcomes (Apodaca & Longabaugh, 2009). Consistent use of reflection versus giving direction increases change talk, and consistent use of motivational interviewing strengthens commitment to change, leading to change behavior as long as the practitioner does not “get ahead” of the client (Miller & Rose, 2009).

EVIDENCE-BASED RESEARCH

A number of studies on motivational interviewing have been captured in systematic reviews and meta- analyses. Initial meta-analyses combined studies across a variety of behaviors including substance abuse, smoking, and health behaviors such as safe sex and weight loss, because there were few random controlled studies of each behavior. Outcomes included self-report and objective measures. The results are reported as effect size for continuous variables with larger correlations indicating greater effects or reported as level of risk. Relative risk is derived from dividing the risk, for example, relapse in one group by risk in another, and odds ratio is the number of people in a group with an event (e.g., relapse) divided by the number without an event (Kissling & Davis, 2009). The large ranges in effect sizes indicate that motivational interviewing has differential effectiveness across behaviors. Many of the early studies implemented adapted versions of motivational interviewing and most did not assess the fidelity of motivational interviewing.

TABLE 7.1 Meta-Analyses of Motivational Interviewing With Substance Use, Smoking, and Health- Related Behaviors

tx, treatment.

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More recent meta-analyses of motivational interviewing have focused on specific behaviors with most research being done on alcohol and drug abuse and nicotine dependence (see Table 7.1). The majority of these meta-analyses yielded medium effect sizes (0.50) following intervention and small effect sizes (0.20) with longer follow-up (Cohen, 1992). This indicates that motivational interviewing is effective, but its efficacy lessens with time.

Research on the effectiveness of motivational interviewing for individuals with serious mental illness is limited. Kelly, Daley, and Douaihy (2012) reviewed random controlled studies of individuals with comorbid psychiatric and substance abuse disorders. In one study, motivational interviewing, cognitive behavioral therapy (CBT), and family therapy with individuals who had schizophrenia reduced their substance use over 1 year (Barrowclough et al., 2010). Another study (Bellack & Gearon, 1998) cited by Kelly and colleagues (2012) examined motivational interviewing and case management in individuals with comorbid serious and persistent mental illness and substance abuse. The combination of motivational interviewing and case management was effective in keeping individuals in treatment, and they were 59% more likely to have clean urine compared to 25% in the control group. Steinberg et al. (2004) evaluated a motivational interviewing session in individuals with schizophrenia who were nicotine dependent to see whether it motivated them to seek treatment for tobacco dependence. A greater proportion of those receiving motivational interviewing contacted smoking cessation providers and attended the first session compared to those receiving psychoeducational counseling or advice.

Since 2000 motivational interviewing has been used to motivate individuals diagnosed with anxiety disorders to engage in psychotherapy. Westra and Dozois (2006) examined motivational interviewing prior to CBT and found that those receiving motivational interviewing attended more CBT sessions and reported lower anxiety at 6 months post-treatment than individuals receiving only CBT. Similar results were found in a subsequent study of individuals with generalized anxiety disorder (Westra, Arkowitz, & Dozois, 2009).

Cassin and colleagues (2008) offered one session of motivational interviewing to a community sample that met criteria for binge eating. Compared to a self-help handbook, the motivational interviewing group reduced the frequency of binge eating compared to the control group at 8 and 16 weeks.

MOTIVATIONAL INTERVIEWING SKILLS

In the latest edition of their book, Miller and Rollnick (2013) introduced phases in the process of change that allows practitioners to tailor communication to the client’s phase of change. The communication skills are captured in the acronym OARS: asking Open questions, Affirming, Reflecting, and Summarizing. Open questions are simply questions that cannot be answered yes or no or with short answers. Affirmations are comments on the person’s strengths and efforts. Reflections are statements mirroring the content or feelings explicitly or implicitly stated by the person. Reflections are distinguished from questions by voice inflection; inflection goes up at the end of a question and down at the end of a reflective statement. Reflections can be simple, staying with what was said, or complex, adding to the content, feeling, or highlighting discrepancies in behaviors or beliefs. See Box 7.1 for examples of reflective statements. Summaries link together what has been stated or serve in moving from one idea to the next idea. Motivational interviewing consists of detecting what phase the person is in and using OARS skills judiciously to help the person move through the phases toward change.

BOX 7.1

SIMPLE AND COMPLEX REFLECTIONS

Simple reflections Example 1: Mother whose adult son took his life “I cry myself to sleep every night, I keep thinking I shouldn’t have left and maybe he would still be alive.” Content: “You think if you stayed he would still be alive.” Feeling: “At night you feel especially sad.”

Complex reflections Adding meaning: “You believe you could have prevented him from taking his life.” Adding feeling: “You’re feeling overwhelmed with guilt.” Double sided: “Part of you

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feels responsible but another part knows that when he was using drugs he was impulsive.”

Simple reflections Example 2: Man beginning alcohol abstinence “I need to have a bottle of Jack Daniels on hand in case one of my buddies comes by.” Content: “You want to have liquor in the house.” Feeling: “You feel you gotta have liquor on hand for your buddies.”

Complex reflections Added content: “Offering your buddies a drink is expected.” Added feeling: “You’d feel weird if you didn’t offer them a drink.” Double sided: “You’re used to having liquor around but know it is a temptation.”

Phases of the Change Process

Engagement is the phase in which a trusting and respectful relationship is established. Without this there is little hope of facilitating change in behavior. Focusing is the process of clarifying the client’s goals and direction. Evoking is eliciting motivation for a specific change, and the final stage is planning a specific change strategy.

Engagement encompasses client-centered counseling skill with special emphasis on reflections that convey understanding. Psychiatric nurses have a history of understanding the role of empathy in interpersonal relationships (Peplau, 1952/1991), but like other interpersonal competencies these skills need to be periodically revisited and reaffirmed. Empathetic reflections are based on active listening (Klagsbrun, 2001) for both what is not said as well as what is. If accurate, these reflections are acknowledged by the person’s nonverbal behaviors such as shaking the head up and down, sighing and lowering shoulders indicating relaxation, or by verbalizing a feeling of being understood. Listening and reflecting on what is not being said can be difficult; overstepping what the person feels ready to acknowledge can increase suspiciousness. Engagement can be assessed by how responsive the person is in the conversation and by asking yourself how well you understand the person’s situation. Box 7.2 shows potential OARS communication statements during engagement.

Focusing is guiding the interaction to identify a direction of change. This may emerge without prompting, but in many cases it is a matter of narrowing the focus and prioritizing the options. Clients may present global issues, and it is difficult guiding them in selecting a focus. Open questions are used to understand what the person knows about the outcomes of not changing. Practitioners instinctively want to share information about the consequences of unhealthy behaviors. Although well intended, these automatic “right” reflexive comments frequently engender resistance, such as “My drinking is not a problem, I have never gotten a DUI.” Miller and Moyers (2006) advocate using reflection to diffuse resistance, for example, saying “Your drinking has never caused you to be arrested.” Another method of “rolling with resistance” is to convey to clients that changing is their choice. This intervention needs to be stated in a sincere manner because it can easily be misinterpreted as dismissive or as giving permission to continue the behavior. If you discover that the client may not understand consequences of the behavior, ask permission to relate your understanding of the effects of continuing the behavior; for example, “You mentioned sleep is important to you, and you are only getting about 4 hours a night. I am concerned how your smoking might be related to sleep. I wonder whether that might be something we could talk about?” If there are multiple directions for change, asking clients what aspect is most important to them may be effective. The focusing phase has been achieved when there is a clear direction that is acknowledged by you and the client. Box 7.2 shows potential OARS communication statements during the focusing phase.

Evoking is eliciting and responding to change talk. In moving to the evoking phase, listen for change talk and amplify it with reflective statements in order to develop discrepancy between sustaining and changing the behavior. Sometimes the clues are subtle, such as the client relating she had a nicotine patch and stopped smoking when she was in the hospital or surviving without a daily Coke on Easter when visiting family. It is easy for practitioners to elicit resistance in the evoking phase. Miller and Rollnick (2013) believe there is a strong pull to continuing the same behavior because it is supported by habits and environmental cues. As with most behavioral and cognitive therapies, resistance emerges from interactions that evoke defensiveness. Change may be elicited by cautiously asking whether there is anything positive about changing behavior: such

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as “reducing the amount you drink on weekends,” “reducing the sugary drinks you consume,” or “not eating during the night?” Summarizing the pros and cons of changing, always ending with the pros can be useful, stating “You know it’ll be difficult, but you worry about your health if you don’t.” Gauging commitment to change can be assessed by asking how important it is to change on a scale of 1 to 10 with 10 being most important. Because you want to support change, follow with what would make changing more important. Listening to see whether change talk is more predominant than sustain talk is the best way to assess whether the client is ready to move to the planning phase. Box 7.2 shows potential OARS communication statements during the evoking phase.

BOX 7.2

PHASES OF CHANGE AND OARS COMMUNICATION SKILLS

Phase of Change OARS Communication Skills

Engagement Goal: Establish trust and helping relationship

Open questioning: Tell me more about that? What concerns you most? What led to your decision to come? Affirming: It took effort to come today. You took the first step and are ready to take the next. Reflecting: You are getting tired of helping your mother. Being short with your kids is a warning sign. Summarizing: Your father’s death and now pressure from your relatives to get a job are too much.

Focusing Goal: Identify direction/target of change

Open questioning: What concerns you the most? What aspect of managing your son’s behavior is most troublesome to you? Affirming: It is your choice of whether or not to tackle this right now. You have been successful in the past. Reflecting: You are not sure whether individual or group therapy would be most helpful. You feel swimming is the best exercise for you. Summarizing: You have eliminated simple sugar from your diet but are not sure what else to do to prevent diabetes.

Evoking Goal: Bring forth person’s motivation for change

Open questioning: What do you see as some of the downsides to your present weight? How do you want things to be different? Affirming: You care that your kids will be happier if you stop smoking. You were successful before in quitting. Reflecting: You know it will be difficult but you worry about your health if you don’t lose weight. You feel anxious about not checking whether your door is locked more than two times but are concerned with getting to work on time. Summarizing: You have identified that it will be hard for you to exercise in the morning but are not sure you can fit it in after work.

Planning Goal: Elicit plan that will be followed

Open questioning: What is the first step in making this happen? Have you thought how you might make this change? Affirming: Praying for his success is the best way to support him now. Beginning therapy is a big step, but you have found a way to make it work. Reflecting: Gaining a little weight is a possible pitfall if you stop smoking, but it is worth it if your breathing is easier.

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Summarizing: You decided to get away when you quit so you don’t alienate your roommate. You think that suddenly stopping all sugary drinks is the best way for you to work on your diet.

Evoking hope is important when individuals lack confidence that they can change. This is especially true of individuals with serious mental illness who suffer relapses that challenge their motivation to continue working toward recovery. Confidence in changing can be assessed by asking how confident the client feels on a scale of 1 to 10 with 10 being very confident. Follow up on what would increase confidence. Miller and Rollnick (2013) suggest that breaking change behavior into smaller steps and acknowledging past attempts are helpful methods to increase confidence that change is possible.

Planning is the fourth phase and involves reinforcing commitment and assisting the client in developing a plan for change. Readiness to begin the planning phase can be detected when clients begin to use verbs like will, begin, do, and plan rather than verbs like need and should (Amrhein et al., 2003). In this phase the automatic “default” is for the practitioner to give the person suggestions about how to proceed with change. This is likely to elicit client resistance and stall or delay change. Returning to open-ended questions, affirmations, and reflections are most helpful. For example, “What ideas do you have about how to begin changing your drinking/eating/increasing physical activity?” Box 7.2 shows potential OARS communication statements during the planning phase.

MODIFICATIONS OF MOTIVATIONAL INTERVIEWING

Motivational interviewing has been incorporated into a best practice substance abuse treatment based on the Transtheoretical Five-Stage Model of Change of precontemplation, contemplation, preparation, action, and maintenance combined with motivational interviewing (Center for Substance Abuse Treatment, 1999). The treatment uses a FRAMES approach that includes (1) personalized Feedback on substance use from standard tests, (2) giving the individuals Responsibility for change, (3) presenting Advise with permission in a nonjudgmental manner, (4) offering a Menu of change options with (5) Empathy and empowering (6) Self- efficacy. Motivational interventions are tailored to the person’s stage of change and evidence shows that they are helpful with individuals from different cultural backgrounds and socioeconomic levels (Center for Substance Abuse Treatment, 1999). Enhanced motivation for change has been widely adopted in substance abuse programs, and the manual is available from the Substance Abuse and Mental Health Services Administration. Another similarly based program for adolescent cannabis addiction is available at www.motivationalinterview.org (Sampl & Kadden, 2001). It entails a five-session motivational enhancement prior to cognitive behavioral treatment for adolescent cannabis use.

CASE EXAMPLES

Two cases from different clinical settings illustrate the spirit and communication skills of motivational interviewing. Case 1 is a 35-year-old Caucasian woman seen in an integrated primary care office who was referred for counseling on her alcohol use. She had no previous psychiatric services, was married, and had three young children. Because motivational interviewing is a communication process, a process recording is the best way to illustrate application.

CASE EXAMPLE 1

Engagement

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PMHNP [psychiatric-mental health nurse practitioner]: I’m a psychiatric nurse practitioner, and your practitioner asked me to see you. Perhaps we could start with what you understand about our meeting.

Sue: I’m not sure. She asked me about my drinking and ordered some tests. PMHNP: Maybe we could start there. Your lab results look fine except for some elevation in your liver enzymes. I want

to explore what might be causing this. You mentioned that you do drink, and alcohol can raise liver enzymes. Can you tell me more about your drinking? (open questioning)

Sue: I don’t drink that much. You have to understand, I stay at home all day. I have three kids—do you have any kids? 9 months, 3, and 5.

The oldest is in kindergarten now, but getting the 3-year-old down for a nap and now that the baby is crawling and putting everything in her mouth …

[pause] I have a drink after lunch. And it helps. A lot. I’m not sure how I’d handle it otherwise.

PMHNP: You find it stressful being home with three young children and having a drink helps you relax? (simple reflection)

Sue: Yes. Yes. Exactly. Because I don’t get time off. This is not a “job” I can take a break from. My husband, he leaves, he gets time away. But me? I’m always watching them, feeding them, breaking up fights. And the boys —they FIGHT. My 5-year-old son has real issues with anger.

PMHNP: There’s a lot of energy in a house with boys. You don’t have the opportunity your husband does to get away. (simple reflection)

Sue: And Eric, my husband, has no idea what it’s like staying home with small children. He imagines I watch cartoons all day, eat ice cream.

PMHNP: You don’t feel supported by him? (complex reflection) Sue: Shakes head yes …

PMHNP: Maybe he doesn’t recognize the strain you feel caring for the children all day. It sounds like you’re drinking during the day to help you handle the stress. (simple reflection)

Sue: I guess I am.

Focusing

PMHNP: We could go in any number of directions here. I wonder what makes the most sense to you. Your relationship with your husband and the lack of support you feel is an issue. I’m also concerned about how your drinking is affecting your health. What would you like to focus on? (closed question)

Sue: I don’t know, I … Eric would be so angry if he knew that I drink during the day and when Eric gets angry he doesn’t yell—

nothing like that—he just shuts down. Completely. Ignores me AND the kids. PMHNP: If you share that you are drinking, you feel he would shut you out more. (complex reflection)

Sue: Yes. Definitely.

Evoking

PMHNP: What kind of relationship would you like to have with your husband? (open question) Sue: I want to have a relationship where we communicate with each other, where he listens to me, and asks me

what my day has been like. We used to have a relationship like that. We talked much more before Amy was born. You see, we didn’t plan on having more children—she’s 9 months now—and I’m happy we have a girl and so

is Eric, but I think he feels overwhelmed with the finances. … I didn’t drink during the pregnancy but since Amy stopped nursing …

PMHNP: You feel Eric might be shutting you out because he is stressed with money. (complex reflection) Sue: Sure. I guess that’s possible.

PMHNP: You remember when your relationship with your husband was better and you weren’t drinking during the day. (simple reflection)

Sue: Yes. PMHNP: How important is it to you to stop drinking and improve your relationship with your husband? Say on a scale

from 1 to 10 with 10 being very important. (closed question) Sue: I’d say at least an 8.

I know we should sit down and talk, but I’ve been so stressed and angry lately, it’ll be hard not to just blow up at him.

Planning

PMHNP: You’re concerned you won’t be able to share how much you miss your time with him. (complex reflection)

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Sue: I am not sure he misses me. PMHNP: It is difficult sharing how you feel, particularly if you’re concerned about him shutting you out. But perhaps

it’s a risk worth taking. (simple reflection) Sue: Yes. You’re right. I know you’re right.

PMHNP: And perhaps if you can clear the air with Eric, you’ll feel less anxious and overwhelmed. Soon, you may not need that drink after lunch. (complex reflection)

Sue: Yes. Yes. I know. … I think I’ll talk with him tonight.

Analysis of Interaction: Case 1

Using reflection and open questioning revealed that Sue was feeling isolated from her husband, which she related to her alcohol use. If the PMHNP had focused exclusively on her alcohol use, her strained relationship with her husband might not have emerged. It is doubtful Sue would be willing to consider changing her drinking without addressing the issue of her husband as well. Miller and Rollnick (2013) recommend examining the frequency of OARS communication skills to attain competency in motivational interviewing. In this encounter, the PMHNP offered more open-ended questions than closed questions and more reflections than questions.

CASE EXAMPLE 2

Case 2 is a 20-year-old woman, Melena, who attended a medication visit with her case manager at a community mental health center. She is diagnosed with mood disorder not otherwise specified and borderline personality disorder and is prescribed lamotrigine, trazodone, and citalopram. Melena has just returned from an out-of-state visit to see her boyfriend.

PMHNP: How is it going? (open questioning) Melena: He has another girlfriend; he didn’t want to tell me on the phone.

PMHNP: That must be distressing after you traveled to get there. (complex reflection) Melena: When he told me I told him I was going to start cutting.

PMHNP: You were angry with him? (complex reflection) Melena: He told me he would have sex with me if I did not cut on myself.

PMHNP: How did that go? (open questioning) Melena: So I didn’t do any cutting, but since I’ve been back I’m angry about small things. At the airport I just wanted

to knock the cowboy hat off a man. Nothing helps. I can’t sleep and started drinking four to five shots of beer with whiskey at night.

PMHNP: You’re drinking to help you sleep? (simple reflection) Melena: I get to sleep but don’t sleep long.

PMHNP: You think that might be related to your drinking? (simple reflection)

Melena: I don’t know? PMHNP: If you’re willing, I would like to tell you about the effects of alcohol on sleep? (asking permission to give

information) Melena: Shakes head positively.

PMHNP: Alcohol initially makes you sleepy, but with large amounts your body begins withdrawal, which disrupts your sleep.

Melena: I didn’t know that. PMHNP: Remind me of the coping skills you have used in the past? (open questioning)

Melena: I have a special pillow. I used to listen to my MP3 player, but I haven’t got a charger so can’t now. PMHNP: So music has been helpful. (simple reflection)

Case manager: We could see about replacing the charger and look at what other activities you have in your wrap plan. PMHNP: Is that something you are willing to do? (closed questioning)

MELENA: [Shakes head yes.]

Analysis of Interaction: Case 2

This brief motivational interviewing intervention helped to avert a full relapse into drinking to

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cope with her anger and disappointment about her boyfriend.

TRAINING IN MOTIVATIONAL INTERVIEWING

No definitive certification for motivational interview exists that is widely recognized. Training programs are designed to prepare a wide range of professionals such as case managers, primary care practitioners, counselors, and therapists from varying disciplines. Online and live programs are usually divided into beginning and advanced motivational interviewing skills each lasting 2 to 3 days live or 40 to 50 hours online.

There are three key methods to consider in learning motivational interviewing:

1. Break down the skills into steps (Miller & Moyers, 2006). 2. Practice the skills in live sessions, taping them if possible. 3. Get coaching and feedback on direct observation of skills.

One of the best resources for training is the motivational interviewing Network of Trainers website at www.motivationalinterview.org, which offers videotapes of experts implementing motivational interviewing, online programs, and a list of live training opportunities. Look for programs that incorporate experiential and practice sessions.

Rosengren’s workbook (2009) is excellent for all stages of learning motivational interviewing. The book by Naar-King and Suarez (2010) is a guide to using motivational interviewing with young adults and adolescents.

As with any communication skill, there is drift over time, so a mechanism for follow-up training is important. This can be achieved by creating learning groups that listen and code tapes of real clients and offer consultation with difficult clients. Learning groups are most effective when sanctioned or sponsored by one’s workplace. Coding systems used by trainers focus on interviewer responses or examine both interviewer and client responses and provide feedback on level of mastery of motivational interviewing. Miller and Rollnick (2013) recommend counting reflections and questions with the goal of having twice as many reflections as questions and identifying the client’s change talk and therapist’s responses inconsistent with motivational interviewing. Inconsistent responses include using confrontation such as, “You will get diabetes if you continue what you are doing,” or persuasion, “You will feel so much better if you exercise regularly.” Confrontation and persuasion are based on the false belief that denial needs to be directly attacked. This is not supported by research (Miller, Benefield, & Tonigan, 1993; Miller, Andrews, Wilbourne, & Bennett, 1998).

CONCLUDING COMMENTS

Motivational interviewing facilitates the client’s inherent motivation to change. It is not a therapy but a method of communication that partners with clients accepting their autonomy and respecting that they have within themselves the knowledge of how to change. Motivational interviewing is an evidence-based person- centered approach that started in addiction counseling coupled with the Transtheoretical Model (Prochaska & DiClemente, 1983) of Change. It can be used in helping people engage in lifestyle changes to improve their health. Also motivational interviewing can be used to motivate individuals to initiate therapy for anxiety disorders preceding more action-oriented therapy.

Some may see motivational interviewing as a time-consuming intervention in our fast-paced, cost- conscious health care delivery system. However, with the growing focus on patient outcomes and the need for people to embrace healthier lifestyles, there is evidence that using motivational interviewing is an important and needed skill for all health professionals. For example, physical activity is a difficult behavior to increase. Approximately 70% of the U.S. population is sedentary (USDHHS, 2006) and individuals with serious mental illness report less physical activity than the general population (Daumit et al., 2005). Even when physical activity is increased there is a high relapse rate (50%) (Castro & King, 2002). Motivational interviewing can be implemented in both initiating and maintaining increased physical activity.

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DISCUSSION EXERCISES

1. Describe differences in implementing motivational interviewing in an established relationship versus an initial relationship.

2. Discuss the philosophy and principles of motivational interviewing. 3. Identify situations from your clinical practice in which motivational interviewing would be

applicable. 4. What function is served by asking the client “How important is it to change your behavior on a

scale of 1 to 10 with 10 being very important?” 5. Discuss why offering reflections versus asking questions reduces defensiveness. 6. Describe the approach in the “Enhancing Motivation for Change for Substance Abuse” program. 7. What steps facilitate learning motivational interviewing?

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Cognitive Behavioral Therapy SHARON M. FREEMAN CLEVENGER

his chapter provides a brief overview of cognitive behavioral therapy (CBT). This chapter begins with guiding principles and evidence-based research for CBT. Basic cognitive and behavioral techniques are

presented that the advanced practice psychiatric nurse (APPN) can integrate into practice. A modification of CBT, schema-focused therapy is discussed, as well as application of models of CBT treatment for specific populations. The chapter concludes with a case study illustrating the use of CBT and postmaster’s and certification requirements.

CBT is the most widely researched psychotherapeutic model with demonstrated effectiveness in the treatment of a wide range of emotional and behavioral problems (Beck & Dozois, 2011; Jakobsen et al., 2011; Karlin et al., 2010; Kliem, Kröger, & Kosfelder, 2010; Neacsiu, Rizvi, & Linehan, 2010). CBT is the first order of business and treatment of choice for most patients who need internal resources and coping skills enhanced. The therapist, together with the patient, structures each session and sets reasonable, measurable, specific goals so that both participants know when progress has been made. Goals include problems to overcome as well as positive changes that need to be made. Each session ends with homework assigned, which is then reviewed at the beginning of the next session. CBT is based on treatment plans that are clearly conceptualized and tested theories that guide the clinician through each action, session, and overall plan of care.

BACKGROUND INFORMATION

Cognitive therapy “is a collaborative process of empirical investigation, reality testing, and problem solving between the therapist and the patient” (Beck & Weishaar, 1986, p. 43). The basic premise is that depression is the result of cognitive distortions (CDs) and these distortions are learned errors in thinking. It is generally agreed that CBT evolved primarily from the work of Aaron T. Beck. Beck, originally trained in psychoanalysis, departed from psychoanalytic concepts as he studied Adler, Horney, and Sullivan. Beck concentrated on a person’s distortions in self-image, thereby creating a more systematic cognitive behavioral conceptualization of both psychiatric disorders and personality structure (Clark, Beck, & Alford, 1999). Through a series of studies on depression and suicidal thinking, Beck developed a systematic structuring of cognitive therapy with a blueprint of guiding principles and specific procedures to follow (Beck, 1976, p. 15).

During the 1970s, researchers began to apply behavioral theory to cognitive theories and strategies. Traditional behavior theory focused on guided experiments to shape measurable behaviors such as avoidance and suicidal ideation with little attention paid to the cognitive processes involved in the behavioral changes. For example, fearful responses were extinguished with exposure protocols. Meichenbaum (1977) and Lewinsohn (Lewinsohn, Hoberman, & Teri, 1985) began to incorporate these behavioral interventions within the cognitive theoretical structures and noted that this added depth, context, and deeper understanding to outcomes. Since then extensive research has demonstrated significant efficacy in the combined approach using cognitive techniques (i.e., cognitive restructuring) along with behavioral techniques (i.e., exposure therapy and relaxation training).

Cognitive therapy and/or CBT is a “system of psychotherapy based on a theory which maintains that how an individual structures his or her experiences largely determines how he or she feels and behaves” (Beck & Weishaar, 1986). The model posits that dysfunctional (or maladaptive) thoughts relating to self, world, and/or others are rooted in irrational or illogical assumptions. The individual’s view of self and the world is central to the determination of emotions and behaviors and thus by changing one’s thoughts, emotions and behaviors can also be changed. In addition, CBT is structured hierarchically with cognitive processes understood in terms of primary and secondary thinking. Secondary thinking views the social and cultural world in determinate, positive, rational terms while primary thinking recognizes the indeterminate, negative,

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and irrational as a part of human action forever. Finally, CBT places significant importance on cognitive information processing and behavioral change. The resultant theoretical model combines features of traditional psychotherapy within a unique conceptual framework.

Clinical strategies are used to help the individual recognize the dysfunctional nature of their thinking patterns and to help the individual change their conclusions. Theoretical refinement of the model along with empirical testing has resulted in a consensus that it is the interplay among thoughts, feelings, and behaviors within one’s environment that results in psychopathology. Therefore it is imperative that interventions target all three foci in order to affect sustainable changes, cognition being the pivotal point.

EVIDENCE-BASED RESEARCH

There have been many research studies validating the efficacy of CBT for both medical and psychiatric disorders as well as many mental health problems. See Table 8.1 for a selected list.

COGNITIVE TECHNIQUES FOR STABILIZATION

Specific techniques have been delineated that can be integrated by the APPN psychotherapist that assist in changing or modifying the patient’s thinking and behaviors. Cognitive therapy advocates guided discovery rather than directly challenging the patient’s views. There are times when it is necessary to be direct or even confronting such as in cases in which the therapist must intervene quickly. However, it is always best to be as collaborative as possible and to allow the patient to find the answers to their problems or dilemmas as much as possible. This minimizes debate and increases the sense of mastery and participation.

Socratic Dialogue

The Socratic dialogue (SD) is a technique described as “mutual discovery in which the therapist guides the patient through a series of questions and answers to elicit automatic thoughts and assumptions, and examine the logic and evidence that relates to them” (Leahy, 2001).

TABLE 8.1 Evidence-Based Research for CBT Medical Disorder Citation Tinnitus Andersson et al. (2005); Hesser et al. (2012)

Chronic pain Bogduk (2004); Skinner, Wilson, & Turk (2012); Thomas (2005); Thorn (2004)

Premenstrual dysphoric disorder (PMDD) Hunter et al. (2002); Lustyk et al. (2009)

Sexual dysfunction Hoyer et al. (2009); Nofzinger et al. (1993)

Chronic insomnia Espie, Inglis, & Harvey (2001); Mitchell et al. (2012)

Chronic fatigue syndrome McCrone et al. (2012); Price & Couper (1998)

Myocardial infarction Delisle et al. (2012)

Depression DeRubeis et al. (2005); Hollon et al. (2006); Jakobsen et al. (2011)

Anxiety and panic disorders Coull & Morris (2011); Heldt et al. (2005); James, Soler, & Weatherall (2005); Klinger et al. (2005); Ost, Thulin, & Ramnero (2004); Persons et al. (2005); Stanley, Diefenbach, & Hopko (2004)

Eating disorder Glisenti, Kevin, & Esben Strodl (2012); Leung, Waller, & Thomas (2000); Pike et al. (2003)

Personality disorders Bhar et al. (2012); Leichsenring & Leibing (2003); McMain et al. (2012)

Substance misuse disorders Sobell & Sobell (2011); Tyrer et al. (2003); Tyrer et al. (2004)

Marriage and couple problems Dattilio & Epstein (2005)

Posttraumatic stress disorders (PTSD) Bisson & Andrew (2005); Chard et al. (2010); Hinton et al. (2005); Karlin et al. (2010); Otto et al. (2003); Paunovic & Ost (2001); Taylor et al. (2001)

Self-injurious behaviors Riaz & Agha (2012); Tyrer et al. (2003)

Obsessive–compulsive disorder Benazon, Ager, & Rosenberg (2002); McLean et al. (2001); Olatunji et al. (2013); Piacentini et al. (2002); Rufer et al. (2006); Whittal, Thordarson, & McLean (2005)

Schizophrenia and schizophrenic symptom reduction Hofmann et al. (2012); Jones, Cormac, Silveira da Mota Neto, & Campbell (2004); Rector & Beck (2001, 2002); Turkington et al. (2004)

Health anxiety (Hypochondriasis) Bouman & Visser (1998); McManus et al. (2012)

Antisocial behaviors Kazdin, Marciano, & Whitley (2005)

Sexual offenders Yates (2003) Borderline personality disorder (using a DBT approach) Binks et al. (2006); Kliem, Kröger, & Kosfelder (2010); Neacsiu, Rizvi, & Linehan (2010)

DBT, dialectical behavior therapy.

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Socratic methods are radically different from psychodynamic schools and nondirective styles of therapy technique (Freeman, 2005). The former synthesizes the patient’s information and the therapist interprets it back to the individual encapsulating intentions, motivations, and conflicts (Freeman, 2005). The therapist’s interpretations are thought to lead the person to insight, integration, and eventual change. In contrast, SD involves the therapist asking specific questions derived primarily from restatement of the individual’s own words as the major technique leading the individual to self-discover insight leading to subsequent changes (Freeman, 2005).

TABLE 8.2 Socratic Dialogue 1. History questions: How many children did you have in your first marriage? (non-SD) 2. Memory questions: (remembering that the individual’s recall is influenced temporally, interference and “facts” being considered

inconsequential) When did you first notice that your sleep patterns had changed? 3. Translation questions: (asks the patient how the data refers to the individual) When you say you become anxious, explain to me what it

feels like to feel anxious to you. 4. Interpretation: (helps the patient identify relationships between facts and experiences) How does your sensitivity to criticism play out with

your husband? 5. Application: (asks the individual to apply previously mastered skills to a new situation) How can you use what you learned with your boss

in your discussion with your son? 6. Analysis: (requires breaking a problem into a number of parts) What evidence do you have to support this conclusion? 7. Evaluation: (asks the individual to make decisions/judgments based on data) On a scale of 0 to 10, where would you rate your level of

anxiety today? And how does that compare to 4 months ago?

There are basically seven types of questions involved in the SD: memory, translation, interpretation, application, analysis, synthesis, and evaluation. It is a series of well-placed questions that literally guide the patient to the expected response, rather than simply pointing out the answer to the individual. It is a much more powerful technique to have the individual find the answer for themselves than to direct the individual. Table 8.2 describes the types of questions used in the SD method of therapeutic interaction (Freeman, 2005).

Table 8.3 illustrates the basic rules for SD adapted from Freeman (2005) used in conjunction with the types of questions described on the following page.

DOWNWARD ARROW

This technique was first used by Beck in 1979 to refer to the technique of logical sequencing of reasoning. The individual is helped to uncover underlying assumptions in logic and sequence through careful questioning by the therapist asking, “If this is true, then what happens?” For example, Mrs. Jones, a successful attorney, was concerned that a staff member she was having problems with would undermine her practice if she terminated her even though she and this woman had not been able to work out their differences for months. The APPN asked her what specifically would happen if she fired Jane.

Mrs. Jones: She would bad mouth me to her friends at the courthouse and that would give me a bad name! Therapist: And how would that affect your practice?

Mrs. Jones: Everyone would believe her and I have a lot of clients that work at the courthouse! Therapist: And how many of those clients do you have at the courthouse?

Mrs. Jones [thinking]: I guess about 15. Therapist: And how many clients do you have in your practice?

Mrs. Jones: About 250. Therapist: And how many of the 15 at the courthouse would believe Jane and drop you?

Mrs. Jones [laughing]: Okay, about 2 or 3 maybe. Therapist: So, if you fired Jane, 2 or 3 clients out of 250 would possibly drop you.

Mrs. Jones: Yes, I guess I do this all the time! I’ve been making myself nuts over nothing!

IDIOSYNCRATIC MEANING

The therapist assists the patient to clarify statements and terms used so that both the therapist and the patient have a clear understanding of perceived reality.

For example, Mr. Smith says, “When she makes those little faces it just puts me out! You know what I mean.” Therapist: “No, I don’t know what you mean. Please explain what you mean by ‘puts you out’.”

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TABLE 8.3 Socratic Dialogue Basic Rules 1. The techniques are embedded in the collaborative dialogue and are goal directed and specific. 2. The therapist has a problem list that generates the plan of direction that begins the SD process. SD is not a series of drifting questions that

“follow the patient.” Each question must be strategically placed in order to reach the predefined goal. This is where the concept of “guided discovery” comes from for the therapeutic interaction.

3. The questions must be short, focused, and targeted. For example, “Do you experience difficulty agreeing with your husband?” “Is this similar to interactions with others?” “How does this play itself out in this situation?” “Can you think of another way to respond that may result in a less defensive response from him?”

4. The questions must progress in a manner that keeps anxiety at a minimum for the individual. 5. The SD questions should be framed in a way to elicit an affirmative response. For example, to a reluctant individual: “There are probably a

lot of places you would rather be than here, right?” 6. The additional point to the above is that negative responses to questions mean that the therapist must reframe the question to gain an

affirmative response. “Is it your idea to come to therapy today?” “No! I don’t want to be here!” “There are probably a lot of things you would rather be doing today than sitting here.” “Yeah! That’s for sure!”

7. The therapist must monitor the patient’s reactions and moods on an ongoing basis. If a question increases a reaction, the therapist needs to address it immediately. “What just happened—I noticed a reaction—what was that?”

8. The therapist must pace the questions to suit the individual’s mood, style, and content of information. 9. The questions must be planned and in logical sequence. The therapist must have an internal map for the session and move the session in a

planned direction toward the desired goal. 10. The therapist must be careful to self-monitor and not “jump in” to offer interpretations or solve the patient’s problems. This is not only

more respectful to the patient but it also allows for greater clarity. 11. Self-disclosure should be extremely limited and only used with extreme caution and great care as to the motive for the disclosure.

Comparing what the therapist did or does with what the patient did or does moves away from SD into discussion and possibly misjudgment.

12. The therapist may use everyday experiences as therapeutic metaphors. For example, this author uses Aesop’s Fables and other well-known story characters to make a point such as “sour grapes” that can elicit both content and affect.

TABLE 8.4 Cognitive Distortions All or nothing I’m either a success or a failure.

Mind reading They probably think that I’m incompetent.

Emotional reasoning Because I feel inadequate, I am inadequate.

Personalization That comment must have been directed toward me.

Global labeling Everything I do turns out wrong.

Catastrophizing If I go to the party, there will be terrible consequences.

Should statements I should visit my family every time they want me to.

Overgeneralization Everything always goes wrong for me.

Control fallacies If I’m not in complete control all the time, I will go out of control.

Comparing I am not as competent as my coworkers or supervisors.

Heaven’s reward If I do everything perfectly here, I will be rewarded later.

Disqualifying the positive This success experience was only a fluke. The compliment was false.

Perfectionism I must do this perfectly or I will be criticized and be a failure.

Time tripping I screwed up my past and now I must be vigilant to secure my future.

Objectifying the subjective I have this belief that I must be funny to be liked, so it is fact.

Selective abstraction All of the good men are taken or gay.

Externalization of self-worth My worth is dependent on what others think of me.

Fallacy of the change of others You should change your behavior because I want you to and it will immediately make me happier/feel better.

Fallacy of worrying If I worry about it enough, it will be resolved.

Ostrich technique If I ignore it, maybe it will go away.

Unrealistic expectations I must be the best absolutely all of the time.

Filtering I must focus on the negative details while I ignore and filter out all the positive aspects of a situation.

Being right I must prove that I am right as being wrong is unthinkable.

Fallacy of attachment I can’t live without a partner. If I was in a relationship, all of my problems would be solved.

Fallacy of perfect effect If I do things perfectly, the results will be perfect.

LABELING OF DISTORTIONS

Individuals are helped to identify automatic thoughts that are “dysfunctional or irrational” as a type of self- monitoring for more accurate descriptives.

See Table 8.4 for examples of CDs. Patients are initially asked to choose four or five of their “favorite” CDs in their first session and to bring this information to the next session. This information is then integrated into future sessions as educational material as it is noticed in the patient’s verbalizations and/or written information. The patient is stopped and asked to “notice” what he or she has said (thought) and encouraged to reframe the information.

Other examples of distorted automatic thoughts are also “caught” and similarly restructured as needed.

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QUESTIONING THE EVIDENCE

This technique assists the individual in questioning the facts related to their cognitions and conclusions. This procedure investigates whether their information is based on facts or assumptions. For example, Mr. Hanson has been struggling with intimacy issues with his wife and reported that they had “finally” had sexual intercourse after 2 years of abstinence. He was very happy that this had occurred but was upset because he was sure she was not satisfied with the experience. The therapist stopped him at this point and asked him for his evidence to this fact. He said he just “knew.” The therapist did not let this statement stand as evidence and helped Mr. Hanson review the basis for his conclusion. After the review, Mr. Hanson reported that his wife had said that she was happy and felt “good.” The therapist said “So you think she lied to you?” Mr. Hanson said “No.” The therapist said, “Well either she lied to you or she felt happy, which do you think was true?” Mr. Hanson replied, “I guess she was happy.” He then smiled.

EXAMINING OPTIONS AND ALTERNATIVES

This technique involves the development of all possible alternative explanations in order to learn the skills in generating options rather than “only one way” thinking. For example Mrs. Umber was going to visit her son and daughter-in-law whom she did not get along with very well. She said, “I just can’t stand the idea of spending a whole week with them!” The therapist said, “How did you choose to spend the entire week?” Mrs. Umber said, “Well it is clear out on the coast so if we are going clear out there it doesn’t make sense to only go for a weekend.” The therapist said, “What are your options?” Mrs. Umber replied, “I am not sure what you mean.” “You are going to the coast for a week; do you have to spend the entire week with your son?” “I hadn’t thought about that,” said Mrs. Umber, “I guess I don’t, do I!” With that revelation she began to explore the possibilities of shortening her visit with her son and instead having a brief vacation with her husband in addition to the visit with her son.

REATTRIBUTION

In individuals with the habit of accepting all or most of the blame for outcomes, this is an excellent technique for redistribution of responsibility. This is also helpful for individuals with personality disorders that place the blame squarely on the shoulders of others for most outcomes. Mrs. White: “I can’t believe he left me! I am such a loser!” Therapist: “You were married to him for 22 years and he had five affairs that you knew of. You yourself said that you were more there for him than any other woman would have been. How is that being a loser?” “I know, I just feel like a loser!” Therapist: “What was his part in this break up?” Mrs. White: “I guess he had some of it, but maybe if I wasn’t such a loser he wouldn’t have had all of those affairs.” Mrs. White has a way to go here but she has opened the door to the possibility that her husband played a part in the ending of her marriage. The therapist can now work with her in identifying the component parts of her husband’s responsibility and hers.

DECATASTROPHIZING

Catastrophic thinking is one of the hallmarks of anxious individuals. These individuals tend to focus on the most negative possible outcome of any given situation. Decatastrophizing allows for balance and realistic focusing by examining the “worst possible outcome” and developing a plan of action. For example, a young woman complains that she can’t sleep.

Women: I haven’t been able to sleep for 2 months! If I can’t get some sleep I won’t be able to stand it! I can’t live like this! Therapist: Take a deep breath and tell me what is the worst thing that would happen if you can’t sleep.

Woman: I can’t live like this! Therapist: But what would happen if you continue to not sleep?

Woman: I would walk around like a zombie! Therapist: Have you been to your doctor for sleeping medication?

Woman: No! I am worried I would get addicted! Therapist: What would be worse, not sleeping or getting addicted?

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Woman: Not sleeping. Therapist: Do you think your doctor would let you get addicted?

Woman: No, she has known me for years. She is really careful. Therapist: Would you let me call from here and get you an appointment today for an evaluation for medication?

Woman: Yes. I guess I am really overreacting because I am so tired!

ADVANTAGES AND DISADVANTAGES

For individuals who appear to be stuck between two options, examination of the advantages and disadvantages of certain situations helps them to develop alternative perspectives. This breaks the “all-or-nothing” mindset and permits a more balanced view of the situation. For example, Mr. Black is wondering whether or not to accept a promotion at work that means more money but more travel and time away from his family. The therapist may help him outline a list of advantages and disadvantages in a cost–benefit analysis similar to what he may do at his job that looks familiar to him so that he can “weigh” out his choices by placing points next to each choice and then total the categories to help him decide.

PARADOX OR EXAGGERATION

This type of technique should only be used by the very skilled therapist; otherwise the patient may view this technique as sarcasm or belittling. When used appropriately, the therapist takes an issue to the extreme to help the person see the absurdity of their sometimes overinflated viewpoints. One therapist had been working with a couple for a number of months. The couple had originally come in with issues related to his obsessive– compulsive tendencies for neatness and her tendency to be a free spirit. They had reached a number of compromises and were now very happy. At one point in the session they were talking about putting in a garden area and were having difficulty deciding how to organize the arrangements. The therapist said to the couple: “Oh my goodness! He wants the plants in rows and to be neat and orderly! Where on earth would he get an idea like that?” The couple realizing that this exactly matched his style immediately started laughing.

TURNING ADVERSITY TO ADVANTAGE

This technique is akin to making lemonade out of lemons. The individual is helped to identify how to use what appears to be a negative situation to his or her advantage. For example, being turned down for a job may open the individual up for more attractive possibilities that had not been investigated previously.

COGNITIVE REHEARSAL

Prior to making a behavioral change, it is sometimes less threatening to “practice” the new behavior through visualization and discussion. For example, this would include practicing assertiveness in a mirror or “talking through” a confrontation out loud prior to actually following through with the conversation.

AUTOMATIC THOUGHT RECORDS

The automatic thought record is a key component of CBT. The record was first introduced by Beck in 1979 to capture and analyze automatic thoughts both during and between sessions (Beck, Rush, Shaw, & Emery, 1979). The automatic thought record is used as homework after introducing the process within the therapy session. The individual completes the columns, identifying a troubling situation, resulting emotion, and thoughts associated with both. The therapist and patient work on clarification and development of “rational” responses in order to debate or challenge the original reaction. When practiced and repeated, the process of clarification and debate becomes internalized in the individual. See Appendix 8.1 for a copy of a form for an automatic thought record.

THOUGHT STOPPING

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This is one of the simpler techniques in CBT. Basically the patient interrupts his or her stream of thought with a sudden stimulus such as snapping a rubber band on the wrist, saying “Stop it!” out loud, or some other real or imagined stimulus and then changes his or her stream of thought. The technique is most credible when demonstrated to the patient in session and then assigned as homework. Once a patient is given a loud stimulus in a session, such as “Stop it!” and then allowed to regain composure and report what his or her thought pattern is after the stimulus, the person realizes that this simple technique is very effective.

COGNITIVE RESTRUCTURING

The process of cognitive restructuring refers to the use of an automatic thought record combined with other cognitive techniques to effect changes in negative thinking patterns. The patient is asked to check in a few times a day at random times and write down what he or she is thinking. After keeping the automatic thought record for a week, the therapist and patient review the log and underline which thoughts are negative and identify the CDs the patient uses (see Table 8.4). Then the patient is asked to say the negative thoughts aloud to enhance awareness and to slow them down and say out loud to himself or herself the targeted negative messages whenever they occur during the next week. A list is then generated with the patient that counters those distortions. For example, one patient who was anxious about going to an upcoming social event became aware that her negative thoughts reflected her poor self-esteem: “I will have a terrible time since nobody likes me.” The positive comment developed to counter this was: “People usually like me.” The patient was asked that whenever she found herself thinking the negative thought in the next week that she practice thought stopping and substitute her positive statement from her list of positive statements that she carried with her. See Table 8.5 for steps in cognitive restructuring.

TABLE 8.5 Steps in Cognitive Restructuring 1. Tune in…keep a thought diary 2. Focus on the words that are unhealthy 3. Stop the messages 4. Change the negative to positive

BEHAVIORAL TECHNIQUES

Assertiveness Training

Assertiveness training involves a combination of cognitive and behavioral practice. Prior to beginning an assertiveness training program, the advanced practice registered nurse (APRN) therapist needs to define the terms “assertive, aggressive, and passive.” For example, a person who is demanding, blunt, and self-righteous may perceive his or her behavior as assertive when in fact it is aggressive. In this type of a situation, the therapy starts by educating the individual in the importance of modifying the confrontational style. Most individuals with depressive disorders tend to exhibit more passive behaviors and would require education on assertiveness as opposed to aggressiveness in order to make the idea of assertive changes more appealing. The therapist may, for example, model assertive behavior, assist the patient within the session with role-play, and finally develop in vivo experiments that increase in complexity over time until the new behavior is internalized. A basic textbook for patients with assertiveness issues is Mind Over Mood: Change How You Feel by Changing the Way You Think by Dennis Greenberger and Christine Padesky (1995). It is an excellent general workbook and reviews CBT techniques with helpful homework examples and information.

Behavioral Rehearsal

The behavioral component usually follows the cognitive training component and again includes behavioral experiments to gather more evidence or to develop more effective responses and styles. Rehearsal is usually practiced first in the therapy session itself often with role playing and then as often as possible outside of the session. The person then reports back in the following session for modification of the behavior if necessary.

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For example, Kevin, a 15-year-old male, often gets into arguments with his 6-year-old brother, Galen. The arguments usually stem from Galen “getting into my stuff” according to Kevin. After exploring the purpose of Galen’s behavior (obtaining attention from Kevin), Kevin was encouraged to increase positive exchanges when Galen was not expecting it. This was practiced in session until Kevin felt comfortable with the modified exchanges. Initially Kevin stated, “I can’t do that, I’d feel dumb being nice to him! He’s a kid!” In order to help Kevin feel more comfortable with specific things to say and do, the therapist and Kevin explored possible exchanges and then put them into “play” in the therapy setting. The rehearsal repeated until Kevin reported, “Okay, I can do that—that’s cool.” In situations where the APRN is assisting the individual using this technique, it is important to evaluate for safety as well as understanding of behavioral boundaries. In the example above, the therapist would problem solve possible outcomes to prepare Kevin for responses as well as set boundaries with him regarding potential aggressive interchanges.

Contingency Management

Contingency management is based on the systematic application of generally accepted principals of human behavior. An undesirable behavior is more likely to recur if it is immediately followed by some kind of reinforcer that is pleasurable (positive reinforcement). Positive reinforcers or rewards are more effective at changing behaviors than punishment (aversive reinforcement). An example of an aversive stimulus is punishing the child who does not behave. Negative reinforcers are those that increase the probability that a behavior will recur by removal of an undesirable reinforcing stimulus. For example, if the child behaves, the child does not get scolded. The use of contingency management is very useful for individuals with self- control problems because it provides a self-motivator for internal motivation of control. It generalizes well, which means it can be used in a variety of setting such as home, school, work, and social settings.

For example, in substance misuse settings, reinforcement is usually in the form of vouchers exchangeable in the form of groceries or other goods, services such as self-care, transportation, or health care, and sometimes local retail services. The reinforcers target abstinence behaviors such as attendance, adherence to treatment goals, compliance with medication, participation in therapy, abstinence from substances, and completion of therapy. It is important to evaluate the value of the reinforcer to the individual. The likelihood of the reward effectiveness increases with the perceived value of the reward. Lamb and colleagues discovered that higher payment amounts and the easier target criterion resulted in a higher likelihood of participants meeting the criterion (Lamb et al., 2004).

A contingency contract is a more formalized written agreement that is developed in collaboration with the person and/or significant other in order to explicitly state the positive and negative reinforcers for performing the desired behavior as well as aversive reinforcers for failure to perform the behavior. Suitable targets are those behaviors that are observable. See Table 8.6 for a checklist to assist the therapist in developing a contingency contract. The steps below should be sequential because if secondary gains are not identified (see Item 4), the individual will not be able to accomplish the desired behavior. Often, secondary gains are unconscious and should be explored with the patient prior to beginning the subsequent steps.

TABLE 8.6 Checklist of Patient Outcomes for Contingency Contract 1. Identify target behavior 2. Explore reasons for behavior 3. Verbalize knowledge of consequences of behavior 4. Identify secondary gains from behavior, i.e., attention 5. Keep diary of when problem behavior occurs 6. Keep log of sequence and pattern of behavior (who, what, when, how, and why) 7. Identify feelings that precede and follow behavior 8. Keep diary of behavior and feelings 9. Identify alternatives to behavior

10. Write conditions under which desired behavior will occur and how behavior will be observed and measured 11. Select positive reinforcers, i.e., weight loss and rewards 12. Select aversive consequences for failure of desired behavior, i.e., chores 13. Carry out plan for one week 14. Practice desired behavior, step by step 15. Keep diary of practice 16. Involve family/friends in feedback/encouragement 17. Identify other positive aspects associated with changed behavior 18. Monitor ongoing weekly progress Reprinted from Dykes and Wheeler (1998).

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Bibliotherapy

The CBT therapist will often prescribe specific readings related to the individual’s difficulties. Readings and references can be given to the patient of the many CBT-based self-help books as an adjunct to in-session work. A full list of readings and CBT-based self-help books can be found on the Academy of Cognitive Therapy website at www.academyofct.org. The website is updated regularly to include the most relevant and up-to-date titles for both clinicians and patients.

Guided Relaxation and Meditation

Therapists often employ behavioral techniques aimed at reduction of autonomic nervous system responses to anxiety. These include deep breathing, relaxation training, meditation, and other exercises. These techniques help the individual to distract oneself from the upsetting thoughts, increase awareness of conscious control over breathing, heart rate, and other anxiety symptoms and thoughts. The individual may be assisted in “overbreathing” as a way to demonstrate control over “hyperventilation.” This technique should be used only by the experienced therapist. One very brief relaxation exercise is to have the patient breathe in deeply for 5 seconds, breathe out for 5 seconds while saying: “Relax … relax … relax” in a soothing tone. I recommend that patients practice this easy exercise a minimum of 10 times daily until they find they are able to do it almost automatically.

Social Skills Training

These skills are often taken for granted by many individuals. It is therefore important for the therapist to review and instruct on behaviors that will improve the potential for successful social interactions. For example, a therapist may notice that the patient looks at the floor or the ceiling during their conversation or when introducing themselves. The therapist may make use of this information by role-playing skills such as maintaining eye contact during an interview, shaking hands assertively, developing techniques for self- expression, and conveying opinions as well as overt changes such as appropriate language in public.

Shame-Attacking Exercises

This technique was first introduced by Albert Ellis, the father of rational emotive therapy (RET). In this type of therapy, the therapist engages the individual in exercises that emphasize his or her concern for what others think of him or her. For example, a person who is afraid of drinking soup in public may be assigned the task of going to a restaurant with a friend, ordering soup, and drinking it loudly while the friend makes note of how many people are really interested in what they are doing. They would then have their friend share the notes on the actual responses of the other diners as a way to disarm the person’s irrational belief that others are looking at him or her eat, slurp, and so on.

Homework

The hallmark behavioral technique in CBT is the use of homework assignments. Activities, some of which have been described above, are designed within the therapy session to be carried outside and practiced in between sessions. The self-help designed assignments reinforce and continue what has been learned and addressed within the therapy framework. This results in a truly collaborative process between the patient and the therapist. For example, the therapist may develop a homework plan for deep-breathing exercise practice, role-play practice on how to act in a certain social situations or in cases of alcohol misuse, practice ways to decline an alcoholic beverage. New, redeveloped, or revised rational responses are practiced until they replace previous, unhealthy responses. Homework also allows individuals to “try on” and experiment

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with new skills in order to give feedback to the therapist on which techniques work and which do not work. Techniques that do not work can then be modified or discarded as needed.

Psychoeducation

Psychoeducation is an integral component of all CBT techniques. In CBT, the educational component is skillfully interwoven within the specific therapeutic techniques that the therapist is choosing and supplemented with bibliotherapy if that is appropriate. For example, a couple came for marital therapy following the husband’s serial episodes of infidelity. The husband was not sure about whether to remain in the marriage or to leave his wife and two teenage sons so that he could continue to have serial affairs without guilt and restrictions. The therapist assigned two specific books to read: After the Affair by Janis Abrahms Spring (1997) and Not Just Friends by Shirley Glass (2003). In addition, the therapist used the SD to guide the husband through a cost–benefit analysis of each choice making sure to help him focus on the realities of the cost and benefit to the decision to leave versus the decision to stay. After completing the cost–benefit list, the therapist pointed out that he had not identified any costs to his sons as far as lessons learned from him about how men treat women and families with respect to responsibility (education). The next step was to help the patient self-identify that he had missed this component and discuss how he might be teaching his sons lessons that are unhealthy and explore his thoughts about this consequence. The focus on consequences became a focus of his therapy, not as a “blaming session” but a moment of education and self-identification of behavioral consequences of actions.

MODIFICATIONS OF CBT

Schema Therapy

Schemas develop early in life based on an individual’s experiences with others and their environment. Schemas are fundamental core beliefs or assumptions and are part of the perceptual filter people use to view the world. People are guided by templates, or schemas, through every action, reaction, and interaction based on their own developmental, personal, religious, familial, cultural, gender, and age-related experiences (Beck, Freeman, & Associates, 1990; Beck, Freeman, Davis, & Associates, 2003; Beck et al., 1979; Freeman & Freeman, 2005). Schemas are in a constant state of change and adaptation and become increasingly complex as one ages. Although schemas are alterable, the process of accommodation and adaptation may serve to help or hinder the individual when he or she applies the schema to new situations or functions that come his or her way. For example, those with an abandonment/instability schema would be plagued by thoughts about the unreliability of those available for support and connection and may have borderline personality traits while those with a social/isolation/alienation schema would have thoughts of being different from the rest of the world and might suffer from schizoid traits. Schemas are selected for recall or activated from memory and are used for interpretation of information, generation of affect, motivation, and action, and/or control (Beck et al., 1990; Freeman & Freeman, 2005). Understanding an individual’s schemas, belief systems, and underlying attitudes is essential in understanding the individual (Freeman & Freeman, 2005). See Table 8.7 for maladaptive schemas.

TABLE 8.7 Maladaptive Schemas

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Young proposed that early schemas are more resistant to change than schemas that develop later in life (Young, 1991). He identified these schemas as Early Maladaptive Schemas. According to Young: “In comparison with standard cognitive therapy, schema therapy probes more deeply into the childhood origins of distorted thinking, relies more on imagery and emotion-focused techniques, and is somewhat longer-term” and is often combined with traditional cognitive therapy (Young, Klosko, & Weishaar, 2003). For example, Young uses the CBT technique for identifying whether the patient is using an emotion that is adaptive or maladaptive to guide the patient’s decision making and cognitive processing and then assists to facilitate the identification of beliefs that block the process of change. Images are powerful forms of cognitions and long before we develop language, we develop memory encoded as pictures or images. Schema therapy is, and has been, a critical component of classical CBT.

Young uses many of the CBT techniques of guided imagery, imagery rescripting, imagery substitution, or even cognitive restructuring of images to reframe the view of an image to something more positive, less distressing, or even useful for a patient. See the website www.schematherapy.com for more information.

Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) is a multimodal cognitive behavioral treatment developed by Dr. Marsha M. Linehan to work with subgroups of those diagnosed with borderline personality disorder (BPD), specifically those who abuse substances (Linehan, Tutek, Heard, & Armstrong, 1994). DBT works very well in the subset of Cluster B personality disordered patients, which includes those viewed as dramatic– emotional such as antisocial, borderline, histrionic, and narcissistic individuals (Linehan, Heard, & Armstrong, 1993). DBT has recently been modified for those who have both BPD and eating disorders (ED) (Linehan & Chen, 2005). Please see Chapter 14.

COGNITIVE TECHNIQUES FOR PROCESSING

Evidence-based CBT interventions for processing include those that involve exposure components through flooding, prolonged exposure, in vivo exposure, directed exposure, interoceptive exposure, and imaginal exposure. Exposure involves confrontation with the feared stimulus with prolonged excitation of the fear response until habituation and then extinction of the fear response in the presence of the trigger when it

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occurs. Deciding which exposure component to use depends on the person’s presenting problem as various methods for exposure have been developed. If the person suffers from panic anxiety, interoceptive exposure should be considered. This involves exercises such as stair stepping and head shaking that bring on panic-like symptoms. If the person does not suffer from panic, imaginal exposure through writing or talking about the trauma is appropriate.

Exposure or prolonged exposure involves the ongoing systematic activation of the fear response until extinction or desensitization occurs. The process may involve specific or nonspecific environmental cues in reality (in vivo) or through imaging. It can be likened to watching a scary movie over and over again until it no longer creates hyperarousal and fear. For example, when an individual experiences fear of an object, he or she tends to avoid it. Avoidance or escape from the phobic object results in a temporary reduction in anxiety. As a result the individual’s coping choice is reinforced through negative reinforcement. In prolonged exposure, the therapist uses a process of systematically desensitizing the individual to the avoidance pattern by gradually exposing the individual to the phobic object (either virtually or actually) until it can be tolerated without disabling anxiety.

Prior to beginning the desensitization process, the therapist and the individual explore alternative cognitive strategies such as distraction to cope with anxiety. This helps the individual build a set of tools to control fear. After the individual has mastered alternative responses, he or she is gradually exposed to the feared object. Someone who has a fear of contamination, for example, would be assisted in developing a fear hierarchy with individual situations rated on a scale of “10” (worst possible exposure) to “1” (very limited exposure). The therapist and the individual practice with increasingly unpleasant situations: a sink at a public restroom to a visibly contaminated or a smelly outhouse, for example. At each step in the progression, the patient is desensitized to the fear through the use of the coping technique. The person realizes that nothing bad happens to him or her, and the fear gradually extinguishes. For example, a person with a fear of attending classes may begin with driving around the school, then gradually moving up to touring a classroom both empty and filled, before actually signing up for and attending a class.

The patient is guided through mastery of relaxation sessions and then gradual mastery of each level of the hierarchy until he or she is ready to master the actual situation in vivo. For example, a psychologist, Dr. J, came to treatment for an inability to drive over bridges without significant anxiety after suffering a seizure while he was driving several friends in the car. Six months previously he had been diagnosed with a brain tumor after suffering a seizure. Dr. J had surgery and the tumor was removed without complications and he had not needed radiation or chemotherapy. He was now on anticonvulsant medication and reported that his surgeon felt he had a good prognosis and suffered no residual neurological deficits. See Table 8.8 for the hierarchy constructed and how this was paired with relaxation and imagery.

TABLE 8.8 Hierarchy for Driving Fear of Bridges 1. Thinking about going in the car if he has to go across a bridge 2. Imagining driving across the bridge (pick a specific bridge) 3. Getting into the car with the idea you are going driving 4. Drive the car for about 2 to 3 minutes with image of the bridge 5. Riding in the car to a bridge with a friend driving, do not drive over the bridge 6. Riding in the car with a friend driving and going over a small bridge 7. Driving the car with a friend and getting off the exit before the small bridge 8. Driving the car with a friend and going across the small bridge 9. Driving the car alone and going across the small bridge

10. Driving the car alone and going over a slightly larger bridge 11. Repeat with larger bridges

After constructing this hierarchy, Dr. J practiced deep-breathing exercises in sessions guided by the therapist along with a safe-place exercise (see Appendix 1.7 for safe-place exercise). He was asked to practice these exercises at home during the week every day for 15 to 20 minutes. At his next session, he was asked to visualize himself at 1 in his hierarchy of fears, thinking about going in a car over a bridge with as much vividness and detail as possible, as if he was “right there” but imaging himself as confident and calm, dealing with the situation as he would like to. He was asked to stay with the fear thought for about 1 minute and then was asked to rate his anxiety on a 1 to 10 scale with 10 being the worst and he responded that it was a 2. He was then asked to repeat a calming affirmation “I am calm and at ease” while picturing himself handling the situation in a calm and confident manner while deep breathing. Returning again to Item 1 on his hierarchy, he was now able to proceed and was asked to spend about a minute in his safe place scene so that he could get fully relaxed. Then 2 was imaged in the same way, repeating the fear and alternating with the safe place (about a minute each). If the client experiences greater than a 4 on a 0 to 10 scale with the fear, he or she should stay

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in the image for only 10 seconds and retreat to the safe place until he or she is relaxed. Continue guiding the client step by step in imagination from the safe place to the fear. It may be necessary to add another step that is intermediate if the client has difficulty proceeding. The person should be comfortable with the previous step before going onto the next one. The APRN must remain sensitive to the individual’s response pattern in order to prevent traumatization or increasing anxiety. Dr. J was able to work through this exercise and could then transfer this learning in vivo.

APPLICATION OF CBT TO COMMON PSYCHIATRIC DISORDERS

CBT has been applied and developed for specific problems and populations such as depression, anxiety, personality disorders, and substance misuse patients.

Cognitive Model for Depression

The cognitive model of depression emphasizes the cognitive triad to illustrate depression generation and maintenance. The premise is that individuals develop and then maintain a negative self-view, and this attitude extends to the world, their experiences, and on into the future. As a result they perceive themselves as worthless, abandoned, and inadequate. As depression takes hold, the individual feels overwhelmed with demands and seemingly impenetrable barriers, preventing the individual from realizing his or her goals. The world takes on a gray cast devoid of pleasure and is viewed pessimistically.

CBT focuses on altering the person’s view of himself or herself, the situation, and the resources around him or her (Shaw, 1977). Therapy is structured, active, and reality based as well as time limited. The individual is taught to take certain specific steps to combat his or her depressive views. These steps include identifying and monitoring automatic thoughts, critical examination of evidence, substitution of objective interpretations for their automatic negative attributes, and recognizing connections between thoughts and feelings.

For those who have been traumatized, numerous negative cognitions may be present, particularly those who have suffered from interpersonal violence. These include thoughts about self-blame, guilt, shame, low self-esteem, danger, defectiveness, and unworthiness (Briere & Scott, 2006). It is important that the client is able to describe his or her thoughts and perceptions related to the trauma. This can be accomplished through the narrative as well as through journaling about the event. The journaling can be assigned as homework occasionally during the course of therapy so that the client writes about a specific topic, recalling in as much detail as possible the event. The person is then asked to read it aloud to the therapist the following week. Using the Socratic method described above, the APPN can ask open-ended questions that allow the client to examine his or her interpretations about the experience. Briere and Scott list typical questions that might include:

“Did you have any thoughts while it (the traumatic event) was happening? What were they?” “Given, the situation, do you think there was anything else you could have done?” “So, that made you feel that you were to blame/responsible/bad/stupid/seductive. Can we go over what happened and see what made you think that?” “Did you want him/her/them to rape/beat/abuse/hurt you? Do you remember ever wanting that?” “You say that you were hurt/raped/beaten because you asked for it/were deductive/didn’t lock the door/were out late. Can we go over the evidence for that conclusion? Maybe it’s more complicated than that?” “If this happened to someone else, would you come to the same conclusion?” “It sounds like you believe what he/she said about that. Was he/she a person you would believe when he/she said something?” “Why do you think he/she did that? Did he/she get anything out of it?”

(Briere & Scott, 2006, pp. 112–113)

Through the use of brain imaging techniques, researchers have discovered that cerebral blood flow in specific

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brain areas responded with equal vigor to both CBT treatment and pharmacologic treatments for both depression and anxiety disorders (Furmark, Tillfors, & Marteinsdottir, 2002; Goldapple et al., 2004; Nakatani et al., 2003; Paquette et al., 2003).

Cognitive Model for Anxiety

Anxiety is actually an adaptive survival strategy. When the body experiences or perceives a threat to survival, it prepares for flight, fight, or fleeing through activation of the autonomic nervous system. The nervous system activation is experienced as increased heartbeat, muscle tension, increased blood flow, and diaphoresis (to cool the body). If there is an actual threat, the individual is prepared to respond adaptively. If there is no threat, the individual interprets the symptoms as anxiety with the accompanying psychological response called “fear.” Anxiety symptoms that seem to come out of nowhere cause the individual to fear the onset of this uncomfortable experience. The individual scans the environment and may or may not locate something to attribute to the symptom activation. As more and more attributions of threat occur (e.g., bridge, heights, and public speaking), the person becomes more and more alert to potential activation. This sets the person up for a “fear of fear” response. The anxious individual distorts innocuous events, exaggerates the potential for harm, and develops behaviors that interfere with adaptive coping strategies. As the cycle increases in velocity, the individual believes that he or she is unable to cope and is therefore helpless against the anxiety symptoms. The best illustration of the efficacy of CBT for anxiety comes from the work of Barlow and Clark on the treatment of panic disorders (Barlow & Cerney, 1988; Clark, 1986; Clark, Salkovskis, & Hackmann, 1994). They observed the constellation of cognitive symptoms that team with behavioral symptoms to create a panic reaction/response in an individual. Through extensive research, they demonstrated that combining cognitive techniques to modify fearful cognitions along with specific behavioral approaches reduced or eliminated the panic response/reaction in most individuals (Barlow & Cerney, 1988; Clark, 1986; Clark et al., 1994).

Cognitive Model for Personality Disorder

One of the hallmark treatments of personality disorders is CBT. Cognitive theorists and psychoanalysts have both agreed that it is imperative to identify and then modify “core” problems when treating individuals with personality disorders. The difference between the two theories lies in the perspective of the structure of personality disorder. Psychoanalysis believes that the structures are unconscious and therefore are mostly unavailable to the individual while the cognitive theories believe that the products and processes are within the realm of awareness and therefore more accessible. Dysfunctional behaviors, thoughts, and feelings, according to cognitive theory, are in large part due to the function of certain schemas (rules or patterns we have developed for living). These schemas consistently bias our judgments and create a tendency to skew our views, creating situations in which we tend to make cognitive errors and draw faulty conclusions (Beck et al., 2003; Freeman, Davis, & DiTomasso, 1992).

It is rare that an individual presents for treatment of his or her personality disorder. Instead the individual usually comes into treatment at the behest of some significant other or other external pressure. The individual may also come in for treatment of a secondary result of the outcomes of his or her behavior patterns such as depression, relationship difficulties, anxiety problems, or other issues. Often these individuals will see their problems as independent of their own behavior and describe themselves as victims with little to no idea as to how they got into these difficulties, how they contribute to their problems, and/or how to change. Others in their lives are well aware of the self-defeating elements of their behaviors (such as overdependence, lack of empathy, self-centeredness, inhibition, and drama) and may express frustration, dismay, or even incredulousness that the individuals do not see it themselves (Beck et al., 2003; Freeman et al., 1992). For additional information on this very interesting topic, the readers are referred to the current leading resource on the subject (Beck, Freeman, Davis, & Associates, 2003).

Cognitive Model for Substance Misuse

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The community reinforcement approach (CRA) has been developed for use with patients who abuse substances. Contingency management is a key component and interventions include social, recreational, familial, and vocational reinforcers in order to help the person through the process of abstinence and maintenance. Additional components in CRA include (1) functional analysis of substance use, (2) social and recreational counseling, (3) employment counseling, (4) drug refusal training, (5) relaxation training, (6) behavioral skills training, and (7) reciprocal relationship counseling. The National Institutes of Drug Addiction Therapy Manual recommends a reinforcement model that typically includes vouchers for behavioral outcomes such as clean urine drug screens, participation in treatment, and completion of the treatment program (www.drugabuse.gov/pdf/CRA.pdf). Vouchers are used as opposed to cash or saleable items to avoid triggering the individual’s craving response to cash (cash is usually associated with the ability to purchase substances). See Table 8.9 for therapist resources and websites for specific populations.

CASE EXAMPLE

Bethany is a 44-year-old woman who has been married for 20 years to her step-uncle who raised her after her parents died and is 40 years her senior. She has no children and works as an attorney. She described her parents as distant, paying minimal attention to her while she was growing up. Her mother and father died when she was 15 and the loss was considered “a surprise and shock.” She has one brother whom she describes as “distant” and seldom available to her. Her brother lives at a significant distance from her, making contact difficult. She has occasional affairs, but they are less frequent and less pleasurable than they used to be.

Bethany has had more than 10 years of treatment with medications as well as a variety of psychotherapeutic techniques for her self-reported depression and attention deficit disorder (ADD). Her Beck’s Depression Score at intake was 51 (out of 63 possible) and her Quick Inventory of Depression Symptomatology was 23 (out of 27 possible), both of which are in the severe range. She denied suicidal ideation or intent. There was no evidence of hallucinations, delusions, or cognitive impairment. She reported significant sleep problems with daytime somnolence. She stated that she used to be very productive, creative, and happy; however, she has not felt that way for a very long time. She was extremely tearful during the interview reporting feeling overwhelmed, hopeless, and exhausted. She felt extreme guilt that she had not been the kind of wife her husband deserved and wondered why he puts up with her. She was concerned she would lose her job due to her inability to concentrate and low productivity level. She felt unappreciated at work by her supervisor who told her she was the “least productive” member of the firm. Bethany stated that she had no energy, restless sleep, irritability, indecisiveness, and felt like a “total failure at life.” She has only one close female friend who has been unaware of her affairs.

Bethany is very attractive and maintains good physical condition (however, she does not verbalize satisfaction with her self) and experiences moderate to severe pain related to fibromyalgia and arthritis. Treatment included several long-and short-acting opiate pain relievers as well as gabapentin (an anticonvulsant used for neuropathic pain relief).

Her diagnosis from previous and current psychiatrists included major depression, recurrent, severe ADD, nonhyperactive type. Medication attempts had included more than 10 different antidepressants (all noneffective) as well as several stimulants for treatment of her ADD. Laboratory tests were ordered including thyroid function tests, liver and kidney function tests, B12 and folate levels, electrolytes, and a complete blood count.

TABLE 8.9 CBT Therapist Website Resources for Specific Populations Population Specific Approaches and Website References for Additional Information Addiction http://www.nida.nih.gov/TXManuals/CBT/CBT1.xhtml

Therapy Manuals for Drug Abuse: Manual 2: A Cognitive-Behavioral Approach: Treating Cocaine Addiction. The manual includes chapters detailing history of CBT, components of CBT, applications of CBT to cocaine dependent individuals, relapse prevention, follow-up, and empirical support for the use of CBT in treating substance dependence as well as measures to evaluate competence in therapists using CBT.

Depression http://www.psychologyinfo.com/depression/cognitive.htm Brief overview of treating depression by Psychology Information Online developed by Donald J. Franklin, PhD. Reviews the thoughts, feelings, and behaviors common to depressive diseases as well as the therapeutic interventions used in CBT to reverse the depressive cycle. Automatic thoughts are outlined as are specific ways to cope more effectively.

Child sexual abuse http://www.nrepp.samhsa.gov/viewintervention.aspx?id=135 Substance Abuse and Mental Health Services Administration Model Programs: Trauma Focused Cognitive Behavior Therapy Model Programs http://www.nrepp.samhsa.gov/viewintervention.aspx?id=135

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http://www.drugabuse.gov/pdf/CRA.pdf

http://www.nida.nih.gov/TXManuals/CBT/CBT1.xhtml

http://www.psychologyinfo.com/depression/cognitive.htm

http://www.nrepp.samhsa.gov/viewintervention.aspx?id=135

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Anxiety and social anxiety http://www.socialanxietyinstitute.org/ccbtherapy.xhtml http://www.anxietynetwork.com Dr. Thomas Richards, director of the Social Anxiety Institute, has posted several excellent monographs on treating anxiety disorders with CBT on his websites. He discusses the cognitive, behavioral, and physical components common to these disorders in easy to understand terms. The reader is “walked” through the guidelines of the CBT process of treatment and referred to additional resources.

Obsessive–compulsive disorder http://www.ocdonline.com/definecbt.php This website outlines the basic CBT treatment of obsessive–compulsive disorder. The explanation also includes a brief explanation of the integration of behavioral techniques used within the CBT framework to augment the total CBT therapeutic armament, thereby strengthening the overall treatment effect.

Eating disorders http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2928448 This website discusses CBT treatment of eating disorders, specifically self-image components, incorrect beliefs about the disorder, behavioral changes that the individual will be making (such as meal diaries), developing mastery over mood and other facets of their lives, and other very important components of the eating disorder spectrum. The outline also discusses expectations of treatment, length of treatment, relapse, and follow-up.

Chronic pain http://www.springerpub.com/prod.aspx?prod_id=45957 Cognitive Therapy With Chronic Pain Patients by Winterowd, Beck, & Gruener, Springer Publishing. http://www.guilford.com/cgi-bin/cartscript.cgi?page=pr/caudill.htm&dir=trade/self&cart_id=456893.3089 Managing Pain Before It Manages You by Margaret Caudill Both of these volumes are excellent adjuncts to the CBT clinician working with individuals with chronic pain conditions. They contain full explanations of the physiology of pain, the cognitions association with chronic pain as well as behaviors common to chronic pain sufferers. In addition they contain the techniques used in CBT to alter the thoughts, feelings, and behaviors that cripple chronic pain sufferers.

Schizophrenia http://www.psychologyinfo.com/schizophrenia/cognitive.htm There is a misconception that CBT cannot be used with persons who are “too dysfunctional.” This is incorrect. In fact, CBT is very effective with individuals who are cognitively impaired. The therapist simply uses a greater number of behavioral techniques in these cases. In cases with individuals with schizophrenia, the therapist is often working with the family members in addition to the patient. Dr. Donald Franklin has a very brief discussion on his website of this type of treatment.

General information Wright, Basco, and Thase (2006). Learning Cognitive-Behavior Therapy. American Psychiatric Publishing, Inc. Washington, DC http://en.wikipedia.org/wiki/Cognitive_behavior_therapy Online encyclopedia definition and description of CBT available at: www.appi.org/pdf/wright

The initial interview focused on eliciting her current impression of her problems,

her view of her treatment history, and underlying beliefs regarding both of these issues. It was important to determine the psychodynamic impact regarding her lack of improvement over the past decade in order to evaluate the effect this had on her expectations for change, hope for improvement, and impact on motivation for another type of intervention. Care was taken to create a timeline of symptoms both historically and temporally. Information was documented using her own words whenever possible. Patient-generated metaphor, life rules, and conclusions were noted regarding her perception of her illness and its impact on her function, cognition, and outlook.

For this patient, it was clear that several factors could be contributing to her depressive symptomatology. These factors are outlined below:

1. Chronic pain. It is well known that patients with chronic pain disorders are susceptible to depression due to feeling trapped in the pain, a lack of hope for improvement, and lack of sleep that disrupts normal sleep architecture. In addition, this patient was being treated with narcotic pain relievers at a significantly high dose. Narcotic pain relievers are notorious for problematic side effects that include somnolence, insomnia, and confusion. Somnolence and insomnia create severe lack of energy and motivation that can be mistaken as depressive symptoms.

2. Stimulant use for ADD. Stimulant use, prescribed or not, has known side effects that include nervousness, insomnia, depression, and drowsiness. These medications can fuel an already existing depression and add an anxious quality.

3. Chronic severe depression. The patient’s temporal course of severe depression would make it very likely that she would develop the negative cognitive set as described above. A person’s expectation of treatment failure is a significant predictor of treatment outcome. Her disappointment in previous psychotherapeutic interventions as well as pharmacologic interventions makes it likely that she does not trust that treatment, or treatment professionals, will be able to help her.

Formulation and Treatment Plan

The first step in any case formulation and treatment plan is an accurate diagnosis. The evaluation of Bethany’s symptoms included exploration of hypomanic episodes to rule out a cyclical mood disorder such as bipolar disorder. Two episodes of spending in excess that included reduced need for sleep were uncovered in the previous 12 years. Each of the episodes was memorable to Bethany but did not create a severe hardship on herself or her husband, thereby meeting the criteria for hypomania as opposed to mania. Given this information, it was determined that Bethany did not suffer from Major Depressive Disorder. Her diagnosis was changed to Bipolar II Disorder, which is not as amenable to traditional antidepressant therapies. It was

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http://www.anxietynetwork.com

http://www.ocdonline.com/definecbt.php

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2928448

http://www.springerpub.com/prod.aspx?prod_id=45957

http://www.guilford.com/cgi-bin/cartscript.cgi?page=pr/caudill.htm&dir=trade/self&cart_id=456893.3089

http://www.psychologyinfo.com/schizophrenia/cognitive.htm

http://en.wikipedia.org/wiki/Cognitive_behavior_therapy

http://www.appi.org/pdf/wright

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also determined that Bethany did not suffer from an Axis II Personality Disorder as determined through an assessment of function and behavior prior to the first depressive episode. Once the diagnosis was in place, a full medical and medication evaluation was completed using the patient report and documented medical information. It was determined that the medications previously prescribed for Bethany were negatively impacting her level of depression as well as increasing her feelings of pessimism about medication and health care professionals’ ability to help her. To minimize the impact of narcotic analgesics on her depressive symptoms and energy levels, a consultation was sought with her pain management team with Bethany’s consent and cooperation. A narcotic medication taper was agreed to by Bethany, her pain team, and therapist to limit the dose to the lowest effective dose for pain while minimizing cognitive impairment of confusion, lack of concentration, and somnolence. Given that the patient had never experienced symptoms of distraction and lack of concentration prior to the time her depression became severe, it is most likely that her problems were due to hypomania and agitation. Therefore, it was agreed that the medications for ADD would gradually be tapered and discontinued.

Finally, she was prescribed a course of lamotrigine, which is indicated for bipolar disorders that are primarily depressive in quality. Patients who are severely incapacitated by depressive cognitions and symptoms are not as likely to respond to cognitive interventions until the depressive symptoms begin to abate. She was educated in the expectations for the new medication for effect and side effect. She was also educated in realistic expectations of medication for control of her symptoms specifically that the medication would not be a “magic” solution. In order for her to experience maximum benefit, the APPN felt that she would have to “undo” the automatic thoughts and beliefs that perpetuated the depression. Providing her with a realistic introduction is the first cognitive intervention in her treatment plan. It says, “This is treatable, this is what to expect, this is what the pill will do, AND this is what you will need to do.” (NOTE: These steps are not always contained within the cognitive therapy model of treatment.)

It should be noted that her decision to marry a man 40 years her senior who is/was her father figure was most likely due to her low self-esteem and need for a father figure after her father’s death. Her frequent affairs also point to an underlying personality disorder that is most likely fueled by the hypomania. She gains powerful feelings from attracting men and this gives her short-term relief from her otherwise empty life. Because stabilization is the most important first goal, these issues should not be addressed immediately as they would push the patient rather quickly out of therapy. If and when she wishes to bring these issues up in therapy they can be dealt with, but only at that time. It is important for the therapist to remember that it is the patient’s goals, not the therapist’s, that set the agenda in therapy.

Course of Therapy

The initial session included the components of assessment, preparation for therapy, introducing the patient to cognitive therapy, problem conceptualization, and initial goal development. The second session reinforced the above and integrated the information obtained from collateral sources which refined the treatment plan. Medication changes were begun in the second session once it was clear that the patient understood the rationale for each of the changes recommended. Each session subsequent to these two sessions included a medication and symptom check prior to beginning the psychotherapy component of the session. Sessions typically begin with a review of any homework (out of session practice, or experiments). Initial interventions for Bethany were behavioral in content, given the level of cognitive impairment she was suffering. For example, Bethany’s level of physical inactivity was affecting her energy, self-concept, and negative cognitions. A daily exercise program was negotiated with Bethany that included 20 minutes of walking each morning.

Subsequent sessions focused on uncovering specific irrational automatic thoughts as they appeared in the session. Once a thought was identified, the therapist repeated the thought and discussed it with the patient. For example, “Everyone thinks I am such a slug!” Bethany was asked “Everyone? Virtually everyone thinks you are a slug?” Her response was “Well, no not everyone, almost everyone.” This was explored further and it was determined that the only one who had complained about Bethany’s activity level was her boss. Another example of Bethany’s use of overgeneralization was “There is nothing normal in my life!” and “Why do these things always happen to me?” Bethany was interrupted each time she used an overgeneralization. The thoughts were challenged in a respectful, exploration friendly manner until Bethany was stopping herself in therapy by saying “I don’t mean ‘always,’ I mean most of the time.”

Decatastrophizing techniques were used when Bethany began escalating, beginning when a small discrete problem, “I couldn’t find my keys for a couple of minutes!,” is changed from “My mind is a mess! I can’t

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remember anything! I am never going to be able to convince my boss that I can do my job!” The APPN modeled slowing down and evaluating the pattern of escalation by beginning with the activating event (losing the keys). Another technique that was useful with Bethany was the use of Socratic questioning, for example, asking, “What might be another explanation?” Questions framed in this way helped Bethany to break down errors in thought such as all-or-nothing thinking. Exaggerations in thinking were assessed using a scaling technique when Bethany expressed dichotomous categorical thinking processes. Breaking down categorized variables such as “I didn’t get any sleep at all!” into “on a scale of 1 to 100, where would you rate your sleep last night?”

Interruption of Bethany’s tearfulness was difficult during the early sessions due to the depth of her depression. In order for interruption to be considered respectful and helpful as a technique to (a) de-escalate and (b) evaluate, Bethany was introduced to the technique early in the relationship. The introduction included the component that “In order for me to really understand what you are saying, I will be interrupting you at times to ask questions. In order for me to help, I need to make sure I have a clear understanding of what you are telling me.” Allowing Bethany to dissolve into tears perpetuates her current method of dealing with her depressive thinking. Interruption coupled with Socratic questions and scaling helped Bethany experience disruption of her escalation, which reinforces her ability to interrupt the process on her own.

Therapy Monitoring and Use of Feedback Information

Bethany’s progress was monitored through use of the Beck Depression Inventory (BDI) and the Quick Inventory of Depression Symptomatology-Clinician Rated (QIDS-C). Bethany scored 51 (out of a possible 63) on the BDI and 23 (out of a possible 27) on the QIDS-C at the time of initial assessment. The scores fall into the severe range of depression. Repeat measures were taken at biweekly intervals. Using the standardized instruments was a helpful adjunct to clinical judgment in psychotherapy in that it provided concrete evidence of improvement of symptoms.

Bethany’s self-reports during her first two return visits were “I am still a mess! I am not any better at all!” Use of the instruments supported the cognitive approaches utilized including using evidence to challenge her self-defeating thinking patterns. The evidence was introduced in a respectful manner using a method of cooperative inquiry. “Let’s look at the scores on your reports. They indicated that your depression is still in the severe range but there are some changes. It looks like you are moving in the right direction.” With assistance in evaluating each of her symptoms rather than her overall experience, Bethany began to express hesitant optimism that she was improving. During the first month, her scores decreased from 51 and 23 to 38 and 15 on the BDI and QIDS-C, respectively.

Once Bethany began to experience an improvement in her mood along with hope for additional improvement, she moved into a more active role in the therapy sessions. The APPN then was much more active during her first four sessions, given her severe disabling symptoms and her weight. Her sleep gradually improved and her daytime somnolence began to abate. With the increase in energy, she was able to walk 5 minutes a day beginning week 5 of therapy. Initially the exercise increased the pain of her fibromyalgia, which is an expected response. The therapist warned her that this was to be expected and did not indicate that she was harming herself. According to Bethany, several of her health care practitioners had told her that the best treatment for fibromyalgia was exercise but she had never felt motivated enough to begin a program.

Getting Bethany to take an active part in her health care (via exercise) was a key component in her therapy. Exercise served multiple purposes: (a) it helped reduce the pain experience, (b) it increased her body’s tolerance for physical activity, (c) it increased her energy and motivation level, (d) exercise increases release of the body’s endorphins and serotonin, both of which improve mood, and finally (e) reduced her weight, which motivated her to continue the program of activity and therapy.

At this point, Bethany was introduced to two other components in her treatment: the daily thought record (DTR) and her activity/mood diary. She was assigned the book Mind Over Mood by Padesky and Greenburg (1985) as her resource and for supportive information both in and outside of the sessions. Bethany had experienced success in challenging her automatic thoughts in the therapy setting and this information was used to reinforce DTR homework as a productive and helpful adjunct to her sessions. The APPN also used the DTRs that are suggested by Padesky and Greenburg including daily written entries indicating the person’s (a) situation, (b) current mood rating, (c) automatic thoughts, (d) evidence that supports the hot thoughts, (e) evidence that does not support the hot thoughts, (f) alternative or balanced thoughts, and finally (g) post-

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exercise mood rating. Bethany’s affect remained labile in the sessions with tearfulness during periods when she talked about

feeling overwhelmed and useless. She would point this out and dichotomize her perception of the episode as “I am so tired of feeling like this all the time! I am never going to stop crying all the time!” Her expressions “all the time” and “never get better” were highlighted to help her evaluate the tearful episodes rationally. This type of situation lends itself to the use of scaling techniques. This technique breaks down “all-or-nothing” thinking into a continuum to help the patient experience her perception in a more balanced way.

For Bethany this meant asking her “When you say ‘all the time,’ help me to understand how much of the time is ‘all the time.’ Is it 100% of the time (holding my hands about 2 feet apart), 50% of the time (moving my hands closer together), or another percentage of time?”

Bethany’s response was to stop crying, think deeply for a few minutes during which the APPN remained quiet and then she said “I am not sure … maybe 50%.” The perception of all the time was broken down even further now that she was considering that “all the time” did not mean “100% of the time.” To help her evaluate her perception with more data, the therapist asked: “When you came in the first day you said you would cry about four to five times a day for an hour or two each time. That means you were crying between 4 and 10 hours a day. Let’s take the first variable. How many times a day are you crying?”

B: Maybe once or twice. APPN: So you have reduced the number of times you are crying from 4 or 5 to 1 or 2. That is about 60% to 75%. And each time

you have a crying episode, how long are you crying? B: Oh, only about 10 minutes, sometimes as much as 20 minutes, but never more than that.

APPN: It sounds like the duration of crying is pretty significantly reduced! As much as 80%. Let’s go back and look at what you said earlier, “I cry all the time.” What do you think about crying now?

B: I get it. I am doing it again! [laughs]. It is still so easy to bury myself by automatically thinking the worse that can happen. When I stop and look at things realistically, I know I am doing much better now. I have to practice stopping myself!

Documented baseline measurements help with the process of examining the evidence. Capturing the patient’s own words, especially if there are measurable data points, is critical in the process of examining the evidence of progress when a patient has a bad moment or a bad day. Using the data to confront in a kind and respectful manner reinforces hope of recovery, which is one of the cornerstones of motivation to maintain change.

Concluding Evaluation of the Therapy’s Process and Outcome

At this point in treatment, Bethany has been in therapy for 6 months, beginning with a weekly session for eight sessions and tapering to one session a month. She continued to use the DTR for tough times and felt more confident with the process of challenging her automatic thoughts. The most difficult times for Bethany include those times when her pain flares up, usually during periods of unusual activity. Her overall pain ratings have fallen from her initial daily ratings of “8 or 9” to baselines of “4 to 6.” A reduction in pain experience of 50% is considered successful in a pain management program. Bethany is happy with the change in baseline and is more functional. She walks twice a day, 10 minutes each time which is a 100% increase in activity from her first session.

Bethany had a good response to the lamotrigine, which managed her hypomania very well. It is important with patients who have a disruptive underlying psychiatric problem amenable to medication that the medication is integrated into the therapy treatment plan. The APPN reinforced to Bethany that the medication would help stabilize her moods but would have no effect on the automatic thoughts, habits, and other destructive forces that had fueled her severe depression. The first 10 to 15 minutes of each session were devoted to evaluation of medication effectiveness, side effects, and dose response until she stabilized. Again, this is not a usual component of traditional cognitive psychotherapy; however, psychopharmacological education needs to be integrated into the treatment plan if the therapist is also the prescribing practitioner. See Chapter 9 for further information about integrating prescribing with psychotherapy.

POSTMASTER’S CBT TRAINING AND CERTIFICATION REQUIREMENTS

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Competency standards for CBT have been outlined by Jesse H. Wright, MD, PhD; Donna Sudak, MD; David Bienenfeld, MD; and Judith Beck, PhD (2001) for the American Association of Directors of Psychiatric Residency Training (AADPRT). A supervision checklist is also available as designed by Wright and colleagues (www.appi.org/pdf/wright). The academy of cognitive therapy (ACT) offers certification for licensed mental health professionals in CBT and evaluates applicants’ knowledge and ability before granting certification. The standards of the academy are designed to identify and credential clinicians with the necessary training, experience, and knowledge to be effective cognitive therapists. ACT requires 40 hours of course work, completion of a compiled list of assigned readings including at least one core text on CBT theory and methods, a written case formulation, case supervision, and the submission of audio or videotaped sessions that are reviewed and rated by experienced cognitive therapists. In addition, the practitioner must have significant practice experience treating individuals with CBT with a variety of diagnoses. APPNs who wish to pursue CBT certification can find the requirements on their website at www.academyofct.org.

CONCLUDING COMMENTS

CBT is the most widely researched psychotherapeutic model with demonstrated effectiveness in the treatment of a wide range of emotional and behavioral problems. CBT is a “system of psychotherapy based on a theory which maintains that how an individual structures his or her experiences largely determines how he or she feels and behaves” (Beck & Weishaar, 1986). The underlying premise of CBT is that dysfunctional (or maladaptive) thoughts relating to self, world, and/or others are based on irrational or illogical assumptions. CBT places significant importance on cognitive information processing and behavioral change. Therapy is structured, active, and reality based as well as time limited. The individual is taught to take certain specific steps to combat their dysfunctional or maladaptive views. These steps include identifying and monitoring automatic thoughts, critical examination of evidence, substitution of objective interpretations for their negative, dysfunctional attributions, and recognizing connections between thoughts and feelings. It would be incorrect to say that severely impaired individuals, such as individuals with schizophrenia, cannot be treated with CBT. For these individuals, the therapist uses a greater number of behavioral techniques, for example, than cognitive techniques. For higher functioning individuals, the therapist uses more cognitive techniques. For any individual, therapy is a collaborative process taking schemas, ability, and physiology into account when deciding the plan of action.

DISCUSSION EXERCISES

1. Discuss the importance of assisting the individual to identify his or her own cognitions, behaviors, and other factors that contribute to the individual’s problems.

2. What is the role of homework in cognitive therapy? Why is homework important? 3. What are some common types of distorted thinking styles in a person with an anxiety disorder?

What techniques would be helpful for this problem? 4. According to cognitive theory, what is the basis for depressive disorders? 5. Would you refer an individual with severe anxiety to a cognitive therapist? Why or why not? 6. Describe two cognitive techniques and two behavioral techniques. In what types of situation

would you choose each? 7. Develop a written contingency contract for yourself for a behavior that you would like to change. 8. Fill out the automatic thought record for a recent situation that you found disturbing.

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Adapted from Gilson, Freeman, Yates and Freeman (2009), with permission.

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Interpersonal Psychotherapy PATRICIA D. BARRY KATHLEEN WHEELER

nterpersonal psychotherapy (IPT) is a brief, structured psychotherapeutic approach based on the operating principle that psychiatric disorders occur within an interpersonal, social context. Symptoms of psychiatric

disorders in four specific areas of social functioning create problems in which IPT therapists are trained to intervene: interpersonal disputes, role transitions, grief, and interpersonal deficits.

This chapter provides an overview of IPT theory and techniques by tracing the history of the approach and identifying relevant psychological and nursing theories congruent with the concepts of IPT. The application of IPT to specific populations with depression, perinatal depression, eating disorders, adolescent depression, drug misuse, bipolar disorder, and borderline personality disorder (BPD) is discussed. Goals and phases of treatment are delineated, and a case illustrates use of the IPT approach. The chapter ends with where to obtain further training in this treatment modality.

FOUNDATIONS OF IPT

The work of three psychopathology theorists shaped some of the underlying approaches of IPT (Markowitz & Weissman, 2012a). Their theories emphasized the importance of the interpersonal environment and the relationships therein as the foundation of personality development. A brief background of the theorists and their theoretical frameworks are described in relation to the foundational concepts of IPT:

Harry Stack Sullivan is recognized as one of the major figures in American psychiatry. He became interested in the field in his early 30s and is widely recognized as a charismatic leader who became a pioneer in the treatment of schizophrenia. Sullivan’s view on the development of mental illness was influenced by many other fields including cultural anthropology and political science (Horowitz & Strack, 2011). His central theory is that interpersonal relationships and the communications therein form the basis for psychiatric disorders. He believed that effective communications are interfered with by anxiety. Sullivan also posits that “each person in a two-person relationship is involved as a portion of an interpersonal field, rather than as a separate entity, in processes which affect and are affected by the field” (Sullivan, 1953, p. xii). Sullivan and nurse theorist Hildegard Peplau, who is discussed later in this chapter, are both recognized as pioneer thinkers in the treatment of schizophrenia (Peplau, 1952). Although IPT is not recognized as a treatment model in the treatment of schizophrenia, the humanistic approaches of Sullivan and Peplau are respected as universally applicable in the mental health treatment of individuals in emotional pain.

Adolf Meyer was a Swiss psychoanalyst who was strongly influenced by the psychobiology and psychopathology theories of Darwin, Freud, and Jung. He became the primary architect in professionalizing the field of psychiatry when he became the first professor of psychiatry at Johns Hopkins University in Baltimore, Maryland. Meyer used the findings and recommendations for the field of clinical psychiatry that appeared in the Flexner Report, published early in the 20th century, when he implemented the use of research, professional scholarship, and full-time faculty to improve clinical knowledge in the field of psychiatry. Meyer “viewed mental illness as an attempt by the individual to adapt to the changing environment” (Klerman et al., 1984, p. 42). Adolf Meyer is recognized as one of the founding fathers of the field of social epidemiology, the field that researches the causes and effective treatment of social and mental ills.

John Bowlby is an English psychoanalyst who developed the concept of attachment theory. He is recognized as one of the century’s most influential theorists on personality development and social relationships (Horowitz & Strack, 2011). When Bowlby worked with infants and children as the head of

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the Children’s Department at the Tavistock Clinic after World War II, he recognized the powerful effects of mother–child separation. Bowlby believed that the attachment of the child to the mother had an evolutionary basis, rather than the oral gratification theoretical approach held by the Freudians. Bowlby is well known as the author of three important texts describing how the mother–child bond affects human responses to attachment, separation, loss, and depression over the life continuum.

NURSING THEORY AND IPT

The IPT model is in strong alignment with the primary themes of nursing. In this section, the approaches of three nursing theorists who have examined the psychosocial dimensions of illness are reviewed to demonstrate the similarity of the values of psychiatric nursing with those of IPT.

Many psychotherapy models are studied in the course of becoming a proficient psychotherapist. Graduate students in any of the mental health discipline learn a set of core theoretical concepts about the evolution of psychopathology and its treatment. These concepts are derived from the theories of leaders in the field of mental health. Often, these theories are colored by and tailored to the primary clinical interests of the graduate student’s professional field. Among the professional groups that address psychiatric disorders, nursing consistently prioritizes and values the interaction of biopsychosocial processes and environmental factors that support adaptation, as well as those that contribute to maladaptation, one of the roots of psychiatric disorder (Barry, 1989).

Jacqueline Fawcett (1984) and Margaret Newman (1982) identified four themes that are the foundation of nursing theories that describe the clinical relationship and interactions of nurses with their patients. They are patient, nursing, environment, and health. An overview of these themes from the perspective of Hildegard Peplau, a nurse theorist whose work is related to the IPT model, appears below. While reading Peplau’s framework, observe the similar themes of its perspectives compared with those of Sullivan, Meyer, and Bowlby, which were described previously.

Peplau is considered to be the founder of the field of mental health nursing. Hildegard Peplau’s model and the fundamental values of psychosocial nursing are congruent with the foundational concepts of IPT. A core concept is the importance of interpersonal relations in nursing. Her clinical model of nursing interaction is outlined in her view of the major themes of nursing:

1. Patient: a unique biopsychosocial being

An organism that lives in an unstable equilibrium 2. Nursing: the assistance provided to patients to aid their understanding of the course of their health

problem and to help them learn from the experience

A significant therapeutic interpersonal process that promotes the health of the individual (defined subsequently)

3. Environment: the psychodynamic milieu

The existing forces outside the person that provide the social context in which psychological healing occurs 4. Health

Ongoing development of the personality and other developmental processes that lead to full personal development, including constructiveness, creativity, productivity, and self and social fulfillment (Barry, 1989; Fawcett, 1986; Peplau, 1952, 1991)

Martha Rogers’s theoretical framework, the Science of Unitary Human Beings, is similar to Sullivan’s field theories. Her theories, based on foundations in physics and systems and psychosocial theories, emphasized the power of fields in the maintenance of health and the development of and treatment of disease (Rogers, 1970). Watson’s Transpersonal Caring Theory emphasizes the importance of the therapeutic and healing presence of the nurse who focuses his or her attention on caring, healing, and wholeness, rather than on disease, illness, and pathology. A meaningful nurse–patient relationship is based on caring and the demand for authentic person-to-person exchange (Watson, 2013).

The holistic nursing model outlined in Chapter 1 evolved from these theoretical roots and is consistent with the major themes of nursing identified previously. The individual is embedded in relationships with

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others that affect and influence all dimensions of the person. Interpersonal interactions reveal the perceptions, feelings, and thoughts unique for a person and give expression to implicit memory networks. IPT focuses on relationships, targeting current social and interpersonal interactions. By understanding the effects of the person’s problem on significant relationships and how past and present relationships affect the problem, new relational patterns and roles can be discussed and implemented. Changing the social context and relationships with others reverberates to all dimensions of the person, because all components are interrelated. Through interpersonal change, right relationship with others and self occurs.

HISTORY OF IPT

IPT was developed by Myrna Weissman and the late Gerald Klerman in a research setting as a treatment intervention in the early 1980s for a series of studies conducted on the assessment and treatment of depression (Markowitz & Weissman, 2012a). These studies tested whether antidepressants or antidepressants and psychotherapy resulted in better outcomes and less recidivism. The results of these studies guided the development of an IPT treatment manual based on the premise that most psychiatric disorders occur within a social context. The IPT treatment manual addressed the four types of interpersonal problems (interpersonal disputes, role transitions, grief, and interpersonal deficits) described earlier.

Within the different psychiatric disorders studied, including depression, bulimia nervosa, and others mentioned previously, these four types of interpersonal difficulties produced symptom clusters that were uniquely different from each other (Klerman et al., 1984; Weissman et al., 2000). As the psychiatric disorders were studied, it was found that the assessment and treatment of each disorder required modifications in the original model for depression (Markowitz & Weissman, 2012a). These IPT clinical approaches to a variety of psychiatric disorders and treatment settings are described later in the chapter.

Underlying Assumptions of the IPT Model

The work of John Bowlby in describing disruptions in the maternal–child relationship as the source of psychosocial difficulties in adolescence and adulthood is foundational to IPT. Bowlby’s research and teaching emphasized the impact of early life issues, with separation and loss as the underlying basis for depression. The development of IPT was based on the theoretical perspectives of Bowlby and on the social interaction theories of Sullivan and Meyer (Markowitz & Weissman, 2012a).

IPT recognizes that psychopathology arises from underlying personality issues that will not become the focus of treatment. Instead, IPT emphasizes that the problems created by the psychiatric disorder occur interdependently within the conscious social and interpersonal realms. These problems and conscious awareness of the context are the focus of IPT treatment (Markowitz & Weissman, 2012a).

In developing the IPT approach, it was thought that earlier depression treatment programs paid too little attention to techniques aimed at reduction of symptoms and easing the patient’s current social functioning and interpersonal relations (Klerman et al., 1984). IPT emphasizes the patient’s disputes, frustrations, anxieties, and goals in his or her current social and interpersonal environments. The purpose of IPT is to intervene with symptoms and to reduce the risk of additional symptom formation by relieving current problems in interpersonal relations and social adjustment.

Symptoms are described as the development of depressive affect and its accompanying indications that may be the result of psychobiological or psychodynamic mechanisms. Although the IPT founders recognize the presence of unconscious (implicit) personality and character dynamics in the development of depression, the IPT approach, which is a time-limited treatment model, does not intervene directly with these underlying dynamics. Social and interpersonal relations are described as interactions in social roles with others. These interactive social problems are addressed with “reassurance, clarification of emotional states, improvement of interpersonal communication, and testing of perceptions and performance through interpersonal contact” (Klerman et al., 1984, p. 7). Related aspects of IPT are addressed in subsequent sections of this chapter.

Contrasts Between Underlying Assumptions of IPT and Psychodynamic

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Psychotherapy

Weissman and Klerman, the original developers of IPT, were well schooled in the underlying theory of psychodynamically oriented psychotherapy (Markowitz & Weissman, 2012a). They recognized the importance of understanding the original foundations of personality difficulties whose origins were based in early and later childhood and acknowledged that these foundations were primarily housed in the unconscious (implicit memory) realms of depressed persons. Because of the many years of treatment usually required for dynamic psychotherapy or psychoanalysis, a new psychotherapy model was created, motivated by the changing worlds of the mental health treatment setting and by health care economics, both of which were oriented to a shorter length of mental health treatment than was generally available in the 1970s (Barry, 2002).

During the formative and developmental studies of depression, research models were created to demonstrate the most explicit operational approach to effective depression treatment. The original premises of the research recognized the seminal psychoanalytic and psychodynamic contributions of Freud and his followers. However, new ground was covered by integrating an updated approach to the theory of the causes of depression and empirical evidence about the treatment of depression based on the findings of depression researchers through the 1970s (Barry, 2002; Markowitz & Weissman, 2012a).

In addition to the emerging knowledge of the dynamics of depression post–World War II, there had been a significant change in the social face of psychiatry because of increased awareness of gender and race issues, concern about human potential, and increased interest in and striving for personal well-being. There was also an important scientific and professional shift in recognition of the importance of personal development and interpersonal relations over the life span (Barry, 2002; Markowitz & Weissman, 2012a).

The result of these important changes in society and the field of psychiatry was that IPT theorists and practitioners recognized that psychodynamic psychotherapy was not a realistic clinical approach to use with the masses of people who were suffering from depression and who required a time-limited and affordable approach to treating psychiatric disorders. IPT switched the traditional psychodynamic focus on unconscious mental processes and implicit memories to what they called a “purely interpersonal approach,” which focuses on social roles and interpersonal interactions in the patient’s current and past experiences. The IPT model addresses interpersonal relations, essentially addressing the interactions between self and other, whereas the psychodynamic therapist focuses on object relations, which is an intrapsychic formulation of self with others (Barry, 2002; Markowitz & Weissman, 2012a).

PRINCIPLES AND GUIDELINES OF IPT

The development of IPT was driven by the belief that progress in creating new clinical interventions should be guided by clinical experience and research evidence. Research evidence is acquired by carefully designed, well-controlled investigative trials (Markowitz & Weissman, 2012a). The social roots of depression are the primary focus of IPT so that diagnosis and treatment of depression could occur in a timely manner and expedite the recovery time of depressed individuals to meet the requirements of the up-and-coming managed care insurance world during the late 1970s and subsequent decades. Mental health research during the 20th century pointed strongly to social factors being critical in the development of depression.

The driving force in the development of IPT was to treat and relieve the three primary aspects of depression:

1. Symptom function: how depressive affect and neurovegetative signs and symptoms are affecting the patient personally and with others

2. Social and interpersonal relations: how a person interacts with others, based on early childhood experiences, current social reinforcement, and the sense of mastery

3. Personality and character problems: characterological traits, such as pessimism, poor self-esteem, resentment, and poor communication with others

IPT actively addresses the first two sources of depression described. Personality and character problems, the third source, are generally viewed as being deep seated and having their origins in unconscious (implicit) memory (Markowitz & Weissman, 2012a). Although IPT does not actively address this aspect of personality and character issues, the active work on the first and second points, the symptom characteristics and interpersonal functioning, supports the development of new social skills that may reduce

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some of the characteristic personality difficulties. Weissman and colleagues (2000) describe IPT as follows:

[IPT is a] focused, time-limited psychotherapy that emphasizes the link between mood and the current interpersonal relations of the depressed client while recognizing the roles of genetic, biochemical, developmental, and personality factors in the causation of and vulnerability to depression. IPT is not a causal explanation for depression, but a pragmatic treatment for it. (pp. 4– 5)

Weissman and her colleagues (2000) explain that it is important for the IPT therapist to recognize clinical depression as described in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and to be aware of its social, biological, and medical precipitants. The IPT therapist is then urged to recognize the interpersonal context of the depression and the importance of its underlying roots of difficulties with attachment, bonding, stress, and interpersonal disputes. The prominence and persistence of the depression are also associated with neurovegetative signs of sleep disruption, such as appetite disturbance, changes in weight, and energy level, as well as thought and memory processes, including worthlessness, guilt, helplessness, and thoughts of death and suicide.

IPT was used in research studies that investigated methods to support the early improvement in functioning observed 2 to 4 weeks after inception of antidepressant therapies. Research on depression treatments in the mid-20th century found a consistent and gradual decline in the original clinical improvement of patients. Treatment approaches were identified that built on the theoretical underpinnings of the origins of depression and that would sustain the early improvement related to psychopharmacological interventions. Hundreds of clinical studies have demonstrated success in developing a clinical intervention based on a manual with very specific assessment and treatment criteria. Many of those studies (described later) demonstrated the efficacy of modifications to the original IPT protocol for use with other types of psychiatric populations.

The following features provide a summary of the IPT approach (Weissman et al., 2000) compared with other psychotherapy models:

1. Time limited, not long term 2. Focused, not open ended 3. Based on current, not past, relationships 4. Interpersonal in nature, not intrapsychic 5. Interpersonal, not cognitive or behavioral 6. Aware of personality, but not focused on it

The Role of the Therapist in IPT

The foundation of the role of the therapist is related to the personality style of the therapist. The guidelines of the therapist are to be nonjudgmental, warm, and communicating with unconditional positive regard. The therapist is viewed as an ally fostering the patient’s positive expectations about the therapy. Because of the time-limited nature of the therapy and the active, advocating role of the therapist, there are limited issues of transference. Transference is not addressed in the IPT model unless the patient’s feelings toward the therapist are clearly disrupting the therapeutic relationship and progress of therapy.

TABLE 9.1 Interactive Dialogue: Evidence of Abnormal Grief Task Task Therapist’s Questions Multiple losses What else was going on in your life around the time of the death?

Has anyone else died or left? What has reminded you of it since it happened? Has anyone died in a similar fashion or when your circumstances were similar?

Inadequate grief in the bereavement period In the months after the death, how did you feel? Did you have trouble sleeping? Could you carry on as usual? Were you beyond tears?

Avoidance behavior about the death Did you avoid going to the funeral? Did you avoid visiting the grave?

Symptoms around a significant date When did the person die? What was the date? Did you start having problems around the same time?

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Fear of the illness that caused the death What did the person die of? What were the symptoms? Are you afraid of having the same illness?

History of preserving the environment as it was when the loved one died What did you do with the possessions? What did you do with the room? Were the possessions left the same as when the person died?

Absence of family or other social supports during the bereavement period Who could you count on when the person died? Who helped you? Who did you turn to? Who could you confide in?

Adapted from Klerman, Weissman, Rounsaville, and Chevron (1984).

The IPT model is one in which the therapist is able to be interpersonally open with the patient when the therapist’s experience can be used to illustrate a point in the discussion. Activities between the therapist and patient that do not relate directly to the therapy should not be engaged. The therapist is active and proactive in the relationship, while at the same time recognizing that change is the responsibility of the patient. The therapist usually does not make active suggestions for change. Rather, change is viewed as the desired outcome of the interactions of the patient and therapist in the IPT therapy. Homework is not assigned in IPT. It is expected, however, that the results of clinical sessions will bring about gradual change that is reported in subsequent sessions (Weissman et al., 2000).

Table 9.1 shows examples of interactive statements used by an IPT therapist based on the principles of the IPT therapeutic protocol.

Establishing the Therapeutic Alliance in IPT

Because the therapy process is strongly guided by adherence to goals and principles outlined in the IPT instruction manual, the therapy process is strongly influenced by the model itself, an essential aspect for the outcome of IPT efficacy. Another significant factor in the course of therapy is the quality of the therapeutic relationship established between the therapist and patient. The findings reported in this section have been summarized from a number of studies on the therapeutic alliance in a variety of therapy approaches.

An important aspect of the therapeutic alliance is that therapists can be well-trained in therapeutic skills and treatment models, but there are essential factors that cannot be gained through training. These factors include the personality and emotional styles of the therapist. These factors usually have been operative in therapists long before they became therapists. As the result of their studies on the effects of training in therapists, Strupp and Anderson (1997) concluded that the effects of the training were filtered through the therapists’ preexisting personality dispositions. They found that although therapists were trained to use a therapy using a specific manual that directed all aspects of patient–therapist interactions, the therapy results were strongly colored by the underlying personality characteristics of the therapists.

There were additional findings related to the use of training manuals by therapists. Although therapists demonstrated compliance with the recommended approaches of the manual, there were unanticipated consequences of manual-based therapies. In general, Henry and colleagues (1993) found that many therapists delivered the therapy in a “fairly forced mechanical fashion” (Safran & Muran, 2000, p. 4). Therapists with a style that was identified as self-controlling and self-blaming were more inclined to astutely follow the treatment manual and showed more hostility and a lack of warmth and friendliness with their patients. One of the questions in the conclusions of this study was how to avoid the possibility of the manual approach becoming an external standard that had to be conformed to, rather than a personally integrated way of being present with patients (Safran & Muran, 2000). A challenge for therapists who are using a manual approach to IPT therapy is to remain open and be aware of their interpersonal style with patients and to create a social environment for the therapy that is human to human in its interpersonal style.

APPLICATION OF EVIDENCE-BASED IPT

IPT was originally developed as a clinical intervention with a specific orientation to adult depression and the unique clinical syndromes that contribute to it. The use of IPT in adult depression has been studied meticulously by one of its founders, Myrna Weissman, a psychiatric epidemiologist at Columbia University. She and other researchers were able to demonstrate that IPT was effective in reducing symptoms of depression during IPT therapy and after the completion of IPT therapy (Dowrick et al., 2000; Frank, 1991; Frank et al., 1992; Hollon et al., 2002; Klein & Ross, 1993; Klerman, 1988; Shea et al., 1992; Ward et al.,

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2000). IPT has also demonstrated efficacy in conjunction with pharmacotherapy (Frank et al., 1990) for bipolar disorder (Swartz, Frank, Frankel, Novick, & Houck, 2009). In addition to depression, IPT is effective when used for several other types of disorders and in a variety of mental and physical health settings, including perinatal depression, eating disorders, adolescent depression, somatization, substance abuse, BPD, and bipolar disorder. IPT counseling, which is an abbreviated form of IPT, is used primarily in medical illness settings.

Treating Depression With IPT

Depression is posited to arise in the context of losses, role transitions, role disputes, or social isolation that serve as the treatment focus. IPT does not focus on cognition but on emotions and interpersonal interactions. Thus, there is no specific homework and IPT is less prescriptive than cognitive behavioral therapy (CBT). The focus is on the person’s current life rather than on the past causes of the problem. Social supports are stabilized and the therapist is warm, hopeful, and positive.

A seminal study demonstrating the efficacy of IPT was completed in the early 1980s using sites at Harvard and Yale Universities—affiliated mental health centers that serviced patients from a wide range of social backgrounds. The initial IPT study was considered advanced for its time because the mental health clinicians who participated in the study adhered to a treatment manual (Weissman et al., 2000). The treatment manual eventually became the basis for IPT therapy training (Weissman et al., 2000). There were four groups of depressed individuals in the study: persons who received IPT intervention; persons who had IPT and antidepressant therapy; persons treated with antidepressant therapy with no psychotherapy; and persons who had unscheduled treatment, which involved each participant being assigned to a psychiatrist and being told to call the psychiatrist and talk whenever he or she needed to do so. The patients could also schedule an appointment with a psychiatrist for a 50-minute session no more than once per month if their symptoms were of a certain level of intensity. All study participants were assessed on a regular basis by a clinician who did not know the group to which the patient had been assigned.

At the end of the study, the participants who were in the groups that consisted of IPT alone or IPT with antidepressant medication were significantly improved compared with the individuals who were in the nonscheduled treatment group. Those who were treated with antidepressant medication alone also improved compared with the nonscheduled treatment group. There were important differences, however, in the outcomes of the IPT groups and the group that received only the antidepressant medication. IPT recipients had improvements in mood, improved work performance and interest, and decreased suicidal ideation and guilt. These improvements were statistically significant after the initial 4 to 8 weeks of treatment. In contrast, those who received medication alone showed improvement only in decreased neurovegetative signs of depression: sleep, appetite disturbance, and somatic complaints (DiMascio et al., 1979).

There have been numerous studies demonstrating the beneficial outcomes of IPT treatment of depressed individuals since the original studies that brought optimism to the treatment of depression (Blanco et al., 2001; Dowrick et al., 2000; Klein & Ross, 1993; Klerman, 1988; Reay et al., 2003; Shea et al., 1992; Ward et al., 2000). The primary method used in these studies to demonstrate improvement in depressive symptoms was a statistical difference in the mean scores on depression scales of IPT recipients at the beginning of IPT and the mean scores on completion of the therapy (Blanco et al., 2001; Dowrick et al., 2000; Klein & Ross, 1993; Klerman, 1988; Klerman et al., 1984; Reay et al., 2003; Shea et al., 1992; Ward et al., 2000; Weissman et al., 2000).

Treating Perinatal Depression With IPT

The term perinatal refers to the gestation period of 20 to 28 weeks of pregnancy to 1 to 4 weeks after delivery. A longitudinal study of 14,000 prenatal immigrant women from the Dominican Republic found that 13.5% scored in the range of probable depression at 32 weeks of pregnancy (Evans et al., 2001). To add credence to these findings of depression incidence in pregnant women, a study done at two intervals with impoverished, single, inner-city, pregnant women found that they had depression rates of 27.5% and 24.5% during the two periods of measurement (Hobfoll et al., 1995).

Evans and colleagues (2001) conducted a study that involved a perinatal 6-week, 16-session research methodology for one IPT group and one group of parenting education. Both groups improved in mood over

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the course of therapy. The IPT group improved by 33.3%, and the parenting education group showed a change of 11.8% (Evans et al., 2001). Spinelli and Endicott (2003) conducted a 16-week, 16-session study of depressed antepartum women who were placed in a parenting education group or an IPT group. The IPT group showed a significant improvement in mood on three different measures compared with the parent education group.

Because of the specific focus of IPT on interpersonal dynamics, IPT has been used as an intervention with mothers who develop depression after delivery. One of the great concerns for women who develop this condition is the impact it has on their social role and interpersonal functioning, particularly the mother–infant bond, and also relationships with their spouses and other children (Stuart, 2012). The period after birth is particularly challenging, because it requires an almost immediate need to redefine relationships with family members and friends. Another demand that many new mothers experience is the sudden change in their work role as they assume the care of a new infant. Most women who become depressed during this postpartum period are averse to the use of medication, primarily because many of them are breastfeeding. Accordingly, IPT is often a welcome intervention for new mothers.

Several meta-analyses provide empirical support for the use of IPT for postpartum depression (Cuijpers, Brannmark, & van Straten, 2008; Sockel, Epperson, & Barber, 2011). A number of randomized clinical trials have found a significant decrease in the depression scores of IPT recipients compared with depressed postpartum women who were placed in a group waiting for treatment (Grote et al., 2009; O’Hara et al., 2000; Reay et al., 2003). Positive outcomes for IPT have also been demonstrated for IPT used within a group setting (Klier, Muzik, Rosenblum, & Lenz, 2001; Reay et al., 2006; Mulcahy, Reay, Wilkinson, & Owen, 2010).

Treating Eating Disorders With IPT

IPT is an effective intervention for eating disorders, primarily for patients with bulimia nervosa. One of the primary contributing factors to eating disorders is a disturbance in one or more significant relationships (Fairburn et al., 1986; Fairburn, 1993). In addition, social withdrawal and low self-esteem are common for this population, and interpersonal difficulties contribute to the maintenance of eating disorders (Murphy et al., 2012). Since the identified focus of IPT on interpersonal relationships and focus on the here and now, IPT became a choice for a treatment option that has been studied by eating disorder researchers.

Fairburn and colleagues (1986, 1993) compared IPT with CBT and behavioral therapy (BT) for overall improvement for those with bulimia during group therapy. CBT is a therapeutic approach that assumes that maladaptive thought patterns result in maladaptive behavior and distressing emotions. The responses of group members who received IPT compared favorably with members of a group who received CBT. Patients receiving IPT did not improve as rapidly during the study period as those receiving CBT and BT. Both the IPT and CBT therapy approaches showed good outcomes, with no immediate clinical deterioration at the end of the group period when compared with results for BT group members. IPT recipients showed a more enduring increase in improvement after the end of the treatment period while BT group members showed deterioration in outcome over time. A 6-year follow-up evaluation of the participants in the three groups showed that 86% of the BT participants met the criteria for an eating disorder and 37% of the CBT group members met the criteria for an eating disorder, compared with 28% of individuals who completed the IPT group training.

The consensus of these studies indicates that BT does not provide the enduring clinical outcomes for patients with bulimia that were observed for those who were treated with IPT or CBT. One of the modifications in the traditional IPT methodology that Fairburn initiated is to avoid discussion of current eating and the medical model’s implication that the patient is sick after the initial one to four sessions are completed. Fairburn’s research methodology, which shows positive outcomes for IPT in treating bulimia, includes this modification in the original IPT protocol (Fairburn et al., 1986, 1993).

Positive outcomes have also been found for those with binge eating. Wilfley and associates (2002) compared the outcomes of group intervention for 162 overweight individuals with binge-eating disorder in a CBT-training group with outcomes for an IPT-training group. Abstinence rates after therapy and at 1-year follow-up treatment for the CBT group were 79% and 59%, respectively, whereas the abstinence rates for the IPT group were 73% and 62%, respectively. IPT demonstrated slightly longer-term positive outcomes. A more recent trial comparing IPT, CBT, and BT found IPT interventions were superior to BT at follow-up (Wilson, Wilfley, Agras, & Bryon, 2010). For a further discussion about the phases of treatment and practice

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considerations for using IPT with those with eating disorders, see Murphy and colleagues (2012).

Treating Adolescent Depression With IPT

Modifications were made in the original IPT model when treating depressed adolescents (Morris, 2012). Mufson and her colleagues (1993, 1994, 1999) reported on the adaptation of the original IPT manual to research the efficacy of IPT with adolescents (IPT-A). The findings of their study recommended shortening the traditional 16-week IPT protocol used with adults to a 12-session model for adolescents. A study comparing 12 weeks of IPT with sertraline in the treatment of 49 adolescents with major depressive disorder found that both treatments led to improvement but that IPT was superior across all measures (Santor & Kusumakar, 2001). More recent studies using this IPT model with inner-city adolescents reported good results for those with depression (Gunlicks-Stoessel, Mufson, Jekal, & Turner, 2010; Miller, Gur, Shanok, & Weissman, 2008).

In the revised treatment manual for adolescents, use of the terms sick and sick role, which were used more actively with adults, was minimized with adolescents. A final modification in the protocol was the addition of parents in the adolescents’ treatment. Parents’ involvement in the IPT model includes psychoeducation for the parents and teen about the following:

Recognizing the symptoms of depression Emphasizing the importance of family involvement in treating the depression If there is a communication problem with one family member, asking the family member to participate in the active treatment phase of IPT so that communication issues can be addressed and improved

Modifying home and school expectations of the adolescent while the depression symptoms are active Clarifying the original expectations at home and school as the depression lifts

Problem areas of adolescent functioning contributing to depression have been identified as separation from parents, exploration of authority in relation to parents, development of dyadic relationships with members of the opposite sex, initial experience with death of a family member or friend, and peer pressures (Mufson et al., 1999). IPT has been significantly more effective than other psychotherapies in decreasing depressive symptoms in adolescents, accompanied by general improvement in overall social functioning. The typical course of treatment and further discussion of this model are provided by Morris (2012).

Treating Drug Misuse With IPT

IPT is used with patients who have addictive disorders in a variety of settings. Different aspects of the original IPT approach have been modified for persons with addictive disorders using well-respected principles for the treatment of this disorder. Each goal is actively discussed in every IPT session. Two of the primary goals of traditional IPT are to reduce symptoms and improve social functioning. These two goals are modified to help the patient reduce drug use and develop more effective coping strategies to deal with the social and interpersonal problems connected with the onset and ongoing drug use. Three goals were created to assist the patient in the process of stopping drug use:

1. Accepting the need to stop using drugs 2. Coping with and managing impulsiveness 3. Recognizing the environments in which drug acquisition and use occur

IPT has shown mixed results in some studies with drug-abusing patients. In general, however, the following recommendations have been summarized from research as possible treatment choices for particular subpopulations of drug-abusing patients (Carroll et al., 1991; Klerman et al., 1984; Rounsaville & Carroll, 1993; Rounsaville et al., 1983):

1. Patients who are entering drug abuse treatment 2. Patients with low levels of drug dependence 3. Patients who have not benefited from other treatment options

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4. Patients who are receiving other treatment modalities 5. Patients who have achieved stable abstinence

Bipolar Disorder and IPT

Since the advent of medications that improve the treatment of and prognosis for patients with bipolar disorder, there has been increased recognition of the personal and interpersonal and social disruption associated with the condition. Psychotherapy is used to address four primary areas of distress in persons with bipolar disorder:

1. The high relapse rate, even with medication 2. Noncompliance with medication 3. The personal, interpersonal, and social events that trigger manic or depressive episodes 4. The overwhelming social and interpersonal results of bipolar episodes

Mental health clinicians have introduced many types of approaches for use with persons with bipolar disorder. During the mid-1990s, an IPT model was created for use with patients with bipolar II disorder called interpersonal and social rhythm therapy (IPSRT) (Frank et al., 1994, 1997; Frank, 2005). IPSRT has been found to be effective in combination with medication (Miklowitz et al., 2007) and without medication (Swartz et al., 2009). Modifications included attention to the social rhythms of the traditional IPT issues, such as mood states, regulation of social rhythms, emotion regulation, management of grandiosity, regulation of levels of stimulation, and evaluation of comorbid substance abuse. Attending to the social rhythms provides an opportunity to regulate and stabilize the patient’s functioning so that interpersonal relationships are less threatened; the patient feels more secure with self and others; and the vulnerability created by the social stress activation of the bipolar episodes is decreased (Swartz, Levenson, & Frank, 2012).

Borderline Personality Disorder and IPT

A more recent application of IPT to a specific psychiatric disorder has been for those with borderline personality disorder (BPD). The rationale lies in the fact that patients with BPD have considerable problems in relationships, attachment, depression, and symptoms of rapid mood fluctuations, impulsivity, and cognitive distortions. These manifestations are embedded in the context of interpersonal relationships. Extending the traditional model for IPT to focus on the regulation of the self within interpersonal interactions becomes the primary focus of treatment. Emphasis is not on talking about past losses but rather on the effects of social support currently in place and how to develop new ones. Four areas have been identified as needing greater emphasis for this population than in the traditional IPT model and these include development of the therapeutic alliance and maintaining the structure of the treatment, management of high-risk behaviors, longer treatment than traditional IPT for depression, and a focus on the regulation of self through interpersonal relationships. See Bateman (2012) for further discussion.

There are only a few research studies on using IPT adapted for BPD. These include a randomized clinical trial of 55 patients with BPD for 32 weeks of treatment with either fluoxetine with clinical management as a standard treatment or fluoxetine with IPT (Bellino, Rinaldi, & Bogetto, 2010; Bellino, Zizza, Rinaldi, & Bogetto, 2005). IPT with medication was more effective for interpersonal relationships, affective instability, and impulsivity as well as overall improvement in psychological and social functioning. Another smaller study of eight patients diagnosed with BPD found that five out of the eight showed significant improvement after being treated with IPT modified for use with this population (Markowitz et al., 2006). Clearly, more research is needed but IPT offers promise for positive outcomes for people with BPD.

Interpersonal Counseling in Medical Settings

The traditional IPT protocol was modified so that it could be used more effectively with persons in medical settings who did not have a preexisting psychiatric disorder but were experiencing adaptive challenges to

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current stressors in their lives in addition to their medical conditions. The counseling model is used in six or fewer sessions of 15 to 20 minutes each. This counseling approach can be utilized well by medical clinicians who are not mental health specialists and who are provided with an 8-hour training program in interpersonal counseling (IPC) (Weissman et al., 2000).

The types of problems addressed in this counseling intervention include stressors at home, in the workplace, in the extended family, or in friendships. In general, the counseling is intended to relieve distress in interpersonal relationships. Its efficacy has been demonstrated in two medical settings in studies with medical personnel who had a master’s degree or higher educational preparation in a medical, rather than psychiatric, clinical discipline, administering the therapy (Klerman et al., 1987; Mossey et al., 1990). This illustrated the utility of integrating IPC into many settings.

GOALS AND PHASES OF IPT

Specific strategies have been identified in the IPT psychotherapy model. The therapist uses an IPT treatment manual as a guide in the treatment process that outlines the specific goals and strategies to use in IPT treatment. These strategies occur within three phases of treatment:

1. The initial sessions: assessment phase (sessions 1 through 4); the therapist and patient deal with the depression.

In this stage of IPT, the patient is assessed for the presence of depressive symptoms. The therapist gives the depression a name. The nature of depression and its treatment are explained to the patient. The effects of depression on the person are explained. Depressive symptoms are evaluated to determine the possible benefit of medication. The effects of depression on interpersonal relationships are clearly identified. The results of the depression are discussed with regard to prior interpersonal relationship patterns and the effects of the depression on current relationships. Significant relationships and the interpersonal expectations and mutual needs of the patient and significant persons are discussed as they are affected by the current depression. The satisfying and unsatisfying aspects of these relationships are also addressed. The patient is assisted to verbalize the changes she or he desires in the relationship. The patient’s sick role is discussed, with an expectation of the patient’s responsibility to work toward recovery. The major problem area in interpersonal relations that the depression is impacting is identified. The primary problem is clarified. Treatment goals associated with this problem and its interconnection with the depression are determined. The effects of the depression on the significant relationship and the steps toward resolution of this interpersonal problem are formulated and built into the treatment plan and treatment contract.

2. The middle sessions: active treatment phase (sessions 5 through 12); the IPT model delineates specific goals for the identified problem area affected by the depression and how the problem should be addressed by the therapist. The treatment focus agreed on by the therapist and patient is the main topic for each session. Concerns of the patient are discussed with an eye to the use of specific strategies to address the concerns.

This phase of IPT treatment offers the opportunity for the patient to create new relational patterns in established relationships and to develop interest in new relationships and roles. This process involves grieving what has been lost in old relationship patterns related to the depression. In this phase of treatment, the patient is asked to discuss experiences occurring between the weekly sessions as they relate to the specific problem identified as the focus for treatment. The therapist guides the patient to connect the symptoms described in the weekly meeting with the identified interpersonal issue. The therapist greets the patient during each session with a general question about what has been happening. The focus is on the here and now concerns and events. Strategies appropriate to the initial treatment contract and the stage of therapy are discussed. The patient’s experiences are discussed, with the therapist leading the patient to understand the experience within the framework of the identified problem and its intended focus. As the therapy progresses, the patient is encouraged to use alternative strategies if and when the originally identified strategies are not successful in reducing the distress surrounding the focus problem.

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3. The final sessions: termination phase (sessions 14 through 16); the work of the final sessions overlaps with the final sessions of the middle phase of treatment. The focus of this stage is the ending of treatment, working with the grief of the loss of therapy and the relationship with the therapist, and attending to the issues of relapse prevention. One of the aspects of IPT is that there is purposeful discussion about which number the session is in the overall total of 16 sessions throughout the treatment process. This enables the patient to deal with the upcoming loss and to not avoid it until the final therapy sessions.

Follow-up research after the conclusion of IPT shows that the beneficial outcomes of the therapy are increasingly demonstrated during the months following IPT treatment (Markowitz & Weissman, 2012a). These findings support the importance of addressing ways in which the patient is able to continue the work of the therapy independently. An IPT maintenance model was developed to work specifically with individuals who were at higher risk for relapse after conclusion of traditional IPT (Klerman et al., 1984). The following aspects of the termination phase of treatment support the potential for effective outcomes of IPT:

Engage in frank discussion about the end of therapy, particularly during the final three sessions, as well as during the earlier sessions if the patient demonstrates distress when the therapist discusses the number of sessions that have been completed.

Acknowledge the patient’s reaction to the end of therapy, and initiate discussion about the patient’s reaction.

Allow that the ending of therapy is a time of grieving. Recognize the patient’s movement during therapy to independent compliance and success in mastering strategies to change original relationship patterns.

Assess the treatment, and review future needs. Examine early warning signs of relapse, and discuss strategies to address them. Discuss self-assessment criteria to indicate the need to re-enter treatment.

The case example in this chapter illustrates the four interpersonal difficulties that are the primary criteria recommended when considering using IPT as a psychotherapy choice: interpersonal disputes, role transitions, grief, and interpersonal deficits.

CASE EXAMPLE

Tom Moylan is a 39-year-old, married father of three girls, ages 8, 5, and 3 years. He is employed in a low-level management job in the federal government. His wife is employed part- time in a secretarial position. Tom’s family history includes being the youngest child in a family with two older sisters. His father was a strict disciplinarian when Tom was a child, and he used the strap frequently, exclusively on Tom. His sisters were exempt. Tom’s oldest sister had an excessively fused relationship with their mother. The mother and sister reported to the father when he arrived home in the evening about Tom’s transgressions. Tom felt deep rage and humiliation about his father’s beatings. When Tom became an adolescent, he was viewed by his father, mother, and his oldest sister as the black sheep of the family.

Tom’s performance in high school and college was not exemplary. His work history included a series of jobs in which he was underemployed for his education level. He proceeded in his late 20s to obtain a master’s degree in his management specialty. At 31, he was diagnosed with non-Hodgkin’s lymphoma and was successfully treated; there was no recurrence of disease.

Tom entered therapy at the urging of his wife because of her concern about the stress he was experiencing at work and the potential effects that this unresolved stress was having on his mental and physical health. In his initial session, his presentation was apologetic and pervasively marked by self-defeating comments. It seemed as though his experience with his father had left him beaten down. Although he was an intelligent, well- spoken, and attractive man, he genuinely appeared not to be aware of the deficits in his self- image that were affecting his interpersonal functioning. He told the advanced practice psychiatric nurse (APPN) that his advanced degree had no effect on his employment status because he had been employed in a low-level job that he had held for the past 7 years. Despite attempts for 3 years to advance in his work, he was unsuccessful. His assessment of every

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situation discussed in the initial sessions was rated as either all good or all bad, with his view of himself as all bad, no matter what issue was being discussed. He reflected pessimism about every issue. In addition to his pervasively negative self-view, hopelessness about his current life condition, and difficulty making decisions, he suffered from chronic back pain, general joint distress, and fatigue. He met the DSM-5 clinical criteria for persistent depressive disorder (dysthymia).

This history was gathered during the initial phase of treatment. Tom’s circumstances included elements of interpersonal difficulties with role transition to independent and effective functioning as an adult when he left home and was no longer experiencing the mental cruelty of his father and family. It is likely that Tom’s difficulties were related to unresolved grief about his painful experiences with his family. The primary focus of IPT is to address the current “here and now” situation that is contributing most strongly to a patient’s interpersonal distress. The primary factor that was causing his interpersonal problems was his own perception of interpersonal deficits—he felt he was not good enough. As this focus was discussed with Tom, he agreed strongly that his perception of interpersonal deficits would be the issue most helpful to address.

One of the initial recommendations to Tom was to obtain a complete physical examination so that his current health status would be clarified. The specter of cancer recurrence undermined his thinking about the future. In his mind, cancer was one of the interpersonal enemies that were out to get him. Optimism was not possible because cancer was always there as the nemesis. Another aspect of his interpersonal deficits was that he had no confidence that he was cured, despite his physician’s assertions.

Each session of the 16 started with this question: “How are things going?” During the initial phase of treatment, Tom’s early pessimism and dysthymic symptoms began to improve as he began to discuss his desire for change in his interpersonal relationships, primarily at work. Tom also recognized that if there was an improvement in his self-view and self-esteem, it would benefit all of his relationships. Early in the therapy process, Tom spoke about reentering college to begin training in a new field. He did not have a strong sense of what that field would be. His self-perception of being inadequate was pervasive. Despite holding a master’s degree in his field, he could not imagine himself being able to advance in his current occupation. In his distorted reasoning, he saw himself as being able to improve his occupational options only by beginning education in a new field, which meant 6 years of full-time academic work and no significant income, despite having a wife and three children.

Tom’s problems were syntonic, which means that whatever is going on is in agreement with a person’s internal view. The APPN engaged Tom in discussion about the way in which he put himself down consistently and asked him whether he was aware of how he viewed himself negatively. Surprisingly, he was genuinely unaware of the totality of his self- negating view. The purpose of the IPT approach was to support Tom in discovering a different self-view so that he could interact with others from a position of self-acceptance and self-esteem.

Another dimension of Tom’s negative self-view was his view of God as unforgiving, harsh, and damning. Changing this view was one of the goals of the IPT therapy that he agreed to. The APPN explored whether Tom had rejected God as he imagined God rejecting him for not being good enough. Tom had felt abandoned by God when he was an adolescent. He had no interest in talking with a minister about his view of God. The therapist asked Tom to consider reading a few books on Buddhism, and he was willing to do so. The books discussed the Buddhist view of letting go of expectations. Because Tom’s expectations, no matter what he was thinking about, were negative, it was possible that the simple format of these books might bring about a different view.

As Tom’s therapy entered the intermediate phase, his self-view and personal rules began to soften. Tom was referred to a career coach when he indicated an interest in reviewing and rewriting his resume. During a session in this middle phase of IPT, Tom mentioned to the therapist that there was a position being advertised in his department that he would like to interview for, but he believed he did not have the qualifications. When Tom brought in the list of qualifications, the APPN asked him which ones he thought he was missing. He said that he did not have 10% of the promotion criteria. In discussion about the possibility of being a candidate for the job, his enthusiasm began to rise. Tom interviewed for the job a few days later. He did not get the job, but for the first time in his 7-year employment, his supervisor sat with

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him, and the two developed a plan for increasing his experience to qualify for a job promotion in the future. The plan included some in-service training and extra on-the-job experiences that were not included in his current resume.

Another focus of interpersonal deficits that came to light in the early phase of treatment was Tom’s harsh treatment and expectations of his children. It was as though he was attempting to shape his daughters so that they would be stronger than him. He seemed to be enforcing the same unreasonable expectations that his father had placed on him. By asking Tom what it might be like for his children when he used this approach, he was gradually able to recognize his negative feelings toward his father. Initially, he had described his father as doing what he needed to do. In other words, because Tom was a bad kid his father had no choice but to discipline him harshly. As Tom heard his own voice and listened to his reasoning, he rapidly developed insight that he was not a bad kid, and he recognized that his father’s approach had been misguided.

In keeping with the IPT model, Tom’s final IPT sessions addressed the ending of the therapy, the possibility and normalcy of feeling grief about the loss of the therapy process and the relationship with the therapist, and recognition of the increasing independence of the patient. Tom was able to discuss these dimensions of the closing of the therapy realistically and insightfully. The termination phase of Tom’s therapy focused on the changes in Tom’s perceptions of himself and in relation to his job, his children, and God:

1. His gains in self-view and decision making were demonstrated by his ability to enter the competition for a job promotion.

2. There was a difference in his interactions with his children; he had become more affectionate, loving, and less punitive with them.

3. His propensity for self-judgment lessened. 4. His feeling of well-being was enhanced by the results of his physical examination and

successful treatment of his chronic back pain by a chiropractor. 5. He had an increased sense of control and choice in his life. 6. He recognized that he could become a more optimistic partner with his wife in their marriage

and in raising their children.

Tom was moved by the shift in his view of himself and of relationships with the important others in his life. The others included himself, his original cancer diagnosis, and God. The final sessions included discussing how he would be able to quiet his negativism and recognize when it was undermining his emotional balance and optimism.

POSTMASTER’S IPT TRAINING AND CERTIFICATION REQUIREMENTS

There is no single standard for training and competency in IPT. Although no certifying body exists, the International Society for Interpersonal Psychotherapy (ISIPT, 2006) oversees the certification and training standards for this particular IPT clinical approach. The UK IPT organization proposes guidelines for certification but whether these become adopted universally is doubtful. Relevant websites for information on IPT are shown in Box 9.1.

IPT training usually begins with reading the IPT training manual and then attending a 2- to 4-day introductory training course. After completion of the initial course, the APPN begins working with a certified IPT supervisor with two clinical cases that fit the IPT supervisory model. The first supervised case is with a patient diagnosed with major depression. The second case is one that fits into the recommended list of clinical diagnoses that have been studied for efficacy with IPT. These include dysthymia, adolescent depression, or bulimia or binge-eating disorder.

The recommended clinical course for an IPT therapy case is 16 sessions. All sessions are recorded. A minimum of three randomly selected tapes from each of the two cases are reviewed and discussed in 4 or more hours of clinical supervision. On completion of this level of supervision, the IPT trainee uses IPT with at least two individuals over a 1-year period, receives ongoing supervision in the management of the cases at least monthly, and attends pertinent IPT training programs and conferences. A Casebook of Interpersonal

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Psychotherapy (Markowitz & Weissman, 2012b) provides clinical background to supplement IPT treatment manuals that are available.

BOX 9.1

WEBSITES RELATED TO IPT

www.interpersonalpsychotherapy.org: This website supplies information about the interpersonal psychotherapy (IPT) method and about related training protocol and standards. www.ipt-institute.com: The IPT website provides specific information about training opportunities. http://web4health.info/en/answers/psy-ipt-what.htm: This website offers many questions and answers about research findings using IPT, including its multiple uses in the clinical setting for a wide variety of psychiatric disorders. www.interpersonalpsychotherapy.org/onlineDocuments/isipt_accreditation_standards.pdf: This website offers guidelines for certification of IPT therapists and supervisors.

CONCLUDING COMMENTS

IPT is a psychotherapy approach developed during the 1970s, responsive to medical economics and societal changes, and focuses primarily on a protocol for treating depression. This model has been tested in multiple settings in randomized clinical trials and is efficacious compared with behavioral, cognitive, and pharmacological interventions. Efficacy of IPT is documented in a number of other clinical conditions, such as dysthymia, adolescent depression, substance misuse, bipolar disorder, eating disorders, and medical settings as a short-term counseling intervention (Klerman et al., 1984; Markowitz & Weissman, 2012a). The validity and efficacy of IPT with a variety of mental health disorders offer promise and prove to be worthwhile for both patients and therapists. The ongoing changes in the delivery of health care in an increasingly restrictive economic environment value brevity of care, often at the expense of quality of care. IPT meets the challenge of short-term treatment without sacrificing effective outcomes.

DISCUSSION EXERCISES

1. What are the differences in approach when using IPT compared with psychodynamic psychotherapy?

2. Discuss the rationale for using a time-limited structured approach such as IPT with the problem focus areas that IPT was created to address. These focus areas include interpersonal disputes, role transitions, grief, and interpersonal deficits.

3. What are the potential benefits to using IPT for depression in antepartum and postpartum women?

4. What are the training requirements for becoming an IPT therapist? 5. Discuss the advantages and disadvantages of using a protocol-driven psychotherapy intervention

such as IPT with depressed patients. 6. Name the types of psychiatric disorders that can be effectively treated with IPT. What are your

ideas about why this type of intervention is successful with these clinical conditions? 7. What do you think it is about the problem-focused approach of IPT that makes it most successful

with depressed patients? 8. What are the primary interpersonal values incorporated in the IPT approach? How do they

compare with the interpersonal model of Hildegard Peplau?

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cognitive behavioral therapy and group interpersonal psychotherapy for the treatment of overweight individuals with binge-eating disorder. Archives of General Psychiatry, 59, 713–721.

Wilson, G. T., Wilfley, D. E., Agras, W. S., & Bryson, S. W. (2010). Psychological treatment of binge eating disorder. Archives of General Psychiatry, 67, 94–101.

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Humanistic–Existential and Solution-Focused Approaches to Psychotherapy CANDICE KNIGHT

his chapter provides an overview of humanistic–existential therapy and solution-focused therapy (SFT) for the advanced practice psychiatric nurse (APPN). It addresses the influence of the humanistic–

existential approach in nursing and traces its historical evolution. Four major humanistic–existential approaches are described, explicating their key concepts, goals, and therapeutic interventions: person-centered therapy, existential therapy, Gestalt therapy, and emotion-focused therapy. Motivational interviewing, an important humanistic–existential approach, is covered in Chapter 7 and is not addressed in this chapter. SFT, a postmodern, social constructivist psychotherapy with humanistic–existential elements, is also included. Attention is focused on the practical aspects of conducting psychotherapy and delivering therapeutic interventions that a beginning level APPN would be able to use. Evidence-based research in humanistic– existential and SFT is presented. Case examples are provided to illustrate therapeutic interventions. The chapter concludes with a description of postmaster’s training and certification programs for humanistic– existential and SFT.

NURSING AND THE HUMANISTIC–EXISTENTIAL APPROACH

The humanistic–existential approach has long served as a foundation for psychiatric nursing with its emphasis on holism, self-actualization, facilitative communication, and the therapeutic relationship. In undergraduate programs, psychiatric nursing students are commonly taught Abraham Maslow’s theory of human needs and Carl Rogers’s facilitative communication techniques.

Important humanistic–existential nursing theorists include Joyce Travelbee, Josephine Paterson, Loretta Zderad, and Jean Watson. Their work is commonly found in nursing theory courses. Travelbee’s Human-to- Human Relationship Model of Nursing is an application of the existential work of Søren Kierkegaard and Victor Frankl and emphasizes free will and the search for meaning in experiences of pain, illness, and distress (Travelbee, 1971). Paterson and Zderad’s humanistic nursing views nursing as a lived dialogue between patient and nurse and places the phenomenological method of inquiry at the center of importance (Paterson & Zderad, 1988). Watson’s Theory of Human Caring emphasizes a caring relationship with patients that includes Carl Rogers’s unconditional acceptance and positive regard as well as creating caring moments of healing (Watson, 2011).

In advanced practice psychiatric nursing as well as in all mental health disciplines, the humanistic– existential concepts of empathic attunement and the therapeutic relationship are emphasized in psychotherapy courses. The major theoretical orientations of person-centered psychotherapy, Gestalt psychotherapy, and existential psychotherapy have stood the test of time and are commonly taught as the three foundational psychotherapies of the humanistic–existential approach. Other important humanistic–existential therapies include transactional analysis, focusing, actualizing therapy, and redecision therapy. More recently, emotion- focused therapy and motivational interviewing have received much attention. These two empirically validated therapies have placed the humanistic–existential school in a position of importance.

HISTORICAL ROOTS

The historical roots of humanistic–existential psychotherapy extend back in time to the birth of the philosophies of humanism, existentialism, and phenomenology. Humanism, a reform movement of the 14th- century European renaissance, developed in response to medieval religious ideologies and focused on human

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values rather than the divine. Humanism’s dominant themes were happiness, spontaneity, creativity, actualization, holism, and the goodness of the human spirit (Kendler, 1986).

Existentialism emerged as a reaction to the dominant philosophy of rationalism and the objectivity of science during the mid-19th century. Beginning with the writings of Kierkegaard (1813–1855), existentialism focused on personal choice and commitment. Later existential leaders such as Friedrich Nietzsche (1844– 1900) introduced existential themes of responsibility and courage. Jean-Paul Sartre (1905–1980) later recognized the importance of human freedom, emotions, and imagination (Kendler, 1986).

During the early 20th century, Edmund Husserl’s (1859–1938) phenomenological philosophy broke with the dominant science of positivism and focused on a person’s lived experience as the source of knowledge and truth (Husserl, 1925). Phenomenology is dedicated to the descriptive study of consciousness and subjective experience, completely free of preconceptions, interpretation, explanation, and evaluation. Martin Heidegger (1889–1976), another phenomenological philosopher, later applied phenomenological methods to understanding the meaning of experience (Heidegger, 1962).

In the United States, the philosophies of humanism, existentialism, and phenomenology merged into the humanistic–existential movement soon after World War II. Although articles began to emerge in the late 1950s, scholars consider the birth of humanistic–existential to be in 1964, when a group of psychologists, including Carl Rogers, Abraham Maslow, Rollo May, Clark Moustakas, Gordon Allport, and others, met in Old Saybrook, Connecticut, and unmistakably defined and described humanistic–existential psychology. After that historic meeting, the movement gained widespread popularity.

Psychoanalysis and behaviorism, respectively known as the “first force” and “second force” of psychotherapy, were joined by humanistic–existential psychotherapy, which became known as the “third force,” a term coined by Abraham Maslow in his text, Toward a Psychology of Being (Maslow, 1962). Humanistic–existential psychology’s ideas and values became incorporated into and nourished the great social upheavals of the 1960s and 1970s including the feminist, civil rights, antiwar, and human potential movements. Humanistic–existential psychotherapy also spawned a plethora of pop psychology texts that are widespread today. Five decades of substantial advances in theory, practice, and research have accumulated supporting the effectiveness of humanistic–existential psychotherapy (Cain & Seeman, 2002; Elliott, 2002; Kirschenbaum & Jourdan, 2005).

HUMANISTIC–EXISTENTIAL PSYCHOTHERAPY

The humanistic–existential psychotherapy approach includes a diverse group of psychotherapies. Each shares philosophical assumptions that rest on the philosophies of humanism, existentialism, and phenomenology.

Characteristics of Humanistic–Existential Psychotherapy

Seven distinctive characteristics of humanistic–existential psychotherapy distinguish it from the characteristics of other approaches. A list of these characteristics can be found in Box 10.1 and are described in more detail below.

BOX 10.1

CHARACTERISTICS OF HUMANISTIC–EXISTENTIAL PSYCHOTHERAPY

Commitment to the phenomenological perspective Centrality of the therapeutic relationship Belief in holism Focus on the here and now Emphasis on humanistic–existential themes Prominence of process Use of experiential techniques

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COMMITMENT TO THE PHENOMENOLOGICAL PERSPECTIVE

A phenomenological perspective strives to understand the subjective experience of the client in the context of his or her unique experience. The therapist brackets (sets aside) all presuppositions and preconceptions that interfere with the ability to attend to the immediate experience and enters into the client’s frame of reference without prejudgment about what content is real or false or which is significant or trivial. The client, rather than the therapist, generates explanations and interpretations (Rogers, 1980). Commitment to the phenomenological approach is grounded in the belief that clients are uniquely capable of reflective consciousness and this capacity leads to self-determination and self-actualization (Greenberg & Rice, 1997). In most psychotherapeutic approaches, the therapist conceptualizes the client’s narrative using preconceptions removed from the direct, unfiltered experience of the client. In a phenomenological perspective, the client’s lived experience is paramount. For example, a victim of a traumatic assault may experience fear years after the event, even when no apparent threat exists. What does this fear mean? Where does it come from? How is it experienced from the client’s perspective? The answers bring the therapist closer to the phenomenon that is lived by the client.

CENTRALITY OF THE THERAPEUTIC RELATIONSHIP

The therapist–client relationship is the primary source for constructive change in the humanistic–existential approach. The relationship, described by Martin Buber as a genuine “I–Thou” encounter, stresses a collaborative, authentic, dialogic encounter (Buber, 1937). The therapist focuses on empathic understanding of the client and trusts that the client has the capacity to make choices and strive toward meaningful life goals. The humanistic–existential literature has been foremost in publishing research on the centrality of the therapeutic relationship. In fact, Carl Rogers (1957) was the first to empirically discover that the therapist’s characteristics of empathy, genuineness, and unconditional positive regard, along with the client’s ability to perceive these characteristics, are the necessary elements for therapeutic change. Contemporary research has consistently shown that the therapeutic relationship is the common factor responsible for positive therapy outcomes and that therapists who are empathic, caring, and congruent are more effective (Duncan, Miller, Wampold, & Hubble, 2010; Wampold, 2001).

BELIEF IN HOLISM

The etymological roots of the word holism stem from the Greek word holos, meaning the total or entirety. Holism was brought to the attention of psychology by the South African statesman and philosopher, Jan Smuts, who described the holistic nature of the personality in his text Holism and Evolution (1926). Smuts had a profound influence on Frederick Perls, the founder of Gestalt therapy, who integrated the concept of holism into Gestalt therapy (Perls, 1942). It soon became a major tenet in the humanistic–existential approach to psychotherapy. Holism recognizes that people are unique, whole individuals who cannot be reduced to separated parts, encapsulated in the expression, “the whole is greater than the sum of its parts.” It posits that each person is a unified whole of mind, body, and spirit and that these aspects work together in a synergistic fashion, mutually and reciprocally influencing and modifying each other (Smuts, 1926). Holism understands dysfunction from an integrated perspective seeking to comprehend the entirety of the person and rejects a reductionist point of view, which understands dysfunction by identifying a specific part such as a thought or a chemical imbalance.

FOCUS ON THE HERE AND NOW

Humanistic–existential therapy believes that authentic contact and change can only happen in the present; thus, the here and now is the focus of therapy. The here and now, a frequently misunderstood concept, is not merely talking about what is currently happening in the client’s life nor is it an exclusion of the past or the future. Instead, the past, present, and future are experienced in the here and now through various interventions introduced by the therapist. For example, if the client begins to tell a story about something that happened in the past, the therapist might say, “Tell me the story as if it was happening now, in the present tense,” so that

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the past comes alive in the moment. The client who begins to tell a difficult situation that happened during the week may be asked, “What are you experiencing right now as you impart this information?” The humanistic–existential approach is also interested in what is emerging in the moment within the therapeutic relationship. For example, a person who believes that the world is bereft of support may at times feel unsupported within the therapeutic relationship. Addressing the issues that emerge during the session poignantly brings the here and now into focus.

EMPHASIS ON HUMANISTIC–EXISTENTIAL THEMES

Humanistic–existential themes are concerned with the universal human experiences of life (the givens of existence). Most prominent themes include awareness, authenticity, freedom, choice, responsibility, meaning, and self-actualization. Awareness allows one the freedom to choose and organize life in a meaningful way. Authenticity, rather than self-deception, allows a person to be fully responsible and live life with aliveness rather than with feelings of dread, guilt, and anxiety. The humanistic–existential approach believes that a person is faced at every moment with choice and is responsible for the choices that are made. There is also a belief in the self-actualizing tendency and the notion that if a person is provided with the appropriate conditions, he or she will automatically grow in positive ways and find meaning in existence (Cain & Seeman, 2002). The approach holds that a person is endlessly remaking or discovering himself or herself and there is no essence of human nature to be discovered once and for all. The humanistic–existential approach is concerned with the significant experiences of being human.

PROMINENCE OF PROCESS

Humanistic–existential therapies focus more on the process rather than the content of therapy. The process of therapy describes the flow of action and reaction within the session. The content of therapy, in contrast, refers to what is being discussed in therapy. The content is easier to observe than the process for it refers to the specific facts such as the client’s description of problems and perspectives about their causality. Humanistic– existential therapy does not ignore the content, for knowledge of content is necessary for empathy and connection. The emphasis, however, is on the process, for the process is what provides the essential information as to how the client is experiencing and provides an avenue for real change to occur. For example, while listening to the content of the client’s narrative, the humanistic–existential therapist pays attention and notices the how of experiencing. The therapist may say, “What just happened inside when you told me about this difficult situation?”

USE OF EXPERIENTIAL TECHNIQUES

Humanistic–existential therapists do not interpret or give advice, but use experiential techniques that are reflective and experimental in style. They work actively with clients, using interventions to heighten awareness, promote the expression of emotionally laden material, support contact, and guide attentional focus to stimulate novel experience (Greenberg & Goldman, 1988). Experiential techniques are carefully tailored to a client’s specific wants and needs at a given moment, and serve the purpose of enhancing a client’s experience in the here and now. Experiential techniques give the client a chance to try out, in the safety of the therapeutic situation, variations of current behavior. The possibilities of experiential techniques are unlimited and may include attention to the body such as the breath and the voice, exaggeration to emphasize awareness, and reenactments of problematic scenes of the past in the here and now to create healing moments. They may include the use of creative arts, including drawing, music, and movement. They may include working with dreams or the empty chair (Greenberg, 1979). Experiential techniques vary and depend on the developmental readiness of the client, the characteristics of the client, the stage of the therapeutic relationship, and the style and creativity of the therapist in the moment.

BELIEFS ABOUT CLIENTS IN THE HUMANISTIC– EXISTENTIAL APPROACH

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The humanistic–existential approach has specific beliefs about clients. A list of these beliefs can be found in Box 10.2 (Cain & Seeman, 2002).

Humanistic–existential therapists attempt to receive clients with curiosity and openness, endeavoring to grasp their subjective world, and believing that clients are the experts on their own experience. They use the phenomenological approach of suspending preconceptions and bracketing anything that may interfere with their ability to attend to immediate experience. They view clients as unique beings who are understood only in the context of their experiences. They appreciate multiple perspectives on reality and believe that the same experience can be interpreted in diverse ways. Humanistic–existential therapists have an implicit optimism in clients’ capacity for growth and change, while not denying the existence of dark, destructive aspects of self and the extremes of emotional pain. They have a commitment to democratic principles in negotiating differences and are inclined to engage in relationships that are collaborative, authentic, and provide optimal freedom (Cain & Seeman, 2002).

BOX 10.2

HUMANISTIC–EXISTENTIAL BELIEFS ABOUT CLIENTS

Clients are: Endowed with an inherent tendency to develop their potential Resourceful and have the capacity to draw on inner and outer resources Free to choose how to live and are responsible for the choices made Resilient in manifesting their natural inclination to survive and grow Holistic and not reducible to the sum of their parts Contextual and best understood in relationship to others and their environment Meaning making and find meaning by creating and constructing realities from experience Social beings and have a powerful need to feel valued and belong Diverse in worldviews and viable lifestyles that result in satisfying lives

PERSON-CENTERED THERAPY

Overview

Person-centered psychotherapy, also known as client-centered psychotherapy, was founded by Carl Rogers (1902–1987), the most influential psychotherapist of the 20th century (Cook, Biyanova, & Coyne, 2009). He developed a nondirective, client-centered approach to psychotherapy that recognized the importance of facilitative counseling techniques such as reflection, exploring, and clarification (Rogers, 1942) as well as the three facilitative conditions necessary for positive therapeutic outcomes: unconditional positive regard, empathic understanding, and congruence (Rogers, 1961). Rogers popularized the term client rather than patient, emphasizing the egalitarian relationship between the therapist and the client. Initially, he named his approach client-centered psychotherapy as a way to highlight the prominence of the client’s knowledge in determining the focus and direction of therapy. He rigorously trained students as well as conducted extensive research by recording, transcribing, and studying transcripts of audio-recorded therapy sessions in an attempt to understand therapy processes (Kirschenbaum & Jourdan, 2005). His book Counseling and Psychotherapy: Newer Concepts in Practice (Rogers, 1942) contained the first complete transcript of an actual therapy session, the case of Herbert Bryan, which was the first phonographically recorded verbatim transcript of an entire course of psychotherapy ever published. Rogers’s approach to psychotherapy training was later used by graduate psychiatric nursing programs in the form of audio and written process recordings.

Later in his career, Rogers became increasingly interested in working with groups and systems including education, industry, and politics and renamed his approach person-centered psychotherapy, reflecting its application to diverse populations. His last years were devoted to international relations, applying his theories to situations of political conflict in his pursuit of world peace, and he was nominated for a Nobel Peace Prize. The influence of Rogers’s work has continued today, with over 200 training institutes worldwide (Kirschenbaum & Jourdan, 2005). Natalie Rogers (1993) has integrated person-centered therapy with the creative arts and developed expressive arts psychotherapy. Virginia Axline (1964) has

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applied the person-centered approach to children and play therapy. Eugene Gendlin (1981) developed experiential techniques such as focusing as a way to enhance client experiencing. Person-centered therapy also serves as an integral component of motivational interviewing (Miller & Rollnick, 2002) and emotion-focused therapy (Greenberg, 2011), two contemporary, humanistic–existential psychotherapy approaches.

The central belief of person-centered therapy is that people are basically good and have a vast potential for self-growth if their potential is tapped within a special type of therapeutic relationship that provides the necessary, facilitative conditions of empathic understanding, unconditional positive regard, and congruence (Rogers, 1957, 1961). Over the last decade, research has repeatedly demonstrated that successful psychotherapy depends on these common factors (Duncan, Miller, Wampold, & Hubble, 2010; Wampold, 2001).

Key Concepts

BELIEF OF HUMAN NATURE

A central belief in the person-centered approach is that there is a positive center at the core of all individuals. People are thought to be trustworthy, creative, and resourceful. They are capable of self-understanding and self-direction and able to live effective and productive lives. People become destructive only when a poor self- concept or external constraints override the core sense of goodness (Rogers, 1961).

SELF-CONCEPT

An organized, consistent set of perceptions about the self, continually influenced by experience and its interpretation. Self-concept includes self-worth (what a person thinks about self), self-image (how a person sees self), and ideal self (how a person would like to be). People are in a state of congruence with a higher sense of self-worth when their self-image and ideal self are similar to each other, a necessary state for self- actualization (Rogers, 1951).

ACTUALIZING TENDENCY

The innate drive, basic motivational force, and directional process in humans to grow, develop, and strive toward self-realization and fulfillment (Rogers, 1951). Rogers stated, “The organism has one basic tendency and striving - to actualize, maintain, and enhance the experiencing organism” (Rogers, 1951, p. 487). A belief in the actualizing tendency places trust in the client’s capacity to know what needs to be worked on and what choices to make.

FULLY FUNCTIONING PERSON

An individual who is fully engaged in the process of self-actualization. A fully functioning person demonstrates the following: (1) knowledge of subjective experience, (2) existential living emphasizing choice, freedom, and responsibility, (3) awareness of emotions, (4) ability to take risks and seek new experiences, and (5) engagement in a continual process of change (Rogers, 1961).

Goals of Therapy

The goal of person-centered therapy is for the client to become a fully functioning person engaged in the process of self-actualization. When achieving this level of development, the client is able to live life more authentically and cope well with current and future problems. The therapist provides a climate conducive to helping the person achieve these goals (Rogers, 1961).

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Psychotherapeutic Interventions: Assessment

The therapist begins the assessment by asking the client where to begin and what issues to work on. The client’s phenomenological experience, rather than the presenting problem, is the focus. The therapist is genuine, empathic, and caring and sets aside preconceptions in an attempt to understand the inner world of the client. The therapist creates an understanding atmosphere that encourages clarification and reflection of present feelings. For example, to the client’s comment, “I’m depressed most of the time,” the therapist might respond with, “You constantly feel unhappy?” The client is then able to pursue his or her own line of thought, resulting in a fuller exposure of the client’s subjective experience.

Traditional assessment procedures such as taking a psychiatric history or using psychometric tests are not used because these approaches encourage an external focus and give the client the message that the therapist is the expert who provides the solutions. The client is not considered a sick patient in need of treatment, but a person who is prevented from realizing his or her potential. Diagnosing is not highly regarded in this approach. Rogers believed that diagnostic constructs are inadequate, prejudicial, and often misconstrued (Rogers, 1942). If providing a diagnosis is necessary, a collaborative approach is used in which the client and therapist together formulate the diagnosis (Bohart & Watson, 2011).

Psychotherapeutic Interventions: Psychotherapy Techniques

In the person-centered approach, each session is considered fresh and unpredictable. Structured techniques and process interventions beyond facilitative listening are avoided. The therapist honors the wisdom of the client and the ability of the client to determine the direction of therapy. This encourages greater self- exploration and improves self-understanding (Rogers, 1961).

NONDIRECTIVE–FACILITATIVE COUNSELING

The person-centered approach emphasizes a nondirective–facilitative counseling approach with the aim of helping clients become aware of their inner experiences and processes. This approach is quite different than the directive and interpretive approaches that were practiced during the time when the person-centered approach was developed. In Rogers’s early text, Counseling and Psychotherapy: Newer Concepts in Practice (1942), the practice of nondirective counseling and facilitative counseling techniques were explicated. The therapist attempts to understand the inner world of the client and the client’s lived experiences through a discovery-oriented approach. While techniques such as giving advice, persuasion, and interpretation are discouraged, techniques such as reflecting, clarifying, and exploring are encouraged: “Is this what you are saying or experiencing?” “Do I have that right?” “Does it fit?” Other techniques include presence and immediacy, which are being completely attentive to and immersed in the client’s expressed concerns and addressing what is specifically going on between the client and therapist, respectively (Cain, 2010).

It is important to note that the person-centered approach is not just a repertoire of techniques or merely reflecting the last part of the client’s statement, which some critics of the approach often state. The attitude of the therapist and the therapeutic relationship are the heart of person-centered psychotherapy rather than the technique. The relationship provides a supportive structure within which clients’ self-healing capacities are activated and where change occurs. A psychotherapist who is too directive or too busy guiding the client toward goals will find it difficult to establish the essence of a therapeutic relationship (Rogers, 1961).

PSYCHOLOGICAL CONDITIONS NECESSARY FOR PERSONALITY GROWTH

In the person-centered approach, the therapist embodies and implements the three core conditions, which are both necessary and sufficient for successful therapy. Rogers believed that the therapist needs to be evolved as a person in order to provide these conditions (Rogers, 1961). They are fully explicated in Rogers’s seminal text, On Becoming a Person (Rogers, 1961) and include:

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Congruence. The therapist who is genuine and authentic during the therapy session embodies the core condition of congruence and serves as a model to the client. Congruence involves having inner and outer experiences that match. The therapist openly expresses feelings, thoughts, and reactions with the client, which may include the expression of a range of feelings including annoyance, but in a well-timed, constructive fashion that is attuned to the emerging needs of the client. As the client experiences the genuineness of the therapist, pretenses drop and authenticity prevails.

Unconditional positive regard. The therapist has a deep caring for the client best achieved through empathic identification. The therapist is nonjudgmental of the client and warmly accepts him or her without placing stipulations on the acceptance. The greater the degree of caring and accepting, the greater the chance the therapy will be successful (Rogers, 1957). It is uncommon to feel acceptance and unconditional caring at all times, but if there is little or an active dislike for the client, therapy is not likely to be fruitful. If the therapist’s caring stems from his or her own need to be liked and appreciated, change is also inhibited. The greater the degree of caring, prizing, accepting, and valuing of the client, the greater chance the client will begin to see worth and value in himself or herself.

Accurate empathic understanding. Accurate empathic understanding is the cornerstone of the person- centered approach. Empathy is a very deep understanding of the client and requires attunement to the client’s experience as it is revealed moment to moment during the session. To sense the subjective experience in this way encourages the client to feel more deeply and to recognize and resolve the incongruity that exists within himself or herself. It goes beyond recognition of the obvious feelings to a sense of the less clearly experienced feelings. The therapist attempts to understand the meanings expressed by the client that often lie at the edge of awareness. Showing empathy requires understanding the client’s feelings and reflecting them back to the client to help him or her understand these feelings (Elliott, Bohart, Watson, & Greenberg, 2011). The therapist can share the subjective world of the client by drawing from his or her similar experiences, which helps the client process his or her own experience. Sixty years of research has consistently demonstrated that empathy is the most powerful determinant of client progress in therapy (Cain, 2010).

GESTALT PSYCHOTHERAPY

Overview

Gestalt therapy, founded by Fritz Perls (1893–1970) and Laura Perls (1905–1990), is a theoretically and clinically complex approach to psychotherapy. Gestalt, a German word meaning organized whole, recognizes the unity of humans as integrated wholes, not divided into parts, taken out of context, or generalized. Fritz Perls, a German physician, was influenced by Jan Smuts’s views of holism, Kurt Goldstein’s ideas of organismic self-regulation, Kurt Lewin’s field theory, Martin Buber and Paul Tillich’s views on relationships and existentialism, and by his own analysts: Wilhelm Reich, a body-oriented psychoanalyst who stimulated his interest in how unexpressed energy is held within the body, and Karen Horney, an interpersonal psychoanalyst, who inspired his interest in neurotic structures and layers of the personality. His training in theatre and Zen Buddhist practices were also an important influence for therapeutic interventions. Laura Perls, a German psychologist, studied Gestalt psychology with Kurt Goldstein and Max Wertheimer, phenomenological and existential philosophy with Paul Tillich and Martin Buber, and field theory with Kurt Lewin. As a psychoanalyst she trained with Otto Fenichel, an analyst interested in sociological explanations, and had her personal analysis with Frieda Fromm-Reichmann and Karl Landauer. Laura Perls’s early training as a classical pianist and modern dancer influenced her therapeutic interventions.

Soon after Nazism descended on Germany, the Perls left Germany and settled in South Africa, where they became directors of the South African Psychoanalytic Institute and collaborated on the book, Ego, Hunger and Aggression: A Revision of Freud’s Theory and Method (Perls, 1942). This book broke with the traditional psychoanalytic approach to include concepts of holism, existentialism, and phenomenology. After immigrating to the United States, they broke away from the psychoanalytic community and officially launched Gestalt therapy in 1951, with the publication of Gestalt Therapy: Excitement and Growth in the Human Personality (Perls, Hefferline, & Goodman, 1951). Within a short time, the New York Institute for Gestalt therapy was formed and workshops and study groups began throughout the country. Fritz Perls eventually settled at the Esalen Institute in California, where he trained numerous clinicians in his well-known Gestalt therapy workshops. Gestalt therapy has continued to develop and thrive, further expanding its concepts and

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methodologies (Wheeler, 1991; Yontef, 1993; Zinker, 1977), and establishing training institutes worldwide (Knight, 1996).

Gestalt therapy can be described as a humanistic–existential psychotherapy with theoretical roots firmly grounded in holism, phenomenology, existentialism, humanism, Gestalt psychology, Organismic Theory, interpersonal psychoanalysis, and Eastern philosophy. It integrated aspects of these theories to create a unified, unique approach to psychotherapy.

Key Concepts

ORGANISMIC SELF-REGULATION

A natural process whereby the organism is continually disturbed by the emergence of a need and strives to restore equilibrium by constantly reorganizing and adapting to changing circumstances. Organismic self- regulation is a growth process by which a person moves toward wholeness and integration. It has been operationalized into a cycle of experience: (a) awareness of sensation, (b) figure and ground formation, (c) mobilization, (d) action, (e) contact, and (f) withdrawal. This cycle provides a way to understand health and dysfunction as well as guide therapeutic process interventions.

Awareness of sensation (e.g., feelings, drives, or perceptions) commences the cycle as an experience from within or in response to an environmental stimulation. Figure formation organizes sensation into a meaningful want or need in relationship to the environment. Mobilization is the surge of energy that impels the figure formation into action. Action is the movement that brings the person into contact with self or an environmental object. Contact is the meeting of self and other at the boundary to either assimilate or reject the object. Withdrawal is the fading of the figure into the background, disengagement, and the closure of the Gestalt. When people are functioning well, they move through the cycle of experience in a rhythmic, sequential fashion with awareness, excitement, and aliveness. When functioning poorly, they are unaware and interrupt the organismic process, reducing vitality and creating dysfunction (Perls, 1973).

INTERRUPTIONS

Interruptions to awareness and contact, also known as boundary disturbances, refer to dysfunctional processes, developed early in life, that people employ in an attempt to meet their needs. Gestalt therapists bring awareness to these interruptions and create experiments to reduce them and restore organismic self-regulation. Some examples include:

Introjection. To uncritically accept others’ beliefs and standards without discriminating and assimilating what belongs to self and eliminating what does not. Examples are, “be a good girl,” “don’t be angry,” and “boys don’t cry.”

Projection. To disown certain unacceptable aspects of self by ascribing them to other people or the environment. Examples are blaming others for problems within the self or believing others do not like you when you actually have strong negative feelings toward them.

Retroflection. Turning back onto self what is meant for someone else. Instead of engaging with the environment and directing energy outwards, energy is redirected inwards. Examples of retroflection include biting one’s lip, self-harm behaviors, and symptoms of depression and psychophysiological disorders.

Confluence. Blurring the differentiation between self and the environment where there is no clear demarcation between internal experience and outer reality. Confluence allows a person to blend in and get along with everyone. Examples include extreme agreeability or the belief that people experience similar thoughts and feelings to self.

Deflection. Distractions that diminish the intensity and sustained sense of awareness and contact. Examples include avoiding direct eye contact, overuse of humor, generalizations, asking questions rather than making statements, and being overly polite (Polster & Polster, 1973).

FIGURE AND GROUND

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A theoretical explanation for how the self develops and organizes experiences as it interacts within the environmental field. The field is differentiated into figure (foreground) and ground (background). People organize aspects of the field into meaningful patterns in which one element stands out as the figure of interest, while the others recede into the ground. The figure is the dominant need at a given moment. As soon as the need is met or interest is lost, it recedes into the ground and a new figure emerges. All behavior is organized around emerging needs and their satisfaction. With healthy individuals, there is a natural flow of Gestalt formation and completion (Perls, 1973). In contrast, people with more dysfunctional patterns have incomplete Gestalts that clamor for attention. These incomplete Gestalts usurp the full attending powers for meeting new situations and dampen aliveness (Perls, 1969).

LAYERS OF THE PERSONALITY

When natural self-regulatory processes are disrupted, interruptions to awareness occur with frequency, parts of the self are disowned, and incomplete Gestalts become abundant. Each incomplete Gestalt represents an unfinished situation, which interferes with the formation of any novel Gestalt. Instead of growth, a person lives life within inauthentic layers of the personality (cliché, role, impasse, and implosion) rather than by organismic self-regulation. Cliché is the ordinary social chitchat and the most superficial, top layer of the personality; role is the part played in an interpersonal context such as the “good person” or the “invulnerable person”; impasse is a layer of confusion and stuckness, representing the conflict of moving to a deeper layer versus returning to role or cliché; implosion is the death or paralyzed layer where a part of self has been cut off or interrupted. Explosion is the last, authentic layer where contact with the genuine self occurs and feelings of joy, grief, anger, or orgasm explode into awareness. During therapy, specific interventions by the therapist help the client move through the layers to contact the authentic self (Perls, 1973).

Goals of Therapy

The goal of Gestalt therapy is to assist the client in restoring his or her natural state of organismic self- regulation. Disowned parts of self are reintegrated, inauthentic layers of existence are worked through, and unfinished Gestalts are completed (Perls, 1973). New Gestalts can then emerge and complete with fluidity. The client returns to a natural state of excitement, aliveness, and growth and is able to live a more vital, integrated, authentic, and meaningful life.

Psychotherapeutic Interventions: Assessment

Assessment in Gestalt therapy is a discovery process that allows for understanding the client’s experience and recognizing factors that hinder organismic self-regulation. Assessment occurs during the initial session and is ongoing throughout the course of therapy. It is both individualized and collaborative and addresses process and content factors. Process factors are figural and include such things as how the client relates to the therapist, the manner in which the narrative is related, the level of awareness and contact, interruptions to awareness, and nonverbal behavior such as body language, voice tone, mannerisms, posture, and energy level. Content factors are background and include information such as the precipitating problem, symptoms, stressors, developmental and family history, and mental status.

A goal of assessment is for the therapist to develop an empathic understanding of the client’s experience and unfolding story. To a major extent, this occurs by the use of facilitative communication and empathic responses. The therapist approaches assessment with a respect for the client’s figure and ground movement, allowing the client to bring to the foreground what is deemed important. The therapist has a notion of areas of the client’s life that are important to explore, yet, these notions are bracketed to allow for the natural unfolding of the session; thus, assessment is not viewed as a linear questioning procedure.

Collaboratively, the client and therapist come to a shared understanding of what is poignant, salient, and relevant for exploration. An agreed-on case formulation and goals are determined, which are tentative and always take second place to the client’s flow of experiencing (Watson, Goldman, & Greenberg, 2007). Process diagnoses such as retroflected anger or deflected sadness during a session take precedence and serve as a guide

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for interventions.

Psychotherapeutic Interventions: Psychotherapy Techniques

Change occurs in the here and now; thus, Gestalt therapists are interested in what is emerging in the moment and in making the past, present, and future come alive in the here and now. They pay close attention to the client’s organismic self-regulation and interruptions to awareness and contact. Gestalt therapists closely track the client’s process and content with moment-to-moment awareness in order to understand what is immediate and to guide and tailor appropriate interventions. Two critical therapeutic skills for the Gestalt therapist are the ability to establish an authentic, I–Thou relationship and to craft creative experiments (Perls, 1973).

I–THOU RELATIONSHIP

An authentic, nonjudgmental, dialogic relationship is carefully nurtured between the client and the therapist. This relationship, first discussed by the existential philosopher Martin Buber (1937), is a major component of Gestalt therapy and is necessary for change to occur. It is an encounter between the client and therapist where both persons are subjects, rather than one being subject and the other object. The client is not “talking to” an aloof expert, but rather “communicating with” a therapist who is aware, authentic, vulnerable, and fully human. The therapist strives to understand the client’s phenomenological field by experiencing his or her own reactions to the client and the therapeutic process, while also attending to the client’s thoughts, feelings, and behavior.

A Gestalt, I–Thou relationship requires suspending preconceptions and bracketing anything that may interfere with an ability to attend to immediate experience. It also requires an attitude of openness and humility and to approach the client with genuine interest, curiosity, and profound respect. It also requires the therapist to create a safe environment where the client feels understood rather than concerned with being judged or criticized (Yontef, 1993).

CREATIVE EXPERIMENTATION

Designing and implementing creative experiments is the cornerstone of Gestalt therapy interventions. Experiments heighten awareness, promote the expression of emotionally laden material, support contact, and guide attentional focus to stimulate novel experience. Creating experiments requires the therapist to be very aware and attend to the nonverbal as well as the verbal content of the client’s narratives in order to understand and focus on what is alive and immediate for the client. The specific experiment is not merely a technique imitated from an experienced Gestalt trainer or a technique to apply at whim, but a spontaneous, one-of-a- kind, tailored experiment, emerging from the dialogic interaction (Zinker, 1977). Experiments are creative and unlimited. Gestalt therapists bring their unique life experiences and skills to the creation of the experiment; thus each Gestalt therapist’s work is different. For example, one Gestalt therapist may pay close attention to the body such as the rate and depth of breath or the volume, timbre, or tone of the voice, while another may pay close attention to the syntax, fluidity, and meaning of language. Another Gestalt therapist may use metaphor and imagery to deal with a problematic situation, while another may use movement or the creative arts to deal with the same situation. Some well-known Gestalt experiments follow:

Body awareness. Clients frequently have blocked body energies manifested by shallow breathing, speaking in a restricted voice, shaking legs, or fidgeting fingers. Gestalt therapists pay close attention to the client’s body and create experiments to heighten body awareness. A therapist may ask, “What are you experiencing right now in your body?” or “Go inside and see what is emerging in your body now.” An example of this in-session process is as follows:

Client: Last night, I was so angry at my partner. After I finished telling him something important that happened to me during the day, I saw he was not paying attention to a word I said.

APPN: As you tell me this story, what are you experiencing?

Client: I am feeling angry and want to yell at him, but I can’t.

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APPN: Where are you experiencing the anger in your body? Client: In my throat, my voice. APPN: Can you support that part of your body and tell him how angry you are?

There are varied experiments that a Gestalt therapist may use to heighten body awareness to blocked energy. A client may be asked to exaggerate a body movement where energy is blocked. For example, a client who is moving the foot back and forth might be asked to do it more and exaggerate the movement. Or, a client may be asked to allow an image to emerge from a blocked body sensation. For example, a client experiencing confusion was asked to create an image and came up with a slide carousel going round and round. When asked to stay with the image, the client realized that the carousel could not stop because then a slide would pop up on the screen and she might not be able to deal with what she might see. This image was symbolic of the client’s fear of going deeper into her experience of traumatic memories that were beginning to move closer to the surface of her awareness (Knight, 1996).

Focusing. Focusing is used to make contact with disowned or alienated aspects of self (Gendlin, 1981). For example, in the following dialogue, the APPN notices that a person who is speaking calmly about a recent loss starts blinking:

APPN: I noticed when you told me the story of your recent loss, your eyes began blinking. Can you give a voice to your blinking eyes? Client: I am my blinking eyes—I am sad—blinking keeps my tears from flowing. APPN: Just breathe deeply into your blinking eyes. Client: After a few moments, the client’s tears begin to flow …

There are numerous experiments that a Gestalt therapist may use to deepen contact through focusing. Especially useful are the creative arts, such as music and art (Rogers, 1993).

Empty-chair dialogues. Empty-chair dialogues may be used to complete unfinished business with a significant other (Paivio & Greenberg, 1995) or with two conflicting aspects of self (Greenberg, 1979). The purpose is to evoke associated sensations and engage in dialogue with the significant other or with the conflicting parts of self. An example of the former is a person who is not able to express his or her feelings to another person, and he or she will be asked to put the person in an empty chair and tell him or her what needs to be expressed. An example of the latter is when two parts of self are in conflict. For example, a female client who was told as a child (introject) not to express anger will be in conflict with her authentic self who wants to express healthy anger when experiencing a violation:

Client: I would like to express my anger at my partner but I stop myself. APPN: Would you agree to an experiment where you imagine each of these parts of yourself in an empty chair? Client: Okay. APPN: The part of you that would like to express your anger sits in one chair and the part that cannot express anger sits in another.

Client: I would like to sit in the chair that can’t express my anger first.

APPN: Go ahead and start in the chair that cannot express your anger. Client: I can’t express my anger, but I want to. I am afraid something bad will happen if I express my anger. APPN: Now switch chairs. Client: You’ll never be able to express anger. You should not express anger. Something bad will happen. You will be destroyed. APPN: Now switch chairs. Client: I have a right to my anger. You can’t stop me any longer.

Language of responsibility. This is a technique that focuses specifically on deflected language that a client may use to decrease the intensity of awareness and contact. For example, clients may use questions rather than statements to keep themselves safe or use pronouns such as “it” or “you” to deflect the intensity of feelings. When using the language of responsibility, the therapist asks the client to put a question into a statement or use a first person pronoun to heighten awareness.

Client: It is so difficult to find a partner. APPN: Would you be willing to say, “I am finding it so difficult to find a partner.”

Dreamwork. In Gestalt therapy, working with dreams is a common intervention. The characters and objects in the dreams are viewed as projections of disowned parts of self that need to be reintegrated. When working with dreams, the therapist has the client assume all parts of the dream and tell the dream as

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if it was happening in the here and now, using present tense rather than past tense (Perls, 1969). For example:

Client: I’d like to recount a dream I had last night. I was climbing a precipitous mountain and felt exhausted. About halfway to the top, the mountain suddenly turned into meatloaf. I became immobilized, unsure if I should continue climbing or stop.

APPN: Can you retell the dream using the present tense—as if the dream was happening right now. Client: Sure. I am climbing a precipitous mountain and I feel exhausted. I am halfway to the top. The mountain has turned into meatloaf.

I don’t know what to do. I am immobilized. I don’t know if I should continue climbing or stop. APPN: What are you experiencing now retelling the dream? Client: I am confused. APPN: Would you be willing to speak as different parts of the dream—the steep mountain, the mountain made of meatloaf, yourself? Client: (as the meatloaf mountain) I am alive, rich, tasty, vital, nourishing. (as the mountain) I am barren, rocky, lacking vegetation,

without much life, and dying.

As the dreamwork continued, the parts of the dream were asked to speak to each other and eventually the client became very tearful, realizing that the dream represented her struggle between her inauthentic desire to live a life of sheer ambition, pushing (an introject from her parents) and her authentic desire to live a more balanced, nourishing, and fulfilling life.

The client was eventually able to create a new ending for the dream where she stopped climbing the mountain.

These are merely a few examples of the many types of experiments used in Gestalt therapy. Gestalt therapists pay close attention to the client’s process and create experiments based on the client’s needs that emerge moment-to-moment during the session (Knight, 1996).

EXISTENTIAL PSYCHOTHERAPY

Overview

The formal beginning of existential psychotherapy in the United States can be traced to 1958 with the publication of the text Existence: A New Dimension in Psychiatry and Psychology by May, Angel, and Ellenberger (1958). Although many people helped shape the existential psychotherapy movement, Rollo May (1909–1994), Victor Frankl (1905–1997), and Jim Bugental (1915–2008) were the leaders who played an early role in developing and promoting existential psychotherapy while Irving Yalom (1931–) and Kirk Schneider (1956–) are the contemporary leaders involved in further developing this approach.

Rollo May, a psychologist often referred to as the father of American existential psychology, was concerned with the importance of anxiety for self-growth as well as themes of freedom and responsibility. May believed that psychotherapy should be concerned with the problem of being rather than problem solving (Bugental, 1996). Victor Frankl, a physician and philosopher sent to a concentration camp when Hitler came to power, wrote Man’s Search for Meaning (1963) based on his experiences. This compelling book introduced Frankl’s logotherapy, an existential therapy that translates into meaning therapy, which supports the view that people have the freedom to choose their attitude in any given set of circumstances and discover meaning (Frankl, 1963). James Bugental, a psychologist, focused on living an authentic and responsible life (Bugental, 1965). He contributed a great deal to the practice of therapeutic presence rather than therapeutic techniques in conducting existential psychotherapy (Schneider & Greening, 2009). Irving Yalom, a psychiatrist, addressed the four givens of existence: freedom and responsibility, isolation, meaninglessness, and death (Yalom, 1980). Yalom’s existential application to group therapy, seen in his widely used and respected text Theory and Practice of Group Psychotherapy (Yalom, 2005), has solidified a continued place for existential therapy in the group therapy modality. Kirk Schneider, a psychologist and contemporary spokesperson for existential–humanistic psychotherapy, is well known for his development of the existential concept of awe and how to cultivate awe in existential psychotherapy (Schneider, 2009). Schneider, cofounder of the Existential– Humanistic Institute in San Francisco, has been integral in fostering global dialogue of existential themes in psychotherapy, a framework for psychotherapy integration, and a link between existential theory and postmodernism (Schneider & May, 1995).

Existential psychotherapy, a philosophical approach to psychotherapy, addresses the large, universal themes of life. These themes, considered to be the givens of existence, are frequently found not only in psychotherapy but are written about in great novels. For example, Albert Camus, in his well-known novel

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L’Etranger, has Meursault, the main character, accept his mortality, reject the constrictions of society he previously placed on himself, and become unencumbered to live his life as he chooses. These themes of death, choice, and freedom as well as others create a focus for existential psychotherapy.

Key Concepts

Existential psychotherapy is centered in resolving life’s existential themes. Dysfunction occurs when existential themes are unresolved and people live a meaningless life. A list of common existential themes can be found in Box 10.3, with more detailed descriptions to follow:

BOX 10.3

EXISTENTIAL THEMES

Choice Freedom Responsibility Awareness Aloneness Meaning Anxiety Death Authenticity Awe

CHOICE

A range of choices exists that is available to everyone. Although choices may be somewhat limited by external circumstances, the existential approach embraces the idea that people are free to choose and rejects the notion that choice is predetermined or restricted.

FREEDOM

An openness, readiness, and flexibility to grow and change, which necessitates a capacity to choose among alternatives. People are free to shape their destiny and are the authors of creating their own world.

RESPONSIBILITY

With freedom comes accepting responsibility for the choices made and actions taken in determining a self- directed life. Existential therapy is rooted in the premise that people are responsible for their lives, their action, or their failure to take action (Bugental, 1987).

AWARENESS

Increasing self-awareness leads to an emphasis on choice and responsibility and the view that a worthwhile life is one that is authentic and genuine. Existential therapy believes that it takes courage to become aware of self and live from a place of authentic choice. Through self-awareness, people are able to choose their actions and create their own destiny.

ALONENESS

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Part of the human condition is that people enter and depart the world alone. Strength and meaning are derived from the experience of looking to oneself and sensing this separation and aloneness. People nevertheless desire to be significant to others and thus need to create close relationships with others while accepting the existential aloneness (Yalom, 1980).

MEANING

A part of the human condition is the struggle for a sense of meaning and purpose in life. Meaninglessness leads to emptiness and an existential vacuum. Faced with the prospect of mortality, people may ask: “Is there any point to what I do now, because I will eventually die? Will what I do be forgotten once I am gone?” The existentialist position encourages people to search for meaning by living fully and responsibly, accepting the consequences of their choices, and engaging in a commitment to creating, loving, working, and building a meaningful life (Frankl, 1963).

EXISTENTIAL ANXIETY

An essential part of existence entails accepting existential anxiety as a condition of living. As awareness of the consequences of freedom, choice, responsibility, isolation, and death increases, anxiety is inevitable. Existential anxiety is a stimulus for growth and an appropriate response to having the courage to be. The aim of therapy is not to eliminate anxiety but to be aware of it and embrace it in order to live a fulfilling life.

DEATH

Awareness of death is the terrible truth and ultimate human concern that gives significance to life. The fear of death and the fear of life are related, for the fear of death looms over those who are afraid to participate fully in life. Existentialists believe that those who fear death also fear life; thus the fear of death must be faced before one can truly live (Schneider & May, 1995).

AWE

A state of being that incorporates wonder, dread, mystery, veneration, and paradox. Cultivating awe in existential therapy requires a movement away from many contemporary values of consumerism, conventionality, mindless entertainment, competitiveness, and the “quick fix,” efficiency-oriented culture (Schneider, 2009).

Goals of Therapy

The goals of existential psychotherapy center on the given themes of existence and helping clients face the anxieties of life, freely choose their life direction, take responsibility for their choices, and create a meaningful existence. Clients are encouraged to face the anxieties generated by personal freedom, choice, aloneness, and death. Existential therapy can be viewed as an invitation to help clients recognize how they are not living fully authentic lives and make choices that will lead to living life authentically (Corey, 2011).

Psychotherapeutic Interventions: Assessment

In existential psychotherapy, the emphasis of assessment is on a phenomenological understanding of the subjective world of the client rather than employing traditional assessment procedures and diagnostic constructs. Preconceptions are bracketed in order to be present with the immediate experience. The existential psychotherapist is generally not concerned with the client’s past; instead, the emphasis is on the choices to be made in the present and future.

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The first session is extremely important for building an authentic, therapeutic relationship. Client’s values and assumptions about the world are examined during the assessment. The therapist attempts to understand the client’s current life situation, freedom of choice, potential for meaningful change, and expectations for therapy (Corey, 2011).

Psychotherapeutic Interventions: Psychotherapy Techniques

A fundamental characteristic of existential psychotherapy is that the approach does not identify with a set of specific techniques. Existential therapists have themselves examined and worked through the universal themes of life. Interventions are thus based on an understanding of what it means to be more fully human. The existential psychotherapist is free to draw on techniques from other orientations (Schneider, 2008). To follow are some notions related to interventions:

THERAPEUTIC RELATIONSHIP

Existential therapy places a high premium on the quality of the therapeutic relationship as a healing agent. It emphasizes an authentic, I–Thou encounter between the client and therapist. It supports equality in the therapeutic relationship and an encounter characterized by mutuality, authenticity, openness, immediacy, and dialogue. The use of the therapeutic self is the core of therapy; thus, the therapist needs to be mature and have a personal philosophy that is congruent with the theoretical underpinnings associated with the existential psychotherapy approach.

PRESENCE

The existential psychotherapist cultivates the quality of presence. Presence is a subjective experience of being here and now in a relationship and intending, at a very deep level, to participate as fully as one is able (Schneider, 2008). Bugental (1987) wrote that therapists need to maintain full presence to the client’s experience in the moment and to closely attend to client’s immediate inner flow of experience. “Be there!” and “Insist that the client be there!” were well-known mantras of Bugental’s existential approach (Schneider & Greening, 2009).

EXPERIENTIAL REFLECTION

The existential psychotherapist asks in-depth questions about universal themes in order for clients to experientially reflect on how their life is being lived in the present. The client is challenged to grapple with complexities and paradoxes of the human condition and to face the givens of existence. Experiential reflection through in-depth questioning helps the client recognize the range of life choices, remove obstacles to freedom, find meaning, and take responsibility (Yalom, 1980). For example, a question such as, “How is your freedom impaired?” seeks to bring awareness to the client’s obstacles to freedom. Prototypic questions include:

What is the purpose of your life? Where is the source of meaning for you? You want to live an authentic life, yet you stay in a relationship and a job that give you little satisfaction. How are you keeping yourself stuck?

What might be accomplished in treatment that would help you live a more authentic life?

A recent client of mine was confronting the possibility of disability and an early death from Parkinson’s disease. As an existential therapist, I encouraged him to confront the probable disability and possible early death and, accordingly, face decisions that this disease thrust upon him. Questions focused on helping him reflect on understanding that his life, akin to everyone else’s life, is finite but that he is still capable of finding meaning and making different decisions about his illness and his life’s path. The focus in therapy was on choosing a life he wanted to live and assuming responsibility for his choices. He was in a difficult and unsatisfying relationship with a partner who abused substances and who had an Internet addiction. He was

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very unhappy in his job as well. In therapy, he was encouraged to evaluate his choices and his accompanying anxieties regarding change. He was asked, “What prevents you from living an authentic life?” He was helped to understand that making difficult choices in the face of illness is actually a way to find wholeness and meaning. This client eventually chose to live a less encumbered life and discard some of the constraints he previously placed on himself. He ended his relationship, quit his job, and moved to a city where there were more medical facilities and support and where he could avail himself of public transportation. He joined a support group for people with Parkinson’s disease. He found a new life direction that gave him purpose and meaning. Once he was able to face his own mortality, he truly developed the courage to be.

EMOTION-FOCUSED THERAPY

Emotion-focused therapy (EFT) is an evidence-based, short-term humanistic–existential psychotherapy approach. Developed in the 1980s, primarily by Canadian psychologist Leslie Greenberg (1945–), EFT has invigorated the central role of emotion in psychotherapy, which has been routinely eclipsed in importance by cognition and behavior in the last few decades. “You need to feel to heal” and “I feel, therefore I am” are mantras frequently touted in the EFT community.

EFT integrates person-centered therapy, Gestalt therapy, and the neuroscience research of emotions. When the approach was predominantly a blend of person-centered and Gestalt therapy, it was called process- experiential therapy; however, when the Neuroscience Theory of Emotions was integrated in the 1990s, the name was changed to emotion-focused therapy. Nevertheless, person-centered therapy and Gestalt therapy have retained their strong influence, especially in regard to therapeutic interventions. Extensive evidence- based research has been conducted using EFT with very positive results. It has also been manualized and many of its interventions operationalized. Nonetheless, learning this approach requires a great deal of training and psychotherapeutic sophistication (Greenberg, 2011).

Key Concepts

EMOTIONS

An affective state of information processing that informs a person of important needs and creates an action readiness that prepares the self for action. For example, fear sets in motion a search for danger, sadness informs of loss, and anger signals a violation.

Emotions exert influence on cognition and behavior. They are signals that keep people energized, interested, and connected to others (Greenberg, 2011).

Emotion Schemes

Complex memory networks within the amygdala and neocortex pathways, formed in response to emotional life experiences, which are the basis of adult emotional responses. They are activated rapidly, without thought or awareness, by learned, situational cues (e.g., visual images and verbal triggers) of evoked emotion from prior life experiences. Schemes are oriented toward action and serve to satisfy needs and goals. If adaptive, they form positive, flexible emotional-processing systems with clear pathways. Maladaptive schemes, caused by unprocessed emotions from difficult situations (e.g., betrayal, abandonment, and trauma) may form negative, inflexible emotional-processing systems. Changing the negative emotion scheme is the target of therapeutic intervention and central to change (Greenberg, 2011).

MEMORY CONSOLIDATION

A time period after an emotional life experience when memory of the experience is fragile and can be disrupted. The memory becomes permanent fairly soon after the event. The more highly aroused the emotion,

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the more the experience and evoking situation will form a memory (Greenberg, 2010).

MEMORY RECONSOLIDATION

A time period after a memory is reactivated later in life when it is again fragile and can be disrupted. Changing an emotion scheme during EFT occurs during this memory reconsolidation period (Greenberg, 2010).

PRIMARY EMOTIONS

Genuine, authentic emotional reaction initially activated in response to a situation. Primary emotions may be adaptive or maladaptive (Greenberg, 2011).

Primary adaptive emotions. Direct reaction consistent with the situation and results in appropriate action. Primary adaptive emotions are accessed for their useful information and capacity to meaningfully organize action and include sadness, fear, anger, joy, love, and surprise. Sadness, for example, occurs in response to a loss, anger in response to a violation, and fear in response to danger (Greenberg, 2011).

Primary maladaptive emotions. Also a direct reaction to a situation but an overlearned response based on prior traumatic experiences that does not result in appropriate action. They are maladaptive emotional states that are familiar, occur repeatedly, and neither change in response to different circumstances nor provide adaptive direction for problem solving. Examples include a core sense of abandonment, worthlessness, or shame. A person who experienced extreme fear to early sexual abuse, for example, may as an adult experience fear in response to closeness rather than warmth and pleasure. Primary maladaptive emotions are accessed and transformed during EFT (Greenberg, 2010).

SECONDARY EMOTIONS

Emotional reaction to a primary emotion or thought that follows, replaces, or obscures a primary emotion. Examples include feeling guilty about feeling angry or feeling angry in response to feeling hurt. Therapeutic interventions in EFT attempt to reduce the secondary emotions in order to access primary emotions (Greenberg, 2011).

INSTRUMENTAL EMOTIONS

Emotional expression used to control, manipulate, and elicit support. An example of an instrumental emotion is crying insincere “crocodile tears” to manipulate the environment and elicit support.

MARKERS

In-session, problematic emotional-processing states that clients enter during therapy that are indicative of underlying affective problems. They are identified by certain statements and behaviors and are used by the therapist to guide therapeutic interventions. Examples of markers include problematic reactions, conflict splits, unclear felt sense, and unfinished business. Currently 15 process markers have been identified (Greenberg, 2011).

Goals of Therapy

The goal in EFT is to help clients move toward wholeness and self-actualization by helping them develop emotional awareness and adaptive emotional processing. Clients develop the ability to access important information that emotions provide and use that information to live a full, vital life. Clients are able to use emotions as signals to inform them of their needs and deal effectively with life experiences. Clients learn how

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to access their primary adaptive emotions and transform primary maladaptive emotions. Maladaptive emotion schemes are evoked for reprocessing, thereby enabling clients to create new emotional narratives. A goal is also to decrease the use of secondary and instrumental emotions, so that clients are not encumbered by them (Greenberg & Goldman, 1988).

Psychotherapeutic Interventions: Assessment

Assessment in EFT is the first phase of therapy in the bonding and awareness phase. In this phase, a strong therapeutic relationship is developed based on the person-centered work of Carl Rogers, emphasizing empathy, congruence, and unconditional positive regard. The therapist enters the client’s frame of reference, validates the client’s feelings, and empathically follows the client’s experience to deepen emotional experiencing and access core emotions. Emotional functioning is assessed including emotional awareness, emotional regulation skills, and emotion schemes. The therapist provides a rationale for working with emotion, establishes a collaborative focus, and promotes the client’s awareness of emotional experience (Greenberg, 2011).

Psychotherapeutic Interventions: Psychotherapy Techniques

Therapeutic interventions involve accessing and evoking problematic feelings, primary maladaptive emotions, and maladaptive core schemes using process-directed, Gestalt therapy style experiments. Therapeutic interventions are marker guided; thus, in-session states of underlying affective problems are identified and specific process interventions employed that flow from the in-session markers (Greenberg, 2011). The therapeutic process is construed as a sequence of events in which specified markers repeatedly present themselves in therapy as opportunities to employ effective process interventions. Thus, the psychotherapist is constantly engaged in assessing for the presentation of a marker and must be proficient both at making process diagnoses of markers as well as implementing appropriate interventions to help resolve the problem indicated by the marker. Perceptual skills are needed for recognizing markers and determining the appropriate intervention (Greenberg, Rice, & Elliott, 1993).

BOX 10.4

COMMON EMOTION-FOCUSED THERAPY MARKERS

Problematic reactions Unclear felt sense Conflict splits Self-interruptive splits Unfinished business Vulnerability Trauma narrative

MARKER EXPERIMENTS

In-session markers (problematic emotional-processing states) are identified that guide experiments to help clients access and transform their maladaptive primary emotions and negative emotion schemes (Greenberg, 2011). Numerous markers have been identified in EFT. A list of the more common markers can be found in Box 10.4. Examples follow to illustrate these markers and their interventions (Greenberg, 2011).

Problematic reactions. Emotional overreactions to particular stimulus situations perceived as problematic and expressed by puzzlement. An example is a comment a client made during a recent session: “On my

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way to therapy, I saw a plume-tailed dog and became very fearful and I don’t know why.” The intervention is a systematic unfolding procedure that allows the client to arrive at the implicit meaning of the situation, make sense of the reaction, and resolve the problematic reaction. The client is asked to provide detailed and concrete descriptions of the situation and the emotional reaction through the use of evocative language. The therapist then amplifies the description with the use of vivid, imagistic language, which promotes re-experiencing the situation (Greenberg, 2011).

Unclear felt sense. An inability to get a clear sense of an experience perceived as problematic. The client may say, “I just have this inner tenseness, but don’t know what it is.” The intervention is a focusing technique where the therapist guides the client to approach the unclear felt sense with attention and willingness to access and create a symbolic expression of it in the form of a metaphor or image. The therapist may say to the client, “I’d like you to attend to your inner tension, breathe into the area in your body with curiosity, stay with it, and allow an image to emerge.” Resolution involves a bodily felt shift to the creation of new meaning (Greenberg, 2011).

Conflict split. When one aspect of self is critical toward another aspect. The client may say, “A part of me feels so inadequate while the other feels very competent.” The intervention is two-chair work where the two parts of self are put into contact by dialoguing with each other in two separate chairs. Thoughts, feelings, and needs within each part of self are explored and communicated. Resolution involves a softening of the critical voice, integration of the two sides, and self-acceptance (Greenberg, 2011).

Self-interruptive split. When a client interrupts a part of self. For example, a client states, “I can feel the tears coming up, but I just tighten and suck them back in; no way am I going to cry.” A two-chair enactment is used to make the interrupting part of self explicit. The client is guided to enact the way the tightening and sucking back the tears occur in order to experience the self as an agent in the process of shutting the part of self down. The client is invited to challenge the interruptive part of self. Resolution involves expression of the previously blocked experience (Greenberg, 2011).

Unfinished business. Unresolved feelings toward a significant other. For example, a man abandoned by his mother may be resentful when his wife is busy and pays little attention to him. An empty-chair intervention may be used where the client activates his internal view of his mother and expresses unresolved feelings and needs. “You were never there for me. I have never forgiven you. I will never feel support. I needed you to be there and comfort me.” The resolution involves holding the other accountable or understanding and forgiving the other with shifts in views of both self and other (Greenberg, 2011).

Vulnerability. A state in which the self feels fragile, ashamed, or insecure. The patient states, “I feel like I’ve got nothing left. I just can’t carry on.” The intervention is affirming empathic validation and attunement from the therapist who must capture the feeling content; mirror the tempo, rhythm, and tone of experience; and validate and normalize the experience of vulnerability. Resolution involves a strengthened sense of self (Greenberg, 2011).

Trauma narrative. When the client experiences internal pressure to tell a difficult life story. The client states, “I am remembering a very traumatic situation that happened when I was in college, but even though I want to, I am having difficulty speaking about it.” The intervention is to assist the client to retell the trauma narrative. Resolution brings relief, restoration of narrative gaps, and creation of a new narrative (Greenberg, 2011).

The unique aspect of working with markers in EFT is that specific interventions have been identified for each type of marker. This gives the beginning therapist clear guidelines as to how and when to use a specific intervention (Greenberg, 2011).The reader is referred to the work of Greenberg (2011) for a comprehensive list of markers and their interventions. At the end of an intervention, reflection of the experience occurs between the client and therapist in order to make sense of the experience. Validation for new feelings and support for an emerging sense of self are given (Greenberg, 2011).

SOLUTION-FOCUSED THERAPY

Overview

SFT is a brief psychotherapy embedded in the philosophy of postmodernism and the Theory of Social Constructionism, a psychological application of the postmodern worldview. Postmodernism and social constructionism emerged in the 1960s as a reaction to the assumed certainty of scientific and objective efforts

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to explain reality and an awareness of an increasingly more diverse, complex, and uncertain world. Both postmodernism and social constructionism are, in many respects, similar to humanistic–existential worldviews and share common beliefs about psychotherapy. Some of the early postmodern philosophers were existentialists (e.g., Kierkegaard and Nietzsche) and phenomenologists (e.g., Husserl and Heidegger) (Schneider & May, 1995).

Postmodernism recognizes that there are no objective or absolute universal truths, and it is skeptical of explanations that claim to be valid for all cultures and groups. Instead, it believes that there are multiple ways of knowing, and reality is believed to exist only through the interpretation of each person. Postmodernism relies on individual experience, knowing that the outcome of a person’s experience will necessarily be fallible and relative, rather than certain and universal. Postmodernism denies the existence of ultimate scientific or philosophical truth that will explain everything for everybody. It promotes the restructuring of theory and methodology to include more ethics, diversity of representation, and cultural relativism (Kvale, 1992).

Social constructionism places emphasis on truth, reality, and knowledge as socially embedded. Reality is based on the use of language and the situations in which people live. Language is viewed as the vehicle through which people attribute meaning to their experience (Gergen, 1985, 1999). For example, a person is bipolar when he or she accepts a definition of self as bipolar. Once this definition of self is assumed, it is difficult to recognize behaviors opposed to the definition, such as a period when the person had a stable mood. Some basic premises of postmodernism and social constructionism can be found in Box 10.5.

BOX 10.5

BASIC PREMISES OF POSTMODERNISM AND SOCIAL CONSTRUCTIONISM

The subjective experience of the client is most important and valued Problems and solutions take shape and have meaning within a dialogic context Clients are viewed as experts about their own lives Clients are cocreators and cofacilitators of the therapy process Hierarchy and power differential increase the potential for exploitation Therapist and client are collaborative in the psychotherapy structure and process Knowledge and skill of the therapist are not as paramount as the relationship Therapists disavow the role of expert Manualized and empirically supportive treatments (EST) are flawed Diagnosing and pathologizing clients should be avoided Self-report ratings of dysfunction are inadequate interventions

Adapted from Gergen (1985, 1999).

Postmodernist thought has influenced the development of a number of contemporary psychotherapies. The most well known are SFT, narrative therapy, and feminist therapy. SFT, a brief therapy that is easily understood and mastered, was codeveloped by husband and wife Steve de Shazer and Insoo Kim Berg in the early 1980s with their team at the Brief Family Therapy Center in Milwaukee, Wisconsin. It has been strongly influenced by the work of Milton Erikson, Gregory Bateson, and the Mental Research Institute in Palo Alto, California as well as the philosophies of Buddhism and Taoism (Corey, 2011).

Insoo Kim Berg (1935–2007), a social worker and psychotherapist, applied the approach to working with couples and families as well as clients with addictions (Berg & Miller, 1992). Steve de Shazer (1940–2005), a social worker and psychotherapist, wrote several seminal texts on SFT (de Shazer, 1985, 1988, 1991, 1994). Both were popular workshop leaders and trained therapists in SFT throughout North America, Europe, Australia, and Asia. Other well-known leaders and trainers in this approach include Michele Wiener-Davis, Bill O’Hanlon, Yvonne Dolan, Eve Lipchik, Scott Miller, John Walter, and Jane Peller. They applied SFT to a number of different problems including alcoholism, domestic violence, and trauma and have added greatly to the SFT literature (Corey, 2011).

SFT believes that the therapy process does not necessitate processing problems in order to resolve them. Therapy is solution focused rather than problem focused and is present and future oriented rather than past oriented. Therapy seeks to empower the client and is positive and nonpathologizing. The client is viewed as

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competent, having resources needed to construct solutions. Therapy is expected to result in change. Even long-standing issues are resolved in a relatively short period of time. SFT believes that smaller changes lead to bigger changes, and the effects of change tend to multiply (De Jong & Berg, 2008; de Shazer, 1985, 1988, 1994).

Key Concept

SOLUTION TALK

From social constructionism, the belief that language creates reality was applied to SFT with the key concept of solution talk. SFT espouses the view that a problem-focused approach using “problem talk” actually helps maintain the problem, but that a solution-focused approach using “solution talk” helps the client change in a positive direction. Solution talk highlights what the client wants to achieve through therapy rather than the problem that made the client seek help. By identifying what is desired, the therapist invites the client to construct a concrete vision for a preferred future. Thus, to change a problem, the language must be shifted from problem talk to solution talk (de Shazer, 1991).

Goals of Therapy

The goal of SFT is to help the client change by constructing solutions to problems rather than dwelling on them. The two key therapeutic goals are to determine: (1) how the client wants his or her life to be different, and (2) what it will take to make it happen. Creating a detailed picture of what it will be like in the future when things change creates a feeling of hope and makes the solution seem possible to the client (de Shazer, 1991).

Psychotherapeutic Interventions: Assessment

During the assessment, the therapist creates a positive climate of hope, respect, dialogue, inquiry, and affirmation. The focus is on understanding the subjective experience of the client as well as developing a collaborative therapeutic relationship. The client is given the message that he or she is viewed as the expert and the therapist assumes a not knowing position in order for the client to construct the solutions and develop well-formed goals. SFT focuses on the present and future rather than the past. The therapist pays little attention to history taking and traditional assessment data, for this type of knowledge is believed to be inconsequential and may actually hamper the development of solutions. The therapist also does not give the client a diagnosis, for this is believed to be irrelevant to finding solutions (Berg & Miller, 1992).

During the assessment, a goal that is important and meaningful to the client is established. The goal focuses on desirable behaviors (e.g., I will, rather than I will not) and is concrete, specific, and behavioral. It includes a detailed explanation as to how it will be accomplished, which increases the ability to achieve the goal (Berg & Miller, 1992).

Psychotherapeutic Interventions: Psychotherapy Techniques

SFT uses specific types of questions to help the client access solutions. The following questions are examples of the most popular SFT questions.

PRE-SESSION CHANGE QUESTIONS

Questions that ask the client what improvements have been made during the time period of contracting for

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services and the first session. Scheduling an appointment starts the change process and asking this question encourages the client to engage in solution-building conversations from the beginning (de Shazer, 1985, 1988).

Between now and when we meet, I would like you to notice one thing in your life that has improved.

JOINING

A process of connecting and accommodating to the client’s world (de Shazer, 1985, 1988). Some examples of joining questions are:

How can I be helpful to you? What improvement have you noticed since you made the call to come in? On the way in, what were you most worried I would or would not do? Where would the perfect therapist do?

What needs to happen today so that when you leave you’ll think this was a good session?

MIRACLE QUESTIONS

Questions that ask the client to imagine how things would be different if the problem was solved. This helps the client identify goals and envision the future without the problem. The intent is to help the client describe realistic steps toward the solution (de Shazer, 1991). The therapist uses a hypnotic voice quality to ask the miracle question:

Suppose that one night there is a miracle and while you were sleeping the problem that brought you to therapy is solved.

How would you know? What will you notice different the next morning that will tell you that there has been a miracle?

Therapists may become very concrete with the miracle question, asking what they would notice first, what would happen next, and so forth (De Jong & Berg, 2008).

EXCEPTION QUESTIONS

Questions that identify times in the client’s life when the identified problems were not as problematic. SFT believes that there were always times when the problem was less severe or absent for the client. The therapist seeks to encourage the client to describe what different circumstances existed or what the client did differently. The goal is for the client to repeat what has worked in the past, and to help him or her gain confidence in making improvements for the future (De Jong & Berg, 2008).

When was a time that a problem could have occurred but didn’t? Tell me about times when you don’t get angry. Was there ever a time when you felt happy in your relationship?

SCALING QUESTIONS

Questions that help the client assess and track progress on different dimensions (e.g., motivation, hopefulness, and confidence). The poles of a scale range from the worst the problem has ever been (0) to the best things could ever possibly be (10) (De Jong & Berg, 2008). On a scale from 1 to 10 with 0 being the lowest and 10 the highest:

How bad is the problem? On a day when you are one point higher on the scale, what would tell you that? Where would you place your depression when you first came in and now? What would it take to move from a 3 to a 4?

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FUTURE-ORIENTED QUESTIONS

Questions that focus on guiding the conversation from problems to envisioning a better life in the future. When a problem is stated, the therapist asks questions to explore what could be better if the problem was resolved (De Jong & Berg, 2008).

How will this make you happier? What will be better for you after this occurs? What do you see down the road after this is resolved?

COPING QUESTIONS

Questions designed to elicit information about the client’s resources that may have gone unnoticed. These questions work well when the client is going through a difficult time, for even the most hopeless story has within it examples of coping that can be explicated (De Jong & Berg, 2008). With coping questions, the first part of the intervention is a validating statement and the second part gently challenges the client:

I can see that things have been really difficult for you. How have you managed to carry on and prevent things from becoming worse?

I am struck by the fact that, even with all of your losses, you manage to get up each morning and do everything necessary to get the kids off to school. What keeps you going under such difficult circumstances?

It is admirable how you have been able to keep on going under such difficult circumstances. How did you do that?

COMPLIMENTS

Questions that reinforce the client’s successes through validating the difficulty of the problem and acknowledging what the client is doing well and what is working. It invites the client to self-compliment by virtue of answering the question (De Jong & Berg, 2008).

Wow! How did you manage to finish that task so quickly? What do your colleagues appreciate in how you work?

ENDING

Experiments or homework assignments are suggested by the therapist for the client to try between sessions. For example, suppose the client states that she wants to feel more competent (De Jong & Berg, 2008). An experiment and homework might be:

Let yourself envisage that when you leave the office today, you feel more competent. What will you be doing differently? Try that during the week.

During the week, record any time you feel competent and then notice what you were thinking and doing.

SUBSEQUENT SESSIONS

At the start of each new session, the therapist will ask about what learning has occurred since the last session (De Jong & Berg, 2008). The therapist reviews experiments and homework assignments:

So what is better, if anything, since our last meeting? What would need to happen so you did not need to come back to therapy anymore?

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EVIDENCE-BASED RESEARCH

Since 1964 in Old Saybrook, Connecticut, when humanistic–existential psychotherapy was launched, five decades of substantial advances in theory, practice, and evidence-based research have accumulated supporting the effectiveness of humanistic–existential psychotherapy for a wide range of client problems. The research demonstrates that the humanistic–existential psychotherapies are as effective or more effective than other major psychotherapy approaches. Person-centered therapy, Gestalt therapy, existential therapy, and EFT have effect sizes comparable with therapies such as CBT (Cain & Seeman, 2002; Elliott, 2002; Elliott, Greenberg, & Lietaer, 2004; Kirschenbaum & Jourdan, 2005) and therapy gains are maintained over time (Elliott, Greenberg, Goldman, & Angus, 2009). Much of the research that has been done in humanistic–existential therapies is process research, which looks at what occurs during the session to bring about positive results. Theories of change processes have been tested empirically by using a task-analytic approach to the study of therapeutic change processes (Greenberg, 1986, 1991; Greenberg & Rice, 1997). Readers are referred to Cain and Seeman’s Humanistic Psychotherapies: Handbook of Research and Practice (2002) for an extensive review of the research in humanistic–existential psychotherapies.

A great deal of research has been done in person-centered therapy by Carl Rogers and his colleagues on the importance of the therapeutic relationship. Much of the current research on psychotherapy outcomes, which calls Rogers’s core conditions the common factors or the therapeutic working alliance, has validated Rogers’s original work (Duncan, Miller, Wampold, & Hubble, 2010; Wampold, 2001). Rogers’s work, far ahead of his time, is experiencing a major revival. Increasingly, most schools of psychotherapy recognize the importance of the core conditions (Kirschenbaum & Jourdan, 2005). A compilation of the extensive research in the person-centered approach can be found in Kirschenbaum and Jourdan’s article, The Current Status of Carl Rogers and Person-Centered Approach (2005) and Cain’s text, Person-Centered Psychotherapies (2010). Applying the person-centered approach with various populations is wide-ranging and usually descriptive. A recent article used the approach successfully with lesbian, gay, bisexual, and transgendered teens working toward acceptance of sexual identity (Lemoire & Chen, 2005). A limited number of outcome studies compared person-centered therapy with other types of treatment. One recent article revealed that person- centered therapy is more effective than medication in working with clients diagnosed with borderline personality disorder (Teusch, Bohme, Fink, & Gastpar, 2001).

Most of the research in the existential approach has been case studies. Nevertheless, the approach has been very successful in working with certain life conditions such as grief, facing a significant decision, developmental crises, coping with failures in marriage and work situations, and physical limitations. It has also been extremely successful in working with clients faced with terminal illness (Schneider, Bugental, & Pierson, 2001; Travelbee, 1971).

Gestalt therapy has been applied to different populations such as children (Oaklander, 1978), families (Resnikoff, 1995), groups (Feder & Ronall, 1980), and organizational systems (Nevis, 1987) as well as disorders such as body image (Clance, Thompson, Simerly, & Weiss, 1994), attentional problems (Root, 1996), trauma (Serok, 1985), addictions (Matzko, 1997), and psychoses. Gestalt therapy has a research base in both quantitative and qualitative research, but lacks meta-analyses. The Handbook for Theory, Research and Practice in Gestalt Therapy (Brownell, 2008) and Becoming a Practitioner Researcher: A Gestalt Approach to Holistic Inquiry (Barber, 2006) are useful resources in Gestalt research. Outcome studies have demonstrated this approach to be equal to or greater than other therapies for various disorders including personality disturbances, psychosomatic disorders, and substance abuse problems (Corey, 2011).

Emotion-focused therapy is one of the most highly researched, evidence-based approaches. Texts for reviewing the research include Elliott, Greenberg, and Lietaer’s chapter on research in experiential psychotherapies in Bergin & Garfield’s Handbook of Psychotherapy and Behavior Change (2004) and Schneider, Bugental, and Pierson’s The Handbook of Humanistic Psychology: Leading Edges in Theory, Research, and Practice (2001). Watson, Gordon, Stermac, Kalogerakos, and Steckley (2003) compared the effectiveness of EFT with cognitive behavioral psychotherapy in the treatment of depression and found EFT to be more effective and that therapy gains are maintained over time.

Berg and Dolan (2001) offer a collection of success stories by clients and therapists on a variety of presenting problems for SFT. Miller, Hubble, and Duncan (1996) and Gingerich and Eisengart (2000) have published a review of relevant outcome research and applications of SFT with different populations (Berg & Miller, 1992).

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Assessment

Joy, a 40-year-old nurse practitioner, has been married for 16 years and has three children, aged 10, 8, and 6. She entered therapy with symptoms of anxiety that began when she realized her husband was viewing excessive amounts of Internet pornography on a daily basis. She has not revealed to him that she knows about his Internet addiction. Joy has been dissatisfied with her marriage for a number of years and states she has fallen out of love with him. She has frequently thought of leaving her husband in the past but concluded that the prospect was too frightening. Recently, she has experienced her relationship with her husband as particularly emotionally void and empty. From her perspective, he is very emotionally restricted so that she dreads being alone with him and is embarrassed to be in his company with friends. The discovery of his pornography addiction has increased her desire to leave. She met her husband on graduation from college at the age of 22, a time when she was insecure and unstable. He had a stable, corporate job and seemed to be supportive of her. She married him 4 years later. She feels that there is a part of herself that is still unstable, and fears without the safety of the marriage, she might be unable to cope with the vicissitudes of life. During most of their married life, Joy worked part-time as a nurse, and when not working, immersed herself in the tasks of childcare. Her husband pursued his professional corporate business career and sports activities. They tried marriage counseling on two occasions without success and she believes that strategy is fruitless. She desires individual therapy to help end the marriage. She realizes that what prevents her from leaving the marriage resides within her.

Conceptualization

Joy is a woman who has difficulty accessing and expressing her primary emotions. Underneath the secondary emotion of anxiety, which emerged with the discovery of her husband’s Internet addiction, is a significant amount of unaware anger and sadness that cannot be contacted, used as a signal to heal from her losses or used to help propel her out of the marriage. She feels betrayed and violated by his Internet addiction as well as sad over the inevitable loss of her marriage and breakup of her family. Responsibility is an important issue thwarting her decision to leave, both a moral responsibility of not depriving her children of their father and the responsibility she feels for her children’s future. She fears he would be an inadequate parent and realizes he will have the children half of the time. Further, she has never faced her existential aloneness and has difficulty with authenticity, freedom, choice, and responsibility. In addition, she has a number of introjects including:

It is not okay to get divorced. I will fall apart if I am alone. He will be a derelict single parent.

Facilitating Change and Working on Problems

Joy’s therapy was an integrated humanistic–existential approach with a few solution-focused techniques. Several existential themes emerged during the course of therapy including her fear of aloneness and taking responsibility for her life. During therapy, she reconnected with a former boyfriend on social media and “fell in love” with him. Although the state of being “in love” is one of the great experiences in life, it usually prevents therapy from moving forward in a deep fashion, for the pull of love is so great that it engulfs even the most well-directed therapeutic endeavors. Joy found her new love to be the “ideal man” and no other man existed for her. What finally made it possible for Joy to work in therapy was that her new male friend, hoping for a long-term commitment, became somewhat frightened by the prospect of having a relationship with a woman who was not yet out of her marriage and told her that he would not see her until she was divorced. Only then was she willing to look at her fear of being alone, her

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anxiety regarding her children, her desire to merge with a man to eliminate her anxiety, and her fear of freedom, choice, and responsibility.

After 6 months of intensive therapy, she gradually became comfortable with the thought of her aloneness. She realized that she could give up some control of her children and although she knew she was the better parent, she realized that the children would be parented “well enough.” She gradually learned that only she was the architect of her life and learned to take responsibility for her choices. She gained awareness and was able to access her primary emotions and use these emotions to move forward with her life. Some excerpts from the work with Joy that represent the humanistic–existential and postmodern–social constructionist approaches follow:

APPN: Where would you like to begin? Joy: Well, I’ve been having a great deal of anxiety.

APPN: Say more about that. Joy: I want to get out of my marriage. I am clear about that. I discovered he is watching Internet pornography on a daily

basis. APPN: Suppose that one night there is a miracle and while you were sleeping the problem is solved. How would you know?

What would be different? Joy: I would be calm without anxiety. I would be divorced. I would have my own house. I wouldn’t worry about the children

being taken care of by my ex-husband, for I would be okay with his parenting. APPN: What would you need to do for this to happen?

Joy: Well, I would need to be less anxious. I would need to confront him about the pornography, for I don’t want my children to follow in his footsteps. I would need to visit an attorney and know my choices. And, I would need to look at real estate and see what I can afford. And, I would need to work full time to get some savings.

The miracle question gave the APPN and the client an understanding of the necessary solutions. A combination of person-centered, Gestalt, existential, and EFT was initiated with Joy. She remained in therapy for 6 months, at which time she was able to leave her husband and move into the world with less anxiety and more authenticity and awareness of her emotions.

APPN: If you divorce, what might that look like?

Joy: If we divorce, I do not think he will take care of the children when he has them. He doesn’t even have them brush their teeth or help them with their homework. He is oblivious to what goes on around him.

APPN: So it’s scary to imagine the children in his care without you there to monitor him.

Joy: Yes, I am also fearful of making the change. We have a nice house and a good life from the outside. I feel sad that everything we have worked for will end.

APPN: As you speak, where do you experience that sadness in your body? Joy: I feel a tightness in my abdomen, like a bunched up fist. [Joy places her hand palm down on her abdomen.]

APPN: I notice your hand on your abdomen. Can you give the sadness some support? Joy: [Joy begins to gently rub her abdomen in small circles and tears form at the corners of her eyes.]

APPN: Can you give the sadness a voice, first person, present tense? I am the sadness … Joy: I am your sadness. You push me down all the time. You are so afraid to feel me. If you cry you will need to leave sooner

and you don’t feel ready. I am feeling another emotion now trying to take over. APPN: Give that emotion a voice.

Joy: I am your anxiety. I have an overwhelming sense of fear to move forward. It’s so safe here, even though I am so unhappy. I will have to start all over. I will lose the house for his parents will give him money to buy me out. He will have the kids three or four nights a week and won’t help them or supervise their homework. He will let them play videogames all night.

APPN: Umm, and you’re helpless to change what happens? Joy: [Joy still speaking as her anxiety with her voice rising.] Yes, here I have all the control, especially with the children. I can

make sure the kids are well cared for. If I leave, I have absolutely no control over what happens. APPN: Umm, so scary … yet, in some ways you have not taken charge of your life and have surrendered control in not deciding

and in living a life that is very unhappy and inauthentic. Joy: Yes, I am dying in this relationship and I have given up control of my life in an attempt to protect the children—control

how the children are taken care of. [Joy becomes tearful and cries.] APPN: If you had a wise fairy godmother right now, what would she say to you?

Joy: [Joy speaks in the pert, matter-of-fact voice of a spunky, intelligent old woman.] Now dearie, just dry those lovely tears. Let them wash away your fear. It can’t be half as bad to go as staying. Besides your children’s well-being is best served by an emotionally whole mother.

APPN: How does that feel to hear? Joy: [Sighs heavily] I feel supported, like I have the answers right inside me.

These brief session dialogues from the work with Joy illustrate some of the ways the APPN would work with a client in individual therapy. An integration of several humanistic–existential

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and SFT therapeutic interventions were used throughout the dialogue.

POSTMASTER’S HUMANISTIC–EXISTENTIAL PSYCHOTHERAPY TRAINING AND CERTIFICATION REQUIREMENTS

Considerable training is necessary in order to conduct humanistic–existential psychotherapy effectively (Greenberg & Goldman, 1988). Experiential learning in a group setting, where theory and practice are interwoven throughout the training experience, is at the heart of humanistic–existential psychotherapy training and serves to differentiate it from other major schools of psychotherapy training (Feder & Ronall, 1980; Knight, 1996). Trainers may sometimes bring their own clients to training sessions for trainees to observe but, typically, trainees observe experienced trainers conducting live therapy sessions with clients culled from the training group. Trainees also conduct live therapeutic sessions in the training group where they work as therapists, clients, and supervisors. Although reading lists, watching master psychotherapists on videotapes, and supervision with trainees’ own clients are typically part of organized training programs, theoretical concepts are taught primarily through informal lectures and processing experiential work in the here and now, rather than talking about therapy sessions that occur outside the group. Individual therapy is usually included as part of the training as well (Bohart, 1995; Gladfelter, 1997; Greenberg & Goldman, 1988; Greenberg, Rice, & Elliott, 1993; Kerfoot, 1998; Wiseman, 1998).

Organized training programs are found in private, postgraduate training institutes, approximately 2 to 4 years in length. Intensive weekend and summer programs are also available at most institutes. There are no national certifying exams in humanistic–existential therapy. Institutes generally provide a certificate of completion and place their graduate’s name on their website for referral purposes. Leading humanistic– existential and SFT institutes are listed in Box 10.6.

BOX 10.6

LEADING HUMANISTIC–EXISTENTIAL AND SOLUTION- FOCUSED INSTITUTES

Association for the Development of the Person Centered Approach, Chicago, www.adpca.org Center for the Studies of the Person (CSP), La Jolla, CA, www.centerfortheperson.org World Association for Person Centered & Experiential Psychotherapy & Counseling, www.pce-world.org Focusing Institute, Spring Valley, New York, www.focusing.org Carl Rogers Institute for Client-Centered Therapy, www.thenewcenterchicago.com Gestalt Institute of Cleveland, www.gestaltcleveland.org Gestalt Center for Psychotherapy and Training, NYC, www.gestaltnyc.org Gestalt Therapy Institute of Philadelphia, www.gestaltphila.org Gestalt Therapy Institute of Los Angeles, www.gatla.org NY Institute for Gestalt Therapy, www.newyorkgestalt.org Existential-Humanistic Institute, San Francisco, http://ehinstitute.org International Institute for Humanistic Studies, Petaluma, CA, www.human-studies.com International Collaborative of Existential Counsellors and Psychotherapists, http://www.icecap.org.uk Emotion-Focused Therapy Clinic, Toronto, CAN, www.emotionfocusedclinic.org Institute for Psychotherapy Training & Supervision, Flemington, NJ, www.wellspringcenterforhealthandwellbeing.com Institute for Solution Focused Therapy, Chicago and Sturgeon Bay, WI, www.solutionfocusedinstitute.com Solution-Focused Brief Therapy Association, http://www.sfbta.org

BOX 10.7

RECOMMENDED TRAINING DVDs

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http://www.adpca.org

http://www.centerfortheperson.org

http://www.pce-world.org

http://www.focusing.org

http://www.thenewcenterchicago.com

http://www.gestaltcleveland.org

http://www.gestaltnyc.org

http://www.gestaltphila.org

http://www.gatla.org

http://www.newyorkgestalt.org

http://ehinstitute.org

http://www.human-studies.com

http://www.icecap.org.uk

http://www.emotionfocusedclinic.org

http://www.wellspringcenterforhealthandwellbeing.com

http://www.solutionfocusedinstitute.com

http://www.sfbta.org

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Psychotherapy.net, www.psychotherapy.net

Carl Rogers on Person-Centered Therapy, Carl Rogers & Natalie Rogers (2004) Person-Centered Expressive Arts Therapy, Natalie Rogers (2006) Erving Polster on Gestalt Therapy, Irv Polster (2012) Existential-Humanistic Psychotherapy: A Demonstration with James Bugental, James Bugental (2005) Confronting Death and Other Existential Issues in Psychotherapy, Irvin Yalom (2012) Rollo May on Existential Psychotherapy, Rollo May (2009). Solution-Focused Therapy, Insoo Kim Berg (2008)

American Psychological Association, www.apa.org

Existential Therapy, Kirk J. Schneider (2006) Existential-Humanistic Therapy Over Time, Kirk J. Schneider (2009) Experiential Psychotherapy, Alvin R. Mahrer (2006) Emotion-Focused Therapy Over Time, Leslie S. Greenberg (2006) Emotion-Focused Therapy for Depression, Leslie S. Greenberg (2007) Three Approaches to Psychotherapy with a Male Client – The Next Generation, Leslie S. Greenberg (2012) Three Approaches to Psychotherapy with a Female Client – The Next Generation, Leslie S. Greenberg (2012)

There are many associations throughout the world for the humanistic–existential therapies. The following two are highly recommended:

Association for Humanistic Psychology, Alameda, CA, www.ahpweb.org Division of Humanistic Psychology (Division 32), American Psychological Association, Washington, DC, www.apa.org

Two major resources are recommended for purchasing humanistic–existential therapy DVDs: (a) psychotherapy.net, and (b) American Psychological Association. The DVDs listed in Box 10.7 have been viewed by the author of this chapter and are highly recommended for training purposes.

CONCLUDING COMMENTS

This chapter provides an overview of humanistic–existential and SFT, highlighting the importance of these approaches for the APPN. It explicates five major psychotherapeutic approaches (person centered, Gestalt, existential, emotion focused, and solution focused), describing their key concepts, goals, interventions, and evidence-based research. It includes a case study with client–therapist dialogue as well as information on how to obtain postgraduate training. It is hoped that the chapter gives the reader a solid introduction to the rich field of humanistic–existential psychotherapy and that the reader will want to learn more and continue training in these powerful approaches. There are other approaches to humanistic–existential therapy not mentioned in this chapter such as redecision therapy, actualizing therapy, transactional analysis, and focusing. It is suggested that the APPN explore these other types of humanistic–existential approaches as well. For a comprehensive compilation of humanistic–existential approaches, two texts are recommended for the APPN new to these approaches: (1) Cain and Seeman’s Humanistic Psychotherapies: Handbook of Research and Practice (2002), and (2) Schneider, Bugental, and Pierson’s The Handbook of Humanistic Psychology: Leading Edges in Theory, Research, and Practice (2001). Original texts are highly recommended for the advanced practitioners and can be found in the reference list.

DISCUSSION EXERCISES

1. What are the similarities and differences among the four major humanistic–existential approaches (e.g., person centered, Gestalt, existential, and EFT) discussed in this chapter?

2. Why is it important for the APPN to have theoretical knowledge and clinical competency in the three facilitative conditions: unconditional positive regard, congruence, and empathic understanding?

3. Identify one existential theme that you commonly find in your work with clients and explain how

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http://Psychotherapy.net

http://www.psychotherapy.net

http://www.apa.org

http://www.ahpweb.org

http://www.apa.org

http://psychotherapy.net

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the theme would be addressed in an existential approach. 4. Gestalt therapy is based on a natural theory of organismic self-regulation. Explain how this flow

can be interrupted. 5. Emotion-focused therapy uses in-session markers to determine interventions. Select a marker and

explain how you would intervene. 6. SFT is based on the philosophy of postmodernism and social constructionism. How are these

philosophies similar to humanism and existentialism? 7. SFT has specific solution-oriented questions that are used as therapeutic interventions. Select one

question and prepare a client–therapist dialogue reflecting a positive outcome. 8. Which humanistic–existential therapy approach do you find the most interesting and hope to

further explore? Why?

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Development, 83, 146–154. Maslow, A. H. (1962). Toward a psychology of being. Princeton, NJ: Van Nostrand. Matzko, H. M. G. (1997). A gestalt therapy treatment approach for addictions. Gestalt Review, 1(1), 34–55. May, R., Angel, E., & Ellenberger, H. F. (Eds.). (1958). Existence: A new dimension in psychiatry and psychology. New York, NY: Basic Books. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: preparing people for change (2nd ed.). New York, NY: Guilford Press. Miller, S. D., M. A., Hubble, M. A., & Duncan, B. L. (Eds.). (1996). Handbook of solution-focused brief therapy. San Francisco, CA: Jossey-Bass

Publishers. Nevis, E. (1987). Organizational consulting: A Gestalt approach. New York, NY: Gardner Press. Oaklander, V. (1978). Windows to our children: A gestalt therapy approach. Gouldsboro, ME: Gestalt Journal Press. Paivio, S. C., & Greenberg, L. S. (1995). Resolving “unfinished business”: Efficacy of experiential therapy using empty-chair dialogue. Journal

of Consulting and Clinical Psychology, 63, 419–425. Paterson, J. G., & Zderad, L. T. (1988). Humanistic nursing. New York, NY: National League for Nursing. Perls, F. S. (1942). Ego, hunger and aggression: A revision of Freud’s theory and method. New York, NY: Gestalt Journal Press. Perls, F. S. (1969). Gestalt therapy verbatim. Highland, NY: Gestalt Journal Press. Perls, F. S. (1973). The Gestalt approach and eyewitness to therapy. New York, NY: Science and Behavior Books. Perls, F. S., Hefferline, R., & Goodman, P. (1951). Gestalt therapy: Excitement and growth in the human personality. Highland, New York, NY:

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Journal, 19, 9–50. Schneider, K. J. (Ed.). (2008). Existential-integrative psychotherapy: Guide posts to the core of practice. New York, NY: Routledge. Schneider, K. J. (2009). Awakening to awe: Personal stories of profound transformation. Lanham, MD: Jason Aronson. Schneider, K. J., Bugental, J. F. T., & Pierson, J. F. (Eds.). (2001). The handbook of humanistic psychology: Leading edges in theory, research, and

practice. Thousand Oaks, CA: Sage Publications. Schneider, K. J., & Greening, T. (2009). James F. T. Bugental (1915–2008). American Psychologist, 64, 151. Schneider, K. J., & May, R. (1995). 2012. The psychology of existence: An integrative clinical perspective. New York: McGraw-Hill. Serok, S. (1985). Implications of Gestalt therapy with post traumatic patients. The Gestalt Journal, 8 (1), 78–89. Smuts, J. (1926). Holism and evolution. New York, NY: Macmillan. Travelbee, J. (1971). Interpersonal aspects of nursing. Philadelphia, PA: F.A. Davis Company. Teusch, L., Bohme, H., Fink, J., & Gastpar, M. (2001). Effects of client-centered psychotherapy for personality disorders alone and in

combination with psychopharmacological treatment. Psychotherapy and Psychosomatics, 70, 328–336. Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Lawrence Erlbaum Associates. Watson, J. (2011). Human caring science: A theory of nursing (2nd ed.). Sudbury, MA: Jones & Bartlett Learning. Watson, J., C., Gordon, L., B., Stermac, L., Kalogerakos, F., & Steckley, P. (2003). Comparing the effectiveness of process-experiential with

cognitive-behavioral psychotherapy in the treatment of depression. Journal of Consulting and Clinical Psychology, 71, 773–781. Watson, J. C., Goldman, N., & Greenberg, L. S. (2007). Case studies in emotion-focused treatment of depression. Washington, DC: American

Psychological Association. Wheeler, G. (1991). Gestalt reconsidered: A new approach to contact and resistance. New York, NY: Gardner Press. Wiseman, H. (1998). Training counselors in the process-experiential approach. British Journal of Guidance & Counselling, 26, 105–118. Yalom, I. D. (1980). Existential psychotherapy. New York, NY: Basic Books. Yalom, I. (2005). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books. Yontef, G. M. (1993). Awareness, process and dialogue: Essays on gestalt therapy. Highland, NY: Gestalt Journal Press. Zinker, J. (1977). Creative process in gestalt therapy. New York, NY: Vintage Books.

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Group Therapy RICHARD PESSAGNO

n one of the very first systematic reviews of what was then the relatively new clinical method of group psychotherapy, Raymond Corsini and Bini Rosenberg (1955, 1992) identified a number of crucial

“mechanisms” (pp. 146–147) that appeared to be essential for the efficacy of all of the group psychotherapies, irrespective of their formal theoretical allegiances. Their concept of mechanisms for change, the intragroup processes that appeared to bring about beneficial change and growth whatever the overt theoretical orientation of the group, was to inspire one of the most prodigious theorists and practitioners in the field of group psychotherapy, the existential psychoanalyst Irvin Yalom. He elaborated on these processes and has described 11 core elements or therapeutic factors in his still widely used textbook (Yalom & Leszcz, 2005) (for the fifth edition, Yalom was joined for the first time by a coauthor, group psychotherapist Molyn Leszcz).

These core elements or therapeutic factors of group are highlighted after a history of group psychotherapy in the United States is presented. Types of groups and the benefits of groups are discussed. The evidence-base supporting group psychotherapy for a range of different mental disorders follows. Phases of group development are delineated and strategies for integrating group work into advanced practice psychiatric nurse (APPN) practice are identified. The chapter ends with a case example illustrating group psychotherapy interventions and guidelines on how to obtain postmaster’s training and certification.

THE HISTORY OF GROUP PSYCHOTHERAPY

Human beings have been discussing mysteries and dilemmas, collaborating, and arguing in groups since the dawn of hominid time (Fehr, 2003, p. 2). Yet, group therapy as a formalized practice did not really begin to take off until the 1940s, just after World War II, when a burgeoning clinical literature began to appear. Under-resourced military physicians during wartime found themselves swamped by psychiatrically disturbed soldiers recoiling from the horrors of war, and these physicians resorted to group work as the most efficient means of trying to treat large groups of soldiers at the same time (Scheidlinger, 2004).

Around this time, Joseph Moreno, a physician, brought a radical new method into the group psychotherapy arsenal: psychodrama. Disagreeing sharply with the Freudian psychoanalysis of his time, which he felt evaded the pressing realities of the here and now in favor of an unreachable distant past, he used an observation of Aristotle as his inspiration: Spectators in a theater often identify passively with the predicaments of the actors they are watching. Moreno concluded that much psychopathology was the product of massively internalized behavioral and emotional controls, which were far in excess of necessity. He devised methods of role reversal in improvised group dramatizations, wherein patients could re- enact, in role play, powerful scenarios from their lives, current as well as past, and learn to outface their fears, and handle anxiety-laden situations less self-defeatingly or destructively. His view, essentially, was that patients needed practice in releasing their suppressed emotions (catharsis) and their creative potential in the here and now (Moreno, 1940, 1966).

Wilfred Bion managed the rehabilitation of traumatized soldiers as a physician in the British army and had noticed that some of them were able to work well together in groups while others were not, despite sharing similar experiences (Bion, 1959). He focused on collective group processes, rather than on the individuals making up the group, and noticed three fundamental patterns, which could undermine the rational, primary task of the group. The “work group” is a term that Bion says is what is supposed to be achieved by the group. The fundamental patterns or “basic assumptions” are primitive, unconscious beliefs that powerfully influenced and sabotaged conscious activity and action in the group. These include “dependency,” wherein a group feels hopelessly lost as to how it should achieve its task and craves a magic solution from a charismatic leader, and “fight or flight.” Here, a change in the group, such as the introduction of a new member or a new idea, upsets the previously established equilibrium and generates powerful

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anxieties, which get deflected or projected onto an enemy (which could be a new thought). The enemy must be fought or fled from: mutual antagonisms and hostilities or a determination to fight an external enemy constitute the fight reaction, while changing the subject of discussion to a less disturbing one constitutes an example of a flight reaction (see Vinogradov & Yalom, 1989, pp. 65–69, for further examples). Finally, Bion described “pairing,” a process that frequently occurs as a group is coming toward its termination; group members tend to pair up with one another in the hope of identifying or creating a Messianic new leader who will solve all of the group’s problems, save it, and perpetuate it. However, the aim is the postponement of salvation, and the endless perpetuation of an imaginary hopefulness; any new leader will rapidly be attacked and neutralized by the group as soon as he or she is proved not to be the wished-for (impossible) Messiah figure (for a useful summary, see Riosch, 1970). In the United States, a major figure in the emerging group psychotherapy discipline was Samuel Slavson, a founding father of the American Group Psychotherapy Association (AGPA), who practiced group therapeutic methods derived from psychoanalysis with disturbed children and adolescents between 1934 and 1956. As Fehr (2003, pp. 20, 28–29) notes, Slavson believed that when engaged in a group task, participants could develop a strong sense of common purpose and solidarity, bringing out dimensions to their personalities that they rarely used, or perhaps did not even know about previously. He directed his interventions to the encouragement and cementing of group cohesion.

By the 1950s, group therapy was becoming increasingly multivocal, with a range of different theoretical backgrounds informing different approaches (Scheidlinger, 2004). As Scheidlinger (2004) notes, in the 1960s and 1970s the climate became distinctly fractious, with disputes not only among the various analytic groups (Freudians, followers of Adler, and neo-Freudians such as the disciples of Harry Stack Sullivan and Karen Horney), but also among them and the emerging new approaches. These included, among others, Berne’s (1961) transactional analysis method of group therapy, the Gestalt approach pioneered by Peris (1969), existential group psychotherapy (see Mullan, 1992, for an overview), and group applications of Rogers’s person-centered approach. By the 1980s, cognitive behavioral therapy (CBT) (see Beck, Rush, Shaw, & Emory, 1979, for the classic text introducing cognitive therapy, and Beck, 2011, for an updated overview of contemporary CBT practice) was making the transition from an individual therapy to a group intervention. Although the literature on cognitive behavioral group psychotherapy is now voluminous, there are few works outlining comprehensive models for the technique’s application in groups. An exception remains the fusion between rational-emotive therapy and CBT outlined by Ellis (1992, 2011).

Despite the burgeoning diversity of different approaches currently available in group psychotherapy, the fractiousness, rivalry, and mutual antagonisms alluded to earlier have given way to a remarkable willingness among practitioners from different schools to learn from one another and incorporate pragmatic strategies from one another into their methods. Both Scheidlinger (2004) and Yalom and Leszcz (2005) believe that the threat to psychotherapy of all kinds posed by the introduction of managed health care systems in the 1990s, which emphasized cost-effective and brief treatments, appears to have made such disunity an unaffordable luxury.

THE PRINCIPLES OF GROUP PSYCHOTHERAPY

Despite the array of different theoretical schools of group psychotherapy today, there are some core principles and underlying assumptions that they have in common. Yalom has argued (Yalom & Leszcz, 2005) that these assumptions are crucial to all modalities if therapeutic progress is to be made. These are the basic mechanisms of change; Yalom’s massive review of the literature on group psychotherapy and change led him to conclude that 11 central factors will be at work in any therapeutically effective group, regardless of overt theoretical allegiances. Primary theoretical models include psychodynamic, cognitive behavioral, interpersonal, solution focused, and person centered (see Table 11.1).

It seems wisest to adopt Yalom’s approach: although there are many more short-term groups with a homogeneous composition today (i.e., groups targeted at specific symptoms or problems, such as eating disorders, panic disorders, acute or chronic depression, and so on), they are of comparatively recent pedigree. The wisdom that can be distilled from the far more long-standing research into (and clinical observations of) long-term, heterogeneous group psychotherapy is of considerable relevance to all psychotherapy groups.

The 11 Therapeutic Factors of Group Psychotherapy

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All groups, whether based on psychoeducation, solution-focused approaches, or CBT, attempt to bring about beneficial change even if the group techniques are a formulaic application. For any form of beneficent progress to occur, however, Yalom and Leszcz argue, therapists need to engage sensitively in the here and now of every group session with the intricacies, ambiguities, and subtleties of interpersonal interaction. Managed-care health delivery systems may be pushing for the setting up of “cost-effective,” short-term groups aimed at relieving specific symptoms, but it would be a mistake to believe that change occurs simply because of a particular technique (e.g., CBT). How those techniques are humanely practiced, how group psychotherapists enable group members to interact freely and safely so that patients can discover how their customary interactions may backfire or cause unhappiness, and how to change these patterns—all require sensitive attention to, and careful stewardship of group process and the nuanced, interpersonal communication patterns, both spoken and nonspoken. The following therapeutic factors or principles, formerly termed curative factors, can be applied to all groups.

TABLE 11.1 Examples of Theoretical Approaches and Focus of Approach

PRINCIPLE 1: THE INSTILLATION OF HOPE

By the time people come to group psychotherapy, the problems they have been struggling with have usually defeated them; seeking help can often be experienced as an admission of personal defeat and despair. A key feature of successful group psychotherapy is therefore the instillation of hope (Yalom & Leszcz, 2005, pp. 4– 6), which means that the inculcation of a belief that, with one another’s shared resources, progress is possible. Without this, little else can be achieved. The therapist’s strong belief in the therapeutic process, coupled with the emerging evidence that group members are indeed beginning to transform as the group progresses, are

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important sources of this realistic, therapeutic hope.

PRINCIPLE 2: UNIVERSALITY

No matter how idiosyncratic, or even shameful, a client may consider his or her difficulty to be, a major factor in group psychotherapy is the cultivation of a belief among all members in universality—essentially, that they are not alone. As Yalom and Leszcz (2005, p. 6) state: “There is no human deed or thought that is fully outside the experience of other people.” Many people have felt forced into isolation and fear intimacy because of their difficulties, and this process of nonjudgmental group acceptance can help dissolve chronic feelings of shame and estrangement.

PRINCIPLE 3: IMPARTING INFORMATION

This is essentially intervening to obstruct the course of destructive thought processes by imparting established knowledge concerning, for example, a particular mental illness, and how it can manifest itself. Although it is often implicit, embodied in the therapist’s comments or queries about a particular belief, for instance, it is sometimes didactic in nature. An example given by Yalom and Leszcz is of a patient believing he is about to die whenever he suffers a panic attack. Great benefits can accrue from describing the physiological foundations of panic attacks, such as the hyperventilation and dizziness stimulated by elevated adrenaline, and by the didactic description of relaxation methods that can easily be practiced to bring the event back under control (Yalom & Leszcz, 2005, p. 10).

PRINCIPLE 4: ALTRUISM

To give is to receive. Yalom and Leszcz (2005, p. 14) cite the example of a depressed man who was beginning to confound other group members by constantly rebuffing their suggestions and ideas. Another group member, a depressed woman who had struggled with substance abuse, explained to him that she, too, used to refuse the help offered by others. She thought she was unworthy; but when she realized that people felt hurt by her rebuttals, she made a concerted effort to receive what was given graciously and began to feel enormously better as a result. Receiving with gratitude appears to bring to life one’s own generosity and desire to help others in need, developments that are intrinsically therapeutic, and even beneficial, to the survival of the species (Phillips & Taylor, 2009, especially pp. 71–96).

PRINCIPLE 5: THE CORRECTIVE RECAPITULATION OF THE PRIMARY FAMILY GROUP

Yalom’s clinical experience and extensive research led him to conclude that most patients seeking group psychotherapy have suffered toxic and harmful experiences in the first group they ever encountered—their original families. Members frequently find that they start to replicate patterns from these original group experiences in the context of the therapy group, transferring unfinished business with parents onto the group leaders, or unresolved issues with siblings onto other group members. The therapeutic group is the ideal setting for such recapitulations, offering a safe and compassionately corrective environment.

PRINCIPLE 6: DEVELOPMENT OF SOCIALIZING TECHNIQUES

Partly through the corrective recapitulation of primary group scenarios and partly through the inevitabilities of misunderstandings, group members learn from each other about how to correct chronic and maladaptive social tendencies. One man, cited by Yalom and Leszcz (2005, p. 17), suddenly became aware in a group meeting of a lifelong habit of obsessively including irrelevant details in all his conversations, something that others found exceptionally off-putting. The group helped him to notice this without condemning or humiliating him. Tactful and compassionate feedback from group members can help clients to process

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complex emotions and develop better social skills, as well as to learn how to resolve conflicts safely, and become more empathic.

PRINCIPLE 7: IMITATIVE BEHAVIOR

Hitherto isolated people frequently learn to expand their repertoire of coping skills and become more accepting of themselves and others in group psychotherapy by “trying out” other people’s behavior and seeing whether it suits them. Both therapists and other group members can be mirrored in this way by clients eager to grow and change; they may adopt physical postures and styles of talking similar to the therapist’s, for example, and even try to think like him or her (Yalom & Leszcz, 2005, pp. 17–19). Similar to the socializing techniques described earlier, imitative behavior can be an occasion for rich, new learning.

PRINCIPLE 8: INTERPERSONAL LEARNING

Interdependence is not a weakness but a great strength for the human animal and, much like the capacity for altruism, has played a part in species survival (Yalom & Leszcz, 2005, p. 19). The need for human contact appears to be fundamental and part of our evolutionary makeup. The group environment can enhance the value of interpersonal connectedness—self-disclosure in groups always implies the overcoming of fears, and the corrective, intelligent emotional responses of group members can help restore (or even create for the first time) a hurt and withdrawn member’s faith in the value of human fellowship for facing life’s adversities. Learning from one another greatly facilitates therapeutic change and personal growth. As a result of interpersonal learning, self-understanding and the achievement of greater levels of insight into the origins and underlying motivation of one’s behavior occurs.

PRINCIPLE 9: GROUP COHESIVENESS

Group cohesiveness occurs when members start to feel that they belong, that they can draw comfort and warmth from their peers in the group, and that they are unconditionally accepted by the other group members. Yalom considers this the primary therapeutic factor in group therapy, facilitating improved self- esteem, hope, and well-being. Group cohesiveness is the indispensable precondition for therapeutic change, enabling the personal exploration and self-disclosure on which effective therapy hinges (Marmarosh, Holtz, & Schottenbauer, 2005).

PRINCIPLE 10: CATHARSIS

Catharsis occurs when group members become able to express deep emotional feeling states, a process that appears to foster profound feelings of release and recovery. As with the other factors, it depends on strong group cohesiveness for maximum therapeutic effect; but other group members appear to benefit and grow from witnessing a peer in emotional catharsis.

PRINCIPLE 11: EXISTENTIAL FACTORS

As an existential psychotherapist, Yalom is profoundly aware that there are occasions when human beings cannot escape from pain; we are mortal and will suffer losses during life, no matter how close and intimate we become with others. These are the ineluctable truths of human existence. The existential factors that Yalom and Leszcz describe essentially refer to the capacity to face these truths, to be with one another in a group with a deep awareness of these truths without taking flight into trivialities. Life is enriched by such awareness, as indeed it is by the existentialist axiom that each individual is ultimately responsible for how he or she lives life (Frankl, 1969).

TYPES OF GROUPS

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There are a wide variety of groups, with both varying purposes and functions. Psychoeducational groups are one of the most commonplace groups to most practicing nurses. These groups primarily function to facilitate education or information to patients and/or families about various psychiatric-mental topics. Psychoeducational groups can mediate an educational process and promote knowledge about a multitude of topics such as psychiatric diagnosis, addictions, medication, self-care, and recovery issues. Groups such as these reinforce information, augment knowledge, and improve wellness. Psychoeducational groups are often time limited with a specified number of sessions being offered. The content of the psychoeducational group lends itself to be structured where group members can assign specific topics for discussion during each session. Psychoeducational groups can be facilitated by either a professional (such as a registered nurse, health educator, social worker, or licensed professional counselor) or nonprofessional (peer specialist or family member) group leader.

Support groups are another type of group that focuses on providing group members with an environment that they share with others who are experiencing a common type of experience (such as grief, cancer, multiple sclerosis, and diabetes). Support groups typically allow group members to share their individual experiences, listen to others, provide information to one another, and provide sympathetic understanding to one another. Support groups often have a specified number of sessions. The structure of these groups can be more formal with specific topics that are covered each week, or the groups can be more fluid and allow group members to direct the formation of topics. These types of groups can be led by nonprofessional or professional group leaders.

Self-help groups are those that are formed in order to provide mutual support to their members. These groups come together because of shared experiences such as addiction in order for group members to help each other deal with this specified experience. Self-help groups provide a medium for group members to share their individual stories and to share struggles and successes with others in order to allow members to feel that they are not alone. Well-known self-help groups include Alcoholics Anonymous and Narcotics Anonymous. Self-help groups are not time-limited groups, and participation in groups can continue for months to years. For groups that focus on recovery, such as Alcoholics Anonymous, participation is seen as an integral part of continued sobriety. The shared community experience is viewed as the medium for change. The self-help group focuses on having a veteran member guiding and supporting newer group members. The self-help group model does not use professional group leaders; all group members take responsibility for group leadership.

Benefits of Groups

Treatments for psychiatric disorders are varied and can include psychotherapy, psychoeducation, support groups, and pharmacotherapy. Treatment choices for patients depend on multiple factors, including availability, cost, convenience, the influence of family and friends, and patient preference (Burlingame, Fuhriman, & Moiser, 2003). Group psychotherapy can be an ideal treatment option for many reasons for both the therapist and the client. Two of the most important factors in today’s health care landscape are cost and cost-effectiveness. The cost-effectiveness of group psychotherapy has made this an ideal choice for many patients (Burlingame et al., 2003; McRoberts, Burlingame, & Hoag, 1998). Cost-effectiveness is articulated as a significant factor in providing group psychotherapy as an alternative treatment to individual therapy in a study comparing the two types of interventions over an 18-month period.

Clients with and without insurance coverage for mental health services may find group psychotherapy an affordable treatment option. For the therapist, group psychotherapy affords group-trained clinicians the opportunity to offer treatment to several patients at once, allowing for greater access to treatment for the client and providing the therapist the ability to see larger numbers of clients at one time. Group psychotherapy also provides the therapist with the option to diversify his or her practice, providing clients with a wide array of services from which to choose. Additionally, from a time management perspective, a group therapist typically can see 6 to 10 clients in a group therapy session using the traditional 90-minute group psychotherapy session. Yet treating each of the same 6 to 10 clients within the confines of an individual psychotherapy session would require the same therapist to dedicate 6 to 10 individual sessions, requiring many hours of treatment.

In addition, the rise of managed-care health delivery systems has led to an upsurge in the use of group psychotherapy, especially relatively short-term interventions, as one of the most cost-effective methods for treating an enormous range of different target groups (see MacKenzie, 1994, for an early articulation of the effects of managed health care policies on psychotherapy service delivery). As Yalom and Leszcz note (2005,

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p. xii), today there are tried-and-tested group psychotherapy interventions available for a vast range of conditions.

Groups exist for anxiety disorders such as panic disorder, depression, perinatal mood disorders, eating disorders such as anorexia and bulimia nervosa, groups for people suffering with HIV/AIDS or cancer, or other conditions such as rheumatoid arthritis, obesity, multiple sclerosis, bone marrow transplant, renal failure, diabetic blindness, paraplegia, myocardial infarction, Parkinson’s disease, irritable bowel syndrome, and for people with a genetic predisposition to cancer. There are also groups for victims of sexual abuse, for parents of sexually abused children, for victims of domestic violence, for people recovering from a first episode of schizophrenia, for people with chronic schizophrenia, for adult children of alcoholic parents, for self- harmers, for the bereaved, for troubled families and couples, and for divorcees. This is by no means an exhaustive list and does not include self-help groups such as Alcoholics Anonymous or Narcotics Anonymous. The scope of group psychotherapy, in effect, is simply vast.

The literature further notes that the homogeneity of psychotherapy groups related to the specific diagnostic similarity of participants can positively influence the group’s outcome and efficacy (Kösters et al., 2006). These same researchers also noted that psychotherapy groups with a limited size of 6 to 10 participants also positively influenced outcomes and efficacy. Patients grouped together based on similar diagnoses, such as cancer, bereavement, or depression, do better than groups with divergent diagnoses among group members (Leszcz & Goodwin, 1997). The more the commonality among group participants, the greater the opportunity that exists for abatement of symptoms. Another meta-analysis of 45 studies evaluated a variety of homogeneous psychotherapy groups that segregated depressed patients, schizophrenic patients, and anxious patients. The psychotherapy groups that were homogeneous or segregated based on diagnosis outperformed psychotherapy groups of patient cohorts that were mixed based on diagnoses (Burlingame et al., 2003).

Group psychotherapy does afford some benefits to the client that are not afforded to clients who seek out and use individual psychotherapy. These benefits include the fact that the therapeutic value of working within a group provides members with the opportunity to share common experiences with others. This ability to share experiences with others has been positively linked to symptom resolution, particularly among depressed and anxious patients (McRoberts et al., 1998). Group psychotherapy also creates a forum for clients to work on relational issues with other individuals within a structured environment. Individual therapy does not provide this benefit. McRoberts et al. (1998) also commented that clients engaged in group psychotherapy saw more rapid resolution of symptoms compared to individual therapy participants, which might support using group psychotherapy interventions (McRoberts et al., 1998).

EVIDENCE-BASED RESEARCH

A review of 107 clinical studies and 14 meta-analyses by Burlingame, MacKenzie, and Strauss (2004) concluded that, for outpatient populations, group therapy was equal in effectiveness to individual therapy, whether it was used as the primary treatment or as an adjunct to a more multimodal treatment program. Group therapy was also found by these authors to be effective for patients suffering with severe mental illnesses such as bipolar disorders and schizophrenia. An earlier meta-analysis by Burlingame, Fuhriman, and Mosier (2003), comparing the effectiveness of outpatient and inpatient group psychotherapy, found that, in comparison to waiting-list controls, outpatient groups significantly outperformed inpatient groups; however, the number of inpatient studies was small, at only six. A more recent meta-analysis of the effectiveness of group psychotherapy in inpatient settings, however, found marked improvements post-intervention (Kösters, Burlingame, Nachtigall, & Strauss, 2006). The authors analyzed 46 studies with pre-post measures and 24 controlled studies, all of which had been published between 1980 and 2004. Patients with mood disorders improved considerably more after group psychotherapy interventions than those with mixed diagnoses or with posttraumatic stress disorder (PTSD), schizophrenia, or psychosomatic illness, although all groups showed measurable improvements.

These studies suggest that, theoretical orientations aside, group psychotherapy as a treatment modality is as effective as individual psychotherapy, and that it may well therefore be considerably more cost-effective. As mentioned earlier, it has been shown to be an effective intervention for patients suffering with physical as well as mental health conditions. For example, the systematic review and meta-analysis conducted by Himelhoch, Medoff, and Oyeniy (2007) into the effects of group psychotherapy on depressive symptoms among male, HIV-infected individuals showed that it significantly reduced depression ratings. Eight randomized, controlled, double-blinded studies encompassing 655 patients were used in the review; five of the studies used

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CBT as the theoretical basis for group therapy, two used supportive therapy, and one used a psychoeducational approach involving coping-effectiveness training. The strongest improvements occurred in the CBT groups.

Spiegel’s groundbreaking work on group psychotherapy with cancer patients was the first to bring cancer patients together to address the terrors, pain, and depression associated with cancer diagnosis and treatment. His research furnishes compelling evidence that both their survival times and quality of life were substantially enhanced as a result of group psychotherapy (see Spiegel & Classen, 2000, for a comprehensive review and abundant clinical illustrations). For patients with advanced terminal cancer, a relatively new group psychotherapy modality, meaning-centered group psychotherapy (based on Victor Frankl’s work on logotherapy, see Frankl, 1969/1988), substantially improved measures of spiritual well-being, optimism/pessimism, desire for death, hopelessness, anxiety, and depression in just 8 weeks of treatment (Breitbart et al., 2010). Follow-up assessment showed that the improvements were maintained 2 months after the cessation of treatment.

There is also growing evidence that group psychotherapy is an effective treatment for depression. A randomized, controlled trial conducted by Mulcahy, Reay, Wilkinson, and Owen (2010) compared brief, outpatient group psychotherapy (an 8-week interpersonal psychotherapy group) with standard treatment (treatment as usual or TAU) for women diagnosed with postnatal depression. Although most of the 50 women included in the trial showed improved depression ratings by the end of the treatment period, women who had been randomly assigned to the group psychotherapy treatment showed markedly better ratings than those assigned to TAU. Improvements for the group psychotherapy for women extended to the marital relationship and to mother–infant bonding and were still evident 3 months after the cessation of treatment.

Even in a notoriously difficult-to-treat subgroup, substance misusers, compelling evidence is emerging that group psychotherapy can be an effective treatment intervention. A systematic review of 24 treatment outcome studies in relation to substance misuse found that group psychotherapy was as effective as individual psychotherapy in the treatment of addiction, although no single modality of group therapy proved any more efficacious than the other group orientations (Weiss, Jaffee, de Menil, & Cogley, 2004). Moreover, in a study by Scherbauma et al. (2005), a 20-session CBT group proved considerably more effective in reducing drug use among opiate addicts than a routine methadone maintenance treatment (MMT) alone. Both cohorts of patients received MMT, but one received CBT group therapy in addition. Moreover, the reductions were still in evidence 6 months after the cessation of treatment and were much more poorly sustained among the MMT-only patients.

These are only a few samples of the voluminous, peer-reviewed research supporting the use of group psychotherapy as an effective treatment modality across an enormous span of different conditions and illnesses. See Table 11.2 for evidence-based research for group psychotherapy.

THE DEVELOPMENT OF A GROUP

How does a group develop over time? This may seem like a relatively straightforward question, but research by Arrow, Poole, Henry, Wheelan, and Moreland (2004) provides ample reasons to explain why it is not necessarily straightforward. For one thing, what version of time is being employed? Beyond the commonsense, everyday notion of time, matters start getting seriously complicated. This research suggests that in many collective human endeavors, such as the work of psychotherapeutic groups, time is socially constructed: how group members think about time, and the meanings they attribute to it, will profoundly affect how they handle temporal issues. These researchers draw on work by Ancona, Okhuysen, and Perlow (2001), which identified five models of time. These are clock time, cyclical time (e.g., the annual cycle of the seasons), time as punctuated by predictable events (e.g., birthdays, paydays, and so on), time as punctuated by unpredictable events (e.g., accidents, natural disasters such as floods or earthquakes, or terrorist atrocities), and life cycle time, which refers to development within a finite life span. Any one human being will experience and contribute to each of these different social constructs of time depending on which of them seems most pressing to the particular group task and group culture in which he or she is engaged. Time can also be experienced as a kind of currency or resource, with people not wishing to “waste” it or expecting a return on their “investment.” These considerations complicate certain research assumptions, such as the belief that groups develop systematically as time unfolds, or that groups exhibit discernible temporal patterns in their development. The inconsistent empirical findings in relation to these expectations have led to the development of more complex theorizations about the development of small group systems, including the

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assumption that groups may be more effectively conceptualized and thus governed by nonlinear dynamics, summating that groups are complex systems (Arrow et al., 2004).

TABLE 11.2 Evidence-Based Research for Group Psychotherapy

Arrow et al. (2004) call for the development of a more adequate “complex theory” of group development, which takes account of the fact that group systems are not “well behaved” (i.e., they do not conform to simple models of linear causality and often show discontinuities and unexpected novelties in their developmental path). Such complex theories should also take account of the fact that group systems interact at multiple levels, both within each group, and in relation to external environmental influences.

MacKenzie (1994) presented a rather striking statistic: more than 80% of patients attending mental health services are seen for no more than eight sessions, and fewer than 15% remain in treatment for 6 months or longer. MacKenzie argues for a creative approach to the impact of managed care, honing skills to assess which patients will require longer-term treatments as accurately as possible in the earliest stages of intervention. This is where clinical acumen is clearly relevant; moreover, being able to judge who will benefit from short-term crisis intervention only, who will require time-limited therapy of between 8 and 26 sessions, and who will need longer-term, group psychotherapy of more than 6 months, can empower clinicians to provide the right help to the right patients in a climate of scarce resources and finite provision.

With these provisos in mind, at the level of clinical stewardship of a group, Yalom and Leszcz (2005) suggest that, while nothing is predictable, much can be gained by having a fundamental clinical awareness of certain necessary transitions in the life of an effective psychotherapeutic group. Four broad phases or stages of group psychotherapy formation or development are identified, and these phases appear to be consistent across a broad range of theoretical modalities (Yalom & Leszcz, 2005).

Psychotherapy groups all seem to begin with an orientation or the forming (Tuckerman, 1965) phase or stage, where members feel somewhat lost and search for structures and goals, feeling exceptionally dependent on the therapist for leadership and guidance in the midst of their uncertainty. This phase eventually transmutes into a period of conflict or storming phase or stage, where issues of interpersonal dominance, rebellion, or submission take center stage similar, in fact, to the descriptions given earlier of the recapitulation of primary family group dynamics. Provided the therapist is able to ensure a corrective emotional experience

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(Jacobs, 1990) in the group, so that damaging original family dynamics can emerge and be ameliorated without being simply replicated, the group appears to move into a phase of internal harmony and warmth, where group cohesiveness takes center stage, and where interpersonal differences are downplayed or ignored. This appears to be a necessary step in the creation of a shared sense of safety, the belief that the group is a secure base for exploration and growth, as attachment theorist John Bowlby (1988) would describe it. See Table 11.3 for the phases of group development.

TABLE 11.3 Phases of Group Formation/Development Group Phase/Stage Characteristic of Phase/Stage Orientation or forming Group members are adapting to being in the group; members will seek out guidance and approval from the group leader

about appropriate boundaries, limits, and behaviors; limited personal disclosure done by group members; some group members may experience anxiety and apprehension.

Storming Group members are attempting to find their place within the group; group members may experience conflict among themselves; group members exchange ideas, which can cause group members to experience conflict; group members begin to notice differences among themselves; this stage/phase is necessary in order for the group to mature and grow.

Norming Group members become more aligned as a whole, and identify and work to a common goal. This stage/phase allows members to experience a great sense of trust among themselves.

Performing Group members are more autonomous and independent; group members feel ownership of group experience. Deeper sense of work is accomplished. Group members are able to be more honest with one another, and a deeper sense of sharing occurs among members.

Adjourning Members have appreciation for other group members. It is during this phase/stage that the termination is addressed and occurs. Group members may experience more difficult emotional responses and emotions to the group ending.

Adapted from Tuckerman (1965).

As group cohesiveness is consolidated, a process that can take a considerable period, another spontaneous evolution appears to take place: the emergence of the mature work group—highly cohesive, but willing to explore, investigate, and analyze with a very high degree of commitment to the group as a whole, its primary task, and to the individual members who constitute it.

INTEGRATING GROUP TREATMENT INTO APPN PRACTICE

Exploring the idea of starting a group within one’s practice can be a daunting task. Psychiatric nurse practitioners (NPs) may feel that their skill level, relative to leading and facilitating a group, may be lacking. There may also be concerns about the process one must undertake in order to start a group. Questions can arise about how to identify the most appropriate type of group, how to screen and select appropriate patients, how to establish a fee schedule, how to implement an advertising strategy, and whether to use a co-therapist leader. Although there are multiple steps one must take in order to initiate a psychotherapy group into one’s practice, this can be an exciting and challenging way to invigorate and diversify one’s practice, no matter what the practice setting.

Yalom and Leszcz (2005, pp. 443–447) provide a lucid overview of the pros and cons of running groups as a solo therapist or as a co-therapist. The decision to lead a group as an individual group therapist or to have co-therapists is dependent on many factors. Many group psychotherapists are comfortable with leading groups individually, but often co-leading adds to the dynamics of the group, providing the opportunity to process group issues with another therapist, to learn from a colleague, and at times make the group process more enjoyable.

Frankly, there are so many forms of communication occurring in a group psychotherapy session, so much that is going on among members, even in prolonged periods of silence, that two heads are often better than one. One therapist, typically, concentrates on the content of interpersonal communication, while the other focuses on the process. Group members often benefit from watching and learning how the co-therapists talk to one another and resolve differences or conflicts. This modeling behavior can be a great medium for group members to witness healthy communication and positive relationship skills. The therapeutic styles, theoretical and clinical resources, and wisdom of the group leaders are multiplied by having two therapists. Additionally, having a competent colleague in the room helps to diminish the inevitable therapist anxieties when running a group psychotherapy session. Using a co-therapist also provides a medium to access, discuss, and debrief clinical issues before and after each group session.

However, there are also drawbacks. Co-therapists who simply do not get along with each other will have a formidable task in managing their own differences therapeutically when they are also managing immensely complex group differences and conflicts. It is also possible for parent–child dynamics to arise if one therapist is more skilled and experienced than the other. Given that group members are likely to recapitulate dynamics originating in their families, it is also very likely that forms of splitting may arise, with one therapist

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apparently idealized, while the other becomes devalued or denigrated. Finally, group members may feel coerced by co-therapists who become adamant in promoting a particular therapeutic message, a phenomenon that can set off underground dynamics of resistance and rebellion.

The first step in starting a group is to identify what the purpose of the group is and what types of patients would benefit from the group. An APPN working within an acute inpatient setting might explore what types of psychotherapy or process groups are currently being provided within the institution. Often, partnering with the hospital-based licensed clinical social workers or psychologists, who may be engaged in leading psychotherapy groups, could prove to be beneficial. Assess what types of patient needs could be met through offering group treatment. For hospitalized patients, would offering a men’s and a women’s therapy group be appropriate? Due to the limited time that patients are hospitalized, groups that have a broader appeal and can be more inclusive will afford more patients the opportunity to participate in inpatient psychotherapy groups. For the APPN working within an outpatient setting (such as private practice, community mental health centers, substance abuse programs, or homeless shelters), using the same process is beneficial. Determine whether other providers are offering groups within your organization.

When starting a group, it is often best to identify a target population. The APPN might notice, for example, that their current caseload includes several patients with the same psychiatric diagnosis, or several patients who share the same issues (such as divorce, new onset of a cancer diagnosis, or gender identity issues). Using a group intervention or starting a therapy group can allow the APPN to expand the caseload of patients, diversify treatment options for clients, provide cost savings to clients, possibly improve revenues for the APPN practice, and potentially improve productivity. Finding a commonality among patients will be helpful in identifying those individuals who might work well together within a group.

After identifying a target population, the APPN needs to identify the type of group to be offered. Will the group be time limited (i.e., offering 8 to 12 sessions) or will the group be longer term (i.e., requiring a patient to commit to 3 months to a year)? It is also important to identify whether the group will be an open or a closed group. Open groups allow new members to join as space permits, and closed groups allow no new members once the group begins. It is also important for the APPN to decide the number of group members. Typical therapy groups will include six to eight members. The theoretical orientation of the provider often will dictate the type of framework used within the group. As noted within the chapter, various theoretical orientations fit well when using group psychotherapy.

The next step is to decide whether the group will be led by one or two group leaders. For APPNs who have little group therapy experience, using a co-therapist can be a good way of becoming more comfortable with the role of group therapist as well as provide a means of sharing the responsibility of group treatment. When offering mixed-gender groups, having a male and a female group leader can provide a means of offering a varying gender approach as well as provide a suitable means for modeling adaptive male–female interaction and behavior. On the other hand, when working with female sexual abuse survivors, the group may prove to be more productive if led by two female co-therapists. The same may be true if a therapy group is offered for gay men; two male co-therapists may create a better therapeutic balance within the group. Regardless of the gender of the co-therapist, having the right fit, relative to skill, interests, alignment of group philosophy and theoretical approach, and ability to create a therapeutic bond within a group environment, is critical to selecting a compatible co-therapist. Remember, selecting a co-therapist who is a good fit for the APPN’s temperament, style, theoretical orientation, and personality is a vital part of building a successful group.

Fees for the group will typically be based on several factors including insurance reimbursement and geographic location. Group psychotherapy fees vary from region to region. Fees are often market driven and dependent on the skill level, education, and experience of the group psychotherapist. For the client, group psychotherapy can be a more affordable alternative to individual psychotherapy.

Marketing and advertising a new group present another set of challenges. Often, networking with colleagues can be an effective way of identifying potential group members. Inform colleagues that a new group is being offered and tell them what types of patients are being sought. Advertising in local newspapers, church bulletins, schools, hospitals, and community centers can also improve visibility of the new group. Using professional websites for psychotherapists or designing a personal website may also be effective means of advertising.

Patient selection will largely depend on the setting. For outpatient settings, it is often beneficial for the group therapist(s) to interview each potential group member to determine whether the group would be a good fit for the patient. Patient goals, group goals, motivation, ability to attend weekly sessions, past psychiatric history, intellectual functioning, past experience with psychotherapy, and personality characteristics may all be factors in determining whether a patient is the right fit for the therapy group.

When setting the schedule for the group, it can be beneficial to hold the group sessions on the same day

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and time each week. This will not only help establish the therapeutic alliance and trust, but it will also allow group members to plan ahead and improve success relative to attendance. Many therapy groups typically run for 90 minutes.

CASE EXAMPLE

The case example in this chapter illustrates the four phases of group psychotherapy and process, as noted over the course of an outpatient, structured, 8-week, short-term psychotherapy group for first-time mothers at risk of postpartum depression. The group is composed of eight women, all of whom had given birth within 1 month of the start of the group. The women were all screened by the APPN prior to the beginning of the group to assess their appropriateness for group treatment including the absence of suicidality and psychosis, as well as each participant’s ability and willingness to attend all eight, 90-minute group sessions. Prior to participating, each woman had completed the Edinburgh Postnatal Depression Scale (EPDS), a publicly available tool that is used to detect depressive symptoms among women during the postpartum period. Each woman had scored an 11 or higher on the EPDS, indicating a risk for postpartum depression. The purpose of the group was to decrease the risk for postpartum depression as evidenced by a decrease in the EPDS after the completion of an 8-week group psychotherapy intervention. An interpersonal psychotherapy orientation was used for the group.

The first group session was spent articulating ground rules for the group. Each participant was asked to maintain confidentiality of the communication within the group by agreeing not to disclose any specific information revealed by other participants. This is a standard ground rule for any psychotherapy group. In addition, during the first session, participants were asked to agree to come to the group sessions on time and not to intentionally miss any sessions. If a participant had to miss a group session, she agreed to call the group leader beforehand to notify him or her of the reason for her absence. This session also addressed the issue of emergency psychiatric services. Participants were instructed that if any emergent psychiatric needs surfaced (such as suicidal or homicidal thoughts, hallucinations, or other thought disturbances) while participating in the group, they were immediately to contact the group leader and/or seek services at the nearest emergency room or crisis center. Emergent psychiatric symptoms were not anticipated, because all of the participants had been deemed safe and stable through the psychiatric evaluation and mental health clearance provided by the group leader and which were conducted individually with the group leader before the start of the group. Group members were also provided with the 24-hour answering service number for the group leader as well as the phone number for the hospital’s emergency room and the local crisis center.

The first two sessions were structured around introducing participants to one another and allowing participants to get to know each other. Participants discussed their birth experiences, the catalyst that made them decide to participate in the group, the types of depressive symptoms the participants were experiencing, and the expectations each participant had for the group. These processes are illustrative of the orientation stage in the group process. In this phase, the group leader provides more leadership and guidance.

The third and fourth sessions provided time for each group member to check in with one another, providing the opportunity for each participant to share how she had been feeling over the preceding week. The group, during this storming phase or conflict phase, processed the issues and feelings regarding role adjustment and discussed strategies for improving individual coping. During these two weeks, group members noted some interpersonal conflict in the form of minor disagreements centering on parenting styles and parenting roles. During these sessions, each group member is attempting to find her place within the group and evaluating other members within the group relative to issues of trust and relationship building. During these sessions, the group leader provided guidance and assisted group members as they addressed issues of conflict as well as helped to clarify statements and issues being identified in the group. The fourth and fifth sessions again followed the same check-in format, allowing each member to talk briefly about her week. During this phase, or the norming stage, group members further developed a sense of belonging to the group as a whole. The focus of these sessions was to address how their depression may have influenced or impacted their relationships, primarily with

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their significant others and their newborns. This session also served as a check-in for participants regarding the progress they were making in the group as well as identified whether the group was meeting the participants’ expectations at the halfway point in the process. In these sessions, the group leader function within the group focused on solidifying the group and assisting members to work together on identifying and pointing out when group members were working cohesively toward the goals of the group.

The sixth and seventh sessions followed the same check-in format, discussing how participants had been feeling over the past week and then refocusing at a deeper level on their interpersonal relationships, examining how their relationships are now changing as new mothers and examining how each member’s communication traits and styles may be impacting their relationships and their ability to discuss their current issues and symptoms with others. The group processed issues and feelings related to interpersonal relationships, and identified ways to strengthen interpersonal relationships to better manage depression. These sessions also addressed means of strengthening participants’ childcare behaviors when the mothers were feeling depressed. Time during the seventh session was also dedicated to beginning to address termination of the group, linking other types of endings in the participants’ own lives. During this session, the therapist function is mainly focused on allowing the group members to lead themselves, providing guidance and encouragement when needed but allowing members autonomy over the processes occurring within the group.

The eighth group session followed the same check-in format, and served as a foundation for participants to examine their progress in the group as well as to identify how the group had helped them individually. The last session also served as an opportunity to terminate with one another and to examine how each member’s mental health needs were met or not met now that the group was ending. Participants were given an opportunity to explore whether they needed more treatment or support and how those needs might be met. Participants were also asked to complete the second EPDS, which would be compared to the first EPDS in order to determine whether the intervention was effective. During this session, the group leader guides the members through termination, identifying any issues that may be surfacing that indicate members may be having difficulty with the group ending. The therapist also clearly articulates the successes and the challenges faced by the group as well as the accomplishments of the group.

At the end of group therapy, EPDS scores for participants did decrease, suggesting a decrease in a risk for postpartum depression. Six of the participants ended treatment with the completion of the group. Two participants decided to begin individual therapy with a previous therapist with whom they had worked in the past.

POSTMASTER’S GROUP PSYCHOTHERAPY TRAINING AND CERTIFICATION REQUIREMENTS

The AGPA has established the competency standards for group psychotherapy. These standards and resources for the group psychotherapist can be found online (www.agpa.org/group/index.xhtml). Various training sessions and postgraduate education for both seasoned practitioners and new graduates are available through the AGPA during its annual meeting as well as through various regional chapters nationwide that are affiliated with the organization.

The International Board for Certification of Group Psychotherapists (IBCGP) (www.agpa.org/stdnt/certindex.xhtml) also offers a means for those interested in credentialing as a group psychotherapist to achieve professional certification. Certification as a Certified Group Psychotherapist (CGP) is available to licensed mental health practitioners with current malpractice coverage and who hold a minimum of a master’s degree in their respective discipline. This interprofessional international certification is open to psychiatrists, psychologists, advanced practice nurses, social workers, expressive therapists, drug and alcohol counselors, pastoral counselors, professional licensed counselors, and marriage and family therapists. For psychiatric-mental health advanced practice nurses, national board certification as either a psychiatric clinical nurse specialist (adult or child and adolescent designation) or a psychiatric nurse practitioner (family or adult designation) are eligible for the Group Psychotherapist certification designation. Further requirements

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for all candidates include completion of 300 hours of group psychotherapy experience during graduate training or after graduation, documentation of a minimum of 75 hours of group psychotherapy supervision either during graduate training or after graduation, completion and submission of two references verifying completion of practice and supervision requirements, and submission of proof of malpractice coverage. Recertification requirements include ongoing clinical practice and completion of continuing education requirements. Recertification must be maintained every 2 years.

CONCLUDING COMMENTS

Group psychotherapy is emerging as a highly effective treatment modality in the age of managed health care delivery systems for an almost limitless array of patient groups. For the advanced practice psychiatric–mental health nurse, group psychotherapy offers the ability to increase access to care for clients, to diversify one’s practice by offering services other than individual, couples, or family therapy, while at the same time affording clients a cost-effective and evidence-based intervention for addressing their mental health issues. This chapter has reviewed the core underlying principles informing all theoretical approaches to group psychotherapy, principles on which the beneficial effects hinge. The evidence suggests that the mechanical application of a theoretical approach will not succeed unless these interpersonal, here-and-now therapeutic factors are handled adroitly and sensitively by competent and trained group therapists. Even though many of the group interventions available today are relatively short-term, there is a rich research base pertaining to long-term group therapies extending back many decades, which shorter interventions can draw from and adapt. Proficiency in specific theoretical orientations is a necessity for all practicing group psychotherapists, but awareness of the nuances, ambiguities, and subtleties of interpersonal interaction, and how to handle them in the immediacy of the clinical encounter to therapeutic effect, are indispensable.

DISCUSSION EXERCISES

1. What are the benefits and the challenges of offering a short-term group psychotherapy group? 2. Discuss key components of group process that occur during all phases of group development,

giving examples of client-focused activity that occurs during each phase. 3. Describe how other theoretical orientations could be used when leading short-term group

psychotherapy. 4. Discuss the benefits and challenges of using one or two group therapists during a short-term

group psychotherapy intervention. 5. Discuss the importance of identifying ground rules for group psychotherapy services. 6. Describe the potential issues that can manifest within a group when termination is discussed and

occurs. 7. Identify a specific group you would like to lead in your practice and discuss the purpose, your

target population, how you would screen and recruit participants, establish a fee schedule, time frame (open or closed), number of participants, theoretical orientation for the group, selection of a co-therapist or why you do not want a co-therapist, marketing and advertising, and length of each session.

REFERENCES

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Arrow, H., Poole, M. S., Henry, K. B., Wheelan, S., & Moreland, R. (2004). Time, change and development: The temporal perspective on groups. Small Group Research, 20(10), 1–133.

Bion, W. R. (1959). Experiences in groups and other papers. New York, NY: Basic Books. Beck, A. T., Rush, A. J., Shaw, B. F., & Emory, G. (1979). Cognitive therapy of depression. New York, NY: Guilford Press. Beck, J. S. (2011). Cognitive behaviour therapy: Basics and beyond (2nd ed.). New York, NY: Guilford Press. Berne, E. (1961). Transactional analysis in psychotherapy. New York, NY: Grove

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Bowlby, J. (1988). A secure base: Parent–child attachment and healthy human development. New York, NY: Basic Books. Breitbart, W., Rosenfeld, B., Gibson, G., Pessin, H., Poppito, S., Nelson, C., … Olden. M. (2010). Meaning-centered group psychotherapy

for patients with advanced cancer: A pilot randomized controlled trial. Psycho-Oncology, 19(1), 21–28. Retrieved from http://psychiatry.unm.edu/IDEAS/common/docs/Breitbart%20MCGPTrial%20Psycho-oncology%202010.pdf

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Burlingame, G. M., MacKenzie, K. R., & Strauss, B. (2004). Small group treatment: Evidence for effectiveness and mechanisms of change. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 647–696). New York, NY: Wiley.

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Family Therapy CANDICE KNIGHT

his chapter provides an overview of family therapy for the advanced practice psychiatric nurse (APPN). Highlighting the importance of this therapeutic approach, this chapter defines the family in

contemporary society and traces the historical evolution of family therapy, identifying its seminal leaders. Four major family therapy approaches are described in detail, explicating their key concepts, goals, and therapeutic interventions. They include systemic, structural, strategic, and emotionally focused family therapies. Attention is then focused on the practical aspects of conducting family therapy, which includes identifying assessment strategies, developing case conceptualizations, determining common diagnoses, and delivering therapeutic interventions that a beginning-level APPN would be able to employ. Case examples are provided to illustrate conceptualization and intervention. Evidence-based research in family therapy is presented and the chapter concludes with a description of postmaster’s training and certification programs for family therapy.

WHY IS KNOWLEDGE OF FAMILY THERAPY IMPORTANT FOR THE APPN?

The first master’s degree in psychiatric–mental health nursing, inaugurated at Rutgers University in 1952, viewed the primary role of the APPN as providing individual, group, and family therapy. For the next four decades, APPNs became certified as psychiatric clinical nurse specialists (CNSs), gained legitimacy, and honed their skills as psychotherapists (American Nurses Association [ANA], American Psychiatric Nurses Association [APNA], and the International Society of Psychiatric-Mental Health Nurses [ISPN], 2007). With new discoveries in neuroscience in the 1990s, APPNs incorporated the role of prescriptive authority, necessitating more knowledge in pathophysiology, health assessment, and pharmacology. As educational programs added content in these basic sciences, psychotherapy content began to be jettisoned, particularly content in family therapy. Although some programs maintained coursework and practicum experience in family therapy, others diminished family therapy by relegating it to cursory lectures or eliminated the content entirely.

By the late 1990s, the role of the psychiatric nurse practitioner (NP) emerged. Leaders in the field debated whether psychiatric NPs should focus on the biological and psycho-pharmacological aspects of care while retaining the psychosocial and individual, group, and family psychotherapy aspects of care for the CNS (Knight, 1997a, 1997b, 1998). Eventually, in response to the mental health needs of society as well as the requirements reflected in the Essentials of Master’s Education for Advanced Practice Nursing document (American Association of Colleges of Nursing (AACN), 1996), the curricula of psychiatric NP and psychiatric CNS programs became more similar than different, with both incorporating a holistic, biopsychosocial model of care. In 2011, a decision was made to have one entry level role for the APPN, with preparation across the life span. This decision, endorsed by the major professional organizations, essentially combines the best of the psychiatric CNS role and the psychiatric NP role for all new APPNs. By the end of 2014, only one certification will exist for all newly certified APPNs, the psychiatric-mental health nurse practitioner (PMHNP-BC) (American Nurses Credentialing Center [ANCC], 2012).

With these changes, it is essential to ensure a prominent place for family therapy in the curriculum of programs that educate new APPNs. Family therapy is an important theoretical and psychotherapeutic approach, especially when working with clients across the life span. In the Scope and Standards of Practice for APPNs (ANA, APNA, & ISPN, 2007) as well as the current updated draft of this document (ANA, APNA, & ISPN, 2012), family therapy retains its place of importance. In particular, when working with children and adolescents, it is essential for the APPN to consider clients within their family systems. APPNs need to know how to do a comprehensive family assessment, well beyond a basic genogram, as well as know how to assess functional and dysfunctional family patterns, develop accurate family case conceptualizations, and conduct

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competent family therapy. An article by Bloch, Sharpe, and Allman (1991) notes that teaching and training in family therapy are

required in psychiatry residency programs and integrated into the routine work of child and adolescent psychiatrists. They strongly suggest that family therapy be integrated into the routine work of adult psychiatrists as well. In their study of 50 families, a significant number of identified clients with diverse diagnoses had an underlying issue primarily associated with family dysfunction. These issues encompassed four main categories: (a) separation and individuation issues of young adults who failed to develop, and which were linked to dysfunctional family relational patterns; (b) family difficulties revolving around dysfunctional parental relationships with one or more of the children deeply involved in parental conflict; (c) family structural issues related to poor role differentiation of parents or children and/or inappropriate relational dyads such as a coalition between mother and children with the exclusion of father; and (d) unresolved grief of family members. As with psychiatry, education and training in family therapy are essential for APPN students and need to be included in education and practicum experiences.

Although it is clear that clients’ symptoms and problems are caused by many factors, including biological and intrapsychic/interpersonal dynamics, a significant cause also emerges from dysfunctional family patterns. It is essential that APPNs use a multidimensional approach when working with clients, especially children and adolescents. The APPN needs to be able to determine how much of the client’s symptoms and dysfunction have their origin in the family system and how much are caused by other factors. Without knowledge of family therapy, the treatment of clients by the APPN would be extremely narrow in scope, which could have deleterious consequences for the client.

Family therapy should not be confused with family-based treatment, an umbrella term used to characterize a broad range of approaches. Although family-based treatment includes family therapy, it also includes supportive (e.g., groups for families having a mentally ill member), psychoeducational (e.g., parenting skill building), and community-based approaches (e.g., crisis intervention and in-home support services) (Diamond & Josephson, 2005). All of these family-based treatment approaches have merit as part of an APPN’s knowledge base. In psychiatric nursing education, however, supportive, psychoeducational, and community-based approaches are commonly taught on an undergraduate level. Family therapy, a more difficult and complex therapeutic intervention, is reserved for the APPN and is taught on the graduate level.

Practicing family therapy at a beginning level of competence is not only possible, but necessary for an APPN. Yet, becoming an expert in family therapy takes a great deal of training beyond that which can be provided in a basic APPN program. In-depth training occurs after graduation at training institutes and professional workshops. A recent case example from my private practice illuminates the importance of family therapy for the APPN.

CASE EXAMPLE

Sarah, an adopted, 16-year-old teen, was brought to an outpatient private practice by her parents who were concerned about their daughter’s behavior. Sarah had begun “cutting” 6 months earlier and did not know why she engaged in self-harming behavior. A detailed family assessment revealed that Sarah and her parents had been experiencing a great deal of conflict since Sarah, according to her parents, transformed from being their “nice little girl” to being a difficult, oppositional adolescent who shunned their company, frequented social networking sites, and demanded total independence. The parents, fearful of these changes, began to set stricter limits, believing that they needed to protect Sarah. The parents had little knowledge of adolescent development and felt exceedingly rejected by their daughter and anxious for her safety.

Sarah’s mother had a difficult adolescence and as a result of parental neglect, “ran wild,” and consequently blundered into significant trauma due to early dating, coupled with the use of alcohol and drugs. Her fear for Sarah was out of proportion to the reality of the situation, and she wanted to control Sarah and protect her from potential harm. Sarah’s father, in contrast, came from an inordinately rigid, controlling family system, which allowed little expression of feelings, especially anger. He was very compliant during his adolescence and spent most of his time in academic and athletic pursuits. He had great difficulty with what he viewed as Sarah’s lack of respect for her parents. After the first two assessment sessions were completed, Sarah’s problems were conceptualized by the APPN from a systems perspective and family therapy was

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initiated. Different session configurations were used, that is, initially two sessions were held with the

parents to teach them normal adolescent development and help them work through some of their own adolescent issues, followed by two sessions with Sarah to help her develop awareness of her feelings and appropriate feeling management skills. Then followed six family sessions with the focus on developing positive family communication, helping the parents begin the process of “letting go” of Sarah, and helping Sarah express love and anger toward her parents and reattach to them in a healthy, adolescent fashion. Toward the end of therapy, Sarah’s self-harming behavior ceased. At the twelfth, termination session, Sarah stated, “When I think about cutting, I just can’t imagine that I did that—it seems so ridiculous now.”

This case study illustrates the necessity for the APPN to possess knowledge and skills in family therapy. Assessment and intervention would have been incomplete without an in-depth understanding of the family system’s role in contributing to the dysfunction exhibited by Sarah. Goldenberg and Goldenberg (2012) take the position that clinicians need to view all symptoms and dysfunctional behavior expressed by an individual client within the context of the family system. A systems approach certainly does not prohibit the APPN from employing other approaches, but broadens the traditional emphasis from one that is exclusively focused on the individual.

Family therapy is decidedly not a panacea, yet it is a significant theoretical and therapeutic intervention that APPNs need to master in order to practice competently. Without family therapy, understanding clients would necessarily be limited to individual case conceptualization and treatment comprising prescription of psychopharmaceutical agents and/or employing individual psychotherapy approaches. An approach devoid of family therapy would be counterproductive and detrimental to the client’s well-being when the family system is a major piece in the mosaic of the presenting problem.

THE FAMILY IN CONTEMPORARY SOCIETY

The family is the basic unit of structure in social organizations and can be viewed as a unique relational system with complex, well-entrenched interactional patterns. These patterns are determined by many variables, including the parents’ values and beliefs, the personalities of its members, and the influence of the extended family and society at large. Families are united by blood or bond, have a shared history and future, and consist of diverse configurations. These configurations include the traditional nuclear family as well as the single- parent, blended, extended, alternative, and institutional family.

The family is the main structure in which children learn what it means to be human within a particular culture. The family transmits cultural values, attitudes, and norms, and serves as a mediator between the needs of its members and the demands of society. It provides nurturance and support and is responsible for developing aspects of the child’s personality and socialization skills including how to learn, express thoughts and feelings, behave, adapt to change, and cope with stress.

Although all families are unique, most experts would agree that functional families are characterized by having a solid structure, clear roles, and open communication patterns. They support differentiation and individuation of its members. As families grow and develop, they are flexible and able to adapt to change. Family members love, support, and encourage each other throughout their lives and live together in relative harmony. Dysfunctional families, in contrast, have a paucity of these characteristics. They express their dysfunction in various ways, such as displaying an excessive amount of conflict and mental health problems. These ineffective patterns may be passed down through generations (Beavers & Hampson, 1990; Nichols, 2012).

FAMILY THERAPY

Family therapy, like individual therapy, comprises a diverse group of approaches, each having specific concepts and therapeutic interventions. While individual psychotherapy approaches seek to understand the client from

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an intrapsychic, interpersonal, humanistic–existential, or cognitive behavioral perspective, family therapy strives to understand the client in the context of a system. Individuals are born into families, grow and develop in families, and live most of their lives in families. Therefore, it makes sense that clients are best understood within the context of the family system. A philosophy that unites the various family therapy approaches posits that the source of dysfunction and the unit for change are located within the family. Common underlying assumptions of family therapy can be found in Box 12.1.

In general, family therapy is a brief form of therapy that takes place within 8 to 20 sessions. Working directly with the family system usually stimulates rapid change. The main focus in family therapy is on here- and-now interactions within the family system and how these interactions contribute to the development and maintenance of symptoms and dysfunctional patterns. The concepts, goals, and therapeutic techniques are determined by the specific family therapy approach as well as by the needs of the family, which are determined collaboratively.

BOX 12.1

UNDERLYING ASSUMPTIONS OF FAMILY THERAPY

Individuals are best understood in the context of their family system The family as a whole is viewed as the client rather than the identified client The family is a unique social system with its own structure and patterns of interaction The behavior of a family member inexorably influences all family members The behavior of the family influences each family member Symptoms are viewed as an expression of dysfunction within the family A family member’s problematic behavior may serve a purpose for the family A family member’s problematic behavior may be unintentionally maintained by the family Attempts at change are best facilitated by working with the family as a whole Treatment may address the identified patient but the focus is on the family system Gender, race, ethnicity, sexual orientation, and socioeconomic/cultural factors all influence the family system and play an important role in family therapy treatment

Family therapy is a viable solution when dysfunction occurs in families and when symptoms occur in one or more family members. The family and its members will greatly benefit when dysfunctional patterns are changed during family therapy. It is common for one family member, usually the healthier member of the adult dyad, to recognize there is a problem and seek psychotherapy. If both adults are willing to enter psychotherapy, the system has a chance of flourishing. If one member is resistant and unwilling to work on the issues, the system usually will not endure. The resistant member, fearful or incapable of change, commonly will create the same dysfunctional patterns in future family configurations.

Although there are many family therapy approaches that offer a wealth of knowledge for the APPN, this chapter focuses on four popular approaches. These four approaches all use a family systems perspective and view an individual’s symptoms and dysfunctional behaviors as a manifestation of a dysfunctional family system. They include systemic family therapy, structural family therapy, strategic family therapy, and emotionally focused family therapy (EFT).

EVOLUTION OF FAMILY THERAPY

The family has long been acknowledged as a significant factor in the emotional functioning of its individual members. Theory development and research studies on dysfunctional families date back to Sigmund Freud. In fact, Guerin and Chabot (1997) note that many of Freud’s published case studies illustrated dynamic family formulations and treatment approaches such as the phobic problems of Little Hans, who Freud treated by coaching his father. Alfred Adler’s emphasis on the importance of the family in the diagnosis and treatment of emotional problems in children led to the Child Guidance Movement in the United States during the 1920s under the influence of Rudolph Dreikurs, a student of Adler (Adler, 1931). Nathan Ackerman, a psychoanalyst and child psychiatrist, published a paper in 1937 on the importance of family caused mental illness in children and emphasized the need to take both individual and family dynamics into account

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(Ackerman, 1958). These early pioneers in the family therapy movement were psychoanalysts who modified Psychoanalytic Theory to include family concepts and experimented with various types of family interventions.

In the late 1940s, a major change in conceptualizing systems was ushered in by Karl Ludwig von Bertalanffy’s General System Theory (Von Bertalanffy, 1968). His theory referred to the self- regulating system found in nature and was applied to many fields including physics, anthropology, biology, and psychology. When applied specifically to mental health problems, individual dynamics were de- emphasized and problems were viewed as an expression of dysfunction in family dynamics. By the 1950s, the family therapy movement emerged (Becvar & Becvar, 2008). During this time, psychodynamic, behavioral, and humanistic–existential approaches dominated the field of psychotherapy. They were considered the first, second, and third forces of psychotherapy, respectively. As researchers and clinicians turned their attention to the family as the unit of change, family therapy became recognized as the fourth force of psychotherapy (Corey, 2011).

Early approaches to family therapy were the communication and the contextual approaches. The communications approach was developed in the 1950s by Gregory Bateson, a well-known anthropologist and a group of psychiatrists and psychologists at the Mental Research Institute (MRI) in Palo Alto, CA, including Don Jackson, Jay Haley, John Weakland, and Paul Watzlawick. Their well-known research on feedback loops and cybernetics; double-bind communication in schizophrenic families; and, the oft-cited idea that when the identified client improves, another family member becomes symptomatic, were highly regarded and influenced the early development of family therapy (Guerin & Chabot, 1997).

On the east coast, at the Eastern Pennsylvania Psychiatric Institute (EPPI) in Philadelphia, Ivan Boszormenyi-Nagi and Paul Framo developed the contextual approach to family therapy in the late 1950s. Their comprehensive model of family therapy integrated individual, interpersonal, existential, and systemic aspects and proposed four dimensions for conducting therapy including: (a) genetics, physical health, and historical events; (b) individual psychology; (c) systemic transactions of family rules, power, alignments, and triangles; and (d) relational ethics of trust, justice, reciprocity, fairness, and loyalty (Nichols, 2012).

By the 1960s and 1970s, the family therapy movement became a major treatment modality. New family therapies developed, which are still prominent today including systemic, structural, strategic, and emotionally focused family therapies. The individuals who developed these approaches became revered leaders in the family therapy movement. Their approaches emerged from working with specific populations such as families with a schizophrenic member (e.g., systems) or acting-out juveniles (e.g., structural). Later, they were adapted to fit many different types of family problems. These four approaches continue to develop conceptually and empirically. The next section describes them in depth.

SYSTEMIC FAMILY THERAPY APPROACH

Overview

Murray Bowen (1913–1990), an American psychiatrist, is the founder of the systemic family therapy approach. He originally trained at the psychoanalytically oriented Menninger clinic. While there, he experienced much success with clients when he began bringing their families into sessions. In 1954, he became the first director of the Family Division of the National Institute of Mental Health and led a research project in which he studied 18 families having a schizophrenic member over a 5-year period. From 1959 to 1990, as an academician and clinician at Georgetown University, he developed and refined Bowen Family Systems Theory. In 1969, he started the Bowen Family Systems Therapy Family Program, working with families and training therapists in his systemic approach. A transformative paper he presented at a professional meeting in 1967 explicated the emotional processes in his own family, which recognized the need for clinicians to work through the dysfunction in their own families if they were to be effective family therapists (Bowen, 1972). Bowen’s theory and therapeutic approach are clearly outlined in his book, Family Therapy in Clinical Practice (Bowen, 1978).

Many of Bowen’s students became leaders in the field and skillful trainers including Phillip Guerin and Thomas Fogarty of The Center for Family Learning in New Rochelle, NY, known for their work on family triangles (Guerin, Fogarty, Fay, & Kautto, 1996); Monica McGoldrick of the Multicultural Family Institute in Highland Park, NJ, known for her work on gender, ethnicity, and genograms (McGoldrick, 1995; McGoldrick, Gerson, & Petry, 2008; McGoldrick, Pearce, & Giordano, 1982); and Betty Carter of the

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Family Institute of Westchester, NY, known for her work on feminism, family life cycle, and stages of divorce and remarriage (Carter & McGoldrick, 1980).

With the systems approach, the family is understood when examined within a multigenerational framework. It describes the family as a complex, self-regulating, emotional unit that strives to maintain homeostasis. Accordingly, a change in the functioning of one family member is predictably followed by a reciprocal change in the functioning of other family members. Family systems therapy proposes that dysfunctional systemic factors maintain problems within the family and seeks to promote functioning by changing the systemic factors that produce the dysfunction (Bowen, 1978). It represents a combination of the psychodynamic approaches that emphasizes the significance of the past and self-development with systems approaches that focus on intergenerational issues and dysfunctional interacting patterns. Bowen’s theory is composed of eight interlocking concepts, six of them addressing emotional processes within the nuclear and extended families and two later concepts addressing processes across generations and in society (Goldenberg & Goldenberg, 2012; Kerr & Bowen, 1988).

Key Concepts

DIFFERENTIATION OF SELF A person’s sense of self or degree of wholeness, demonstrated by the ability to separate one’s intellectual and emotional functioning. The greater the degree of differentiation, the less a person will be drawn into dysfunctional patterns with other family members. Scales to measure levels of differentiation have been developed (Anderson & Sabatelli, 1992; Skowron & Friedlander, 1998). A differentiated person has a firm sense of self and is individuated from the family, yet in contact with them. He or she has clear values and beliefs and is flexible, goal directed, secure, capable of handling stress, less reactive to praise or criticism, and can decide important issues deliberately rather than with emotional reactivity and impulsivity. An undifferentiated person has little or no self and is susceptible to family influence, dependent on others for approval, emotionally reactive, impulsive, vulnerable to stress, and has difficulty maintaining his or her emotional equilibrium.

An undifferentiated ego mass is described as a family system with members possessing low levels of differentiation who are “stuck together” in symbiotic relationships. Members have great difficulty individuating, for they are unable to function independently. Fusion indicates a blurring between self and other that occurs when two undifferentiated people form a dysfunctional interaction pattern and function as a single emotional system, such as an overfunctioning/underfunctioning pattern (Goldenberg & Goldenberg, 2012).

TRIANGLES Three-person systems that manage tension between two people by bringing in a third person. Dyads are inherently unstable, as two people will vacillate between closeness and distance; a triangle can manage more tension (Nichols, 2012). An example would be a couple who has a highly emotional, unresolved argument. Afterward, one person calls his or her best friend to talk about the fight, blaming the partner. Tension is reduced through diversion, yet, the problem between the couple goes unresolved. Undifferentiated people and families with high levels of fusion are likely to triangulate others and be triangulated as well. Family triangles contribute significantly to clinical problems, especially when a child is triangulated by a parent.

MULTIGENERATIONAL TRANSMISSION PROCESS The transfer of dysfunctional family patterns occurs from one generation to the next. For example, the repeated message to a young girl, “You’re just like your grandmother, irresponsible and unable to care for yourself,” will transmit this behavioral pattern to the girl and shape her developing sense of self. Genograms are used to elucidate these patterns (Nichols, 2012).

NUCLEAR FAMILY EMOTIONAL SYSTEM Ineffective patterns used in fused families to cope with family problems and stress. Bowen contends that

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people select partners with equivalent levels of differentiation; thus, an undifferentiated person will select a spouse who is equally fused to his or her family of origin and attempt to reduce anxiety in one of three ways: (a) overt, chronic, marital conflict with dysfunctional patterns such as overfunctioning/underfunctioning (family anxiety absorbed by husband and wife); (b) emotional dysfunctioning of one partner (anxiety absorbed by a symptomatic partner); or (c) psychological impairment in a child (banding together to focus attention on the child) (Bowen, 1978). The novice therapist often focuses on the underfunctioning spouse, the dysfunctional spouse, or the impaired child rather than recognize it is a problem with differentiation for both spouses.

FAMILY PROJECTION PROCESS The way in which parental undifferentiation is transmitted to the children. The child, serving as an emotional extension of the parents, is fused and triangulated to the parents, has a low level of differentiation, and has difficulty separating from the parents. Usually the child targeted is the most emotionally vulnerable and unprotected, regardless of birth order. Other children in the family may have higher levels of differentiation.

EMOTIONAL CUTOFF Reducing or cutting off emotional contact with family members in order to manage anxiety and conflict. As an adult, the person may cut off completely, separate geographically (moving far distances), or put up psychological barriers (superficial, inauthentic, brief contact). He or she may appear to be independent from family members, but is arrested emotionally at the time of the cutoff. Emotional cutoff reduces anxiety but creates isolation and undue emotional significance to subsequent relationships. Reattachment to one’s family of origin must occur in order to become a healthy, differentiated adult (Bowen, 1978).

SIBLING POSITION A person’s functional position in the family hierarchy that each child holds, which predicts certain roles, functions, and personality characteristics. This may reflect the order of birth but is more related to the person’s functional position in the family. Bowen wrote of 10 positions and suggested that the more closely a marriage duplicates one’s sibling place in childhood, the more successful it will be. For example, an oldest child who marries a youngest will feel comfortable taking on more responsibility and decision making. Two youngest children who marry may both feel overburdened by responsibility, while two oldest children may be overly competitive because each will want to be in charge (Bowen, 1978).

Goals of Therapy

The most important goal of family systems therapy is to help family members increase their level of self- differentiation, especially the adult couple. Differentiation results in rewarding emotional contact within the family and across generations. Undifferentiation results in emotional fusion, cutoffs, and transmission of dysfunctional patterns. Other goals are to reduce emotional turmoil in the family as well as detriangulate three-person systems (Nichols, 2012).

Psychotherapeutic Interventions: Assessment

In a systems approach, the therapist begins the session by asking each member his or her perception of the problem. The therapist assumes a neutral and objective role. In this approach, it is crucial for the therapist to be differentiated from his or her own family system; otherwise, the therapist may be triangulated into family conflicts, take sides, and project his or her unresolved issues onto family members. The therapist assesses the degree of emotional functioning and intensity of emotional processes. What is the degree of dysfunction? What are the stressors? How differentiated are the members? Do triangles exist? Are emotional cutoffs operating? Is one spouse more dysfunctional? What are the multigenerational patterns?

An important tool used by systemic therapists is the genogram, a three-generational, graphic diagram of

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family processes that is constructed during the assessment phase of therapy. It is an interpretive tool used to identify patterns, generate hypotheses, and obtain a significant amount of information about the evolution of family problems in a condensed period. A joint family genogram or separate genogram on each family member (common in couple therapy) can be drawn on a sheet of paper or drawn on a flip chart. The flip chart allows everyone in the family to observe the construction of the genogram and begin to understand the dysfunctional processes and how they are handed down from generation to generation. Standard symbols are used to depict gender, dates (e.g., birth, separation, marriage, and death), important life events, illnesses, and occupational roles as well as emotional processes among family members such as conflict, closeness, coalitions, cutoffs, and triangles. A picture of a basic genogram can be found in Chapter 3 of this text. An in-depth look at constructing genograms can be found in the text Genograms: Assessment and Intervention by McGoldrick, Gerson, and Petry (2008). Several online software programs are also available to assist in creating a genogram. See www.smartdraw.com/downloads or www.genopro.com/genogram/how-to-create. Some sample questions that are commonly asked by system therapists in constructing the genogram are included in Box 12.2.

The therapist also assesses the level of differentiation of each family member, identifies family triangles and multigenerational transmission processes as well as dysfunctional emotional processes and interactional patterns. The therapist offers feedback during this process (e.g., “I notice that what attracted you to each other are Jim’s solid, responsible qualities and Megan’s warm, emotional qualities, which are similar to parental patterns in your respective families of origin”).

Psychotherapeutic Interventions: Psychotherapy Techniques

Once the genogram is complete, session configurations are determined. The therapist may choose to meet with individual family members, different dyads, or the entire family. It is common in this approach to meet with the adult dyad or the most differentiated family member for a period of time. Bowen believed that if one person is motivated to work on differentiation, the other family members will inevitably improve. There is less attention focused on the presenting problem and more on increasing levels of differentiation and decreasing emotional turmoil (Kerr & Bowen, 1988). The following are interventions used in this approach.

BOX 12.2

COMMENTS AND SAMPLE QUESTIONS FOR CONSTRUCTING A GENOGRAM

It would be helpful to take some time to learn who the people are in your family in order to better understand your family and the current problems. What I like to do is diagram the family over three generations.

Who are the members of your family? What are their ages and birth and/or death dates? What are other characteristics (e.g., marriage/divorce, ethnicity, occupation, key events)? Give two or three adjectives for each member. What is your relationship with each family member? Has it changed over time? Who are you closest to and most distant from? Are there any members who are emotionally cut off from each other? How and when did emotional cutoffs occur? Are there any family secrets? What are the family scripts (messages given to members)?

PROMOTE SELF-STATEMENTS Assist members to differentiate by helping them identify their own beliefs by using first-person pronouns. The therapist encourages family members to use self-defining “I-position” statements to help separate their own emotions and beliefs from the family. When even one person begins to take “I-stands,” other members inevitably do so as well.

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TRANSFORM DYSFUNCTIONAL GENERATIONAL PATTERNS Identify and change dysfunctional multigenerational patterns. For example, the therapist who is working with the adult female of the dyad may say, “I notice that the women in your family overfunction and marry men who are irresponsible and underfunction.” The therapist would begin to question ways in which these patterns can be changed and would begin a line of questioning, “Would you like to change this pattern in your marriage? How does this pattern affect you? What could you do differently?”

DECREASE ANXIETY AND INTERRUPT CONFLICT Reduce high anxiety and high levels of conflict for they prevent differentiation and cause more emotional fusion. Sessions are controlled and cerebral. Each family member talks to the therapist rather than directly to each other. The therapist minimizes blame and interrupts confrontation while modeling skills of problem solving and conflict resolution. Family members are encouraged to listen, think about the situation, externalize what they are thinking, and control their emotional reactivity. Calm questioning is used by the therapist to defuse emotion and force the partners to think about the issues causing their difficulty. The therapist may ask, “What part do you think you may play in this pattern?”

DETRIANGULATE Neutralize triangles by having family members speak directly to one another, rather than a third person. For example, the therapist might direct a member to speak directly to another by stating, “Can you tell him that directly?” A therapist might attempt to remove an adult client from an intense, emotional triangle with his or her parents by arranging a solo visit by the client to the parents’ home but with a very structured plan of detriangulation.

REPAIR CUTOFFS Reestablish connection with other family members and repair cutoffs. This is crucial in this approach. The therapist may also invite a cutoff member to attend a session in order to bring the person back into the family.

DISRUPT NUCLEAR FAMILY EMOTIONAL PROCESSES Use process questions to interrupt dysfunctional patterns. For example, the therapist may use a statement such as, “I notice you do the tasks that your husband agreed to do but has not, and this frustrates you.” The therapist may ask members to try out different interactional patterns (Goldenberg & Goldenberg, 2012).

STRUCTURAL FAMILY THERAPY APPROACH

Overview

The structural family therapy approach was developed by Salvadore Minuchin (1921–), an extremely creative, much loved therapist, known for his mastery of technique. Minuchin was originally a psychoanalytically trained psychiatrist who studied with Nathan Ackerman, received psychoanalytic training at the Alanson White Institute, and worked with troubled youths at the Wiltwyck School for Boys in New York City in the late 1950s and early 1960s. Realizing the limitations of psychoanalytic methods for treating these disadvantaged boys, he and a group of colleagues developed new methods of working with the boys and their families, which later evolved into structural family therapy. After becoming the director of the Philadelphia Child Guidance Clinic in 1965, he and his colleagues published the groundbreaking text, Families of the Slums: An Exploration of their Structure and Treatment (Minuchin, Montalvo, Guerney, Rosman, & Schumer, 1967) and later his classic text, Families and Family Therapy (Minuchin, 1974). Under Minuchin’s direction, the Philadelphia Child Guidance Clinic became one of the world’s foremost family therapy training centers. In 1976, Minuchin stepped down as director of the clinic and started his own center in New York City, where he continued to practice and train family therapists until 1996. Although currently retired, the legacy of his work continues by well-known structural family therapists including Harry Aponte, Michael Nichols, and

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Braulio Montalvo (Nichols, 2012). The structural family therapy approach believes that symptoms and family problems are embedded in a

dysfunctional family organization. It offers a framework to address problems by focusing on the structure and substructure as well as the imperceptible rules, coalitions, power structures, communication patterns, and boundaries that operate within a dysfunctional system. Minuchin believed that what distinguishes a functional family is not the absence of problems, but lack of an effective organizational structure to handle problems when they arise (Minuchin, 1974).

Key Concepts

FAMILY STRUCTURE An invisible set of functional, recurrent patterns that organize the way family members relate to one another. Structure defines and stabilizes the family. It includes aspects such as family roles and rules, hierarchy and power structures, communication patterns, and decision-making functions.

SUBSYSTEMS Smaller units that carry out necessary tasks for the functioning of the overall family system. They are determined by generation, age, sex, spousal relationship, interest, and function. They may include the spousal subsystem (wife and husband), parental subsystem (mother and father), sibling subsystem (children), and extended family subsystem (grandparents and other relatives). Family members belong to a number of different subsystems that help in the process of individuation and organize the way members relate to one another.

BOUNDARIES Physical or invisible emotional barriers that protect the integrity of individual members, subsystems, and families. These boundaries function to regulate contact, maintain individual identity, modulate emotional closeness, define rules of relating, and regulate the flow of resources and information within the family and the outside environment. Boundaries should be clear and flexible, allowing members to attain a sense of personal identity and connection within the family, without undue interference (Minuchin, 1974).

ENMESHED FAMILY An extreme pattern of family organization in which boundaries are diffuse and permeable, resulting in a denial of differences and loss of personal autonomy. Family members are overly dependent on one another. Interactions among members are intense with an overload of communication and emotions and a great deal of bickering. Parents are overly intrusive and protective, hindering the competency development of their children. Family conflicts revolve around issues of power and control with parents fearful of losing control and children vying for more control. Some examples include: (a) excessive involvement in children’s minor conflict, not allowing them the opportunity to solve their own problems; (b) a family becoming overwrought because a child brings home a poor grade; (c) a mother who tells her 9-year-old daughter the details of her marital problems and asks for advice; and (d) a parent reading a child’s text messages. As families grow, boundaries for closeness and distance change.

DISENGAGED FAMILY An extreme pattern of family organization in which boundaries are rigid and impermeable, resulting in a heightened sense of personal autonomy and independence. Family members are so disconnected that they seem unaware of their impact on each other. There is usually a scarcity of communication, limited support, and interpersonal isolation. Family structure and parental authority are weak. Parents are often immature and overwhelmed with the parental role. Family members are oblivious to the effects of their actions on one another. It is common for members to be dependent on outside systems with little interpersonal engagement within the family. An example would be little involvement with a child who has a serious academic problem or a significant psychological problem.

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COALITION A dysfunctional alliance between two family members against a third. There are several types of coalitions. A cross-generational coalition is when a parent and child side against a third member of the family. A schism coalition is when a child joins one parent of two warring spouses and the joined parent devalues the other parent to the child. A skewed coalition is when one spouse overfunctions for an underfunctioning spouse in order to preserve the marriage and family.

PARENTIFICATION A form of role reversal where a child is given the power and authority that appropriately belong to the parents. The child is put in a position of meeting the emotional or physical needs of the parent or other children. This can occur in many types of situations such as when a parent is irresponsible or neglectful. It is common with addiction or other forms of mental illness. The child willingly accepts the role because it brings with it power and status; however, it is very detrimental to the child. Ultimately, the child is unable to perform the role adequately, increasing his or her anxiety and guilt as well as lowering self-esteem. The child also cannot develop normal peer relationships, resulting in social deprivation (Nichols, 2012).

Goals of Therapy

The most important goal of structural family therapy is to create an effective family structure with functional subsystems and clear boundaries. A strong parental hierarchy is stressed with parents having the necessary power and control. Communication is open and direct, rules are fair, roles are flexible, and decision making is productive. In this way, the family has the capacity to handle problems when they arise (Minuchin, 1974).

Psychotherapeutic Interventions: Assessment

In a structural approach, the focus is not on the presenting problem but on assessing dysfunction in overall structure, subsystems, boundaries, power structures, and communication patterns. The therapist begins by first asking the parents what they believe the problem to be, respecting the parental hierarchy. Each person is encouraged to participate, but without insistence of a response. The therapist joins, accommodates, and affiliates with the family. Joining is a process of uniting empathically with the family, temporarily becoming part of the system, and forming a therapeutic system where each family member accepts the therapist as someone who is influential and can bring about change. Accommodating is adjusting and adapting to the family’s affective style, language patterns, and interactive style by actually emulating these aspects of the family to solidify the alliance. Affiliating is connecting to family members by making positive, confirming statements to help build self-esteem and allow others to see that person in a new light as well as by making negative statements about a family member while absolving that person of responsibility for the behavior. Minuchin and Fishman (1981) give the following examples of affiliating:

To a child, the therapist might say: “You seem to be quite childish. How did your parents manage to keep you so young?” To an adult, the therapist could say: “You act very dependent on your spouse. What does she do to keep you incompetent?” (p. 34)

Psychotherapeutic Interventions: Psychotherapy Techniques

After joining with family members, the therapist continues to work with the entire family. He or she rarely sees individual members alone or in separate dyads.

ENACTMENTS Acting out dysfunctional transactional patterns within the family therapy session. Families are directed by the therapist to demonstrate how they have dealt with a particular problem. This spotlights the structural

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dysfunctions in the family. For example, if the family identifies a great deal of fighting in their structure, the therapist might ask the family to choose a recent issue they fought about at home and demonstrate how it unfolded in the session. With the enactment, the therapist may notice a weak parental hierarchy, a child with too much power, or a couple involved in a pursuer/distancer pattern.

Videotaping an enactment and watching the tape together give the family a chance to see how they interact and come up with possible solutions. Viewing a family snapshot and placing the family in the same dysfunctional positions and then changing them to a healthy configuration in the session is another example. Another technique is to have the family plan an event, noticing the dysfunctional patterns and then modifying them (Minuchin, 1974).

STRUCTURAL MAPPING Commenting on what went wrong within the enactment and reframing the problem in the context of the family’s structure. The therapist maps the family structure with simple symbols and helps the family broaden the problem from the identified client to an inadequate structure. These diagrams are useful in hypothesizing family functioning and forming goals for structural change. For example, boundaries are often mapped as follows:

Rigid boundary (disengagement) ______________ Diffuse boundary (enmeshment) ………………… Clear boundary (normal range) _ _ _ _ _ _ _ _ _ _

For a complete understanding of family mapping, examples can be found in Minuchin’s text, Families and Family Therapy (Minuchin, 1974).

MODIFYING PROBLEMATIC INTERACTIONS Restructuring the system and modifying the dysfunctional interactions observed during an enactmenting by using forceful interventions. The therapist, as the architect of the interventions, creates intense interventions, while not provoking or shaming family members. Some interventions to modify interactions are:

Boundary making. The therapist tries to change the distance between enmeshed or disengaged subsystems. Two examples are:

– An enmeshed father and daughter sit next to each other and frequently exchange looks and laughter, while ignoring the mother, who asks them frequently, “What did you just say?” The therapist asks the mother and father to change seats so that the mother is next to the daughter and the enmeshed father and daughter have more distance.

– A disengaged family attempts to deal with their 12-year-old daughter who failed three courses by shrugging and saying, “What can we do, it’s her life.” The parents are challenged to come up with three possible solutions to the problem that would create conflict.

Unbalancing. The therapist tries to change the hierarchical relationships of a subsystem. Two examples are: – A 15-year-old male client requests an extended curfew and each time he begins to speak, the mother

interrupts, attempting to convince the boy that his request is unreasonable, while the father sits there uninvolved. The therapist sets a 3-minute timer and tells the boy to argue his point for 3 minutes without any interruptions. He is then asked to leave the room while the parents are instructed to come up with a solution together. After 10 minutes, the son returns to the session and the father is asked to inform the son of their joint decision.

– Two school-age children, ages 7 and 9, refuse to pay attention to their parents’ requests that they comport themselves in a less unruly fashion in session. The children are asked to leave the room while the therapist helps to strengthen the parental subsystem, which is very weak.

Tracking. The therapist follows a theme identified from communication and uses it deliberately in conversation with the family. An example is a phrase a 10-year-old boy stated early in the assessment, which was, “I don’t want to receive any low blows in here.” Tracking the phrase, the therapist discovers that a common way the family communicates is by humiliating comments. The therapist closely tracks these undermining comments and when they occur, helps members communicate kindly.

Reframing. The therapist recasts the problem in a new light in order to modify interactions and provide a different perspective. For example, a 12-year-old daughter is described by her parents as difficult. After

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listening to them squabble, the therapist said, “Is this what happens when the three of you try to communicate with each other?” The problem is reframed as a systems problem rather than as an individual problem within the daughter.

Shaping competence. The therapist reinforces new, desirable patterns by praising the family members for their success. For example, the therapist states, “That was terrific that you were able to work together and present a united front to your child.”

The therapist recognizes the dysfunctional structure in this approach and intervenes in a directive fashion to modify the problematic interactions. Further structural techniques can be found in the text Family Therapy Techniques by Minuchin and Fishman (1981).

STRATEGIC FAMILY THERAPY APPROACH

Overview

The strategic family therapy movement is derived from the work on feedback loops, double binds, cybernetics, homeostasis, and circular causality by Bateson and his colleagues at the Mental Research Institute (MRI) when they studied faulty communication patterns in families with schizophrenic members (Nichols, 2012). Their classic text, Pragmatics of Human Communication (Watzlawick, Beavin, & Jackson, 1967), focused on the study of pragmatics (the behavioral consequences of communication). They came up with a number of axioms regarding the interpersonal nature of communication including: (a) all behavior is communication; (b) communication occurs simultaneously at the metacommunication level (gesture, body language, tone of voice, posture, and intensity) and the content (surface) level; and (c) problems develop and are maintained within the context of dysfunctional interactive patterns and recursive feedback loops. The model emphasized that the solutions people use in attempting to alleviate a problem often contribute to the problem’s maintenance or even its exacerbation.

In the 1980s, the strategic family therapy approach took center stage. Its leaders were Jay Haley and Cloe Madanes at the Family Therapy Institute in Washington, DC (Madanes, 1981) and later Mara Selvini Palazzoli, Luigi Boscolo, Gianfranco Cecchin, and Guliana Prata of the Milan, Italy group (Selvini Palazzoli, Boscolo, Cecchin, & Prata, 1978).

In addition to cybernetics, it also incorporated Milton Erickson’s work with paradoxical and solution-generating interventions and structural family therapy’s emphasis on family organization. Jay Haley integrated the Communication Theory of MRI with the work of structural family therapy and Ericksonian hypnosis.

Strategic family therapy believes that dysfunctional family patterns of behavior are deeply embedded within the family. Families maintain and perpetuate these patterns by their own actions, which are misguided attempts to solve the problem. The therapist identifies the sequence that keeps the repetitive patterns deeply entrenched within the system and uses provocative, strategic interventions to change the dysfunctional patterns (Haley, 1976).

Key Concepts

CYBERNETICS The theoretical study of control processes in a system, especially the analysis of the flow of information in a system through feedback loops and how it regulates a system.

HOMEOSTASIS A dynamic state of equilibrium or balance within a system. Families are believed to seek such a state in an effort to ensure a stable environment.

FEEDBACK LOOPS

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Circular processes by which information about a system’s output is continuously reintroduced back into the system, initiating a chain of subsequent events.

CIRCULAR CAUSALITY The view that causality is nonlinear, occurring instead within a relationship context and by means of a network of interacting loops; any cause is thus seen as an effect of a prior cause. All families encounter difficulties, but whether they become problematic depends on the response of family members. Families often make cogent but misguided attempts to solve their problems, and when they persist they apply more of the same erroneous solutions. This produces an escalation of the problem and more of the same repeating cycles (Nichols, 2012).

FIRST-ORDER CHANGES Superficial behavioral changes within a system that do not change the structure of the system itself. Examples are when the family makes a decision to stop shouting at each another. The underlying systemic rules governing the interaction between them have not changed, so the attempt to stop shouting will be violated sooner or later.

SECOND-ORDER CHANGES In-depth behavioral changes that require a fundamental revision of the system’s structure and function. An example would be changing the rules of the family system and reorganizing the system so that it reaches a different level of functioning rather than just calling a stop to shouting (Goldenberg & Goldenberg, 2012).

Goals of Therapy

The goal in strategic family therapy is to alter problematic patterns of behavior that maintain the family dysfunction by using strategic directives, also known as behavioral tasks. The belief is that the problem- maintaining sequences and cycles can be disrupted and extinguished by these strategic directives and replaced by functional sequences (Haley, 1976).

Psychotherapeutic Interventions: Assessment

The therapeutic relationship in this approach is empathic and collaborative. The therapist poses questions to help define the problem completely. Each member is asked to articulate a description of the problem in great detail. The therapist may say, “If we had a videotape of the problem, what would it look like?” The assessment stage demands a complete understanding of the problem by the therapist and the family members. The therapist then determines how the family has attempted a solution, recognizing that the attempted solution more than likely has contributed to maintaining and worsening the problem. The therapist, in collaboration with the family, determines goals to solve the problem.

Psychotherapeutic Interventions: Psychotherapy Technique

The intervention is known as the task-setting stage of therapy and is brief. Here, the therapist concludes the session by suggesting a directive, which is a concrete, tailored, behavioral task the family can do outside of therapy to break their entrenched dysfunctional cycle and outmaneuver resistance. The therapist is collaborative and compassionate in giving the directive and frequently asks, “Is this okay?” “Are you willing to do this?” The therapy is viewed as a staging area with directives typically taking place outside of the session in the family’s real life situation. The directives are often provocative and paradoxical. Further therapy sessions seek to determine the outcome of the given directive, gain further understanding of the family’s problems and

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their maintaining sequences, and develop further directives. The following are examples of common directives used in this approach.

PLACE THE PROBLEM UNDER THE FAMILY’S CONTROL Have the family control the problem rather than have the problem control the family. The therapist gives a specific directive as to how long family members are to discuss the problem, whom they are to discuss it with, and how long these discussions should last. As members carry out the directive, they develop a sense of control over the problem, which helps them deal with it effectively.

PARADOXICAL TECHNIQUE Do a seemingly illogical intervention that runs counter to common sense. The directive entails a maneuver that is in apparent contradiction to the goals of therapy, yet is designed to bring about positive change (Haley & Richeport-Haley, 2007). Major types include prescribing the symptom or problem, restraining change, and exaggerating the problem. An example of prescribing the symptom would be to ask the client to do more of the symptom or problem such as to fight more or be more negative. In restraining change, an example would be for the therapist to ask the couple or family not to change. In exaggerating the problem, an example would be for the therapist to ask the client to amplify the problem.

PRETEND TECHNIQUES Ask a symptomatic person to pretend to exhibit symptoms, reclassifying them as voluntary and not genuine. An example would be to ask an anxious client to pretend to be anxious. This in turn, alters the family’s response, for they do not know whether the symptoms are real when the symptomatic person expresses them. Another pretend technique is to ask the client to do something he or she would not ordinarily do. An example would be to ask someone very neat and compulsive to pretend that he or she is messy.

ORDEALS Direct clients to engage in mildly noxious activities if they engage in the symptomatic or problematic behavior. The consequences for the behavior become more difficult and time consuming than they are worth. For example, a teenager who has a very disrespectful attitude will have to after each episode of disrespect engage in a lengthy process with the family, where everyone, in great detail, expresses how they feel about his or her behavior.

RITUALS Perform a series of actions according to a prescribed order that gives members a sense of belonging and togetherness. For example, the family is directed to exaggerate a family ritual such as preparing and eating a meal together in a specific order.

INVARIANT PRESCRIPTION Break up existing dysfunctional interactional sequences with a new sequence. For example, in a family with an unhealthy coalition, the parents are encouraged to form a secret alliance and sneak away, without informing the children of their departure or return. This new pattern unites the parents and helps the children relinquish inappropriate roles.

EMOTIONALLY FOCUSED FAMILY THERAPY APPROACH

Overview

Emotionally focused family therapy (EFT) is a short-term (10–15 sessions), experiential, evidence-based approach to couple and family therapy, rooted in the humanistic–existential school. It was developed by Leslie

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Greenberg and Sue Johnson, two Canadian psychologists, in the mid-1980s. EFT was derived from emotion- focused therapy, an individual approach to psychotherapy. Although it has many similarities to emotion- focused therapy, this therapy also includes Systems Theory and Attachment Theory and works predominantly with helping couples and families communicate from an in-depth emotional level and fully connect with each other.

As a doctoral student of Leslie Greenberg, Sue Johnson worked with couples in distress. She realized these couples were caught in negative cycles of interactions that kept them stuck and unable to resolve their conflicts. Using theories of attachment and theories of emotions, Greenberg and Johnson developed a treatment to help distressed couples. They believed that basic attachment issues and interrupted emotions were underneath these negative cycles of interactions. Later, the approach was applied to families.

EFT has become immensely popular in the past few years and has revitalized the central role of emotion in couple and family psychotherapy. Greenberg and Johnson and others have carried out extensive evidence- based process and outcome research studies. EFT is currently the most empirically validated couple and family therapy to date. The approach has been manualized, which is useful for beginning-level practitioners (Greenberg & Johnson, 1988, 1995).

Experiential couple and family therapy emerged in the 1960s, preceding Greenberg and Johnson. The early founders were Carl Whitaker (1912–1995) and Virginia Satir (1916–1988), two enormously engaging and intuitive clinicians lauded as the most influential early leaders of the family therapy movement. Whitaker’s Symbolic-Experiential Family Therapy Model and Satir’s Human Validation Process Model saw the family as a dynamic, interactive system that could be reshaped to achieve deep levels of intimacy. Experiential interventions focused on the expression of feelings and authentic communication and included role plays, Gestalt experiments, guided awareness, psychodrama, creative arts, and communication training (Napier & Whitaker, 1966; Satir, 1964; Satir & Baldwin, 1983; Whitaker & Bumberry, 1988). Whitaker and Satir were criticized for their lack of conceptual and therapeutic precision as well as lack of empirical research. Nevertheless, they continue to be praised today for their extraordinary presence, inspirational brilliance, and unique contributions to the field. Gus Napier continues to train therapists in Whitaker’s approach in Atlanta, Georgia. Satir’s work lives on in her numerous writings, training institutes, and DVDs.

During the 1970s, Walter Kempler, Sonia Nevis, and Joseph Zinker of the Gestalt Institute of Cleveland expanded Gestalt therapy to include couples and families and developed a Gestalt Family Therapy Model that integrated family systems therapy with Gestalt therapy. Their experiential approach helps families experience issues in the here and now, release blocked emotions, and increase awareness and contact within and among family members. Gestalt family therapy, although rich in theory, was also criticized for its lack of therapeutic precision.

EFT is a humanistic–existential, structured approach to working with couples and families that integrates Attachment Theory, person-centered therapy, Gestalt therapy Systems Theory, and neuroscience theory of emotions. EFT emphasizes helping couples and families explore their moment-to-moment inner experiences in order to strengthen their emotional attachments. The therapy helps couples and families connect with their primary, core emotions, viewed as central to the development of secure attachment bonds.

EFT believes that couples and families in distress are caught in negative interaction patterns (e.g., pursuing–distancing, attacking–withdrawing, dominance–submission, and rage–shame) that limit contact with one another and create emotional distance. Couples and families conceal their primary emotions (genuine, authentic) and rather display secondary emotions (defensive, reactive), which serve to create the negative interaction patterns. Over time, members fear revealing their primary emotions and attachment bonds are further weakened. In this approach, an empathically attuned therapeutic relationship is used to help couples access primary emotions, strengthen attachment bonds, and change their negative interactional patterns (Greenberg & Johnson, 1988).

Key Concepts

EMOTIONS An affective state of information processing that informs a person of important needs, prepares the self for action, and creates strong attachment bonds. Emotions may be primary or secondary. Primary emotions are the fundamental, initial emotional reactions in response to a situation, such as sadness in response to a loss or anger in response to an attack. Secondary emotions are emotional reactions to thoughts or feelings, rather

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than to the situation itself, such as feeling guilty about feeling angry. The therapist particularly focuses on emotions because they so potently organize key responses in intimate relationships. Negative emotional responses, such as frustration, if not attended to and restructured, undermine the repair of a couple’s relationship, whereas softer emotions, such as expressions of vulnerability, can be used to create new patterns of interaction. From a systemic point of view, emotions are viewed as the primary element in the organization of the couple’s relationship (Johnson, 1996).

ATTACHMENT STYLES Emotional bonds in relationships that are maintained by responsiveness, accessibility, and engagement. Secure attachment occurs when people can express primary emotions, while insecure attachment occurs when primary emotions cannot be accessed. Insecure attachment occurs when people conceal their primary emotions and display secondary emotions. Four attachment styles have been described by Johnson and Sims (2000):

1. Secure attachment—People who are secure perceive themselves as loveable. They are able to trust self and others in relationships. They are able to be vulnerable and express their needs and feelings in relationships.

2. Insecure attachment—People who have a diminished ability to express their needs and feelings and tend to discount their need for attachment. They tend to adopt a position of safe distance and solve problems by themselves without understanding the effect they have on their partners.

3. Anxious attachment—People who are psychologically reactive exhibit anxious attachment and are inclined to demand reassurance in an aggressive and controlling way, frequently blaming and manipulating in order to engage their partner.

4. Vacillating attachment—People who have been traumatized frequently fluctuate between attachment and hostility. They are typically reactive and they vacillate with frequency.

ATTACHMENT INJURIES An emotional injury that is experienced in a couple relationship. The injury is generally characterized as abandonment, betrayal, or violation of trust (Johnson & Whiffen, 1999). An attachment injury can range from infidelity to feelings of abandonment, such as when one partner is unresponsive to the other for the kind of support that is expected of attachment figures during a time of need, life transition, illness, or loss. These injuries, if unresolved, damage the nature of the attachment bond and sometimes prevent the repair of the bond. Some partners may have endured insecure attachment bonds over a period of years and then one incident exacerbates this distress and acts as a symbolic marker of insecure attachment for the injured partner. Other couples may have a relatively secure bond and this kind of incident marks the beginning of their relational distress. Much depends on how the injured partner interprets the injury and how the other spouse responds to expressions of hurt by the injured party. When the other spouse discounts, denies, or dismisses the injury, this prevents the processing of the event in the relationship and compounds the injury. The unresolved event may be the topic of constant bickering or it may lay dormant and unexpressed for a period of time until it re-emerges in the here and now when a current incident evokes an emotional response related to the initial injury. A sudden increase in the emotional intensity of the couple’s interaction is a marker that alerts the therapist that the couple is dealing with an attachment injury (Johnson, Makinen, & Makinen, 2001).

Goals of Therapy

The primary goals of EFT are to expand constricted emotional responses that create negative interaction patterns, restructure interactions so that partners become more accessible and responsive to each other, and foster positive cycles of comfort and caring. Couples are helped to access their authentic emotions, transform negative interactional patterns, and strengthen attachment bonds. This is achieved within an empathically attuned therapeutic relationship (Greenberg & Johnson, 1988).

Psychotherapeutic Interventions: Assessment

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Assessment is described as the first phase of therapy and usually takes two sessions. There are no genograms or other tools used in EFT. During this phase, the therapist creates a comfortable and supportive environment for the couple to have an open discussion about any hesitations they may have about therapy. A strong therapeutic relationship is developed based on the client-centered work of Carl Rogers, emphasizing empathy, congruence, and authenticity. The problematic interactional patterns that maintain attachment insecurity and relationship distress are identified as well as the primary emotions underlying these patterns. There is a reframing and summarizing of the problematic interactional patterns and the attachment needs so that the couple is no longer victim of the patterns but allies against them in the pursuit of positive attachment patterns (Greenberg, 2002, 2010; Greenberg & Johnson, 1988).

Psychotherapeutic Interventions: Psychotherapy Techniques

A central belief in EFT is the premise that positive interaction patterns follow from the attainment of an experience of emotional bonding between the partners during therapy. This occurs when primary emotions can be expressed and responded to during the therapeutic relationship. Change is achieved through the facilitation of three sequential movements:

De-escalation of the conflict between the partners involves the progressive unfolding of the experience that each partner has in the relationship and the clarification of the interactive cycle between them

Re-engagement of the withdrawing or submissive partner in the relationship involves that partner identifying and owning, in the presence of the other, his or her primary emotional experience in the relationship

Softening involves dominant or pursuing partners owning and expressing their primary vulnerability such as the experience of being unloveable or the shame that lies beneath the controlling behavior or critical demands

Interventions used in EFT are for the purpose of accessing core emotions and developing positive attachment patterns (Johnson, 2002, 2004).

EMPATHIC ATTUNEMENT Throughout therapy, the therapist attempts to empathically attune to each partner and connect on a deep personal level. The therapist is concerned not with evaluating the client’s comments as he or she relate to truth, but to make contact with the client’s subjective world. Each member’s experience is closely followed empathically. The therapist speaks slowly, calmly, and patiently, checking frequently with the client to make sure he or she is understood and engaged (Johnson, 1996).

REFLECTIVE STATEMENTS Statements reflecting the deeper, primary emotions that a person possibly experiences based on a comment made by another. For example, a wife makes a comment, “A part of me wants a divorce.” The husband is silent and looks afraid and the therapist comments to him, “It seems you are feeling terribly scared by the comment your spouse made. Is that correct?” This helps the husband access the primary emotion and for the wife to understand his emotional response.

EVOCATIVE QUESTIONS Questions used to evoke deeper, primary emotions that are not experienced directly. For example, a husband states, “She is never home. She always is working or out with her friends.” The therapist comments, “What’s happening now for you as you say that?” This draws attention to the deeper emotions.

CREATIVE IMAGES AND METAPHORS Representations evoked to capture an elusive emotional experience. For example, a client states that she cannot speak when her husband voices anger toward her. The therapist comments, “It feels like a noose around your throat that is strangling you.”

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ENCOURAGING ACCEPTANCE When a family member begins to express deeper emotions and needs, the therapist encourages other family members to be supportive and receptive to this new openness. For example, a husband expresses deep sadness about a job loss. The wife perceives him in a new way, “I didn’t know how sad you are, for I’ve only seen your anger. I see you need my caring.”

CREATING INTIMATE ATTACHMENTS The couple recognizes and expresses their attachment and consolidates a new emotional position. In the example above, the husband states, “I do need your love and caring for I am going through a rough time.” And, she states, “I am able to do this for I see I am needed by you.” At times, the therapist needs to assist the couple in creating new attachment patterns.

PRACTICAL ASPECTS OF FAMILY THERAPY FOR THE APPN

Four approaches to family therapy have been described in this chapter. Systemic, structural, strategic, and emotionally focused family therapies all use a family systems perspective and view an individual’s symptoms and dysfunctional behaviors as a manifestation of a dysfunctional family system. Table 12.1 illustrates these four approaches, articulating their leaders, key concepts, and key interventions. The reader is referred to original texts as well as research articles in these approaches in the reference list at the end of the chapter.

The following section gives practical information for the beginning-level APPN. These suggestions are drawn from the literature and years of experience with the four approaches.

Forming a Relationship

Warmth, empathy, and joining with each family member are important in relationship building, from the beginning contact with the family and throughout the therapy. The APPN also needs to have a spirit of collaboration when working with families.

TABLE 12.1 Four Major Family Therapy Approaches

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The initial phone contact is very important and gives the APPN a beginning notion of the family problem and dynamics. It may influence who the APPN decides to see for the first session. For example, consider the following three phone contacts:

My 14-year-old son is depressed, doing poorly in school, and I am overwhelmed with fear. I have not slept for the past few days.

My husband and I are going through a divorce and my 14-year-old son is having a rough time of it, doing poorly in school and having symptoms of depression.

My 14-year-old son is being discharged from an inpatient unit for depression and needs someone to prescribe his medication.

With this available information, the APPN might choose to see the mother alone in the first case scenario, the family as a unit in the second, and the dyad of mother and son in the third.

Beginning the Session

Often the novice APPN has difficulty beginning a session. With family therapy, it is very important to set clear rules and ask effective opening questions.

SET CLEAR RULES Setting rules is very important for safety especially when working with chaotic or abusive families. At the beginning of the first session, it is imperative to give a clear message that this is your office and you, as the APPN, are in charge and have certain rules and expectations. These may be written on a flip chart or a handout. With more structured, contained families, setting rules may not be as essential to safety, but, in general, it is a good idea to have a few rules even with these families. Box 12.3 gives some rule-setting suggestions.

BOX 12.3

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INITIAL RULE SETTING

No name calling or other forms of disrespect No physical violence No interrupting—only one person may speak at a time No speaking for another person No blaming or evoking guilt No consequences for what is said during the session after leaving the session No continuation of the session after it is over No unproductive communication such as why, should, or can’t

STARTING THE SESSION Starting the session is very important. The initial phone contact as well as the first meeting in the waiting room and on entering the therapy room will provide clues and preliminary ideas as to how to proceed and tailor opening statements and questions. For example, does the family seem resistant? Do they seem scared? Do certain members not want to be there? Does one member seem to have a major psychiatric problem? Where do family members sit when they come into the consultation room? Some beginning statements and questions are included in Box 12.4.

BOX 12.4

EFFECTIVE OPENING STATEMENTS AND QUESTIONS

To start with, I would like to go over a few rules so we are all on the same page. How do you all feel about coming here today? I believe that you are the experts on your family and I am here to help. Today, we will be clarifying problems and seeing what changes need to occur. What happened in your family for you to seek help now? What would each of you like to see changed in your family? I’d like each of you to describe what you consider the problem to be. If you were to awaken tomorrow and magically, your family was exactly how you would like it to be, how would it be different?

What part of the problem does each of you think you play?

Some of these statements and questions are better for certain types of families. For example, with a difficult, resistant family, a solution-oriented lead question might be more effective than a problem-oriented question. A solution-oriented question typically decreases tension as well as provides clues to family interactional problems. In the following dialogue, the initial solution-oriented question gives clues to excessive family conflict with possible enmeshment, without actually talking about problems:

APPN: If you were to awaken tomorrow and magically, your family was exactly how you would like it to be, how would it be different?

Mother: The family would be calm and peaceful. Daughter: My room would be a safe haven.

With a family that strongly identifies one member as the client when it is clear that it is a family problem, the question, “What part of the problem does each of you think you play?” is an effective question. This begins to take the focus of the illness off the identified client and sends a message that everyone most likely plays a role in contributing to the problem.

Conducting the Assessment

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The assessment, as stated previously, begins at the initial phone contact. However, a more formal assessment is carried out during the first session with select family members or the entire family system. The official guidelines of the American Academy of Child and Adolescent Psychiatry (AACAP) state that a family assessment is standard procedure and always indicated in the psychiatric evaluation of a child or adolescent (Josephson & AACAP Work Group, 2007). A genogram, structural mapping, or observation may be used depending on the approach and the needs of the family. As with individual therapy, the assessment is ongoing and information is further collected as the therapy progresses.

When working with children and adolescents, it is important to ascertain the degree of influence of the family on the child’s problems and the child’s influence on the family. For example, in an unstructured family with inadequate boundaries, the degree of family effect on the child is probably more significant in both influencing and maintaining clinical problems. In contrast, in a case of a child with a developmental disability, the influence of the child on the family may be more significant to the clinical problems. A thorough assessment will result in an accurate case conceptualization and determine the best course of action. Important aspects to assess that are informed from all four family therapy approaches include the following.

DIFFERENTIATION Are members differentiated or undifferentiated? Is there fusion? Are there triangles? Is there emotional reactivity? Are there emotional cutoffs?

MULTIGENERATIONAL TRANSMISSION What patterns are passed on from one generation to the next?

EMOTIONAL ATMOSPHERE What is the general atmosphere? Do members feel proud to belong or are they reluctant to be associated with the family? Is the atmosphere conflictual and emotionally reactive or is it happy and loving? Do members feel safe?

STRUCTURE Is the structure solid? Who has the power in the system? Are the parents at the top tier of the hierarchy? Do they work together? Is the parental coalition weak or strong? Is the parental power equal or unequal? Does the hierarchy change with adolescents?

BOUNDARIES Are there adequate boundaries or is there an excess or dearth of emotions, communication, and concern? Are they enmeshed or disengaged? Are boundaries appropriate to age and circumstance? Are they isolated or invasive?

SUBSYSTEMS What are the subsystems and are they functional? Are there coalitions or parentification? Who is close to whom?

DECISION MAKING AND PROBLEM SOLVING How are decisions made and problems solved? Do all family members share in the decision making, or do one or both parents make all decisions? Do family members have a chance to say how they feel about decisions that directly affect them? Who has the power? Does the family move toward resolution or just blame each other? Is decision making effective or ineffective, rigid or adaptable?

CONFLICT RESOLUTION How does the family handle disagreement? Can they fight with each other? How do they fight? Do they fight

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fairly?

ROLES IN THE FAMILY Are the roles clearly defined? Are they flexible or rigid? Are they balanced or imbalanced? Are they prescribed or negotiable? Who deals with school problems and household finances? How are tasks distributed?

FAMILY RULES What are the rules? Are they fair, consistent, and appropriate? Are they vague or clear, fixed or flexible? How are they modified? What are the consequences for breaking the rules?

STRESS AND COPING Are there developmental (e.g., birth of a baby and retirement) or situational stressors (e.g., loss of a job)? Do the adults recognize normal developmental changes? Are members at the appropriate stages of development? How is stress handled? Are there effective coping mechanisms?

RELATIONSHIP OF THE FAMILY TO THE LARGER COMMUNITY Are the parents involved in the outside community? Is the family insulated or involved?

MENTAL ILLNESS Are there signs of psychopathology? Are there addictions, abuse, eating disorders, suicidal ideation, psychosis, or physiological disorders?

RELATIONSHIPS What is the relationship like between the parents? Are they able to be caring and intimate? Or, do they fight to make contact? Are the attachment bonds effective? Does one pursue sexually and the other push away for not getting emotional needs met?

COMMUNICATION PATTERNS Is communication sensitive, responsive, stifled, spontaneous, confused, clear? Do people listen to one another? Do people give clear messages of their wishes, thoughts, needs, and feelings, or do they expect others to magically know? Can people speak freely? Are some or all family members interrupted? Who interrupts? Who talks to whom? Does one person act as the switchboard? Do they take the message in and think about it? Are perceptions accurate? Can members repeat what they have heard?

DYSFUNCTIONAL FAMILY PATTERNS Are there dysfunctional patterns deeply embedded within the family? Do families maintain and perpetuate these dysfunctional patterns by their own actions? What are the sequences that keep the repetitive patterns deeply entrenched?

EMOTIONS How are emotions expressed and dealt with? Can everyone express feelings? Who handles emotional needs? How are anger and love expressed? Is there unresolved anger? Does one person want to talk about feelings and the other not? What is the general feeling tone of the family? Are feelings primary or secondary? Are they adaptive or maladaptive?

Conceptualizing the Problem

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Out of the assessment emerges a case conceptualization, also known as a case formulation. This is a theoretical understanding of the causation of the family dysfunction, which is based on an analysis of the assessment data. The conceptualization guides the APPN in determining a diagnosis and developing interventions. When it is determined that the family’s interactions have precipitated and maintained the problem, the formulation indicates interventions that will alter patterns of family interaction. When it is determined that the family’s interactions are responses to a child’s biologically mediated condition, a supportive, psychoeducational treatment approach may be employed. The family’s formulation of the problem as well as what they want to change is equally important.

The APPN provides an acceptable family systems explanation for the family distress that leads to some action. A plan consistent with the explanation should be provided for the family.

Diagnosing the Problem

Diagnosing in family therapy uses process diagnoses that address dysfunctional patterns of interaction between or among members. Concepts described previously such as fusion, disengagement, differentiation, structure, triangles, coalitions, maladaptive emotions, and ineffective attachment are used to describe family functioning.

Diagnoses may also be used from the V codes of the Diagnostic and Statistical Manual, fifth edition (DSM-5) (2013). These include various relational units associated with clinically significant impairment in functioning among one or more members of the unit or the functioning of the unit itself. These are included in Box 12.5.

Facilitating Change

Facilitating change includes two parts. The first part is contracting with the family and the second is working on the problems to bring about change.

BOX 12.5

DSM-5 CODE DIAGNOSES SPECIFIC TO RELATIONAL PROBLEMS

V61.9 Relational Problem Related to Mental Disorders or General Medical Condition V61.10 Partner Relational Problem (e.g., negative communication, excessive conflict) V61.20 Parent–Child Relational Problem (e.g., impaired communication, overprotection, inadequate discipline) V61.8 Sibling Relational Problem (e.g., negative communication, excessive conflict) V62.81 Relational Problems (e.g., problems with co-workers or peers)

CONTRACTING A plan needs to be made with the family regarding frequency, length, and number of sessions as well as attendance. Family therapy sessions are generally weekly and last for 1 hour. Family therapy usually lasts for approximately 8 to 20 sessions. Depending on the type of family therapy, families may meet as a group or in various configurations. Expectations for work outside of sessions such as homework assignments should be addressed. An APPN practicing from an EFT therapy model will commonly work exclusively within the session while the APPN practicing from a strategic therapy model will give homework assignments.

WORKING ON PROBLEMS The interventions used to work on problems depend on the family therapy approach and the needs of the

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family as well as the creativity and skill of the APPN. To follow are some examples of interventions, reflective of specific problems:

Enmeshed family. If an interaction problem is enmeshment, with a great deal of bickering and parental intrusiveness, the APPN might set up an experiment where the parents have to listen to the children without asking questions, lecturing, or giving advice. Each child is given 10 minutes to talk without any interruptions.

Disengaged family. If a problem interaction is disengagement, where members give limited support and are isolated from each other, the APPN might give a family homework assignment of instructing each family member to spend a minimum of 1 hour with each other family member and learn about his or her interests. Each child is to learn something about each parent’s interests, and each parent is to learn something about each child’s interest.

Coalition. When a dysfunctional alliance is identified, changing the dynamics is suggested. For example, if the APPN identifies an alliance between a father and daughter who side together against the mother, an experiment might be for the daughter and mother to spend several blocks of time together during the week and for the father and daughter to limit their communication. The APPN might ask the parents go out together and spend quality time together.

Triangulation. When two people manage tension by bringing in a third person, the APPN may ask the original dyad to speak to one another. “Why don’t you tell him directly how you feel?”

Ineffective communication. When family members are indirect, the APPN should help them be more direct. Family members may inaccurately perceive each other and the APPN will notice these inaccuracies and help members correct them. For example, an inaccurate perception is obvious in the following dialogue:

Daughter: Hi Dad.

Dad: Can’t talk now. [Dad had a bad day and needs space]

Daughter: [Withdraws believing that Dad is mad at her]

APPN: What did you just hear? [APPN to daughter]

Daughter: That Dad is mad at me.

APPN: Is that what you meant? [APPN to Dad]

TERMINATION During termination, the APPN and the family look back on the work that has been completed. Were the goals accomplished? What did each person learn? What helped or did not help? Termination with family therapy is similar to individual therapy and may bring up a variety of issues for the family including grief and loss issues as well as anger and resistance.

EVIDENCE-BASED RESEARCH

The research regarding the effectiveness of family therapy is extensive and reveals that two-thirds of clients in any kind of family therapy get better, which is similar to individual psychotherapy. Meta-analytic studies have concluded that couple and family therapies are significantly more effective than no treatment and at least as effective as other forms of psychotherapy, with an overall effect size of 0.53 (Shadish & Baldwin, 2002; Sexton et al., 2011). The literature also shows that one family therapy approach is no better than another, even when applied to specific problems (Liddle, Santisteban, Levant, & Bray, 2001). More gains are found however when the therapist is skillful and active in the early phases of therapy (Gurman, 2008, 2011).

Family therapy is effective for treating child and adolescent psychiatric disorders. It has proven effective with a range of problems including anxiety, depression, conduct disorders, school behavior problems, trauma, eating disorders, attention-deficit hyperactivity disorder (ADHD), and substance abuse disorders among others (Sheeber, Hops, Stanton, & Shadish, 1997).

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All four therapies mentioned in this chapter have a strong research base. Systemic family therapy has made notable contributions in family theory development such as McGoldrick’s work with diversity (McGoldrick, Pearce, & Giordano, 1982) and Betty Carter’s work with the family life cycle (Carter & McGoldrick, 1980). Systemic family therapy has also been in the forefront in testing concepts (Nichols, 2012). Instruments to measure differentiation of self have been correlated with many psychological constructs such as marital satisfaction, intimacy, triangulation, and marital distress. Couples with higher levels of differentiation have higher levels of marital satisfaction (Skowron, 2000), greater intimacy (Protinsky & Gilkey, 1996), greater psychological adjustment (Skowron, Wester, & Azen, 2004), more effective coping skills in stressful situations (Murdock & Gore, 2004), less anxiety (Skowron & Friedlander, 1998), and less psychological reactance (Johnson & Buboltz, 2000). Differentiated adults also have a significantly greater therapeutic alliance (Friedlander, Heatherington, Escudero, & Diamond, 2011; Lambert & Friedlander, 2008). Families with lower levels of differentiation have higher levels of triangulation and marital distress (Gehring & Marti, 1993). Multigenerational transmission research has found that parents’ and children’s beliefs are highly correlated (Troll & Bengston, 1979) and that family violence (Alexander, Moore, & Alexander, 1991), eating disorders (Whitehouse & Harris, 1998), and alcoholism (Sher, Gershuny, Peterson, & Raskin, 1979) are highly transmitted from one generation to the next.

A great deal of research has been published on the effectiveness of structural family with poorly structured, low socioeconomic families (Minuchin, Montalvo, Guerney, Rosman, & Schumer, 1967). Studies have shown its effectiveness with families with drug abusers (Stanton & Todd, 1982), physical disorders (Minuchin, Rosman, & Baker, 1978), eating disorders (Campbell & Patterson, 1995), obesity (Jones, Lettenberger, & Wickel, 2011), ADHD (Barkley, Guevremont, Anastopoulos, & Fletcher, 1992), conduct disorder (Szapocznik et al., 1989), and acculturation difficulties (Kim, 2003).

Early research in strategic family therapy was case reports illustrating successful, strategic directives. Later, empirical research has revealed its effectiveness in treating adolescent behavior problems and substance abuse (Santisteban et al., 2003), heroin addicts (Stanton & Todd, 1982), Hispanic youths with drug abuse and behavioral problems (Szapocznik & Williams, 2000), conduct disorders (Coatsworth, Santisteban, McBride, & Szapocznik, 2001), and eating disorders (Castelnuovo, Manzoni, Villa, Cesa, & Molinari, 2011). It has also been effective in reducing bullying behavior, risk taking, and aggression in bullying girls (Nickel et al., 2006). Robbins et al. (2008) found that successful therapy cases have a high level of positive alliance.

There has been significant research on EFT revealing that it is highly effective with couples and families. In general, 90% of families show significant improvement with this approach (Elliott, Greenberg, & Lietaer, 2004; Johnson, Hunsley, Greenberg, & Schindler, 1999; MacIntosh & Johnson, 2008). EFT has been recognized as one of only two empirically validated couple interventions (Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998). It is effective with diverse families, families experiencing chronic stress, and families coping with a chronically ill child (Gordon, Johnson, Manion, & Cloutier, 1996). It has also been effective for couples who have experienced sexual abuse as children (MacIntosh & Johnson, 2008), distressed couples dealing with forms of traumatic stress (Johnson, 2002), and couples in which one partner has symptoms of posttraumatic stress disorder (PTSD) (Johnson & Williams-Keeler, 1998).

CASE EXAMPLE

Assessment

Robert, a 42-year-old attorney, and Keira, a 39-year-old social worker, have been married for 14 years. They have two children, Brendan, age 12, and Jenna, age 10. Keira has been in individual therapy for the past 6 months. Recently, her therapist recommended a course of family therapy because issues related to her marriage and children were encroaching on her individual sessions.

A family assessment revealed that Robert, an emotionally unsupportive, demanding man, works long 14-hour days, underfunctions in the home, and is disengaged from his children. Robert smokes marijuana on a daily basis to relax. Keira, a warm, dependent woman, who overfunctions in the home, is enmeshed with the children. Keira has acquiesced to Robert over the years, letting him make most of the decisions and control the finances. Keira abused alcohol on a daily basis until 2 months ago, then stopped drinking, and began attending Alcoholics Anonymous (AA) meetings. Since she stopped drinking, the tension and conflict in the home

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have increased. Keira is now more inclined to fight with Robert than to go along with his demands. Robert’s marijuana use has increased over the past few months. A genogram revealed male domination and addictions in Robert’s family as well as parental divorce. Submission, anxiety, and addictions were prominent in Keira’s family. Keira’s mother became very bitter as she grew older. Communication patterns between Robert and Keira consist of an abundance of blame with little primary communication.

The children react to the tension in the home by making excessive demands on their mother. Brendan has symptoms of anxiety and difficulty getting along with his peers. He is irritable with his father but is supportive of his mother, often taking her side in marital disputes. Brendan also takes on many adult responsibilities at home. He also feels somewhat responsible for his mother’s well-being. Jenna recently began experiencing nausea and stomachaches in the morning and sometimes resists going to school. Each parent colludes with Jenna, trying to get her take their side in the marital conflict.

Conceptualization

The parents have a low level of self-differentiation. They do not have appropriate parental authority nor work together in rule setting. A number of dysfunctional patterns include cross- generational coalition between the mother and son, parentification of the son by the mother, and triangulation of the daughter by both parents. The parents have an insecure attachment with each other and do not communicate on a primary adaptive feeling level and, thus, do not express their needs or authentic feelings. The parents fight unfairly, blaming each other for the family problems. The family roles are undefined and tasks are not evenly distributed. Parents have a deeply embedded overfunctioning–underfunctioning pattern. Attachment bonds are weak between the parents.

Facilitating Change and Working on Problems

The APPN had an early session with the spousal dyad. Examples of some dialogue follows:

APPN: Do you notice anything about the genogram? [to Robert and Keira]

Robert: Well, the men all worked very hard in my family and many died very young. They all seem to be addicted to work or some substance.

Keira: I notice that many of the women had alcohol problems and seemed to be angry and bitter. I don’t want to be like that, which is why I recently stopped drinking.

APPN: I know that you have stopped drinking 2 months ago and are attending AA.

Robert: Now that Keira has stopped drinking, she spends so much time at AA meetings and is rarely at home to take care of the kids. The kids are falling apart. She needs to be at home.

APPN: And, when Keira spends time away from home, you feel angry that she isn’t there for the family and scared that the children are not being taken care of.

Keira: Well, I’m no longer going to assume all the responsibility for the house while he just lounges around. It’s over for me. He needs to take

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some responsibility too.

APPN: Can you say that to Robert?

Keira: I am no longer going to take all the responsibility in the home!

Robert: I would like to do that, but she doesn’t know how difficult my job is and how much stress I am under.

APPN: Can you tell her that?

Robert: I am under so much stress and pressure at work. When I come home and find you not there, I feel terribly alone and scared that you are going to leave me.

APPN: It seems you are feeling terribly scared by that.

Robert: I would like you to be at home more for I feel scared and abandoned.

APPN: What’s happening now for you as you say that?

Robert: Uh, uh … [he begins to cry]. My mother left my father and I don’t want that to happen. I feel very scared.

A later session was held with the entire family. The APPN asked the children to draw their family. Jenna drew herself in the middle of the page with her parents on opposite sides of the paper. Her arms were abnormally long, in an exaggerated extension toward each parent.

APPN: I notice that your arms are pulled very long. They look a little like stretched silly putty. I wonder what that is like for you.

Jenna: It’s scary. Sometimes I feel like I’m going to be pulled apart.

APPN: What do you think about that? [APPN to parents]

Robert: Well, I guess I do try to get her on my side when I’m arguing with Keira.

Keira: I do the same.

APPN: What do you think you can do, Jenna, to get yourself out of that position of being in the middle?

Jenna: I don’t know.

APPN: How about if you say to Mom and Dad that you will not listen to them complain to you about the other parent. Can you do that?

Jenna: Umm, I think so.

APPN: Can you try that now?

Jenna: [to Mom] If you tell me anything bad about Dad, I will not listen and will tell you to talk to him. [to Dad] If you tell me anything bad about Mom, I will not listen and I will tell you to talk to her.

Brendan drew the family in a row. On the left was he and his mother drawn very close, then

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Jenna in the middle of the page, and then his father on the right side of the page, drawn very small and not close to anyone. It was clear that the relationship between Brendan and his mother was enmeshed and that he was engaged in a parentified role with her, giving her emotional support. Brendan had too much responsibility, which was thwarting his own emotional needs.

APPN: I notice that you are very close to your mother.

Brendan: Yes, I am. She needs me.

APPN: Could you, Mom, tell Brendan, that you can take care of yourself?

Keira: Brendan, I am able to take care of my own needs. You need to look after yourself.

APPN: [The APPN gave everyone a directive.] How about for this week Brendan and Dad will spend two nights together. Mom and Dad will go out by themselves one night and have fun. Jenna will enjoy some time by herself working on some of her art projects.

BOX 12.6

LEADING COUPLE AND FAMILY THERAPY INSTITUTES

Ackerman Institute for the Family, New York, NY, www.ackerman.org Bowen Center for the Study of the Family, Washington, DC, www.thebowencenter.org Minuchin Center for the Family, Oaklyn, NJ, www.minuchincenter.org Philadelphia Child & Family Therapy Training Center, Philadelphia, PA, www.philafamily.com Family Institute of Westchester, White Plains, NY 10604, www.fiwny.org Mental Research Institute for Strategic Family Therapy, Palo Alto, CA, www.mri.org/strategic_family_therapy.xhtml

International Centre for Emotionally Focused Therapy, Ottawa, CAN, www.iceeft.com Emotion-Focused Therapy Clinic, Toronto, CAN, www.emotionfocusedclinic.org/training

These session dialogues from the work with this family illuminate some examples of how the APPN could work in family therapy with a family with numerous dysfunctional patterns and attachment problems.

POSTMASTER’S FAMILY THERAPY TRAINING AND CERTIFICATION REQUIREMENTS

There are national certifying exams in family therapy. The Association of Marital and Family Therapy Regulatory Board (AMFTRB) examination in marital and family therapy is provided to assist state boards of examiners in evaluating the knowledge of applicants for licensure or certification. Although there are a number of APPNs who have a national certification, most APPNs do not pursue this route, because the APPN license allows the practitioner to practice family therapy if they are competent in the area. There are many comprehensive postgraduate family therapy training programs throughout the United States. Most of these are 3 years in length, but weekend workshops and shorter programs are available. Some leading couple and family therapy institutes are listed in Box 12.6 and organizations that offer workshops and postmaster’s

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http://www.ackerman.org

http://www.thebowencenter.org

http://www.minuchincenter.org

http://www.philafamily.com

http://www.fiwny.org

http://www.mri.org/strategic_family_therapy.xhtml

http://www.iceeft.com

http://www.emotionfocusedclinic.org/training

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training in couple and family therapy in Box 12.7. Two major resources are recommended for purchasing couple and family therapy DVDs: (a)

psychotherapy.net, and (b) American Psychological Association. The DVDs listed in Box 12.8 have been viewed by the author of this chapter and are highly recommended for training purposes.

BOX 12.7

WORKSHOPS AND POSTMASTER’S TRAINING

American Association for Marriage and Family Therapy (AAMFT), www.aamft.org American Family Therapy Association (AFTA), www.afta.org International Family Therapy Association (IFTA), www.ifta-familytherapy.org International Association of Marriage and Family Counselors (IAMFC), www.iamfconline.org

BOX 12.8

RECOMMENDED TRAINING DVDS IN COUPLE AND FAMILY THERAPY

Psychotherapy.net, www.psychotherapy.net

Aponte, H. (1998). Structural Family Therapy Coyne, J. C. (1998). Strategic Couples Therapy Guerin, P. (1998). Bowenian Family Therapy Johnson, S. (2001). Emotionally Focused Couples Therapy McGoldrick, M. (1996). The Legacy of Unresolved Loss: A Family Systems Approach.

American Psychological Association, www.apa.org

Carlson, J. (2006). Couples at an Impasse Greenberg, L. (2006). Emotionally Focused Therapy with Couples Johnson, S. (2011). Emotionally Focused Couple Therapy for Clients Dealing with Infidelity

CONCLUDING COMMENTS

This chapter provides an overview of family therapy for the APPN, highlighting the importance of this approach for the practicing APPN. It explicates four major approaches (systems, structural, strategic, and emotionally focused family therapies), describing their key concepts, goals, and interventions. The chapter describes the practical aspects of conducting family therapy. It includes the evidence-based family therapy research, a case study, and information on how to receive postgraduate certification and training. It is hoped that the chapter gives the reader enough of an introduction to the diverse field of family therapy that he or she will want to learn more and continue training in family therapy.

There are other approaches to family therapy not mentioned in this chapter such as psychodynamic, cognitive behavioral, solution-focused, narrative, and feminist family therapy. These approaches, although very valuable, are not considered to be a family systems approach. In general, they apply basic concepts of individual therapy to the family. Nevertheless, it is suggested that the APPN explore these other types of family therapy as well. For a comprehensive compilation of family therapy approaches, the two texts, Family Therapy: An Overview by Goldenberg and Goldenberg (2012) and Family Therapy: Concepts and Methods by Nichols (2012) are recommended for the APPN student and beginning practitioner. Original texts are highly recommended for advanced practitioners and can be found in the reference list.

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http://www.aamft.org

http://www.afta.org

http://www.ifta-familytherapy.org

http://www.iamfconline.org

http://Psychotherapy.net

http://www.psychotherapy.net

http://www.apa.org

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DISCUSSION EXERCISES

1. Why is it important for the APPN to have basic competence in family therapy? 2. What are the similarities and differences among the four major approaches to family therapy (e.g.,

systemic, structural, strategic, and emotionally focused) discussed in this chapter? 3. Draw a three-generation genogram of your family. How do you think your family has contributed

to your development and self-definition? 4. Structural family therapy emphasizes the importance of a structure with a clear parental hierarchy.

What problems emerge when this organization does not occur? 5. Strategic therapy emphasizes issuing directives as its major intervention. Give an example of a

directive that you might use in a specific family situation. 6. Develop a brief couple dialogue that illuminates empathic attunement as used in EFT. 7. Which family therapy approach do you find the most interesting and hope to further explore?

Why? 8. Watch a movie that portrays a family with dysfunctional dynamics. Analyze the movie from a

particular family therapy approach. Some suggestions are:

Hannah and Her Sisters (1986) The Kids Are All Right (2001) Little Miss Sunshine (2006) Lymelife (2008) On Golden Pond (1982) Ordinary People (1980) Parenthood (1989) A River Runs Through It (1992) The Squid and the Whale (2005) Stories We Tell (2013)

REFERENCES

Ackerman, N. (1958). The psychodynamics of family life. New York, NY: Basic Books. Adler, A. (1931). Guiding the child. New York, NY: Greenberg. Alexander, P. C., Moore, S., & Alexander, E. R. (1991). Intergenerational transmission of violence. Journal of Marriage and the Family, 53,

657–667. American Nurses Association (ANA), American Psychiatric Nurses Association (APNA), & International Society of Psychiatric-Mental

Health Nurses (ISPN). (2007). Psychiatric-mental health nursing: Scope and standards of practice. Silver Spring, MD: Author. American Nurses Association, American Psychiatric Nurses Association, International Society of Psychiatric-Mental Health Nurses. (2012).

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Stabilization for Trauma and Dissociation KATHLEEN WHEELER

rauma affects all dimensions of the person, dysregulating and disconnecting the person physiologically, emotionally, spiritually, cognitively, interpersonally, and socially. Trauma refers to an extremely stressful

event or situation that is experienced as overwhelming to the individual and as a result, the experience/memory is stored dysfunctionally in the brain (Cozolino, 2010; Shapiro, 2001). Shapiro (2001) broadened the concept of trauma to include any adverse life experience that has a lasting effect on the self. These experiences may be small t traumas or big T traumas. The latter, big T traumas, coincides most closely with the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) (American Psychiatric Association [APA], 2013) Criterion A event for posttraumatic stress disorder (PTSD), that is, the person has experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. Chapter 1 provides a more comprehensive list of possible traumatic events.

This chapter further explicates the care of individuals who have suffered significant trauma and elaborates psychotherapeutic strategies for care using the treatment hierarchy framework presented in Chapters 1 and 2. In this chapter, the spectrum of traumatic responses is discussed. Wider recognition by the psychiatric establishment of the expanding conceptualization of traumatic experiences is reflected by a new DSM-5 category of psychiatric diagnoses, trauma-related disorders (APA, 2013). Disorders in this category include acute stress disorder (ASD), PTSD, adjustment disorder, specified or unspecified trauma and stressor related disorder for those presentations that do not fully meet criteria for the previous three diagnoses, reactive attachment disorder (RAD), and disinhibited social engagement disorder with the latter two exclusively for children. Other diagnoses directly related to traumatic events include the dissociative disorders (DDs), which include dissociative amnesia, depersonalization/derealization, dissociative identity disorder (DID); and the DSM-5 category somatic symptom and related disorder, which includes somatic symptom disorder, illness anxiety disorder, conversion disorder, and psychological factors affecting other medical conditions. Borderline personality disorder (BPD) is also thought to be caused by early relationship trauma and is discussed in Chapter 14. Other disorders not included in the DSM-5 category of trauma-related disorders that are discussed in this chapter are disorders of extreme stress not otherwise specified (DESNOS) or complex trauma and psychosomatic disorders. The goals of treatment and evidence-based research are highlighted with a particular emphasis on stage 1 (stabilization) along with components of specific stabilization techniques illustrated with clinical vignettes on how to work with these patients. Interventions are aimed toward safety, developing dual awareness through mindfulness, and managing physiologic arousal.

SPECTRUM OF TRAUMATIC RESPONSE

The effects of adverse life experiences and traumatic events can be cumulative and significantly compromise functioning and lead to mental health problems, psychiatric disorders, and physical disorders. An individual’s response and the long-term sequelae of trauma are highly individualistic and depend on the nature, chronicity, and severity of the traumatic events, the person’s age, development stage, genetic vulnerability, prenatal factors, gender, past experiences, preexisting neural physiology, cognitive deficits, emotional maturity, coping skills, hardiness, relationships with others, intrafamilial involvement, sociocultural factors, and a host of other factors (Briere & Scott, 2013; Chu, 2011).

The spectrum of the traumatic stress response is illustrated in Figure 13.1. Traumatic stress disorders include several diagnoses that result from one or more traumatic events and often include symptoms of intrusive thoughts, avoidant behavior, and hyperarousal. These symptoms can be thought of as state- dependent memories that result from earlier experiences caused by a traumatic situation. These memories are stored differently from normal memories; are not integrated with other, more adaptive networks; and may be

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encoded as sensations and images in implicit memories rather than in verbal narrative and context. The traumatic memory is fragmented and not linked to other experience (neural networks) but lives on as a sensation and/or image.

FIGURE 13.1 The spectrum of traumatic response. Adapted from Davis and Weiss (2004).

This unprocessed trauma leads to unexpected re-experiencing or intrusive thoughts related to the trauma, the numbing of awareness or avoidance of situations or circumstances that are associated with the trauma, and a persistent increase in physiologic arousal. The patient may alternate between denial or numbing and experiencing intrusive thoughts or images (Friedman et al., 2011). Figure 13.1 lists common numbing and intrusive symptoms. During denial states, increased activity such as work, sports, or sexual activities may take place, and to quell the intrusive states, substances such as alcohol may be used. Intrusive emotional states reenact the stressor, and through overgeneralization, situations that before the trauma were neutral are infused with anger, fear, and sadness. Chapter 2 explains the neurophysiology of these cycles. Although these symptoms might have been adaptive at the time of the trauma, their contribution to the present can create significant problems for the person in identity, interpersonal relationships, affect dysregulation, and cognitive distortions.

In addition to the triad of hyperarousal, avoidance, and intrusive thoughts, one of the most disturbing symptoms for the patient is dissociation. People can experience dissociation from mild daydreaming and spacing out to depersonalization and derealization episodes to total unresponsiveness, although they are awake and responsive to their environment such as in dissociative amnesia and dissociative fugue (Briere & Scott, 2013). Severe episodes of dissociation occur in DDs and interfere with social or occupational functioning. DID, formerly called multiple personality disorder, is an extreme version of dissociation. Significant dissociative states are characterized by a disconnection of thoughts, emotions, sensations, and behaviors.

Dissociation indicates that neural networks are functioning independently and separately, that the networks are unintegrated, and that information processing has been disrupted. Dissociative states reflect discrete memory networks that have not been linked to other dimensions of consciousness. Dissociation is thought to be primarily a right-brain phenomenon (Schore, 2012). Those who suffer from severe dissociation are those who have suffered significant trauma. Putnam (1989) provides an excellent definition of dissociation from his seminal book on multiple personality disorders: “a normal process that is initially used defensively by

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an individual to handle traumatic experiences [that] evolves over time into a maladaptive or pathological process” (p. 9). Box 13.1 describes patient-reported signs of dissociation, and Box 13.2 lists the observable signs of dissociation that the clinician may notice.

BOX 13.1

CLIENT-REPORTED SIGNS OF DISSOCIATION

Things look different, tunnel vision, colors too vivid or washed out Things sound different, muffled or too loud, “tinny” or echoing Things seem to move in slow motion, or fast forward Emotions become flat, numb; no feelings Feeling out of touch with surroundings Feeling like an observer of their present circumstances Feeling like they are on autopilot People or the world does not seem real; or person feels like a stranger in familiar place Events seem like a dream It seems like one is watching things from outside the body Foggy feeling, clouding of alertness

Dissociation is also considered a primitive type of defense in that as anxiety rises, the person may dissociate in an effort to avoid the perceived threat. Memories or information encoded in one state are not available to that person in another state. Neurophysiologically, the parasympathetic branch of the autonomic nervous system contributes to dissociation when the person experiences overwhelming stress (Porges, 2011). In this process, heart rate and blood pressure are reduced, and endogenous opioids are released (Stien & Kendall, 2006). This is a state of resignation or freeze in that the person cannot escape and the body responds by dissociating emotionally and mentally. This state may be associated with anhedonia, which is an inability to achieve or experience pleasure, and abulia, which is a state of profound apathy and inability to make decisions (Scaer, 2005).

BOX 13.2

OBSERVABLE SIGNS OF DISSOCIATION

Behavior that is an inappropriate response to stimuli, such as falling down after loud noise; disorientation Person is slow to respond Eyes fixed, staring into space, blinking rapidly without focusing, or staring downward Body becomes stiff or still Person drifts off, goes away, spaces out, blanks out, or loses track of what is happening; is inattentive and has memory lapses Person falls asleep in inappropriate circumstances

Adapted from Schiraldi (2001).

This physiologic state gets locked into the brain with all the attending sensations that occurred at the time of the event. This state-dependent dissociation results in fragmented memories disconnected from words and instead stored as images, sounds, smells, and body sensations. Later similar experiences triggered by internal or external stimuli may activate this material (Shapiro, 2001, 2002). For example, internal stimuli and the activation of a physiologic state such as anxiety or pain may serve as a trigger along with external stimuli such as a sound or smell. The dissociated patient may cycle rapidly between arousal with hypervigilance and then numbing confusion, and it may be difficult to distinguish whether the person is aroused or numb. The trauma patient experiences repetitive episodes of sympathetic arousal that in turn reflexively trigger deep parasympathetic dissociation. The trauma patient lives in a state of involuntary and disruptive autonomic

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instability and cycling (Scaer, 2005). Dissociative states may include flashbacks that are disturbing to the patient, and they may occur

automatically when the intensity of feeling becomes too strong (Perry, 2002) or when triggers to the original trauma are encountered. Flashbacks reflect dissociated implicit capsules of memories (Howell, 2005). “The inability to integrate traumatic memories causes the person to fixate at the time of the trauma and impairs the integration of new memories” (Steinberg & Schnall, 2000, p. 42). Adults who experience trauma are not as likely to dissociate memories as children, because a child’s brain does not have the associated neural networks needed to process the overwhelming affects that occur in trauma, particularly with repeated sexual trauma. In general, the younger the child when the trauma occurs and the more overwhelming the event(s), the more likely it is that the event will be dissociated (Chu, 2011; Steinberg & Schnall, 2000). Research has found that children who are severely abused prior to adolescence have either partial or complete amnesia for the events (Chu, 2011). It is not only the negative events that are not remembered but the positive events too so that the person may not remember much about their childhood at all. Dissociation is pathologic when it becomes the primary response to stress (Stien & Kendall, 2006) or becomes problematic to the person.

Structural Dissociation Theory

There are a number of models for understanding dissociative phenomenon but perhaps the most cogent and unified is that of the Theory of Structural Dissociation of the Personality. This theory proposes that patients who have suffered trauma that has not been processed have different parts of their personality, the apparently normal part (ANP) and the emotional part (EP) that are not fully integrated with each other (Steele, van der Hart, & Nijenhuis, 2005). The EP has split off from the ANP due to overwhelming trauma, with the EP that part of the personality holding the emotions, somatic sensations, and cognition of the traumatic experience while the ANP avoids the trauma. Each part has its own responses, feelings, thoughts, perceptions, physical sensations, and behaviors to situations/people. These different parts may not be aware of each other with only one dominant personality operating depending on the situation and circumstance of the moment.

For example, the person may be triggered by an outside event, such as a sound or situation, and the EP who holds the trauma will take over the personality. The EPs involve action defense systems that are ready to act and have been prevented from integration (Steele, van der Hart, & Nijenhuis, 2005). This is called switching. The day-to-day functioning is usually carried on by the ANP that avoids traumatic memories, that is phobic of the traumatic memory. Thus, the person may seem fine some of the time but cannot sustain this state due to outside environmental or even internal bodily events. Bodily sensations such as a rapidly beating heart and the sensation of anxiety can trigger an EP to be dominant. All parts are stuck in maladaptive states that maintain dissociation.

Those with PTSD are thought to have one ANP and one EP, termed primary dissociation; those with one ANP and more than one EP are said to have secondary dissociation, and these individuals are most likely diagnosed with BPD or DESNOS or dissociative disorders not otherwise specified (DDNOS); still others may have several ANPs and EPs and are diagnosed with DID, which is tertiary dissociation. The more parts there are, the more the fragmentation of the personality with the different parts experiencing themselves as younger than they really are. For example, the helpless little child EP who suffered abuse or neglect may take over the personality and leave the person feeling confused, afraid, and even ashamed as they are not sure what is happening. The person may hear an inner voice, an EP, who says: “You are worthless and should be dead” or “Shut up, you are stupid” even though nothing in reality seems to be wrong. They may even hear arguments going on in their head. Because of this, DID is often misdiagnosed as schizophrenia or another psychotic disorder instead of a DD. It is important to remember that all parts have a purpose or function with some parts “helpers” who by dissociating at the time of trauma allowed the person to escape and survive, whereas other parts may hold the anger and rage that were too threatening to experience at the time the trauma occurred. Treatment for those with significant DDs is focused toward increased communication and cooperation between parts with the ultimate goal of integration (Chu, 2011).

Dissociative Disorders

Historically, the defense of repression was thought to underlie most psychiatric disturbances but more

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contemporary thinking posits that dissociation, one of the most primitive defenses, is key to understanding most psychiatric disturbances, including substance abuse, eating disorders, depression, panic anxiety, generalized anxiety, phobias, obsessive–compulsive anxiety and personality disorders, conversion disorders, brief psychotic disorders, as well as other psychiatric disorders (McWilliams, 2011). Dissociation is an unconscious defense mechanism that protects the individual against overwhelming anxiety through an emotional separation; however, this separation results in disturbances in memory, consciousness, self- identity, and perception. Dissociation reflects a disconnection of the flow of information in neural networks. This is consistent with the basic tenet of this book, that disconnected neural networks drive the symptoms that are considered psychopathological.

A dissociative disorder may develop after a significant adverse experience/trauma when the individual responded with a severe interruption of consciousness. Patients with DDs have intact reality testing; that is, although the person may have flashbacks or images, these are triggered by current events, relate to the past trauma, and are not delusions or hallucinations. Dissociation is involuntary and results in failure of the normal control over a person’s mental processes and normal integration of conscious awareness (Spiegel et al., 2011). Dimensions of a memory that should be linked are not and are fragmented. For example, a person may be aware of a sound or smell, but these sensations would not be linked to the actual event itself, leaving the person fearful and/or confused. In addition, the person may reenact, as well as re-experience, trauma without consciously knowing why.

Symptoms of dissociation may be either positive or negative. Positive symptoms refer to unwanted additions to mental activity such as flashbacks; negative symptoms refer to deficits such as memory problems or the inability to sense or control different parts of the body. It is thought that dissociation decreases the immediate subjective distress of the trauma and also continues to protect the individual from full awareness of the disturbing event. Dissociative symptoms, or “mindflight” (Steele, 2012), actually reduces disturbing feelings and protect the person from full awareness of the trauma. This highlights the importance of attachments and relationships so the child can grow socially, intellectually, and cognitively. Factors that contribute to the development of DDs are early age of onset, severity of the trauma, the chronicity, and intrafamilial involvement (Chu, 2011). If abuse or neglect has occurred early in life, these memories become compartmentalized and often do not intrude into awareness until later in life when the person is in a stressful situation.

Dissociative disorders include: (a) depersonalization/derealization disorder, (b) dissociative amnesia/fugue, and (c) DID. Anyone may experience a transient or temporary depersonalization. An actual depersonalization disorder is more severe and is found in 1% to 3% of adolescents and adults, often in response to acute stress (Spiegel et al., 2011). Patients with this disorder usually seek treatment for another problem such as anxiety or depression. Depersonalization is an extremely uncomfortable feeling of being an observer of one’s own body or mental processes while derealization is a recurring feeling that one’s surroundings are unreal or distant. The person may feel mechanical, dreamy, or detached from the body. Some people suffer episodes of these problems that come and go, while others have episodes that begin with stressors and eventually become constant. Dissociative amnesia is also fairly common with a prevalence of about 2% to 7% and may occur in any age group from children to adults. The amnesia is often related to trauma, and memory returns spontaneously after the individual is removed from the stressful situation (International Society for the Study of Trauma and Dissociation [ISSTD, 2011]).

DID was formerly called multiple personality disorder, and a requirement for this diagnosis was the presence of alternate identities. Because switching from one personality to another happens infrequently, many people with this disorder are not properly diagnosed. DID may occur at any age but is diagnosed three to nine times more frequently in adult females than in adult males. There is usually a childhood history of severe physical or sexual abuse. Childhood physical, sexual, or emotional abuse and other traumatic life events are associated with adults experiencing dissociative symptoms. Patients with DID almost universally suffer from comorbid PTSD (Chu, 2011).

Comorbidity is common with DDs. Depression, panic attacks, eating disorders, PTSD, somatoform symptoms, eating disorders, obsessive–compulsive disorder (OCD), RAD, attention deficit disorder (ADD) with or without hyperactivity, personality disorders such as BPD, and substance-use disorders as well as sexual and sleep disorders commonly co-occur with all of the DDs (ISSTD, 2011). In addition, dissociative amnesia may be comorbid with conversion disorder or a personality disorder. Dissociative fugue, a type of dissociative amnesia, is associated with travel and may co-occur with PTSD. Depersonalization and derealization also occur in hypochondriasis, mood and anxiety disorders, OCD, and schizophrenia (Spiegel et al., 2011).

Most clinicians view dissociation as on a continuum, with some dissociation considered a normal

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experience for most people. For example, we dissociate when we go to the movies, get lost in a good book, daydream, space out during a lecture, or drive from point A to point B without paying attention to how we got there. One study of the general population found that 25% of people report mild to severe episodes of dissociation (Steinberg & Schnall, 2000). If trauma is severe or prolonged or occurs early in life, PTSD and DDs are likely to develop. It is curious that dissociation is considered rare in the United States when prevalence rates of DDs range from 2% to 10% occurrence at some time during a person’s life (ISSTD, 2011). Steinberg and Schnall (2000) estimate that the 1-year prevalence rate for the general population is probably around 10%, which is the same as that for major depression and generalized anxiety disorder. A study of outpatients seeking psychotherapy found that 29% of the 84 subjects tested had a diagnosis of DD after being interviewed with a structured interview for DDs (Foote et al., 2006). Only 5% of these subjects had been diagnosed with a DD before the interview. Dissociative disorders are often misdiagnosed and the person may have been treated in the mental health system for bipolar, schizophrenia, schizoaffective disorder, BPD, panic attacks, eating disorders, somatoform symptoms, and major depressive disorder (Cloitre et al., 2012; McWilliams, 2011).

Disorders of Extreme Stress

If the trauma is particularly prolonged or severe, pervasive personality problems develop. This is usually what we call complex PTSD or DESNOS (Herman, 1992). Herman, in her groundbreaking book, coined the term complex post-traumatic syndrome to refer to survivors of childhood abuse who may accumulate a number of diagnoses, including bipolar disorder, depression, anxiety disorders, substance abuse disorders, eating disorders, BPD, somatization disorder, and DDs, in their encounters with the mental health system. Stien and Kendall (2006) add attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) to this list as diagnoses related to complex trauma for children. Some are considered secondary diagnoses, such as substance abuse, OCD, somatization disorder, and eating disorders, because these problems represent attempts by the traumatized person to cope with the effects of the trauma (Chu, 2011).

Brain and hormonal changes may occur as a result of early, prolonged trauma, and these changes contribute to long-term difficulties with memory, learning, and regulating impulses and emotions. Although not a DSM diagnosis, DESNOS is thought to include most people who have suffered significant and severe early trauma. In DSM-IV trial studies, seven clinical issues for DESNOS were identified as most relevant, and these are not included in the PTSD diagnosis (van der Kolk & Pelcovitz, 1999). These issues include difficulties with self-regulation and impulse control, including self-destructive activities; problems in information processing, particularly with dissociation; personal identity issues such as self-blame, shame, and being permanently damaged; somatization of external stress manifesting in the body as disease or physical disorders; problems in interpersonal relationships and being dysfunctionally attached to perpetrators (Dworkin, 2005). These individuals, referred to as the chronically disempowered by Chu (2011), are often survivors of childhood abuse and usually require long-term treatment extending over several years.

Somatic Symptoms and Related Disorders

Somatic complaints have been identified as one of the most clinically relevant symptoms linked to a childhood history of abuse, particularly sexual abuse (Briere & Scott, 2013). Trauma, dissociation, and physical symptoms are inexorably linked. Those with significant somatic symptoms that are not caused by a medical condition are diagnosed under the general heading of somatic symptom and related disorders and include the following diagnoses in the DSM-5: somatic symptom disorder, illness anxiety disorder, conversion disorder, psychological factors affecting other medical conditions, and factitious disorder. These individuals may have an excessive preoccupation with bodily dysfunction and manifest a variety of physical problems, such as neurologic (especially headaches), gastrointestinal symptoms, and chronic pain that cannot be explained based on their medical condition. Conversion reactions include paralysis, anesthesia, blindness, deafness, and seizures (Briere & Scott, 2013). These disorders are characterized by a preoccupation with somatic problems and usually present in medical rather than mental health settings. Many cultures have somatization and dissociation syndromes. These are listed in the DSM-5 Glossary of Cultural Concepts of Distress and include the following: Latin American cultures with Nervios and Susto, Cambodia with Khyal cap, Zimbabwe with

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Kufungisisa, Haitia with Maladi moun, China with Shenjing shuairuo and Dhat, and Japan with Taijin kyofusho (APA, 2013).

Psychosomatic Disorders

Psychosomatic disorders most likely overlap and are closely aligned with somatoform disorders but not specifically delineated in the DSM because they are considered medical illnesses. Psychosomatic disorders include significant physiologic changes in various tissues or organs in the body that are thought to be caused by childhood trauma or overwhelming stress. Psychosomatic disorders are induced by emotions and are mediated by the immune-peptide, autonomic-peptide, and neuroendocrine-peptide systems (Sarno, 2006). Sarno posits that these individuals are repressors; those who have a psychosomatic disorder subjectively do not experience painful and dangerous emotions and instead repress anger and anxiety. These emotions are thought to be too disturbing for the person if made conscious.

Psychosomatic medical illnesses include tension myositis syndrome, which often manifests as back and neck pain; carpal tunnel syndrome; chronic fatigue syndrome; rheumatoid arthritis; fibromyalgia; allergies; asthma; psoriasis; eczema; acne; irritable bowel syndrome; tension and migraine headaches; vertigo and tinnitus; endocrine and autoimmune disorders; sleep-disordered breathing; and paroxysmal and essential hypertension (Hoffman, 2006; Leonard-Segal, 2006; Mann, 2003; Rashbaum & Sarno, 2003; Rochelle, 2006; Sarno, 2006; Scaer, 2005).

Scaer (2005) posits that the parasympathetic freeze response combined with autonomic dysregulation and abnormal cycling underlie psychosomatic disorders. He considers these to be the diseases and disorders of trauma. Although these diseases and disorders are sometimes associated with the presence of specific genes, he believes that they are primarily caused or triggered by early childhood and complex traumas that activate latent genetic tendencies (Scaer, 2005). Because individuals with these disorders most often seek medical attention and usually do not seek psychotherapy and medical researchers are not particularly interested in psychology, there is no solid evidence base for psychotherapy as a first-line treatment. However, there is anecdotal and case study evidence for the efficacy of insight-oriented psychotherapy and eye movement desensitization and reprocessing (EMDR) therapy for some of these trauma-related medical problems. Scaer categorizes these disorders and diseases based on the predominant feature of their abnormal function (Scaer, 2005), as shown in Table 13.1.

TABLE 13.1 Diseases and Disorders of Trauma Diseases and Disorders Examples of Abnormal Function

Diseases of abnormal autonomic regulation Fibromyalgia, irritable bowel syndrome, chronic fatigue syndrome, gastroesophageal reflux disease, mitral valve prolapse or dysautonomia syndrome, multiple chemical sensitivities, migraine headache

Syndromes of procedural memory Whiplash syndrome, cumulative trauma disorder, tics, phantom limb pain, chronic pain, premenstrual dysphoric syndrome, postpartum depression or psychosis

Diseases of somatic dissociation Reflex sympathetic dystrophy, interstitial cystitis, chronic pelvic pain

Disorders of endocrine and immune system regulation Hyperthyroidism, diabetes, rheumatoid arthritis, systemic lupus erythematosus, Sjögren’s syndrome, Graves’ disease, Hashimoto’s thyroiditis, multiple sclerosis

Disorders of cognition and sleep ADD, sleep-disordered breathing, sleep apnea, narcolepsy, cataplexy, hypnagogic hallucination, sleep paralysis

Adapted from Scaer (2005).

Acute Stress Disorder

Acute stress disorder (ASD) was a relatively new diagnosis in the DSM-IV, and the DSM-5 has further honed this diagnosis to include 9 out the following 14 symptoms that occur from 3 days to 1 month after a traumatic event. The essential features of ASD include a subjective sense of numbing; derealization (a sense of unreality related to the environment); inability to remember at least one important aspect of the event; intrusive distressing memories of the event; recurrent distressing dreams; feeling as if the event is recurring; intense prolonged distress or physiological reactivity; avoidance of thoughts or feelings about the event; sleep disturbances; hypervigilance; negative mood; exaggerated startle response; and agitation or restlessness (Bryant et al., 2011). These symptoms develop after a traumatic event lasting from 3 days to 1 month. If the symptoms persist after 4 weeks, the diagnosis changes to PTSD.

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Posttraumatic Stress Disorder

The DSM-5 describes PTSD as the result of having been exposed to; witnessing; experiencing repeated or extreme exposure to aversive events; events occurring to a close relative or friend; or one or more of the following event(s): death or threatened serious injury, or actual or threatened sexual violence (APA, 2013). Intrusive thoughts, avoidance behaviors, negative thoughts and mood, and hyperarousal must be present for at least 1 month after the traumatic event. Duration of symptoms varies, with some individuals recovering in a few months and others who can remain symptomatic for 50 years. It is not uncommon for symptoms to exacerbate or reoccur in response to stressors or triggers of the original trauma. Intrusive states include nightmares and flashbacks, which are fragments of distressing recollections, along with the physical components of the trauma (i.e., smell, physical sensation, taste, emotion, sound, and visual image). Avoidance behaviors include feelings of detachment, not thinking about the event, staying away from places that remind the person of the event, not remembering part or all of the event, diminished participation in, pleasurable activities, not feeling (i.e., psychic numbing), and believing that as a result of the event, the person will not have a normal life. Hyperarousal may manifest by bursts of anger, agitation, or irritability, difficulty concentrating, hypervigilance, difficulty falling or staying asleep, and an exaggerated startle response.

There are thought to be subtypes of PTSD: (a) a dissociative subtype for one-third of those with PTSD, which is associated with hyperactivity of the medial prefrontal cortex coupled with inhibition of the amygdala and (b) an intrusion/irritability subtype with medial prefrontal hypoactivation and amygdala activation (Lanius et al., 2010; Felmingham et al., 2008; Friedman et al., 2011). The implication clinically is that the former type, the dissociative type of PTSD, requires more extensive stabilization and interpersonal support. The second type is linked with externalizing symptoms such as anger/aggression and substance abuse (Friedman et al., 2011).

GOALS OF TREATMENT

Because many, if not most, outpatients and inpatients present with significant trauma histories, it is important that the advanced practice psychiatric nurse (APPN) learn to assess and treat this population. These patients come to treatment with a range of disturbing symptoms and present significant diagnostic and treatment challenges. The complexity of symptoms and multiple diagnoses confuse and challenge clinicians who care for this population. In general, the goals of treatment for PTSD can be applied to those who suffer from other trauma-related diagnoses. These are delineated in the American Psychiatric Association’s practice guidelines for PTSD (2004) and include reducing the severity of symptoms, preventing or treating trauma-related comorbid conditions that are present, improving adaptive functioning, restoring a psychological sense of safety and trust, protecting against relapse, and integrating the danger experienced into a constructive schema of risk, safety, prevention, and protection.

Because trauma aborts normal development and, consequently, interpersonal, professional, and educational opportunities are lost, assisting the person in restoring and promoting progress in the affected areas is important. Maturational social coping skills may be impaired, particularly for those who suffered trauma in childhood. McFarlane and van der Kolk (1996) observe that trauma causes the person to abandon hope because the person is unable to look beyond himself or herself to plan for the future. Clinical signs of recovery include being able to talk about the trauma without feeling upset or numb, functioning in daily life, feelings of being safe and confident, being in healthy relationships without feeling vulnerable, taking pleasure in life, having the ability to rely on self and others, experiencing minimal dissociation, managing emotions, feeling deserving, and being able to plan for the future.

Although these outcomes may seem daunting for patients who are chronically disempowered, they are achievable by following a progression of interventions that build on a strong foundation of safety and stabilization. Symptom outcome measures used for assessment can be used to track progress during treatment and to help determine whether the goals of treatment have been met. Tables 13.2 and 13.3 include dissociation and trauma assessment and outcome instruments.

TABLE 13.2 Assessment/Outcome Instruments for Dissociation Instrument Purpose and How to Obtain Dissociative Experiences Scale (DES) (Bernstein & Putnam, 1986) 28 items; most often used self-report screening tool for dissociation. Included in Chapter 3

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DES-Revised (Dalenberg & Carlson, 2010) Uses a Likert scale instead of percentages

Multidimensional Inventory of Dissociation (Dell, 2006) Self-report with validity scales; available on the ISSTD’s website (http://www.isst-d.org/)

Multiscale Dissociation Inventory (Briere, 2002) Available without cost from John Briere (http://www.johnbriere.com)

Somatoform Dissociation Questionnaire (SDQ-20 and SDQ-5) (Nijenhuis, 2011) Two forms, 20 items on a 5-point Likert scale pertaining to both negative (analgesia) and positive dissociative phenomenon (pain)

Dissociative Disorders Interview Schedule (DDIS) (Ross, 2013) 16 sections on this thorough diagnostic tool with no total score for the entire interview; available for free from http://www.rossinst.com/sample_forms.xhtml

The Structured Clinical Interview for DSM-IV Dissociative Disorders – Revised (SCID-D) (Steinberg, 1994)

Most widely used structured interview for dissociative disorders; evaluates the existence and severity of dissociative symptoms Interviewer’s Guide to the SCID-D. Washington, DC, American Psychiatric Press

Assessment

The assessment itself is therapeutic in that through the therapist’s empathy, knowledge, and communication in the initial interview, the patient feels hopeful, and distress is diminished (Horowitz, 2003). Chapter 3 provides strategies that cultivate an assessment that is therapeutic. A thorough and accurate assessment includes selected appropriate assessment tools that help the APPN formulate a plan. Chapter 3 provides numerous instruments to use for screening and assessment. Chapter 20 provides a table of selected measures for outcome measurement. Assessment is ongoing throughout therapy as more is known about the patient and the therapist evaluates the effectiveness of interventions.

Given the ubiquity of trauma and the consequences of untreated trauma, all patients should be screened for trauma and dissociation; however, many professionals do not routinely do so perhaps for a number of reasons. The clinician may be fearful of eliciting false memories by suggesting that trauma occurred or perhaps fearful of triggering pain and extreme emotional reactions, or the person may not remember whether trauma did occur or the person may not reveal the trauma in the initial interview for fear of being emotionally overwhelmed and retraumatized or ashamed. Nonetheless, all patients should be screened for trauma and one way is to ask: “Have you ever suffered a situation or event as an adult or child that was highly disturbing and/or painful?” The use of common screening tools should be routine for all patients in your practice. These include the Dissociative Experiences Scale (DES) and the Adverse Childhood Experience (ACE) scale, both of which are included in Chapter 3 appendices.

TABLE 13.3 Assessment/Outcome Instruments for Trauma Instrument Purpose and How to Obtain IES-R (Weiss & Marmar, 1997) Most widely used self-report screening tool for single incident trauma; 22 items; included in Chapter

Modified PTSD Symptom Scale: Self-Report Version (MPSS-SR) (Falsetti, Resnick, Resick, & Kilpatrick, 1993)

Self-report 17-item symptom checklist of PTSD symptoms; especially useful for clients with multiple traumas or where trauma history is unknown; does not key to a specific trauma Sherry Falsetti, PhD, Medical University of South Carolina, Crime Victims Research and Treatment Center, Medical University of North Carolina, 171 Ashley Ave. Charleston, SC 29425-0742

Trauma and Attachment Belief Scale (TABS) (Pearlman, 2003)

Self-report scale that evaluates the needs and expectation of trauma survivors in relation to others; taps into underlying assumptions regarding relationships Western Psychological Services, 12031 Wilshire Blvd., Los Angeles, CA 90025-1251; telephone: 310-478-2061; fax: 310-478-7838; web: www.wpspublish.com

Primary Care PTSD Screen (PC-PTSD) (Kimerling et al., 2006)

4-item screening tool for primary care and medical settings; http://www.mirecc.va.gov/docs/visn6/2_ Primary_Care_PTSD_Screen.pdf

Short Post-Traumatic Stress Disorder Rating Interview (SPRINT) (Connor & Davidson, 2001) Eight items on a 5-point Likert scale measuring symptom severity and improvement since treatment. See Appendix 13.1 for tool

The structured interview for disorders of extreme stress (SIDES) (Pelcovitz et al., 1997) Clinician-administered 45-item tool that measures the symptom clusters of DESNOS [email protected] HRI Trauma Center Research Dept. c/o Dr. J. Hopper 227 Babcock Str. Brookline, MA 02116

The Clinician-Administered PTSD Scale (CAPS) (Blake et al., 1995)

The most widely used clinician-administered structured interview for PTSD; assesses frequency and intensity of symptoms as well as effect on social and occupational functioning http://www.ptsd.va.gov/professional/ pages/assessments/assessment.asp Assessment Requests National Center for PTSD (116D) VA Medical Center 215 N. Main St. White River Junction, VT 05009

Patients who score highly on the DES should be further evaluated by the SCID-D or the DDIS. If a DD is present and you are not skilled in working with this population, it is best to either seek supervision from a therapist who is knowledgeable in this area or refer the patient to a clinician who is skilled in the treatment of these disorders because the patient may rapidly destabilize. These individuals may need a prolonged period of stabilization before processing their trauma(s).

The Impact of Event Scale-Revised (IES-R) is the most widely used self-report screening tool for a specific trauma. The SPRINT is shorter and also screens for single incident traumatic symptoms. See Appendix 13.1 for the SPRINT and Appendix 3.4 for the IES. For patients with a high score on the IES and when significant trauma is suspected, more formal interview schedules are available and

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http://www.johnbriere.com

http://www.rossinst.com/sample_forms.xhtml

http://www.wpspublish.com

http://www.mirecc.va.gov/docs/visn6/2_Primary_Care_PTSD_Screen.pdf

mailto:[email protected]

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should be used. The CAPS and the SIDES are two such instruments, and each may require an hour or longer for completion. These interviews are especially useful if the trauma is in the past and the person is not currently distressed. The APPN should be careful not to reactivate trauma memories by encouraging the person to talk about the details of the trauma until stabilization is achieved.

Self-report measures include the MPSS-SR and the TABS. The former scale assesses all DSM-5 criteria for PTSD for a single incident and the severity of the symptoms, whereas the latter does not key symptoms to any single traumatic event and measures disrupted cognitive schemas associated with complex trauma. All of the instruments discussed in this chapter have solid normative data, which means that they measure what they purport to measure and can be used and applied in various settings across situations for traumatized individuals.

Although all of these measures and the instruments in Tables 13.2 and 13.3 target specific symptoms and manifestations of dissociation and trauma, the effects of trauma are profound, pervasive, wide ranging, and affect all dimensions of the person: emotional, intellectual, physical, relational, spiritual, vocational, environmental, and psychological. Holistic outcome measurements rather than symptom-specific instruments may more accurately reflect healing. Examples of measures reflecting holistic outcomes may include quality of life, self-efficacy, overall health status, connection to others (i.e., sense of belonging or social support), spiritual well-being, and resilience. These are listed in Chapter 20 and Table 20.2.

An important area of assessment is differentiating a thought disorder from a flashback if what appears to be psychotic symptoms are present (Briere & Scott, 2013). Flashbacks are trauma memories that come back as fragments: a sound, an image, a taste, an emotion, a scent, or a bodily sensation. Sometimes, the flashback resembles a thought disorder. For example, one patient saw a naked woman on a bench. To determine whether this is trauma related, the APPN needs to know whether the content is about the trauma, caused by a trigger, or is anxiety related and noninteractive. If the patient is observed talking or laughing to a person who is not there, he or she may be experiencing a hallucination rather than seeing an image related to a trauma. The patient knew that the naked woman was not real but said these images came to her at times, especially when she was tired or stressed. This is an important distinction between psychosis and flashbacks; if the person locates the image or object of interaction as coming from inside themselves, it is most likely a flashback and not considered a psychotic hallucination. By history, this patient had been sexually abused as a child in a cult, and the APPN concluded that the image was probably a flashback.

Sometimes, the patient with DID hears conversations going on in his or her head. The auditory hallucinations of 80% of DID patients are heard as emanating from inside the head, whereas for schizophrenic patients, 80% emanate from outside the person (Kluft, 1999). The voices for DID patients have a different quality from those of psychotic patients: the voices refer to a traumatic event; they are coherent; they often reflect an inner conversation among alternate personalities attempting to influence the identity; and they may be harsh and accusing but also may be comforting and helping (Kluft, 1999). If the psychosis is transient and precipitated by a trigger or crisis, it most likely is not a thought disorder but is a flashback (Putnam, 1989). After the traumatic material is processed, the flashback will not be triggered again, in contrast to a hallucination, which is not affected by trauma processing.

Another particularly important area for assessment includes the presence of distorted cognitive schemas. Trauma affects patients’ ideas about themselves and the world. This is true for adults who are traumatized and especially for children who have suffered interpersonal familial trauma. Due to basic cognitive immaturity and the normal egocentric viewpoint of children, the child who has been traumatized draws the conclusion that something is wrong with him or her. The child needs to preserve the idea that the caretaker is loving, because without an adult to care for the child, he or she would die, which is true for any immature mammal. The resulting negative schemas include self-blame, low self-esteem, trust and abandonment issues, need for control, difficulty setting boundaries, guilt, shame, helplessness, fear and yearning for dependency, and overall overestimation of danger in relationships and in the environment. These schemas persist into adulthood, embedded as a blueprint in the neural networks, and they are firmly entrenched in the person’s way of thinking about himself or herself. Usually, these themes are readily apparent in sessions, but a more formalized assessment is provided by the TABS (see Table 13.3).

Constructing a Timeline

One method for assessing and organizing a trauma history is through constructing a timeline of the person’s life. The APPN begins by explaining to the person that it is important to know both significant positive and

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negative events that have occurred in his or her life. The therapist draws a line on a piece of paper with the point at the beginning of the line, the person’s birthdate. The line is usually marked off in either 1-year or 5- year intervals to the present age depending on the age of the person.

Begin constructing the timeline by asking for factual information of events that occurred during the patient’s early years such as siblings born, changes in schools or homes, early losses such as deaths of parents, grandparents, hospitalizations of self/parent, and so on. Some therapists begin with asking about important positive events/people that have made a significant impact on the person, and these are written above the line. The negative events that are elicited are stated below the line. It is important to structure this process in a way that will not require a great deal of detail about specific traumatic or disturbing events so that the person will not be triggered through the narrative. Once all positive and negative events are delineated on the timeline, the person is asked to rate each negative event on a 0 to 10 scale with 0 being no disturbance and 10 being the worst disturbance one can imagine. A timeline can be completed in one session for some people but often occurs over several sessions for those with more complex histories.

The timeline can also be used to clarify the person’s psychiatric history and include times, dates, dosages of medications, symptoms, hospitalizations, and previous therapy or treatment. The advantage of collecting information in this way is that it creates a roadmap for treatment; is easy to explain to the patient; provides a quick visual for reference for the therapist and the patient as therapy progresses; helps the therapist assess positive memory networks and the presence of resources; promotes therapeutic rapport; and assists the person to form a narrative about their life experiences in a coherent way.

The pattern of events can also suggest the level of psychopathology. For example, if the person had many moves and changes in schools as a child, this may indicate family chaos and early developmental trauma. The timeline is dependent on the person’s ability to remember and those who have suffered significant trauma may have a phobia of traumatic memory. Thus, if there are amnesic gaps in one’s early years and there are no memories until age 20, this may indicate dissociation and significant trauma in one’s childhood (Chu, 2011). It is of note that often all events, not just the abusive events, are forgotten. It is not until the trauma(s) are emotionally processed and remembered, that the person can remember positive events too.

BOX 13.3

PRACTICE GUIDELINES FOR TRAUMA AND DISSOCIATION

Guideline Watch (2009): Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1682793

The VA/Department of Defense Practice Guidelines for PTSD (2010) http://www.healthquality.va.gov/ptsd/cpg_PTSD- FULL-201011612.pdf

Guidelines for Treating Dissociative Identity Disorder in Adults (ISSTD, 2011) http://www.isstd.org/downloads/2011AdultTreatmentGuidelinesSummary.pdf

ISTSS Consensus Treatment Guidelines for Complex PTSD in Adults (Cloitre et al., 2012) http://www.istss.org/AM/Template.cfm? Section=ISTSS_Complex_PTSD_Treatment_Guidelines&Template=/CM/ContentDisplay.cfm&ContentID=5185

EVIDENCE-BASED INTERVENTIONS

Empirical research supports the efficacy of cognitive behavioral therapy (CBT) and EMDR therapy for the treatment of PTSD (Davidson & Parker, 2001; Hembree & Foa, 2000; Rauch & Cahill, 2003). A multidimensional meta-analysis revealed that most patients treated with CBT or EMDR improved significantly (Bradley et al., 2005). Practice guidelines for PTSD include CBT and EMDR as effective first- line treatment modalities (APA, 2009; Department of Veterans Affairs & Department of Defense, 2004; ISSD, 2011; WHO, 2013), whereas other modalities are considered adjuncts to either of these approaches. However, further studies have found that exposure treatment for highly dissociative patients is not effective (Ebner-Priemer et al., 2009; Hagenaars, van Minnen, & Hoogduin, 2010). Box 13.3 provides resources for

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http://www.isstd.org/downloads/2011AdultTreatmentGuidelinesSummary.pdf

http://www.istss.org/AM/Template.cfm?Section=ISTSS_Complex_PTSD_Treatment_Guidelines&Template=/CM/ContentDisplay.cfm&ContentID=5185

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practice guidelines for trauma and dissociation.

COGNITIVE BEHAVIORAL STRATEGIES FOR STABILIZATION

There are many CBT strategies that are helpful for building in resources and stabilization (see Chapter 8). The APPN introduces, teaches, and practices with the patient in sessions. Seeking Safety: A Treatment Manual for PTSD and Substance Abuse by Najavits (2002), The Anxiety and Phobia Workbook by Bourne (2010), and Coping With Trauma-Related Dissociation (Boon, Steele, & van der Hart, 2011) are excellent resources for the APPN to use to assist the patient in developing these skills.

Stress inoculation therapy (SIT) is a type of CBT that emphasizes education, skill building, and application. SIT is also helpful in stabilization. SIT can be particularly helpful for those patients who have phobic avoidance due to trauma. For example, a patient may be fearful about leaving the house because of fear that an accident may occur. The APPN using SIT teaches the patient thought stopping, quieting, and guided self-dialogue and then assists the patient by following the steps outlined in Box 13.4.

Cognitive processing, unlike emotional processing, can be safely done in the stabilization stage (Brand, 2001). Later in stage 2 (processing), more detailed and affective exploration can be done. Cognitive processing may be necessary to keep the person safe because trauma-induced beliefs contribute to safety problems. For example, many patients feel that they are bad and deserve to be punished for their abuse. Resolving or at least modifying the self-hatred and misattribution of blame underlying these beliefs is important before emotional processing, which may destabilize the person. Chapter 8 provides useful CBT strategies to modify this type of thinking, such as guided self-dialogue, thought stopping, cognitive restructuring, Socratic dialogue, labeling of distortions, questioning the evidence, reattribution, decatastrophizing, automatic thought record, and listing of advantages and disadvantages.

BOX 13.4

STEPS IN STRESS INOCULATION

Assess the probability of the feared event Use thought stopping and the quieting reflex Control self-criticism with guided self-dialogue Use role playing and covert modeling Use self-reinforcement for skills

Another important adjunct to treatment is dialectical behavior therapy (DBT), which is discussed in Chapter 14. DBT was specifically developed for patients diagnosed with BPD and has great utility for all those who have difficulty with affect management. An important goal of DBT is to teach patients the skills needed for managing emotions, with mindfulness a key component of the treatment. DBT groups are offered in most major cities, and the therapist can refer a patient to a DBT group and/or use exercises with patients during individual sessions from Skills Training Manual for Borderline Personality Disorder by Linehan (1993a). A group provides the opportunity for the patient to gain valuable insights through support and feedback from others. In tandem with individual psychotherapy, group work is effective in developing affect management skills (Linehan, 1993b).

Group Therapy

Research on group treatment for PTSD is limited, but groups have been used for psychoeducation, cognitive therapy, psychodynamic therapy, supportive therapy, and exposure therapy (Ruzek et al., 2003). See Chapter 11 on group therapy. A review of the research indicates that in the few studies that have been conducted, positive outcomes have been demonstrated (Adúriz, Bluthgen, & Knopfler, 2009; Foa et al., 2000; Layne et

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al., 2001). Group work is considered a useful adjunct to individual CBT or EMDR, and current findings do not support one type of group over another. Group therapy is thought to help the person cope with feelings of isolation, alienation, and anhedonia that are common for patients who have suffered significant trauma.

Body and Energy Work

Although not evidence based, body and energy work are sometimes an important adjunct to trauma treatment. A number of trauma experts advocate using body therapies because trauma memories are stored in the brain and manifested in the body (Heller, 2012; Levine, 1997; Rothchild, 2000; Scaer, 2005; van der Kolk, 2003). van der Kolk reasons that because adults typically process information in a top-down manner from the cortex (thinking brain) to the amygdala (emotional brain), bottom-up therapy from the emotional brain to the thinking brain is important to access trauma memories in a more efficient way (2003). Because psychotherapy is largely a left-brain cortex activity, body therapies are thought to be more likely to be effective and access areas involved where implicit memory is stored (amygdala).

Body and energy work to bring the body back into conscious awareness may be needed if the person has somatic problems. Scaer (2005) says these individuals are parasympathetic dominant and suggests a number of body-based therapies for healing. These include somatic experiencing (SE), as described in Levine’s book, Walking the Tiger (1997), and energy therapies, such as thought field therapy (TFT) and emotional freedom therapy (EFT), which use visual imagery, self-affirmations, and tapping on acupressure points. Movement therapies such as dance and other induced movement techniques, including touch, cranial sacral techniques, and gentle massage, may also be useful. Artistic endeavors such as sculpting, drawing, and painting can tap into right-brain states and may assist the person in replicating the traumatic event in symbolic form. None of these methods is considered a sole evidence-based treatment for trauma. EMDR therapy is the only Level A evidence-based treatment that does have a somatic component. See Chapter 6 for stabilization and resource strategies using EMDR therapy.

Debriefing

Debriefing involves talking about the trauma immediately after the event and is referred to as critical incident, stress debriefing, or some variation of these terms. Although debriefing is sometimes used, the American Psychiatric Association (APA) practice guidelines do not support its efficacy (APA, 2009) and state that debriefing or single session techniques may increase symptoms and are ineffective for those with ASD and do not prevent PTSD. This may, in part, reflect the fact that subjects in these research studies did not choose whether to participate in the debriefing. Perhaps those who choose to participate would be more likely to benefit.

Psychodynamic Psychotherapy

Research on psychodynamic psychotherapy for the treatment of trauma and dissociation is relatively sparse compared with that for CBT or EMDR therapy. Chapter 5 addresses methodological issues in psychodynamic research. The value of using psychodynamic psychotherapy for working with traumatized patients lies in the clinician’s understanding of transference, countertransference, and resistance. Psychodynamic psychotherapy involves the activation of attachment relationships and interpersonal processes, but psychodynamic psychotherapy, unlike CBT, strives to deepen the person’s understanding about how trauma has affected these processes. It may be particularly helpful to use psychodynamic approaches with patients who present with attachment and interpersonal difficulties with less specific memories of the trauma. As the interpersonal difficulties are connected with the trauma, the APPN may shift to more CBT strategies to build coping, distress tolerance, and functional skills. Through constructing a narrative, patients examine the meaning of the trauma experience in their lives. This can be enormously strengthening for the individual. Foa and colleagues (2000) conclude in their comprehensive review of psychodynamic research on trauma that more case studies and large-scale, quantitative research are needed to describe outcomes among different

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populations of survivors.

A FRAMEWORK FOR TREATMENT

Given the complexity of responses to trauma, a framework for using psychotherapeutic interventions needs to address the bewildering symptoms and deficits that result, particularly when there has been severe and prolonged trauma. The treatment hierarchy outlined in Chapter 1 provides the framework for treatment (see Figure 1.6). This is a stage-oriented treatment model consistent with evidence-based models included in practice guidelines for trauma and dissociation (Briere & Scott, 2013; Chu, 2011; McWilliams, 2011). Stage 1, safety and symptom stabilization, involves increasing external and internal resources, and stage 2 aims to process the painful memories so that the person can move toward enhancing future visioning. As trauma is processed, the person begins to expand his or her world from surviving the present to planning for the future. Stage 3 focuses on continued integration, rehabilitation, and personal growth. Educational, social, and vocational life skills may be needed that the person might have missed during aborted developmental periods when traumas occurred. This framework is based on the neuroscience underlying the adaptive information processing (AIP) model.

BEGINNING WITH SAFETY

To begin the healing process, decisions are made where to target interventions based on a comprehensive assessment of the strengths and resources the person already has. Chapter 1 explains Maslow’s hierarchy of needs. Safety is always a priority in the stabilization stage, and crisis intervention may be needed. In general, the more urgent and basic the person’s needs are on Maslow’s hierarchy, the more directive the APPN’s interventions. Physical safety and psychological stability must be ensured before discussing traumatic material. A stabilization checklist, included in Appendix 1.5, records indicators that should for the most part be accomplished in stage 1 before moving to stage 2 processing. This checklist is intended to serve as a guide and not every indicator must be met, but good clinical judgment based on these parameters is essential.

In stage 1 (stabilization), the therapist most often does not seek insight to accomplish therapeutic gains. Confrontation with family or others who deny the trauma is not encouraged. The therapist assists the patient in naming the problem, reframing asking for help as a sign of courage, and helping the person restore control. The APPN focus is on coping, distress tolerance, and stress management skills that build the patient’s resources and self-efficacy while providing a safe structure for the therapeutic frame. As the work of stabilization continues, the therapeutic relationship is strengthened, and trust is developed.

In general, the patient’s resources and the traumas experienced need to be balanced; that is, the greater the level of trauma, more resources may be needed to manage the deleterious effect of trauma on functioning. However, the number of traumas and trauma history do not necessarily dictate the number of resources needed. The person may have a significant history of trauma and many cumulative negative experiences, but this may be offset by the quality and quantity of his or her positive experiences and relationships. Positive experiences are essential so that the person can manage the state changes that are essential in trauma processing (Shapiro, 2012). van der Kolk (2006) agrees and says: “it is important to explore previous experiences of safety and competency and to activate memories of what it feels like to experience pleasure, enjoyment, focus, power and effectiveness, before activating trauma-related sensations and emotions” (p. 289). This speaks to the importance of increasing resources so that adaptive positive networks are present. Some patients may need positive experiences created particularly if they are resource impoverished and have an early history of neglect and trauma.

External resources are enhanced through case management techniques and supportive psychotherapy. Case management requires an active approach on the part of the therapist because the patient may need to be connected to nurturing and caring people and appropriate community resources such as rehabilitation or crisis center, child protection agency, a substance abuse or eating disorder program, or residential, partial hospital, or inpatient treatment. The APPN encourages the person to maintain functioning at work, home, or school and to cultivate and maintain supportive relationships. An excellent resource for case management is Seeking Safety: A Treatment Manual for PTSD and Substance Abuse by Najavits (2002). See Appendix 1.4 for a Treatment and Case Management Form. Crucial to case management is the ability of the

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therapist to set limits, to assess regressive and adaptive shifts in ego functioning, and to recognize conflict to help the person assuage anxiety without emphasizing interpretation.

Of particular concern is providing safety and protecting the person from self-harm. Affect dysregulation is cited as the most frequent reason for self-harm and self-mutilation, and patients often report that self- mutilation is an attempt to self-soothe (Briere & Scott, 2013). The National Comorbidity Study found that PTSD was associated with a sixfold increase in the likelihood of an initial suicide attempt (Kessler et al., 1999). This is higher than that for any other anxiety disorder. Numerous studies have found that childhood abuse is strongly associated with self-injury (Herman, 1992; Stien & Kendall, 2006). Self-injury may take the form of eating disorders, cutting, unsafe sexual practices, driving recklessly, alcohol or substance abuse, violent relationships, and parasuicidal behaviors. These behaviors are thought to be an attempt to self-regulate in that opioids are released.

Chapters 3 and 4 describe assessment for suicide and self-harm. Safety issues must be addressed directly and a plan established if necessary. As Chu (2011) observes, many survivors of childhood abuse are addicted to crisis and feel most alive when out of control. These are sometimes the patients who want to rush into recovering memories before a foundation of safety is established. Such a strategy is doomed to failure as the person cycles through periods of intense emotions that alternate with numbing. Self-care and symptom control are foundational to the work of recovering memories and processing.

An important caveat regarding safety is that if the therapist primarily focuses on self-harm behaviors in the treatment, this may reinforce these behaviors. It is far better to provide minimal attention to self-harm behaviors and focus more on consequences and remediation so that the person is not rewarded with increased attention and therapist concern by being out of control. Identification of triggers for self-harm behaviors and education about other opioid-enhancing activities, such as exercise and self-soothing strategies, are essential to avert these cycles of self-harm. Linehan’s (1993a) Skills Training Manual for Borderline Personality Disorder describes treatment strategies effective for working with parasuicidal behaviors. Please see Chapter 14.

Because comorbid disorders are prevalent, particularly in chronic PTSD, treatment interventions must be prioritized. What does the person need first to function and be safe? For example, many traumatized women suffer from panic attacks that are quite debilitating, and treatment initially may need to focus on how to manage these episodes. Helpful strategies may include psychoeducation, medication, making connections between symptoms and catastrophic self-statements, monitoring the attacks, rating the level of the anxiety, and developing coping strategies for when they occur. Coping strategies include abdominal breathing, muscle relaxation, distraction, and coping statements to counter negative self-talk (Bourne, 2010).

For men who have suffered trauma, the priority may be anger management if aggression and violence are in the foreground initially. Anger management strategies may be necessary to ensure the safety of the patient and others. These methods may include psychoeducation, writing, drawing, painting, making a collage, cost– benefit analysis of anger, self-reflection and awareness of triggers, putting anger into words, distraction and self-soothing strategies, taking a time-out, enhancing the ability to communicate, channeling anger, exercise or physical work, relaxation strategies, and thought-stopping strategies (Boon, Steele, & van der Hart, 2011).

There has been some controversy regarding whether to treat comorbid disorders such as alcohol abuse with PTSD simultaneously or separately. Chu (2011) suggests that the substance use must be treated first, followed by treatment of the trauma. However, Najavits (2002) provides an integrative model so that treatment focuses on both disorders. The thinking is that exposure of the person to traumatic memories will intensify the need to use substances and trigger relapse. Self-medication with substances then may increase the person’s risk to future trauma exposure. Because of the interdependent relationship between substance abuse and trauma, addressing out-of-control behaviors should be a prerequisite for trauma treatment (Briere & Scott, 2013; Chu, 2011). This may entail a longer period of stabilization and eventually processing in small increments so that affect regulation is ensured. In any case, a first goal of treatment for those abusing substances is to reduce the abuse. For alcohol abuse, a 12-step program is usually part of the recommended treatment.

Safety in the Therapeutic Relationship

The importance of safety in the therapeutic relationship cannot be overemphasized. The therapeutic alliance cultivates a healing environment for emotional safety and allows the patient to continue therapy and benefit from treatment. Chapters 3 and 4 provide strategies for building a therapeutic alliance. Early implicit memories are activated in therapy and counterconditioning occurs; that is, the patient experiences fear-

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diminishing emotional states in the context of the therapist’s positive regard, compassion, and caring attention (Briere & Scott, 2013; Chu, 2011). However, traumatized patients may have particular difficulty forming a therapeutic alliance, and trust issues are often fraught with anxiety. Often, these patients have been betrayed by those who were trusted and flee into isolation when faced with painful and overwhelming feelings that occur during therapy.

The term traumatic transference has been coined and refers to the particular transference constellations that form for those who have suffered childhood abuse (ISSD, 2011). Therapy may begin to erode dissociative barriers and defenses, leading to greater intrusion of traumatic memories, and the person may fear loss of control due to increased awareness of disturbing emotions and cognitions. Thus, there may be fear and vulnerability that abuse and/or manipulation may occur as in childhood. The APPN who works with these individuals must be prepared to be the object of the person’s anger and suspicion and he or she may even begin to feel as the patient feels: abused, enmeshed, helpless, and violated.

Even experienced therapists often seek supervision when working with those with complex trauma because transference and countertransference issues may be quite intense. Those who have suffered childhood abuse often have had chaotic relationships with caretakers who were supposed to love and protect them, and being close to others represents a threat, not a comfort. The therapeutic relationship offers a corrective emotional experience through collaborative support and connection. However, Chu (2011) cautions that therapy with those who have been significantly traumatized is not just about taking care of patients and that these individuals cannot be loved into health. Maintaining firm boundaries, setting limits, and explaining the inherent difficulties the person may encounter with trust are essential to promote a safe environment.

Patients with current trauma might have had previous complex traumas from the past that have shaped personality and are entangled with the present. They may need attention and longer-term intervention with cognitive behavior, psychodynamic, and interpersonal psychotherapies. Horowitz (2003) says these patients have themes that revolve around excessive fear of future victimization, enduring and irrational shame over vulnerability or incompetence, unusually intense anger and impulses for revenge, extreme sensitivity to guilt, and low thresholds for despair with an expectation of being abandoned. These themes may have reverberated in the person’s life before the trauma, and through the work in resolving the present symptoms, the person may gain personal strengths and reduce prior personality conflicts.

The person’s ability to tolerate painful affects and his or her strengths, resources, and coping skills are additional areas important to evaluate when targeting interventions. A primary goal of the stabilization stage is to attain self-regulation of internal states of arousal. What coping skills have worked for the person in the past? Often, the coping skills the person used as a child included dissociation, and although this was effective at the time for the child, it interferes significantly with adult functioning. What helps the person to relieve anxiety? After assessing current coping skills, new skills may need to be taught (see Appendix 1.2). Internal resources often need to be increased before processing. Internal resources are less tangible than external resources and include the person’s ability to manage positive and negative emotions (i.e., affect regulation), symptom control, a sense of inner strength (i.e., ego strength), and a belief in himself or herself. Affect management skills can be learned, practiced and, over time, lead to internalization of self-soothing capacities.

MINDFULNESS

Because those who have suffered significant trauma have decreased activation of the prefrontal cortex under stress, strategies such as mindfulness that activate this area are extremely important to enhance control over emotions (van der Kolk, 2006). Mindfulness underlies all stabilization and is an important skill to teach patients needing internal resources. Mindfulness allows patients to become fully aware of their experiences and enables them to respond, rather than just react, to experiences. Jon Kabat-Zinn is credited with popularizing mindfulness and developing evidence-based protocols for use with chronic illness (Kabat-Zinn & Kabat-Zinn, 1990). Both DBT and mindfulness teach the importance of staying grounded in the moment and acceptance of oneself without judgment.

Research supports the efficacy of mindfulness for a wide range of mental health problems (O’Haver Day & Horton-Deutsch, 2004). These authors provide a model for integrating mindfulness-based cognitive therapy into individual psychotherapy using experiential techniques such as sitting meditation, body scan, daily meditation, and developing a breathing space for use in times of stress. An excellent resource for guided meditations that can be incorporated into sessions is Guided Meditations, Explorations, and Healings by Stephen Levine (1991). This book includes the loving kindness meditation and specific readings for addiction,

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pain, overwhelming emotional states, and grief. After using these techniques in sessions, the patient can begin to practice between sessions as a way to cultivate mindfulness at home.

It is helpful if the APPN learns and practices mindfulness first prior to teaching to patients. The teaching is then anchored in real experience, and it helps to protect the APPN from the secondary trauma that can occur from working with traumatized patients and bearing witness to violence or trauma. Professional training is available through workshops, conferences, and certification programs. Information about these workshops can be found through an Internet search on mindfulness-based professional stress-reduction training programs. Box 13.5 lists mindfulness resources and tapes.

Some patients have difficulty understanding the concept of mindfulness and may relate better to the terms focusing or noticing. Focusing on the breath may be a helpful starting point for some patients. Slow, deep breathing may assist the person to stay in the present and prevent further dissociation before attempting more advanced mindfulness techniques. The APPN has most likely taught patients in the hospital to deep breathe with abdominal muscles. This is similar and combined with instructions to notice the breath while staying in the moment and asking patients to place their hands on the abdomen; if done correctly, the hands will rise as breath is inhaled. It is most effective if the APPN does this with the person to illustrate the technique. This should be practiced for 10 minutes daily at a specific time during the day with no distractions. Breathing exercises assist the person in developing mindfulness, which aids in the identification of triggers and in modulating flashbacks. Progressive muscle relaxation may also be helpful and involves clenching and relaxing muscles from head to toe; this exercise is explained in Appendix 13.2. A caveat regarding progressive muscle relaxation is that it can lead to increased arousal and dissociation in a minority of patients. This may be because in the person’s brain a hypervigilant state has essentially served to keep the person safe so that relaxation triggers a physiological state of intense anxiety about being not safe.

BOX 13.5

SELECTED MINDFULNESS RESOURCES

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Mindfulness is helpful for patients in developing dual awareness. Dual awareness means being able to maintain awareness of more than one experience at a time, allowing the person to maintain a sense of the present here and now while experiencing sensations from the past then and there. Modulation through dual awareness is essential so that the person can control the level of hyperarousal and not be overwhelmed. Dual awareness activates the frontal lobes, which mediates arousal of the limbic system. This mechanism is compromised in those who have been severely traumatized in that internal sensations are associated with past events and reality is evaluated based on this restricted information (Siegel, 2010). The past becomes the present, and the person feels as if the event is happening now, with all the attendant hyperarousal that may be retraumatizing. See Box 13.6 for strategies that help to develop dual awareness.

BOX 13.6

DUAL AWARENESS STRATEGIES

Ask the patient to remember a recent mildly distressing event, something where he or she was slightly anxious or embarrassed.

What do you notice in your body? What happens in your muscles? What happens in your gut? How does your breathing change? Does your heart rate increase or decrease? Do you become warmer or colder? Is there any change in temperature? Is it uniform or variable in different parts of your body?

Then bring your awareness back into this room you are in now. Notice the color of the walls, the texture of the rug.

What is the temperature of this room? What do you smell here? Does your breathing change as your focus of awareness changes?

Now try to keep awareness of your present surroundings while you remember that slightly distressing event.

Is it possible for you to maintain awareness of where you are physically as you remember that event? End the exercise with your awareness focused on your current surroundings.

Adapted from Rothchild (2000).

Another useful strategy in developing dual awareness is rating the level of disturbance. In the session, the patient is asked to think of a mildly disturbing event and to rate his or her subjective unit of disturbance (SUD) on a scale of 0 to 10, with 10 being the worst they can imagine feeling and 0 being equal to no disturbance. After the rating is obtained, the therapist does deep breathing or progressive muscle relaxation exercises, or both, with the patient and asks him or her to turn the number lower, repeating this sequence several times. After the patient feels confident in the session, transferring this skill to home can be suggested as a homework exercise.

MANAGING PHYSIOLOGIC AROUSAL

For significantly traumatized patients, especially those with attachment trauma or severe and prolonged trauma, affect dysregulation is chronic, and deficits in arousal are present in the sympathetic nervous system (i.e., hyperarousal) and the parasympathetic nervous system (i.e., dissociation and underarousal). The person may fluctuate rapidly between hyperarousal and hypoarousal with both the patient and the clinician confused about whether the person is in the window of tolerance as depicted in Figure 1.3. There may be a very narrow window of tolerance so that the challenge for the APPN is to widen the window through relationship, safety, mindfulness, dual awareness, creating or strengthening resources, safe place, and stress management exercises. The underdeveloped cortex is unable to modulate and inhibit lower parts of the brain. These physiologic changes occur in the brain and result in an autonomic signature in the body (Schore, 2012). Physiologic

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arousal in general can trigger trauma-related memories and, conversely, trauma-related memories can precipitate generalized physiologic arousal. It is thought that flashbacks and nightmares cause repeated release of stress hormones, which further entrenches the strength of the memory (van der Kolk, 1994). Decreasing emotional arousal is critical so that the person can manage triggers and reduce symptoms. If the level of disturbance is reported as greater than a 7 on the 0-to-10 SUD scale, the person may not have access to their frontal lobes at that moment. At these times, anxiety and arousal are hyperattenuated, and the person may have difficulty assuaging anxiety and calming himself or herself.

A safe place exercise is useful in decreasing autonomic arousal and is included in Appendix 1.7. The safe place exercise can be practiced in the session with the patient and practiced as homework during the following week. Some patients may have difficulty with this exercise, and this response can be diagnostic in that there may not be anywhere that the person feels is or has been experienced as safe. Sometimes, attempting to relax may stimulate hyperarousal, which is counterproductive to the process. Explaining to patients that the safe place can be an imagined place or a place they find relaxing or comfortable rather than safe may be helpful in accessing a calming image. Another way to use the safe place is to ask patients to image a person with whom they feel safe and take the patients through the process of accessing somatic sensations related to being in the presence of someone connected with positive memories. This safe person can be an imagined person or a celebrity. One patient developed an Oprah image next to her as her safe person. Some patients find it helpful to close each session with their safe place or person exercise. With regular practice, the safe place lowers arousal levels, decreases biological reactivity, provides self-soothing, facilitates processing, and assists patients in leaving the session safely and calmly.

Stress management and affect-regulation strategies enhance internal resources so that arousal levels can be decreased. Often, those who have been significantly traumatized are alexithymic and cannot express their internal states. Expressive therapies such as art and movement may be safe ways for those who have difficulty in this area. Chapter 2 provides strategies for how to work with patients who have alexithymia. An important point about resource building is that nothing works for everyone all the time and that some things work better than others for certain patients. Understanding what works for this person at this time is essential, coupled with collaboration, trial and error, practice, and patience. The APPN helps the person develop a repertoire of skills that are readily available. The Weekly Plan for Increasing Resources from Chapter 1 is included in Appendix 1.2, and it is a helpful starting point for stress management so that resources can be identified that can reduce hyperarousal and enhance the person’s sense of mastery. The patient may already be doing some of these techniques, and the APPN should review with the patient which strategies are already in place and then assist the person to choose an activity to focus on and practice the following week.

It is important for the APPN to provide a holding environment through the relationship with the person because it may be a bit daunting to see what is supposed to be done in the Weekly Plan for Increasing Resources when the patient is already feeling overwhelmed. Explain to the patient that the list represents a menu of all suggested strategies and that the focus will be on the one per week that will be most helpful at this time. Some items are more appropriate than others, depending on the person’s problems, current resources, and preference and on the therapist’s level of knowledge and skill in teaching selected techniques. For some patients, it may be preferable to use the blank Weekly Goal Worksheet in Appendix 1.3 and fill in a few activities because the person may be overwhelmed by the use of such a comprehensive list. In any case, the plan can then be revisited later as different strategies may be added that may be more appropriate as therapy progresses.

BOX 13.7

CREATING RESOURCES

Actual positive memories Circle of strength** Internalize a helper (real or pretend) Safe place* Awareness of triggers Rating negative feelings on a 1 to 10 scale Soothing activities Basic self-care Yoga Progressive muscle relaxation****

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Guided imagery* Container* Distancing/dual awareness Grounding Cognitive restructuring*** Meditation/mindfulness Deep breathing

*Included in Chapter 1 Appendices. **Included in Chapter 6 Appendices. ***Included in Chapter 8. ****Included in Chapter 13 Appendices.

Box 13.7 describes selected strategies that facilitate the creation of new resources and strengthening of existing resources. Most of these are included in the Weekly Plan for Increasing Resources. Soothing activities might include smoothing on warm body lotion, taking a shower or bath, taking a long walk, looking at a tank full of fish swimming, looking at the sky, mindfully eating something delicious, gardening, and massaging feet or scalp. Deep breathing, progressive muscle relaxation, meditation, mindfulness, and yoga can also decrease arousal. Practicing these skills and helping the person access audiotapes, CDs, DVDs, videotapes, and books to be used to reinforce resources are important adjuncts to treatment. The patient can keep a daily log of the practice to track progress on the Weekly Plan for Increasing Resources or the Weekly Goal Worksheet.

Managing Flashbacks

Because flashbacks and dissociative periods cannot be reliably predicted, various strategies for when they occur can be helpful. These include identifying the phenomenon as a flashback or dissociative period and grounding techniques. Grounding means bringing the person’s level of awareness to the immediate therapeutic environment by noticing things in the present (Briere & Scott, 2013): rubbing the upholstery on a chair, making sure the room is properly lighted, good eye contact, counting beads, stomping one’s feet, touching an object such as a ring or watch that has been designated a safe object, deep breathing, playing with pets, exercising, taking a shower, holding an ice cube, walking outside, or supportive self-talk. An example of supportive self-talk may be repeatedly saying: “This is old stuff. I am scared right now. My feelings come and go. I am safe now. That was then. This is now. Take a deep breath, exhale long, and slow down.”

After dual awareness and grounding skills are in place, further mindfulness strategies can be taught by asking patients to notice what happens during those times when they dissociate or have flashbacks. What happened before? What were they feeling physically and emotionally? What is the last thing they remember? How did they know they were dissociating? What were they trying to avoid? What else could they do? These types of questions (Haddock, 2001) assist the person in the development of nonjudgmental observation and enhanced awareness so that environmental triggers can be replaced with more adaptive ways of responding. As one patient reported after practicing mindfulness over a few months: “I’m onto myself now.”

When working with the patient, consideration should be given to where the person is in the change process to aim interventions toward behavioral change. Chapter 7 explains the stages of change and appropriate interventions for each stage. If imagery is used that can be helpful in moving toward contemplation, the person may experience dramatic relief through experiencing and expressing feelings about loss and change. However, the APPN should help the person modulate the intensity of the experience by naming the experience, rating the level of disturbance (0–10 scale) but not encourage detailed remembering of the trauma. After the patient has moved into the contemplation stage, the therapist helps the person to focus on the discrepancy between now and the way the person would like things to be. This can be accomplished through exploring questions. “How would you like things to be different in the future?” “What’s keeping you from doing things you want to do?” “How does your current behavior fit into your future goals?”

SLEEP HYGIENE AND MEDICATION

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Hyperarousal often compromises sleep and is discussed in Chapter 2. The nightmares that occur for the traumatized person may reflect the brain’s unsuccessful attempt to integrate traumatic material into procedural memory networks (Scaer, 2005). Because sleep disturbances are common for those who have suffered significant trauma and because they compromise daily functioning, good sleep hygiene, behavioral interventions, and medication may be indicated. Sleep hygiene recommendations include exercising regularly; avoiding napping, nicotine, caffeine, alcohol, and heavy meals 4 to 6 hours before bedtime; maintaining a quiet, cool bedroom and a regular bedtime; using the bed for sleep or sex only; and engaging in relaxing activities before bedtime. Behavioral strategies include progressive muscle relaxation exercises (see Appendix 13.2), paradoxical interventions (see Chapter 4), biofeedback, and CBT strategies (see Chapter 8).

Recommended medications for insomnia include non-benzodiazepines such as trazodone (Desyrel), antihistamines such as hydroxyzine (Vistaril) or diphenhydramine (Benadryl), zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta) (Briere & Scott, 2013; Chu, 2011). If the patient is already on an antidepressant, an antipsychotic, or mood stabilizer, switching from twice a day dosing to bedtime dosing may be helpful. If nightmares are present, prazosin (Minipress) may be considered. Melatonin and melatonin receptor agonists are sometimes helpful. It is important for the APPN to differentiate whether the insomnia is sleep avoidance rather than true insomnia. Medication may exacerbate sleep avoidance, or the patient may not take the medication. If the patient describes true fatigue and drowsiness when he or she goes to bed but becomes agitated or cognitively active, self-soothing and environmental safety strategies may be more effective than sedative hypnotics.

In addition to the affect management and coping skills discussed earlier, medication may be needed to decrease hyperarousal. However, antidepressants should not be offered as a first-line treatment in adults for PTSD and should only be considered if trauma-focused CBT or EMDR therapy have failed or are not available or if there is concurrent moderate … severe depression (WHO, 2013). The selective serotonin reuptake inhibitors (SSRIs) are recommended if medication is needed (Friedman et al., 2009). Only paroxetine (Paxil) and sertraline (Zoloft) have been approved for the treatment of PTSD by the Food and Drug Administration (FDA). These medications ameliorate the symptoms of re-experiencing, avoidance or numbing, and hyperarousal, and they treat the comorbid disorders of depression, social phobia, OCD, and panic disorder that frequently occur with trauma. Naltrexone has been demonstrated to reduce dissociative symptoms and flashbacks in a few studies (Bohus et al., 1999). Selected monoamine oxidase inhibitors (MAOIs) and TCAs have also been found to be effective, but because of the potential side effects and lethality in overdose, they have not been used as much.

Clonazepam (Klonopin) sometimes is used, but benzodiazepines are highly addictive and may interfere with the processing of trauma in psychotherapy. Research has not demonstrated benefit with clonazepam for those with PTSD (Briere & Scott, 2013). However, clonazepam is less likely to contribute to dependency than other benzodiazepines because it is a long-acting drug (half-life of 18–50 hours). Clonazepam is often used in the initial trial of an SSRI if needed to ameliorate anxiety until reaching the full effects of the drug. When clonazepam is used, the APPN should inform the patient of the intended use while waiting for the SSRI to take effect and to take the clonazepam daily, not just as needed. If taken only on an as-needed basis, clonazepam becomes an operant conditioning factor, which contributes to a sense of powerlessness and dependency.

For patients who have only a partial response, augmentation may be indicated. Friedman (2003) says: “Excessively aroused, hyperreactive, or dissociating patients might be helped by augmentation with an antiadrenergic agent; labile, impulsive, and/or aggressive patients might benefit from augmentation with an anticonvulsant; and fearful, hypervigilant, paranoid, and psychotic patients might benefit from an atypical antipsychotic” (p. 72). Because of the metabolic side effects of typical and even some atypical antipsychotics, these medications should not be used unless tolerance to benzodiazepines has developed. Risperidone (Risperdal) or quetiapine (Seroquel) in low doses is recommended if the person is having panic attacks or is having difficulty functioning due to anxiety (Chu, 2011).

A number of concerns when prescribing for trauma survivors have been identified, which include problems with compliance, increased anxiety, interference with memory processing, substance abuse, distrust of authority, and fear of overmedication (Briere & Scott, 2013). It should also be kept in mind that research has found that medications do not cure PTSD. One recent study found that at 5-month follow-up after treatment, 60% of those on medication and 58% of those who received placebo still had PTSD while only 20% of those who received psychotherapy still had PTSD (Shalev et al., 2012). Given that medications have side effects and are only slightly more effective than placebo, caution should be used before prescribing. Initial doses of medication can increase anxiety at the beginning of treatment and panic attacks can occur. In addition, because the person may have memory problems, distractibility, arousal, dissociation,

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trust issues, and may rely on their hypervigilance to keep them safe, compliance issues are common. Recommendations for prescribers and therapists that may help to ameliorate compliance issues include:

A follow-up appointment within a week of starting a new medication Cultivating trust to counter the patient’s reluctance to take medications Titrate dose slowly to decrease side effects Educate thoroughly regarding side effects so that there are no surprises Consideration of abuse potential Document informed consent for medication Assuage concerns about overmedication because the patient may fear/he or she may be less responsive to danger if on medication (Briere & Scott, 2013)

Medication is an adjunct to treatment and does nothing to assuage the guilt, grief, and interpersonal difficulties that trauma patients suffer, but it is helpful in providing symptom relief and may discourage the person from leaving treatment prematurely and increase compliance. Medication does not directly promote new learning or processing, but if the person’s anxiety level is decreased with medication, he or she may be more amenable to learning. Symptom reduction is enhanced and lasts longer with psychotherapy than with psychopharmacologic interventions alone (Briere & Scott, 2013; van der Kolk et al., 2007). In a review of the research for psychotherapy and psychopharmacology, the amount of symptom reduction from psychotherapy was considerably larger than that found for pharmacological interventions (Friedman et al., 2009).

FRASER TABLE TECHNIQUE

When working with those with DDs, it is important to be able to work with different alters or ego states; that is, different EPs of the personality. This can be accomplished through an ego state technique called the Fraser table technique (1991), which is a useful adjunct to psychotherapy. Even if the person does not have distinct alters, the use of this technique can be very helpful for those with complex trauma. Because this technique can seem strange, a solid therapeutic alliance is a prerequisite for its use. Originally used with hypnotic induction, it can be used as an imagery exercise without any formal induction. However, Fraser offers two caveats with the use of the table technique. First, the therapist should be knowledgeable about DDs or in supervision with someone who is and, second, there needs to be a plan for follow-up once used as it can open up dissociative barriers that may be destabilizing without the proper resources in place.

There are at least six steps depending on the person and the extent of the dissociation. Step 1 involves educating the person about the technique and normalizing the idea that we all have different states of ourselves that we are unaware of most of the time. For example, we may be one way at work, another way with a friend, or another way in our role as mom. All our different ages and states are still within us and this imagery exercise is a way to deepen our knowledge of these states. Step 2 involves an imagery using a safe place to access relaxation in preparation for the table imagery. See Appendix 1.7 for the safe place exercise. Step 3 involves leading the person through the table imagery to access the table; step 4 involves identifying those who come to the table with a full description of each; step 5 is communicating with the different states with various strategies delineated about how to accomplish this.

Communicating and working with the different states may involve using both stabilization and processing strategies for each state depending on the needs of that particular state. For example, one young woman who had significant attachment trauma identified a young part who was 4 years old that was sad and scared. This part needed resources to enhance attachment and subsequently attachment imagery exercises were used in many sessions that were very helpful in repairing attachment trauma (Steele, 2007). Therapists have developed a number of creative ways to use this technique (Martin, 2012).

The final step is the fusion or integration of the different parts. The latter may not be necessary for those who do not have DID. It may be sufficient to develop an awareness of the different states and build in resources for those states that need stabilization and/or remediation. A full description and a script for each step of this strategy is available at https://scholarsbank.uoregon.edu/jspui/bitstream/1794/1467/4/Diss_4_4_7_OCR_rev.pdf.

PSYCHOEDUCATION

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Psychoeducation is a key component to be integrated throughout all stages. It involves helping the person to understand that many current difficulties he or she is experiencing are adaptive responses to overwhelming events. The APPN may need to repeat intermittently throughout therapy that the person is not bad or crazy and that he or she is not responsible for what happened. In the case of childhood abuse, the patient’s emotional denial of the reality of the abuse maintains a bond with the idealized caretaker and has most likely been an organizing force in the person’s life (i.e., “I was hurt because I was bad”). This idea may be so entrenched that even when patients seemingly agree or intellectually know that they are not responsible, guilt and shame remain pervasive. These patients’ faulty assumptions about themselves and others have permeated and colored all aspects of their life. Intense attachment to the abuser protects the illusion of the child as safe. To acknowledge the reality would be admitting to an even greater horror, which is too anxiety provoking to face, that the people who were supposed to love and protect them did not. Recognizing that their parent(s) are selfish, cruel, and/or insane would mean abandonment and annihilation. The child achieves a measure of control and power through denial because if the child believes that he or she is being mistreated because he or she is bad, then the idealized parent is preserved and it is the child’s fault, which allows the child the illusion of control.

Education about trauma and how the fear response develops and information about sympathetic nervous system arousal, depressive symptoms, panic, and an overview of trauma treatment are relevant according to the person’s ability to understand and take in this information. Stress management techniques and specific strategies to use as resources are important areas to cover. Other important psychoeducational dimensions of trauma, which should be discussed, include reframing symptoms of flashbacks; avoidance, activated memories, and emotional numbing; prevalence of trauma; and safety plans, if necessary. Box 13.8 provides websites that offer educational material on trauma for patients and therapists.

Education about the psychotherapeutic process continues throughout all stages of treatment. Consciously experienced anxiety often occurs before or during symptom amelioration. It is important to explain to the patient that as positive changes occur, they may be followed temporarily by increased sadness, anger, or anxiety because change, even a positive change, may be experienced as a loss. The APPN keeps this in mind because the person may appear to be doing worse after significant gains. It is essential for the overall plan to be kept in mind with the therapeutic aims and gains in the foreground and to convey hope so that progress can continue.

BOX 13.8

EDUCATIONAL INFORMATION FOR CLIENT

International Society for Traumatic Stress Studies: http://www.istss.org/resources/index.htm

Office for Victims of Crime: U.S. Dept. of Justice: http://www.ojp.usdoj.gov/ovc/help/welcome.xhtml

David Baldwin’s Trauma Information Pages: http://www.trauma-pages.com/support.php

The following example illustrates the use of education during the initial stage of treatment of a patient with DID. Dr. K, a 48-year-old university professor, came to treatment because she was becoming increasingly anxious about her partner, whom she suspected was having an affair. Dr. K described her memory as like “Swiss cheese” and said that she wanted to make sense of things and find out who she was. During the first several months of therapy, the sessions were fragmented and confusing, with the patient reporting strange sensations and images that came to her at seemingly random times. For example, she reported that when riding in a limousine to the airport, she became sexually aroused for no apparent reason and began to masturbate. In another instance, she recounted seeing dark figures in her bedroom at night. On questioning, Dr. K knew these images were not real but said she often had images come to her. She had been in therapy previously and remembered then that she had been sexually abused by her grandparents when she was a child. The therapist explained to Dr. K that her brain was trying to make sense of what had happened to her in the

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past and process those events. By not remembering, she had been able to distance herself from what had happened at the time of the trauma, and this was adaptive for her, allowing her to survive. She had functioned well, earning her doctorate, working as an academic, having friends, and creating a life for herself. These images and sensations were most likely flashbacks that may signal that she is ready to deal with the trauma that previously was completely dissociated. In other words, a flashback is an attempt by the brain to process what happened, but it is not quite successful. It is only a fragment of the memory and disconnected from other dimensions (i.e., memory networks) and the context of the original experience. These images and sensations are triggered by present circumstances and sensations.

The APPN then asked Dr. K to notice when she had strange images or sensations that did not seem to fit the situation and explained that together in sessions, the trigger for these events would be examined. She subsequently linked the sexual arousal in the limousine to being in the back seat of the car when she was driven by her grandfather to a place where she was sexually abused. Many patients are disturbed by linking sexual arousal with the abuse because the patient then assumes culpability for the sexual abuse. The therapist explained to Dr. K that sexual arousal naturally occurs when the genitals are touched and that this does not mean that it was her fault but only a normal physiologic reaction to stimulation. The APPN reiterated: “Together we will deepen our understanding of how the trauma from your past affects you now. You are safe here.” This was immensely reassuring to Dr. K, who thought she was “crazy.” This illustrates how educating the patient about trauma in light of the person’s experiences advances the therapeutic relationship and is integral to trauma treatment.

CASE EXAMPLE

Ms. H, an attractive, petite, 42-year-old, full-time housewife, came to psychotherapy initially for severe bulimia, vomiting as many as 40 times each day for the past year. She had previously been diagnosed with PTSD, anorexia nervosa, DDNOS, dependent personality disorder, panic anxiety, major depressive disorder, and polysubstance dependence. In the past, Ms. H self- medicated with alcohol, Vicodin, Xanax, and OxyContin. The Vicodin and OxyContin were taken to relieve her long-standing severe back pain. She was hospitalized twice for polysubstance abuse, and medications taken after hospitalization included Paxil (60 mg each day) and Depakote (250 mg twice daily). Ms. H was physically and emotionally abused as a child by a sadistic father and a neglectful, narcissistic mother. At intake, in addition to the bulimia, she reported depressive symptoms, trouble concentrating, anxiety, and periods of depersonalization and feeling dizzy and confused. She forgot periods of time, for example, she found herself in the grocery store and could not remember how she got there. This occurred particularly when she was stressed and anxious. She denied self-harm and suicide ideation. She had been married for 22 years and reported long-standing marital difficulties.

The history of childhood trauma and her tumultuous psychiatric history indicated that a long period of stabilization most likely would be needed. The APPN worked with Ms. H once a week initially and, after several months, began twice-weekly psychotherapy, which continued over the next 5 years. Within 6 months of beginning treatment, her bulimia subsided. Much of the content of beginning sessions focused on the abuse she suffered from her husband, which was ongoing and included emotional, sexual, and physical abuse. Ms. H initially appeared frightened and confused, especially when asked about her feelings. The therapist supported and validated Ms. H and told her that she was being abused as she vacillated between thinking that she deserved such punishment to feeling anger at her husband. She had idealized her husband, and as she began to see him more realistically, she also began to see herself in a different light, and her self-esteem increased. She began to assert herself more, and her marital relationship further deteriorated because her abusive husband was enraged that he was losing control of her. Plans for her safety were made, and 2 years after starting therapy, she filed for divorce and moved out of their house. This represented a significant turning point because stabilization was not possible previously as long as she was not safe. Her medication was changed to 20 mg of Prozac, and she found a full-time job shortly after the divorce. Over the course of treatment, various stabilization strategies were gradually integrated, which included safe place, container, circle of strength, rating negative feelings, basic self-care, yoga, progressive muscle relaxation, journaling, grounding, cognitive restructuring, walking, deep breathing, in addition to other

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soothing activities. All were new to Ms. H; she had never practiced any of these before therapy. Through mindfulness, Ms. H learned to manage her dissociative symptoms, and these

periods decreased dramatically as she was able to stay in the present, understand the triggers, and talk about some of her traumatic experiences. Her back pain all but disappeared as she became aware that the triggers for these episodes were linked to feelings of anger. Her identification of her feelings in the present, the ability to experience these feelings, and understanding the meaning of her symptoms were crucial to her development of affect-regulation skills. Along with the deepening of her identity apart from her husband, her sense of humor and keen intelligence emerged. Some of her early childhood trauma was processed with EMDR therapy, but much of the work in psychotherapy focused on increasing resources, psychoeducation, and support, with the therapist bearing witness to her struggle and courage. Her healing reflected the return and expansion of her full consciousness through the integration of adaptive memory networks with dissociated neural networks. This was accomplished by creating positive experiences through the therapeutic relationship, learning and practicing specific resources, and weaving a narrative that connected her old and new memory experiences into a coherent tapestry reflecting a stronger, more resilient sense of self.

POSTMASTER’S TRAUMA TRAINING AND CERTIFICATION REQUIREMENTS

The APPN who wishes to attain competency treating traumatized patients should pursue additional training and ongoing supervision. Working with dissociative patients requires a high level of clinical expertise to do so successfully. The International Society for the Study of Dissociation (ISSD) offers postmaster’s training in the treatment of DDs but not certification. The program consists of nine monthly or biweekly sessions of 2.5 hours, which are held in many major cities listed on the website (www.issd.org). The sessions are designed to focus on readings and clinical situations. A distance- learning module is also available, along with advanced coursework.

CONCLUDING COMMENTS

Stabilization and safety are always the first order of business for any psychotherapy. This ensures that the processing needed to integrate the dissociated memory networks will not destabilize the patient. Enhancing resources ensures that positive adaptive memory networks exist for the eventual linking of dysfunctional material so that integration can occur. Strategies for stabilization are basic tools that all APPNs need to know to work with patients who present for psychotherapy. These skills build on the stress management techniques that registered nurses are familiar with. This foundation is deepened by understanding how and when to tailor specific stabilization strategies. Competency in stage 1 (stabilization) reflects the beginning-level skills needed for APPN practice.

There is a wide spectrum of trauma responses, and stabilization is needed before processing trauma. The limiting diagnosis of PTSD does not capture the complexity of traumatic experiences and their sequelae. Neurophysiologic research demonstrates the importance of even subtle negative life events on the developing brain when a state of helplessness occurs (see Chapter 2). The physiologic changes that occur and the perpetuation of those changes over time are determined by the meaning of life events in relation to past trauma (Scaer, 2005). The learned associated responses embedded in memory networks are modified in the safety of the therapeutic relationship. Managing arousal and altering procedural memories begin the work of healing trauma.

The patients of severe childhood trauma are chronically disenfranchised and re-create betrayal and abandonment scenarios wherever they go, especially in the psychotherapeutic relationship as early attachment schemas are reactivated. Most complex child-onset trauma requires painstaking work as resources are increased and a narrative is woven about the nuances of the meaning of the events as the trauma is processed. Individuals who are survivors of childhood abuse present treatment challenges and the complexity and severity of symptoms can seem insurmountable to even the most experienced psychotherapist. However, healing occurs in this relationship with patience, caring, and skill. Novice

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APPN psychotherapists who continue to train and obtain supervision to develop skill in trauma treatment will be richly rewarded in their work. The APPN’s presence bears witness with empathic resonance, creating the atmosphere needed for the most vulnerable of patients to be whole again. Those of us who work with this population marvel at the remarkable capacity for endurance, compassion, depth of character, and resilience of the human spirit. The honor of assisting in the growth of another person changes the patient and the therapist. In the healing journey with another, we heal ourselves.

DISCUSSION EXERCISES

1. Discuss the spectrum of trauma-related diagnoses with respect to specific symptoms that overlap. Use the DSM-5, and explain how you would develop a differential diagnosis.

2. Identify goals of treatment for trauma. 3. What happens physiologically during dissociation, and what would you observe in the

patient who dissociated during a session? 4. Fill out the DES, which is included in Chapter 4, on yourself and score it. Keep track

with a log of all the times you notice yourself dissociating over the course of the next week.

5. How would you know whether a person was stabilized and ready to go on to processing? 6. Discuss why a person who has been traumatized as a child most likely has pervasive

feelings of guilt. 7. Develop a comprehensive plan of all the potential issues and strategies that you need to

teach a patient who has flashbacks. 8. Explain why mindfulness underlies all stabilization, why you should develop this skill,

and how you plan to do so. 9. Practice the progressive muscle relaxation exercise and the safe place exercise in

Appendices 13.2 and 1.7 with a friend or family member. Ask for feedback so that you can improve.

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Overcoming trauma-related phobias. Journal of Trauma & Dissociation, 6(3), 11–53. Steinberg, J. (1994). Structured clinical interview for DSM-IV dissociative disorders. Washington, DC: American Psychiatric Press. Steinberg, M., & Schnall, M. (2000). The stranger in the mirror. New York, NY: Cliff Street. Stien, P., & Kendall, J. (2006). Psychological trauma and the developing brain. New York, NY: Hawthorne Press van der Kolk, B. (1994). The body keeps the score: Memory and the evolving psychobiology of posttraumatic stress. Harvard Review

of Psychiatry, 1(5), 253–265. van der Kolk, B. (2003). Posttraumatic stress disorder and the nature of trauma. In M. Solomon & D. Siegel (Eds.), Healing trauma.

New York, NY: W.W. Norton & Co. van der Kolk, B. (2006). Clinical implications of neuroscience research in PTSD. Annals of New York Academy of Sciences, 1071, 277–

293. van der Kolk, B., & Pelcovitz, D. (1999). Clinical applications of the structured interview for disorders of extreme stress (SIDES).

NC-PTSD Clinical Quarterly, 8(2), 1052–7168. van der Kolk, B., Spinazzola, J., Blaustein, M., Hopper, J., Hopper, E., Korn, D., & Simpson, W. (2007). A randomized clinical

trial of EMDR, fluoxetine and pill placebo in the treatment of PTSD: Treatment effects and long-term maintenance. Journal of Clinical Psychiatry, 68, 37–46.

Weiss, D., & Marmar, C. (1997). The impact of event scale–Revised. In J. Wilson & T. Keane (Eds.), Assessing psychological trauma and PTSD. New York, NY: Guilford Press.

World Health Organization (WHO). (2013). WHO guidelines on conditions specifically related to stress. Retrieved from http://www.who.int/mental_health/emergencies/stress_guidelines/en/index.xhtml

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http://dx.doi.org/10.1891/1933–3196.6.4.179

http://www.childtrauma.org/Memories.htm

http://www.rossinst.com/sample_forms.xhtml

http://www.april-steele.ca

http://www.nicabm.com/traumatherapy

http://www.who.int/mental_health/emergencies/stress_guidelines/en/index.xhtml

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SPRINT 05-30-13

ID number or initials Date:________________________________________

Short PTSD Rating Interview (SPRINT)

Please identify the most distressing traumatic event:

Copyright all Versions and Translations of the Scale © —Jonathan R. T. Davidson, 2000, 2011, 2013. All rights reserved. The scale may not be reproduced or transmitted in any form, or by any means, electronic or mechanical, including photocopying or information storage system, without permission in writing from Dr. Davidson, who can be contacted at [email protected].

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mailto:[email protected]

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Progressive Muscle Relaxation

This exercise can be practiced with the client during the session and it is often helpful if the APPN audiotapes a copy for the client to listen to at home. If done properly, it may take 20 to 30 minutes. Begin with explaining that this is a relaxation exercise that will help to decrease physical tension and enhance the ability to identify where tension is stored in the body.

What you’ll be doing is alternately tensing and relaxing specific groups of muscles. After tension, a muscle will be more relaxed than prior to the tensing. Concentrate on the feel of the muscles, specifically the contrast between tension and relaxation. In time, you will recognize tension in any specific muscle and be able to reduce that tension.

Don’t tense muscles other than the specific group at each step. Breathe slowly and evenly and think only about the tension–relaxation contrast. Each tensing is for 10 seconds; each relaxing is for 10 or 15 seconds. Count “1,000 2,000 …” until you have a feel for the time span. Note that each step is really two steps—one cycle of tension–relaxation for each set of opposing muscles.

Please get in a comfortable as possible position and take a deep breath; let it out slowly. Again a nice slow deep breath … take as deep a breath as possible—and then take a little more; let it out and breathe normally for 15 seconds. Let all the breath in your lungs out—and then a little more; inhale and breathe normally for 15 seconds.

Begin with your muscles in your feet and your calves; tighten and pull your toes up while tensing each foot as tight as you can … hold that and just notice as you tense for 10 seconds … then relax your feet and next tense your calves … squeeze your calves as tight as you can … for 10 seconds 1…2…3…4…5…6…7…8…9…10… just notice and relax …

Next tense your thigh muscles 1…2…3…4…5…6…7…8…9…10… hold … just notice then relax …

Next tense the butt tightly and raise pelvis slightly off chair; relax. Dig buttocks into chair 1…2…3…4…5… 6…7…8…9…10… just notice then relax…

Pull in the stomach as far as possible … push out the stomach or tense it as if you were preparing for a punch in the gut … 1…2…3…4…5…6…7…8…9…10… just notice then relax.

Now tense your chest as tight as you can … 1…2…3…4…5…6…7…8…9…10 good, just tense then relax…

Continue to breathe deeply as you pull your shoulders back … 1…2…3…4…5…6…7…8… 9…10… relax. Push the shoulders forward (hunch) 1…2…3…4…5…6…7…8…9…10 just notice and relax…

Now flex your biceps 1…2…3…4…5…6…7…8…9…10 relax, take a deep breath … now tense your whole arm 1…2…3…4…5…6…7…8…9…10… and just notice as you relax … next flex squeeze your hands and fingers tight 1…2…3…4…5…6…7…8…9…10 and as you relax, take a deep breath.

With the shoulders straight and relaxed, the head is turned slowly to the right, as far as you can; relax. Turn to the left; relax.

Dig your chin into your chest …1…2…3…4…5…6…7…8…9…10… relax … exhale nice deep breath…

Now your face, scrunch your face up as tight as you can 1…2…3…4…5…6…7…8…9…10… and as you relax take a deep breath letting all the air out.

Dig your tongue into the roof of your mouth … 1…2…3…4…5…6…7…8…9…10 and relax. Dig it into the

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bottom of your mouth 1…2…3…4…5…6…7…8…9…10 and relax.

Open your eyes as wide as possible (furrow your brow) 1…2…3…4…5…6…7…8…9…10 and relax. Close your eyes tightly (squint) 1…2…3…4…5…6…7…8…9…10 relax.

Now just continue to breathe deeply and blow all the air out for a while.

These exercises will not eliminate tension, but when it arises, you will know it immediately, and you will be able to “tense–relax” it away or even simply wish it away.

Please note that an exercise program of any sort that stresses and stretches a full range of muscles can be used in this fashion if only you pay attention to the differences between tensions and relaxations of the muscles. Do the entire sequence once a day if you can, until you feel you are able to control your muscle tensions. This can also be combined with soothing music.

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Dialectical Behavior Therapy for Complex Trauma BARBARA J. LIMANDRI

ialectical behavior therapy (DBT), first conceived by Marsha Linehan as a cognitive behavior based approach to treat those with chronic suicidal thoughts and diagnosed with borderline personality

disorder, is highly relevant to treatment of those with complex trauma (Linehan, 1993a). Although not everyone with borderline personality disorder has comorbid posttraumatic stress disorder (PTSD), and not everyone with PTSD can be diagnosed with borderline personality disorder, there are important overlapping symptoms and neurophysiologic correlates that they have in common. Some even believe that there is continuity in the two disorders that would be easier to accept clinically if there were not such a strong stigmatizing bias against borderline personality disorder diagnosis. Chu (2011) points out that the behavior and emotional response of one with borderline personality disorder can best be understood as reenactments of early abusive relationships, especially as one anticipates how others will behave. Key elements of borderline personality disorder related to PTSD include emotional reactivity and sensitivity (hyperarousal), history of invalidation (common in childhood abuse and sexual abuse), dissociation (intrusive symptoms and flashbacks), and affective instability (negative mood and thought changes). As noted in Chapter 13, the person with borderline personality disorder may equally or better be diagnosed with complex PTSD/disorder of extreme distress not otherwise specified (DESNOS).

This chapter discusses the use of DBT with particular focus on utility and effectiveness in treating those with complex trauma histories. This includes an overview of DBT, including the research evidence to support DBT and its application to complex trauma, discussion of the interchange between trauma and borderline personality disorder, especially in relation to the consequences of trauma to the developing person, and the comorbidity of PTSD, personality disorder, depression, and substance use. The major focus of this chapter is evidence-based treatment approaches that are effective in treating complex trauma with emphasis on cognitive behavior, dialectical behavior, and exposure therapies that the advanced practice nurse would use in thoughtful treatment planning. Separating these three psychotherapy approaches is artificial because they are contiguous as will be evident later in this chapter. Although pharmacotherapy is an essential element of treatment, these strategies are adjunctive to psychotherapy and the reader would be better served to consult more specific psychopharmacotherapy references. The advanced practice registered nurse (APRN) who wants to use DBT for treatment should seek a trained DBT therapist as a mentor and be trained in the model both at a basic level and eventually through an intensive training program. At the end of this chapter are resources for the APRN to consider in getting appropriate training.

DIALECTICAL BEHAVIOR THERAPY

DBT may be described most simplistically as cognitive behavioral therapy (CBT) within a Zen Buddhist worldview. Dialectics refers to allowing the polarity of thesis (proposition or position) and antithesis (opposing perspective or position) to coexist and permitting a center position of synthesis, that is, instead of “this (thesis) or that (antithesis)” the truth is “this and that.” The synthesis is a creative middle ground in which the conflict becomes a solution. The fundamental dialectic in DBT is that of change and acceptance. For example, the client may profess that her life is one of misery and fear to such an extent that she can only see suicide as a solution. However, changing her behavior to step outside of her comfort zone and experience new relationships or a different job further invites fear. The therapist’s role is to guide the client toward an alternative position (synthesis) of accepting her fear and pain as a motivating element to change her situation. The process of using dialectics in therapy is through “persuasive dialogue” (Linehan, 1993a) in which the therapist gradually invites the client to new ways of viewing situations, thereby guiding the client to develop more skills in achieving a greater quality of life. Frequently this is done through Socratic questioning that encourages the client to analyze her thoughts, feelings, and behaviors in a nonjudgmental manner.

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Basic to DBT are functions and modes of comprehensive treatment. The functions of treatment are (Dimeff, 2007):

1. Enhancing clients’ capabilities 2. Motivating clients to use and expand their capabilities 3. Ensuring that clients can generalize their capabilities beyond the therapeutic relationship 4. Enhancing the therapist’s skills and motivations 5. Structuring the environment for both the therapist and the client to aid therapeutic progress

To achieve these functions, a DBT program has four essential elements:

1. Weekly individual therapy sessions for the client of about 1 hour each 2. Weekly group skills training sessions for the client of 2.5 hours each 3. Skills coaching via telephone or other electronic means as needed by the client to manage in vivo situations 4. Team consultation to the therapist to maintain treatment fidelity and adherence

The research basis of DBT is based on faithful adherence to the functions and modes, even though this may not always be possible in different clinical situations and settings. When full fidelity is not possible, the clinician needs to be thoughtful about how best to adapt the treatment in keeping with the evidence and theory (Dimeff, 2007).

Assumptions About Clients and Treatment

There are some basic assumptions underlying DBT that were originally directed toward the client with borderline personality disorder (Linehan, 1993a). These assumptions, however, apply more broadly to the client who is struggling with emotional sensitivity, interpersonal crises, behavioral instability, and heightened vulnerability. When the APRN explains these assumptions to the client and regularly revisits them both within the therapeutic relationship and in therapy consultation, treatment stays focused and authentic. Commonly in full DBT programs, the consultation team reviews these assumptions in part or as a whole each week. They include:

Clients are doing the best they can at any given moment. Clients are more familiar with being invalidated and told they are not doing their best, are failing at whatever they are striving to do, or that they just are not trying.

Clients want to improve. Even when clients are exasperating and stalling in their efforts, they keep their appointments, demonstrating their desire to improve.

Clients need to do better, try harder, and be more motivated to change. This is a corollary to the first assumption. Getting better is work, hard work, and worth the effort. When the effort does not seem fruitful, the therapist needs to analyze with the client what is interfering with therapy in a nonjudgmental, problem-solving manner.

Clients may not have caused all of their problems, but they have to solve them anyway. This is especially true with the client who has experienced trauma. What happened is in the past and the client is struggling with behaviors that were adaptive at the time; however, those same behaviors may be holding the client back now. Blaming the past maintains impotency in the client, and the therapist provides the skills training and coaching for the client to make the necessary changes for a worthwhile life.

The lives of clients are unbearable as they are currently being lived. That is, the therapist must validate the client’s distress and accept that misery while also recognizing the only solution is to make a change.

The client must learn new behaviors in all relevant contexts. In the short term, hospitalization may seem the most appropriate way of handling suicidal ideation; however, to the chronically suicidal person hospitalization reinforces the status quo and abdicating the hard work of change. Instead, the therapist coaches the client to practice skills that are more effective, albeit more difficult to use when distressed. Crisis is the peak of the learning moment and requires immense courage and effort for the therapist and client to work together.

Clients cannot fail in therapy. This is one of the most difficult assumptions for both the client and the therapist. When clients stall in treatment, drop out of therapy, or even get worse, the therapy and therapist have failed. Of course, it is tempting to believe that the client does not want to get better or does not have

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the capability to improve when clients do not get better. But such assumptions provide no direction for either the therapist or the client. Instead the therapist needs to enhance the client’s engagement and commitment to treatment and re-examine the hypotheses of the treatment plan.

Therapists treating the difficult client need support. Consultation to the therapist is necessary in DBT to support the therapist and prevent burnout. The consultation group serves to treat the therapist by using the same skills that we ask the client to use. In a weekly consultation group, the team prioritizes the needs of therapists, mindfully engages in discussing the effects of what we are doing, and advocates for each person to take care of self. When discussion shifts to clinical issues and case conferencing, it is the responsibility of each team member to address the avoidance of consultation to the therapist. When the therapist who is in solo practice tries to implement DBT without a consultation group, there is no sounding board for the therapist to find synthesis in one’s work or to mediate over extension or burnout.

To practice within these assumptions, it helps for the APRN to consider the dialectics of the therapist, that is, the balancing skills and attitudes of providing treatment. Figure 14.1 illustrates the characteristics of the DBT therapist (Linehan, 1993a) in terms of the values of the therapist. To prevent passive acceptance of these characteristics, the authentic therapist needs to be confronting these balancing points constantly in providing care for the client. Again the consultation to the therapist provides an opportunity to confront conflicts in self-beliefs and practices. At times the team member may need to act as devil’s advocate in challenging the therapist’s therapeutic stance with a client. Is the APRN seeing the client as fragile, therefore, undermining the client’s capabilities? Is the APRN’s unwavering centeredness preventing him or her from being compassionate toward the client in finding a different solution to problematic behaviors? Sometimes the team may need to recommend the therapist take a break from therapy and ask a colleague to monitor the pager over the weekend or to fill in for the therapist in a skills group as the therapist takes the time to replenish personal reserves.

FIGURE 14.1 Characteristics of the DBT therapist. Adapted from Linehan (1993a).

Principles of Practice

Within the DBT model the therapist orients the client to some basic principles that guide the treatment. An important principle is that of giving the treatment time to work. DBT is designed to teach skills and encourage regularly practicing those skills to live life more fully. For clients who have had devastating experiences that have misshapen their lives, the least amount of time for DBT to be effective is 1 year. That includes at least 6 months of learning skills with necessary redundancy to practice them in different circumstances, then another 6 months of using the skills in daily living while analyzing how to improve on their effectiveness. Commonly the first 2 to 3 months of treatment may be stormy for the client and therapist as the client tests the limits of treatment and challenges the assumptions. After completing a full program many clients choose to continue additional peer group meetings to prepare them for living without therapy as a constant in their life. This group has a therapist who serves as a consultant to the group as needed. Not everyone chooses to participate in accepting the challenges of exiting the system (ACES) and sometimes ACES is countertherapeutic in that it serves as a way for the client to remain dependent on therapy or forestall venturing forth on her own. Some clients may terminate from DBT and seek continuing supportive

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psychotherapy. There are some ground rules for ensuring the likelihood of success in treatment, the most basic of which

is that the client must attend the individual and group skills sessions consistently. If the client misses more than three or four (depending on the ground rule the therapist/treatment team sets) consecutive sessions of any kind (individual therapy, group therapy, and pharmacological monitoring), treatment must end. Usually this means a therapy hiatus of an established period in which the client can reconsider his or her commitment to therapy. With such a rule stated in the beginning of therapy the client has control over his or her commitment. When the client misses two sessions in a row, the therapist sets a priority to examine the therapy interfering behavior, identify vulnerability features, and arrive at some solutions to the problem. However, if the client continues to miss the next session, it is essential that the therapist notify the client of the unilateral termination and the conditions in which the client is welcome to return to treatment, including a plan while on hiatus to improve commitment. To do otherwise would be reinforcing therapy interfering behavior on the part of the client and in turn would be therapy interfering on the part of the therapist. It is crucial to reinforce consistency in behavior in a clear and nonjudgmental manner. Frequently such nonjudgmental consistency was absent in early development, contributing to a sense of boundaryless relationships.

Another principle that the therapist discusses with the client in the beginning of treatment as well as throughout therapy is that suicidal and self-harming behaviors are problems to be solved and are of the highest priority for treatment. Similarly, the client must agree to reduce the behaviors as a goal for therapy and to work with the therapist before acting on self-harming urges. One of the most difficult agreements the therapist must make with the client is that the client can receive coaching on using skills to prevent self-harm but once the client engages in target behavior and enters the emergency department or is admitted to the hospital, the therapist suspends direct consultation with the client. At that point the inpatient staff takes over and may begin discharge planning with the therapist, but the therapist cannot talk with the client until 24 hours after discharge from the facility. The underlying reasoning for such a rule is that hospitalization reinforces the client’s inability to care for self and use skills effectively. When that point is reached, DBT has failed. After discharge the client likely returns to DBT treatment and the focus must return to effective use of skills for safety and re-engaging in treatment goals. The first order of resuming treatment is analyzing the behavioral events that led to target behavior.

The therapist also has some rules to follow that again are made explicitly clear in the orientation to therapy with the client. First, the therapist agrees to make every reasonable effort to provide competent treatment for the client. This means that the therapist is human and fallible. The client may question the effectiveness of the therapist and has the responsibility to discuss this directly and nonjudgmentally with the therapist. In turn, the therapist works with the client to clarify the treatment goals and strategies. The therapist also agrees to use consultation with the team to assure the client of competent care, even though the client may not see that consultation directly. The therapist may model use of skills at times, for example, if the therapist is feeling overly emotional within the session, he or she may say “let us both take a deep breath” and use mindfulness to balance emotional and rational mindedness. The client sees the therapist being human and using skills to be more effective in the interpersonal situation.

Because frequently the client seeking DBT has experienced poor boundary maintenance on the part of influential others, it is especially important for the therapist to make explicit the boundaries of the therapeutic relationship, including ethical conduct and separation of personal and professional roles. This does not mean maintaining a rigid and distant relationship with the client, but rather assuring the client that this is a professional relationship based on mutual respect and the desire for helping the client. The client needs to know that the therapist will maintain confidentiality within the limits of the law and ethical practice; however, there remains the duty to report a clear risk of harm to the client or to vulnerable others. Reporting needs to occur in an as respectful and transparent way as possible to preserve the continuity of therapy. For the client who has experienced childhood abuse, knowing the therapist has the role of protector and takes that role seriously is critically important in the validation process.

Stages of Treatment

The first stage of treatment is actually pretreatment. At this point, the client and therapist negotiate the goals of therapy and arrive at a commitment to the treatment. The therapist may spend two or three sessions gathering information about the client, his or her target behaviors, previous attempts to change behaviors, and

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what worked and did not work. This is also when the therapist makes explicit the assumptions and principles of therapy within the DBT model. Once the therapist and client have committed to working together, the structure for the therapeutic relationship begins to take shape.

The focus of stage 1 in DBT treatment is addressing life-threatening behaviors and therapy interfering behaviors. Because the client is simultaneously in individual therapy and group skills training, he or she is also learning to enhance his or her capabilities. This tends to be a stormy period as the client adjusts to a class-type environment and expectations. For clients who have been in other types of therapy, this might feel awkward and strange, as they want quick fixes or answers to their personal problems. The focus is on behavioral control and management with emotions as a contextual element. Frequently the client complains that the skills do not work, and the therapist needs to validate the client’s frustration while encouraging and reinforcing the use of skills. Diary cards are helpful for the client to monitor his or her use of skills in association with behaviors and feelings. The emphasis is on practicing with the realization that results may take some time. Frequently the client struggles with the homework of keeping a diary card as well as any assignments from the skills group, and instead wants to use therapy and group to talk about target behaviors. When the client does not complete assignments or engages in target behaviors, the focus of treatment shifts to analyzing the behavior, the chain of events that led to the behavior, and the consequences of the behavior. This behavioral chain analysis becomes the staple of treatment in guiding the client to become more mindful and use skills more effectively (see Figure 14.2).

Once the client has progressed through the first phase of group skills training, he or she then can progress to addressing nontraumatizing emotional experiences. At this point he or she can regulate his or her emotions in such a way that he or she can think through them. He or she can bring together the dialectics of emotional mindedness and rational mindedness into wise mindedness, that is, a balanced experience of and response to emotions. It is only then that the client can progress to working on trauma.

In stage three the client integrates his or her skills, awareness of self, and interpersonal responsiveness to begin confronting the trauma he or she has experienced. This is when the therapist begins exposure therapy in which the client gradually re-experiences elements of the trauma in small measured doses, using skills to regulate emotions and behavior. (See the discussion on exposure therapy later in this chapter.) As he or she can experience a memory without overwhelming distress, he or she gains a sense of mastery and self-efficacy. This is also when target behaviors may resurface, requiring the therapist to coach the client in effectively using skills to manage urges (e.g., self-harm behaviors and substance abuse). The therapist may also struggle with feelings of vicarious traumatization or victimizing the client, and need consultation from other team members.

Finally in stage four the client shifts into a transcendent sense of self where he or she focuses on self- efficacy, interdependence, and self-fulfillment. At this point the therapist prepares the client to become his or her own therapist by decreasing the frequency and intensity of contact. The client may become bored with therapy as a genuine response to self-responsibility. There may also be extinction bursts at this time (as well as earlier in treatment) when target behaviors and urges resurface but are quickly thwarted by the client. The therapist’s role here is to maintain calmness without overreacting to the client’s behavior. Reassuring the client that extinction bursts are reasonable and normal and serve more as a testing ground or dress rehearsal to letting go of therapy.

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FIGURE 14.2 Behavioral chain analysis worksheet.

Although it appears that these stages are linear and progressive, the reality is more of a spiraling process. The analogy of the slinky toy traversing stairs is helpful here in that the coils of skills and successes can drive the client in different directions, sometimes forward and sometimes backward. The overall movement is what counts and that there is progress in general.

DBT Skills Training

Skills training is the sine qua non of DBT because clients frequently lack the basic capabilities to manage their lives, thereby contributing to much of their misery. In fact studies indicate that without the skills component, DBT is equally as effective as a variety of CBTs. The evidence supportive of full fidelity (including group skills training), however, demonstrates convincingly that DBT has positive and lasting outcomes, especially with those with borderline personality disorder but also with PTSD, substance abuse, eating disorders, and treatment resistant depression (Andion, Ferrer, Matali, & Gancedo, 2012; Axelrod, Holtzman, & Sinha, 2011; Bloom, Woodward, Susmaras, & Pantalone, 2012; Ost, 2008; Safer, Robinson, & Jo, 2010).

Foundational to skills training is mindful meditation; therefore, these skills are taught in the orientation to group therapy in DBT and repeated at the beginning of each successive module in the 6-month therapy. There are two components to core mindfulness: the “what” skills (observing, describing, and participating) and the “how” skills (nonjudgmental stance, one minded in the moment, and effectiveness) that clients learn, then practice regularly, and include on their diary card (Linehan, 1993b). Although it seems to be a simplistic skill initially, many people (including therapists) struggle with mindfulness, and daily practice over time improves effectiveness and the utility of the other skills. Group sessions begin with mindfulness, team consultation incorporates mindfulness, and both therapists and clients remind each other of the need to stop and activate some brief mindfulness to regulate emotions and behavior. The actual practice of mindfulness can vary widely from quiet meditation to playful games that require full attention to the moment. In guiding the group in mindfulness, the leader provides some background for selecting the exercise and the reasoning for incorporating this activity at this time. Once everyone understands the activity and what to do, the leader signals the beginning to first get into a comfortable, upright, and grounded position, then use deep breathing to relax, and finally begin the exercise. A Tibetan singing bowl or any kind of gentle cue may be

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used to signal each step.

TABLE 14.1 Skills Modules in DBT Module Common Exercises

Core mindfulness Mindful abdominal breathing

Focusing/observing

Describing

Wise mind

Judgment diffusion

Distress tolerance Radical acceptance Distract Relaxation Self-soothing

Emotional regulation Recognizing emotions Reducing vulnerabilities Opposite action to emotion Problem solving

Interpersonal effectiveness Knowing what you want

Making a request

Passive vs. aggressive behavior

Assertive listening

Negotiating

Self-management Realistic goal setting Behavior analysis Contingency management Environmental control

Adapted from McKay, Wood, and Brantley (2007).

Successive modules include sets of skills associated with each topic that help clients modulate their mood, behavior, and interpersonal relationships (Table 14.1). These include emotion regulation, interpersonal effectiveness, self-management, and distress tolerance skills. Each module requires about 4 weeks and follows carefully designed exercises and content from a skills manual (Linehan, 1993a; McKay, Wood, & Brantley, 2007). The manual ensures consistency and fidelity to the program, which is important for clinical practice and research to establish reliability and validity of the therapy. Each group session has a process to follow that can be adapted to different groups (e.g., teens, couples, and parents) to provide relevancy. Included in the group are review of content and reasoning, skill practice, homework assignments, and measurement of mastery when concluding a module. At the end of phase 1 that includes all the basic skill modules, the client graduates to phase 2 that provides reinforcement of the skills and problem-solving effectiveness of skills in real life experiences. Phase 2 anchors skill effectiveness in the client’s life and prepares the client to progress in more difficult therapy, especially when there is a trauma history. Some clients may elect to retake phase 1 or the therapist may recommend this. This is common for clients who experience a stormy orientation with resistance to full engagement or commitment to the program or other environmental barriers to mastery of skills. Finally, many clients elect to participate in a more advanced group after completing phases 1 and 2 and achieving their therapeutic goals in individual therapy. In the ACES group clients work together as peers to solidify their recovery and improve their functioning and quality of life. Those clients who progress through ACES show maintenance of positive outcomes including low use of emergency or hospital admissions, sustained employment or educational advancement, remission of self-injurious behaviors, and subjective satisfaction (Comtois, Kerbrat, Atkins, Harned, & Elwood, 2010).

Individual Therapy

Concurrent with group skills training, the full DBT model includes weekly individual 30- to-50-minute therapy sessions. Individual therapy follows a cognitive behavioral approach that begins with several sessions of orientation to the therapy model and establishing the relationship and commitment to working together for the betterment of the client. In the orientation, the client and therapist arrive at a priority of behavioral targets with life-threatening behaviors as the highest priority, therapy interfering behaviors as the second highest priority, and quality of life enhancing behaviors as the third priority area. This is also where the therapist introduces the client to the diary card (see Figure 14.3 for a sample diary card) to monitor progress and give direction to each therapy session.

As the therapeutic relationship solidifies, the therapist progresses to basic treatment strategies including validation of the client’s experience, problem solving, and making changes (Linehan, 1993a). The therapist

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individualizes these strategies relative to the client’s needs and incorporates stylistic approaches to focus the client in making the necessary changes in behavior to achieve therapeutic goals. More specific discussion of treatment strategies is beyond the scope of this chapter, and the reader would learn and enhance therapeutic abilities through specific training in DBT.

When a client participates in target behavior, the therapist guides the client in analyzing the events in a nonjudgmental and problem-solving way using the behavioral chain analysis. This begins with clearly identifying the problem behavior and describing the events that led to the behavior in a detailed and specific manner. Even though the client may describe steps in the process in a general way, the therapist pushes for specificity and exquisite detail to identify antecedents and consequences of behavior and vulnerabilities that affect the process leading to the behavior. This detail is crucial for the client to understand the various links in the chain of events and accompanying thoughts, feelings, and actions. The role of the therapist in this process is to be the naïve observer who is gathering data and seeking to understand every element of the behavioral chain for the purpose of guiding the client to ascertain the function the behavior served. Figure 14.2 shows the basic form a behavioral chain analysis would take. It helps to draw the behavioral chain as it develops in the session on a whiteboard or tablet for the client to see the process and learn how to use the behavioral chain independently. Figures 14.4 and 14.5 provide examples of behavioral chain analyses related to medication management and a nonpharmacological therapy issue. The last step in the behavioral change involves the use of DEARMAN for the particular issue, which is an acronym for describe, express, assert, reinforce, be mindful, appear confident, and negotiate.

FIGURE 14.3 Sample diary card for standard DBT treatment.

TRAUMA-FOCUSED THERAPY

When the client is no longer engaging in life-threatening or therapy interfering behaviors and has a strong trusting relationship with her therapist, the client and therapist can begin to focus on the traumatic experience that brought the client into therapy. Without the DBT skills and reinforcement of skills in everyday life it would likely be destabilizing to address trauma exposure, and may even contribute to worsening of the client’s

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condition. Inevitably traumatic experiences that have been held in abeyance begin to influence the person’s thoughts, feelings, and behaviors. When done in an unmindful way they can wreak havoc on one’s relationships and personal functioning. Most psychotherapeutic approaches recommend some kind of controlled re-experiencing of the traumatic events to begin processing the memories in a more functional manner, thereby reducing symptoms. This may be through such similar strategies as abreaction, EMDR, or exposure therapy. All of these seem to produce results by connecting what currently seem like disconnected fragmented memories to neural circuits that allow cognitive processing and then storage in ordinary as opposed to fearful memory circuits. From a behavioral perspective, exposure therapy is a process of counterconditioning, that is, substituting an adaptive response for one that is nonadaptive. There are at least two basic types of exposure: imaginal exposure in which the client experiences the stimulus in her imagination only, and in vivo exposure in which the client experiences the actual stimulus in reality. In PTSD, in vivo exposure is limited to the people, places, and situations only and not the actual trauma, of course (Rauch, Foa, Furr, & Filip, 2004).

FIGURE 14.4 Sample behavioral chain analysis for teen conflict with mother.

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520FIGURE 14.5 Sample behavioral chain analysis for medication adherence.

Preparing for Exposure

Prior to exposure work, the client and the therapist need to do considerable preparatory work including what behaviors and emotions to target, the memory structures that are involved, the type of exposure to use, and the orientation of the client to the process. This of course assumes the client has sufficient stability and skills to begin the process. It is not uncommon to interrupt exposure work to restabilize the client and provide some refresher skill development and scaffolding.

In identifying behavioral and emotional targets, it is helpful to consider a hierarchy and decide with the client to address these from the least difficult to the most difficult (graduated exposure) or to begin with the big picture, that is, to rip off the band-aid (flooding). Then the client and therapist discuss scheduling the exposure sessions, that is, scheduling sufficient time relative to the type of exposure that also allows debriefing and reconsolidation, possibly scheduling another therapy appointment for that week to simply debrief and review the diary card, dealing with how the client will conduct the rest of her day, and addressing between session symptom arousal. In orienting the client, it may help to try a behavioral rehearsal for exposure, for example, choose a minor emotion such as embarrassment after a fall on the ice, and practice experiencing the emotions, then extinguishing them through repeated exposure, fully engaging in the emotion, using skills to manage the emotion, and preventing the behavioral response that usually accompanies the emotion (e.g., avoidance). This prepares the client for the process of exposure and builds confidence in doing the exposure work. Because this is an unpleasant experience, it is essential that the client understands and consents in a fully informed manner.

Conducting the Exposure

Begin by determining with the client what situation elicits the unwanted emotional response and the discriminating conditions that influence the response (e.g., the client may experience intense anxiety in small

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social gatherings among strangers but be comfortable in larger groups or with close friends). Then establish with the client the intensity of the emotion before and after exposure, often using the subjective units of disturbance (SUD) scale that ranges from 0 to 100 with 0 being complete comfort and 100 being excruciating distress.

In graduated exposure, the targets for exposure are arranged in a hierarchy of initial SUD intensity and addressed from lower to higher intensity. The therapist then walks the client through the stressful event from the very beginning while being attentive to the client’s emotional response and assisting the client to tolerate the emotion while using skills to manage them, periodically asking the client to rate the discomfort using the SUD scale. Repeat each situation until the SUD is much lower and the client can tolerate re-experiencing with reasonable emotion and without negative behavioral responses. In traumatic events, it may be helpful to break the event into smaller units with lower SUDs and move gradually into more difficult elements. For example, a client who was raped on her way home from work late at night spent several weeks imaging walking down the dark street, using mindfulness to observe and describe the cars parked along the street, the ambient sounds, the smells of early spring, and her rising sense of fear. When she was able to experience this without self-recrimination, her SUD rating dropped to 30 and she was ready to move on to the more frightening part of the experience. In this situation, the therapist combined imaginal and in vivo exposure in a progressive way.

Flooding exposure introduces cues with the highest SUD rating, and research indicates more sustaining long-term effectiveness (Foa et al., 2005). It requires longer sessions and tends to be more distressing for the client. The therapist approaches treatment the same as graduated exposure but focuses on the stimulus that the client identifies as most distressing. The client and therapist review the events repeatedly until the client experiences a tolerable drop in SUDs. The treatment usually requires 9 to 12 sessions and may include between session CBT or DBT focused treatment, although research results indicate that additional cognitive treatments provide no additional benefits to the prolonged exposure (Foa et al., 2005). The client may experience less between session exacerbations of PTSD symptoms, however.

Following exposure treatment there usually is a period of stabilization and transition in therapy toward termination. Although some clients seek additional follow-up sessions, most show reduction in PTSD and depression symptoms to the extent that they return to work and ordinary social functioning. Much of the research has been done with women with acute and chronic PTSD and with veterans of both the Vietnam and more recent wars. Less research has been done with women who have experienced military sexual assault alone or in conjunction with war trauma (Karlin et al., 2010; Nasasch et al., 2011; Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010).

CASE EXAMPLE

Mr. M, a 68-year-old retired Marine who served for 13 months in combat posts in Vietnam during his service, and worked for a construction company as an electrician for 40 years. He has been married three times and has two adult sons and an adult daughter. His current wife was recently diagnosed with cervical cancer and Mr. M is struggling to maintain his 30 years of sobriety as he supports his wife during extensive surgery, radiation, and chemotherapy. His sponsor recommended he see a therapist for support. Although he was reluctant, he finally began to see a psychologist who saw him for three sessions, diagnosed chronic and complex PTSD; major depressive disorder, moderate and recurrent; and sustained remission but now threatened alcohol and cannabis dependency. The psychologist referred the client for continued treatment with a DBT program due to the severity of PTSD and need for a wider treatment base, including group treatment and 24-hour availability for coaching.

In the assessment and orientation phase of treatment, Mr. M reported chronic insomnia characterized by frequent nightmares and sleep avoidance, delayed onset of sleep, frequent interruptions, and early awakening. He also has had several episodes of prolonged depression with suicidal thoughts and two serious attempts including hanging himself when he was 23 years old and within 6 months after discharge from the Marines. The client’s father came home from work early when he found Mr. M unconscious and hanging by his uniform belt in his bedroom closet. In another attempt a year later, Mr. M was drunk and tried to drown himself by walking into the ocean with rocks in his pockets; however, a bystander happened to notice Mr. M’s activity while walking along the beach at 3 a.m. and called the police.

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During the assessment, Mr. M endorsed symptoms of prolonged sadness and irritability, difficulty concentrating enough to even read the newspaper, frequent “spacing out” while at home when his wife was in the hospital or during waits during her treatments, poor appetite with 12-pound weight loss over the past month, intense self-demeaning statements and thoughts, self-blame for his wife’s illness, and extreme leaden fatigue without motivation or interest in anything pleasurable. In the past, his four grandchildren usually made him happy but for the past 6 months even their presence seemed to annoy him. Additionally, Mr. M has strong cravings to drink alcohol, and the week before his first therapy appointment at the DBT program he found himself walking in an area of town where he knew he could buy drugs, even though he did not remember how he got there. He called his sponsor for a ride home.

Mr. M reported his early childhood history was marked by his parents divorcing when he was 3. He lived with his mother and older sister for 2 years but was eventually removed from the home when his mother attempted to kill both children and herself. The father could not be located so both Mr. M and his sister were placed in a series of foster homes where both were physically and emotionally abused, and his sister was sexually abused in two separate homes. Eventually, Mr. M escaped foster care by participating in home robberies and drug possession and distribution and placed in juvenile detention until he was 18 years old.

He completed high school and joined the Marines early in the Vietnam War and was deployed within a year of enlistment. Most of his experience in Vietnam was in ground combat where he experienced the death and injuries of many of his friends to such an extent that he made a deliberate attempt to not form friendships, a pattern he maintained after returning to stateside.

During his year-long treatment he eventually described several particularly gruesome experiences in which he anticipated dying or severe injury. On only one occasion was he actually wounded in a firefight when he was hit with shrapnel from a bomb dropped on his quarters while he and his company were sleeping. Mr. M never described any of these experiences prior to this treatment, and he was particularly resistant to discuss them because he believed they were too long ago, irrelevant, and did not compare to the experience his wife was having with her cancer.

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FIGURE 14.6 Behavioral chain analysis for Mr. M.

Initially the APRN focused on establishing a trusting relationship with Mr. M, which was quite challenging because he would frequently miss appointments, show up late, and not do his assigned homework. After 4 weeks he started in a phase 1 standard DBT treatment with all the other participants having substance abuse issues as well as trauma. Mr. M would fall asleep in the classes the first few weeks and the APRN individual therapist would conduct a behavioral chain analysis of this behavior as illustrated in Figure 14.6. His repair to the group was to discuss his homework first at the next three sessions and to bring a healthy snack for everyone to share. Eventually Mr. M became more consistent in his attendance and brought his diary card to sessions (see Figure 14.7 for sample).

FIGURE 14.7 Mr. M’s early diary card.

In both group and individual therapy, Mr. M focused on the dialectic of his crisis generating behaviors (e.g., fantasizing suicide/murder) and facing his inhibited grieving. It was critically important that he find a middle ground in living his life while allowing his feelings of grief both for his childhood and military experiences and his wife’s illness. After 6 weeks of group therapy he was practicing his skills most days and was beginning to feel more confident of his ability to manage his emotions and behavior without internal or external upheaval or crisis generating behavior. He continued to feel suicidal but frequency and intensity decreased significantly.

After 3 weeks of individual sessions the APRN recommended medications to target the sleep disturbance and depression. Initially Mr. M refused to consider medication because it was a sign of weakness and he was afraid of becoming addicted to the medications. The APRN spent considerable time explaining how medications work on the chemicals in his brain that were not effective, and finally Mr. M agreed to take prazosin 1 mg daily for his nightmares and this was titrated up to 5 mg at bedtime to get sustained relief of nighttime anxiety and improved dreaming. He later agreed to take citalopram 10 mg daily titrated up to 40 mg for his depression and anxiety; however, this was ineffective after 6 weeks

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and the APRN changed it to Cymbalta 60 mg at which point, Mr. M began to feel more activated and motivated. He still had anxiety and agreed to a trial of Latuda 20 mg, titrated up to 40 mg where he felt more activated, less anxious, and improved mood. After 3 months of therapy and medication he no longer felt suicidal and was making plans to visit the national parks in the United States with his wife in their recreational van.

After completing phase 1 and midway through phase 2 of DBT treatment both the therapist and client began exploring Mr. M’s anxiety related to his wife’s illness and likely death. As he allowed his feelings to emerge he began having flashbacks of combat in Vietnam and feeling guilty that he was focusing on his problems instead of his wife. The therapist helped Mr. M consider the dialectics of accepting his wife’s illness and self-compassion for his fears while also working to change his self-invalidating thoughts and angry outburst when he felt sadness. The therapist engaged Mr. M in practicing the skill of opposite action to emotion in which he would watch old comedies with his wife in the evenings following her treatments. He also began to face his emotional vulnerabilities and counteract his self-invalidation. At some point Mr. M began to feel real joy in his life along with the constant fear of his wife’s eventual death. He spent more time with the family including his adult children and their children and took his wife for short trips to the beach.

The day after graduating from phase 2, Mr. M’s wife suddenly died from a pulmonary embolus. Mr. M became rageful and help rejecting. Suicidal urges returned to such an extent that he began carrying his service revolver every day and would sit in his car and rehearse shooting himself. His daughter found him one day and yelled at him for being so selfish and self-absorbed. This shocked Mr. M and he gave his gun to his therapist. They scheduled twice- weekly appointments until he could get back into a phase 2 group to focus on skills. He also attended a spouse bereavement group weekly and returned to daily Alcoholics Anonymous (AA) meetings. His daughter and one son joined him in family therapy at the DBT Program and addressed issues of abandonment and invalidation. His daughter expressed her anger with Mr. M during her early years because he was so distant and “odd” and seemed “so together.” Mr. M and his son began to address their respective apparent competence that prevented others from being able to be supportive or helpful.

Within 4 months of his wife’s death, Mr. M began to connect his early childhood abuse with his military experiences. He recognized that joining the Marines was an attempt to get structure and stability but this backfired when he was sent to Vietnam where stability was impossible. His use of alcohol and marijuana was the only way he could cope. Returning to civilian life did not provide stability as he continued to numb his emotions with substances that eventually contributed to the demise of his significant relationships with his wives and his sister. He began the trauma program at DBT where the therapist first attempted gradual exposure. Mr. M was impatient with his progress, and the therapist and client agreed that using flooding might be reasonable, given his effective use of skills and commitment to treatment. The Vietnam Veterans Association assisted him in gaining access to a virtual reality facility where the therapist and client worked with his combat experiences. This was a difficult time for Mr. M, and his medications were adjusted several times to provide sufficient support in his recovery.

Eventually Mr. M stabilized behaviorally and emotionally. He reunited with his sister after decades of estrangement, and encouraged her to locate a DBT Program in her state to address her traumatic events and the consequential life difficulties she continued to experience. Mr. M had continued in the ACES Program to anchor his recovery in the reality of living his life outside of therapy. He jokes that he is the “poster child for DBT” because he was the worst client ever initially and now is an avid spokesperson. He participates in online forums and maintains a DBT app on his cell phone to remind him of skills to use. Although he saw his treatment as tumultuous, Mr. M recognized how essential it was for him to learn new behaviors before he could tackle “Pandora’s box.”

POSTMASTER’S TRAINING

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Advanced practice nurses who would like to use DBT in their practice would be best served by taking a course through one of the certified training programs. Behavioral Tech, LLC, offers training through regional workshops and online. This organization, founded by Marsha Linehan, has a full staff of trainers who provide authorized certification in DBT and maintains a well-designed website at (www.behavioraltech.org/training). Taking a beginner’s course provides a complete orientation to DBT, in addition to reading the classic text by Linehan (1993a, 1993b) noted in the references at the end of this chapter. Additionally, the book by Dimeff (2007) is an important book to read and use for reference when starting this practice approach. After completing a beginner’s course, the APRN might locate a full DBT clinic to find a clinician as a mentor (www.dbtinformation.org/htm/clinics.xhtml). Starting with skills training and using a skills manual or workbook such as those included in the references at the end of this chapter will help the APRN become more comfortable with the basics of DBT. Finally, it is important to eventually take an intensive workshop, usually a week long, that is offered around the country and builds confidence in practicing DBT. The Behavioral Tech, LLC, website provides an ongoing list of intensive workshops including those for independent practitioners. What is most important in using DBT with complex clients is to develop and maintain a consultative team of colleagues who use DBT not only in their practice but also in their lives. The consultation team provides support and reinforcement of skills needed in working with this vulnerable population.

CONCLUDING COMMENTS

Complex PTSD and borderline personality disorder have more in common both epidemiologically and diagnostically, and therefore, have better outcome effectiveness when treated similarly. The most researched therapeutic approaches to produce effective and lasting improvement include prolonged exposure, CBT, and DBT (Foa et al., 2005; Harned, Korslund, Foa, & Linehan, 2012; Robertson, Humphreys, & Ray, 2004). These are treatments that the advanced practice psychiatric nurse can use with some additional training to provide quality effective treatment for clients. The evidence clearly establishes these treatments as the basis for the best clinical practice when properly used. In providing treatment for someone with complex PTSD, the therapist needs to be flexible and persistent in considering the most appropriate approach for this particular client (Wagner, Rizvi, & Harned, 2007). The client needs to trust the therapist’s competence, skill, and sensitivity before engaging in this work.

With a fully functioning DBT model the therapist also receives the benefit of consultation from other team members when engaging in this difficult work with clients. The advanced practice nurse who is trying to do this in a private practice would benefit from forming a consultation group of other clinicians using CBT and DBT to fortify his or her work and protect him or her from burnout and the added vulnerability of vicarious traumatization. Additionally, the discipline would benefit by APRNs conducting research and writing about clinical work in these situations to demonstrate the role of the advanced practice nursing in this area.

DISCUSSION EXERCISES

1. How does mindfulness serve as a core skill in DBT and for the client in their therapy? How would the APRN guide the client in adding mindfulness to their daily practice?

2. What DBT skills would be essential for the chronically suicidal client with complex PTSD? Why are these skills of higher priority than others?

3. How can the APRN incorporate DBT in a solo practice? What would be essential to maintain the clinician who uses DBT in solo practice? How would the APRN create the optimal environment to incorporate DBT in practice?

4. What would be the limitations of using DBT in solo practice? How would the APRN compensate for these limitations both for self and for the client?

5. How are borderline personality disorder, complex PTSD, and bipolar disorder similar and different? What treatment strategies would the APRN consider in working with populations with these disorders? How might the practice be different with these disorders?

6. Consider a client the student is currently working with or has strong recollections of working with

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in the past. How might DBT enhance the therapy with that client? How might the APRN work with that client now with knowledge about DBT?

7. What role does medication play in DBT? How would the APRN incorporate medication management and therapy with the client in DBT? If providing only medication management, how would the APRN collaborate with the other providers? If conducting therapy with a DBT client, how would the APRN decide whether to include medication management or refer to another provider for medication management?

8. What ethical issues arise in incorporating DBT in clinical practice? How does the APRN’s values and beliefs affect incorporation of DBT in other forms of psychotherapy?

REFERENCES

Andion, O., Ferrer, M., Matali, J., & Gancedo, G. E. (2012). Effectiveness of combined individual and group dialectical behavior therapy compared to only individual dialectical behavior therapy: A preliminary study. Psychotherapy, 49(2), 241–250.

Axelrod, W. P., Holtzman, K., & Sinha, R. (2011). Emotion regulation and substance use frequency in women with substance dependence and borderline personality disorder receiving dialectical behavior therapy. The Americal Journal of Drug and Alcohol Abuse, 37, 37–42.

Bloom, J., Woodward, E., Susmaras, T., & Pantalone, D. (2012). Use of dialectical behavior therapy in inpatient treatment of borderline personality disorder: A systematic review. Psychiatric Services, 63, 881–888.

Chu, J. (2011). Rebuilding shattered lives: Treating complex PTSD and dissociative disorders (2nd ed.). Hoboken, NJ: John Wiley & Sons. Comtois, K., Kerbrat, A., Atkins, D., Harned, M., & Elwood, L. (2010). Recovery from disability for individuals with borderline personality

disorder: A feasiblity trial of DBT-ACES. Psychiatric Services, 61(11), 1106–1111. Dimeff, L. (Ed.). (2007). Dialectical behavior therapy in clinical practice: Applications across disorders and settings. New York, NY: Guilford Press. Foa, E., Hembree, E., Cahill, S., Rauch, S., Riggs, D., Feny, N., & Yadin, E. (2005). Randomized trial of prolonged exposure for

posttraumatic stress with and without cognitive restructuring: Outcome at academic and community clinics. Journal of Consulting and Clinical Psychology, 73(5), 953–964.

Harned, M., Korslund, K., Foa, E., & Linehan, M. (2012). Treating PTSD in suicidal and self-injuring women with borderline personality disorder: Development and preliminary evaluation of a dialectical behavior therapy prolonged exposure protocol. Behavior Research and Therapy, 50, 381–386.

Karlin, B., Ruzek, J., Chard, K., Eftekhari, A., Monson, C. H., & Foa, E. (2010). Dissemination of evidence-based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration. Journal of Traumatic Stress, 23(6), 663–672.

Linehan, M. (1993a). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford Press. Linehan, M. (1993b). Manual for treating borderline personality disorder. New York, NY: Guilford Press. McKay, M., Wood, J., & Brantley, J. (2007). The dialectical behavior therapy skills workbook: Practical DBT exercises for learning mindfulness,

interpersonal effectiveness, emotion regulation & distress tolerance. Oakland, CA: New Harbinger Publications. Nasasch, N., Foa, E., Huppert, J., Tzur, D., Fostick, L., Dinstein, Y., … Zohar, M. (2011). Prolonged exposure therapy for combat- and

terror-related posttraumatic stress disorder: A randomized control comparison with treatment as usual. The Journal of Clinical Psychiatry, 72, 1174–1180.

Ost, L.-G. (2008). Efficacy of the third wave of behavioral therapies: A systematic review and meta-analysis. Behavior Research and Therapy, 46, 296–321.

Powers, M., Halpern, J., Ferenschak, M., Gillihan, S., & Foa, E. (2010). A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical Psychology Review, 30, 635–641.

Rauch, S., Foa, E., Furr, J., & Filip, J. (2004). Imagery vividness and perceived anxious arousal in prolonged exposure treatment for PTSD. Journal of Traumatic Stress, 17(6), 461–465.

Robertson, M., Humphreys, L., & Ray, R. (2004). Psychological treatments for posttraumatic stress disorder: Recommendations for the clinician based on a review of the literature. Journal of Psychiatric Practice, 10(2), 106–118.

Safer, D., Robinson, A., & Jo, B. (2010). Outcome from a randomized controlled trial of group therapy for binge eating disorder: Comparing dialectical behavior therapy adapted for binge eating to an active comparison group therapy. Behavior Therapy, 41(1), 106–120.

Wagner, A., Rizvi, S., & Harned, M. (2007). Applications of dialectical behavior therapy to the treatment of complex trauma-related problems: When one case formulation does not fit all. Journal of Traumatic Stress, 20, 391–400.

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Psychopharmacotherapy and Psychotherapy LISABETH JOHNSTON

sychotherapy and pharmacotherapy are essential competencies, as delineated by the Psychiatric Mental Health Nurse Practitioner Competencies (The National Panel, 2003) and the Psychiatric-Mental Health

Nursing: Scope and Standards of Practice (American Nurses Association [ANA], 2007). The advanced practice psychiatric nurse (APPN) prescriber role has increased dramatically with the emphasis on biologic psychiatry and the expanding scope of practice for the advanced practice nurse. The APPN must be able to conduct psychotherapy when prescribing, even if he or she is serving as the prescriber only. The APPN must be knowledgeable about how to develop and implement split and integrated treatment to have an informed and empowered practice. Integrated treatment is a term applied to treatment in which a single provider provides both psychotherapy and pharmacotherapy. Split treatment refers to treatment in which one provider does the psychotherapy and another provides the pharmacotherapy. Split treatment may be parallel and separate, or it can be collaborative and integrated. The APPN has the privilege and responsibility of creating a role that best serves the patient and that is satisfying to himself or herself.

This chapter provides several practice frameworks for the prescribing APPN treating the adult patient and discusses the essence and practicalities of prescribing for split and integrated treatments. Both types of treatment are considered and guidelines are offered based on the phases of the nurse–patient relationship. It is proposed that there is a pharmacotherapeutic relationship that is necessary for successful prescribing. The APPN prescriber who is aware of psychodynamic issues brings a depth to the prescribing practice that benefits his or her satisfaction with the role but more importantly benefits the patient’s treatment outcome. This chapter begins by discussing the history and scope of practice and the competencies and principles of prescribing. The importance of the nurse–patient relationship is highlighted, and transference and countertransference issues are considered. After the discussion of integrated and split treatments, a case example is provided.

HISTORY AND SCOPE OF PRACTICE

In the United States APPNs have a 20- to 25-year history of prescribing medications in one form or another. The early days of physicians signing pads of prescriptions for nurses, who then assessed and prescribed for the patient, are gone forever. The rationale for that behavior was that nurse prescribing was a delegated function of the medical profession and that the nurse prescriber was carrying out a medical function for the physician. State laws governing scope of practice have changed to ensure patient safety and to clarify where responsibility lies for prescriptions that are written (Kaas & Markley, 1998; Phillips, 2006, 2013). Bailey (1999) provides an excellent history of prescriptive authority in the United States and the evolution of nurse prescribers in terms of scope of practice laws, educational preparation for the role, and the politics involved in the process.

APPNs’ expanded prescribing authority has increased our treatment repertoire, marketability, and collaborative status with colleagues as we have moved more deeply into the prescribing role. With this role come more responsibility and more liability (Grimaldi & Cousins, 1998). The act of prescribing and its consequences are the responsibility of the APPN, who has been authorized to prescribe by virtue of education, national board certification, and by meeting any other requirements of the scope of practice law in the state where he or she is licensed.

Prescribing responsibility may be borne in part by a physician or another advanced practice nurse prescriber if the law is written in such a way that one of these other prescribers supervises the APPN who is prescribing. This does not excuse the prescribing APPN from responsibility, because responsibility always remains with the prescriber. For example, one newly board-certified APPN accepted the advice of his physician supervisor and employer, who told him that the fact that he was working in an employed status in

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his practice excused him from taking the steps necessary to obtain a nurse prescribing license in his state. The APPN came to the attention of the examining board in nursing and was held accountable for practicing without a license. There were severe consequences for him and his family professionally, financially, and personally.

Phillips (2013) reports that 16 states and the District of Columbia allow some categories of APPNs to prescribe without physician involvement, and 34 states allow prescribing with physician involvement at some level (Phillips, 2013). Some states specify the board certification required for prescribing, and some specify the boards that can certify them (Phillips, 2013). For example, some states have allowed only board-certified clinical nurse specialists (CNS) in psychiatric-mental health nursing to prescribe, and they specify that only the American Nurses Credentialing Center is an acceptable body to confer certification. The first and most important function of a nurse prescriber is to understand and strictly follow the requirements of his or her state scope of practice law and any regulations that have been promulgated to explain it. Physician supervision can be defined in different ways in different state statutes; some states use the term collaboration with physicians rather than supervision. These terms may then be defined broadly or narrowly in the statutes of different states. The supervisory or collaborative requirements and their variations have nothing to do with APPN competence, which is determined by academic preparation and board certification, and a great deal to do with turf and politics. In some states, a collaborative agreement is required by statute and developed with the terms of this collaboration delineated, complying first with the practice statute and then with additional terms as agreed by the APPN prescriber and the physician collaborator. The APPN prescriber and the physician sign the agreement. Sample agreements that comply with a particular state’s scope of practice law are included in the appendices. Appendix 15.1 is written as broadly as possible, whereas Appendix 15.2 has more specificity. The broader agreement must satisfy the requirements of the law in each state. Appendix 15.2 was developed to satisfy the wishes of some collaborating physicians for further specificity.

Liability insurance must be carried by every nurse prescriber. The individual and aggregate dollar amounts that must be carried are set in state law by some states. Some APPNs carry malpractice insurance only through the agency of employment; others individually insure. Some malpractice insurers and practitioners argue in favor of maintaining private malpractice insurance as there may be limitations and stipulations on employer coverage. For example, an APPN may not be covered in the case of a lawsuit brought sometime after he or she terminated employment with the agency or hospital if there is a clause in the contract terminating coverage at the point of employment termination. Individual malpractice insurance coverage provides for portability and for coverage that can be fully known and fully evaluated by the APPN. Agency coverage may be attractive to the APPN because it is much less costly in the short run, but it ascribes a great deal of power to the employer and may leave the APPN at risk.

Concerns about liability have made some APPNs reluctant to practice independently. Concern is well founded but need not be a deterrent to independent practice. The APPN is legally responsible for the clinical decisions made in practice, and the importance of understanding and practicing within the law governing APPN practice in the state, and within the scope of practice as defined by the professional organization and certifying bodies cannot be underestimated. This is true whether the APPN is practicing in an independent setting or in another practice arrangement, and it is true in states that allow APPNs to practice without any mandatory collaborative or supervisory requirements and those that have these requirements. APPNs who understand that they are fully accountable for all clinical action and inaction, who practice within their scope of practice, and obey the practice law in their states may deter the possibility of litigation. Those who seek consultation from appropriate expert peers or refer patients for consultation when necessary, and who maintain a strong therapeutic alliance with their patients, create an atmosphere of trust and collaboration that helps protect against misunderstandings, missed communications, and mistakes that can lead to litigation. It is helpful in the clinical decision-making process to think about what a community of peers would say about a planned intervention, and if there is discomfort of any kind, consultation should occur before action is instituted. An important protection for the APPN who does become involved in questions or accusations about his or her practice is the thoroughness and quality of documentation in the record, including consultation discussions.

APPNs who schedule regular clinical consultation are adding depth and new perspective to practice, giving patients the benefit of fresh eyes on the diagnosis and treatment plan, and demonstrate a willingness to allow review of their work by peers or other experts in the field. This is helpful and protective for all involved in the treatment, and it is recommended that this be a routine arrangement in any practice setting. It may be even more valuable in the private practice setting, where the APPN is often working in an isolated environment. These arrangements may be mandatory or voluntary, depending on the state law. Business arrangements between the APPN and the consultant must be carefully established because it can be costly in

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terms of the frequency of the meetings, the fees that are charged, and the time and costs of travel and for the consultation session. The final business contract must be fair and equitable to prevent negative feelings from affecting the work in supervision. It may be necessary to interview more than one potential consultant/collaborator/supervisor before a satisfactory arrangement can be established. It is possible to establish a contract in which a mandatory collaboration requirement for prescribing can be met with the same person with whom the APPN has a contract to do clinical psychotherapy consultation if both parties are agreeable to such an arrangement. An alternative for voluntary clinical supervision/consultation may be to create a peer consultation group in which members agree to regular meetings in which each member brings patient treatment issues before a community of peers for review and consideration. It is always necessary in states that have mandatory supervision/collaboration for prescribing to know what qualifications that supervisor must meet.

APPN prescribers practice in too many settings to enumerate in this chapter. Research supports that APPN psychotherapeutic and pharmacotherapeutic approaches produce direct health benefits (Jones et al., 2006). Practice models for prescribing have emerged in different settings, often from the practice needs of the setting and from the needs of the patients being treated and cared for. Some settings allow for the most liberal interpretation of its state’s prescribing law, and in states where the prescribing law itself is liberal, the APPN may be allowed to prescribe to the full extent of his or her professional scope of practice. Other practice settings are highly restrictive, and APPNs are more limited in prescribing practices than even a restrictive state law would demand. The APPN who practices in a fully independent setting without practice requirements and restrictions imposed by an institution or agency may practice in accordance with the scope and standards of psychiatric-mental health nursing practice as defined by the appropriate professional nursing organizations (ANA, 1994; ANA et al., 2007), but always within the parameters set out in the nursing scope of practice statute in his or her state (Phillips, 2013).

COMPETENCIES AND PRINCIPLES OF PRESCRIBING

A Statement on Psychiatric-Mental Clinical Nursing Practice and Standards of Psychiatric-Mental Health Clinical Nursing Practice (ANA, 1994) delineates the knowledge base required for APPN prescribing. After reviewing this document, Bailey (1999), in her seminal article on APPN prescribing, thoroughly described the components of the neuropsychosocial and psychopharmacologic assessments that are essential in establishing a psychiatric diagnosis and determining appropriate pharmacologic treatments. These include integrated knowledge of the biologic, behavioral, and social and neurosciences; knowledge of central nervous system structures and function; and theoretical understanding of mental illnesses based on biologic knowledge. She states that the APPN must also have knowledge of sleep stages, circadian rhythms, and neuroimaging techniques and the paper and pencil tests available to assess and monitor mental illness and treatment. Twelve areas are identified that require APPN expertise in conducting an adequate neuropsychosocial and psychopharmacologic assessment (Bailey, 1999) (Box 15.1). Specific components of each of these areas are discussed in the comprehensive assessment described in Chapter 3.

BOX 15.1

NEUROPSYCHOSOCIAL AND PSYCHOPHARMACOLOGICAL ASSESSMENT

1. Patient’s identifying data 2. Patient’s identified problem 3. History of the current problem 4. Symptoms that the medications target 5. History of treatment 6. Response and adverse effects to prior medications 7. Family and social history, including ethnicity and culture 8. Personality structure and coping style 9. Medical history and current treatments

10. Drug and other allergies 11. History and current status of substance abuse or dependence and treatment 12. Mental status examination

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Another area that bears exploration in a psychopharmacologic assessment is that of the patient, family, and significant others’ feelings and values about mental illness and the use of medication to treat it. It has been suggested (Busch & Sandberg, 2007) that the introduction of medication discussion or treatment may deepen the prescriber’s understanding of patients’ behaviors/attitudes/reactions and thereby help the prescriber to increase patients’ self-understanding. Introduction of medication discussion can elucidate influences from family and others on patients’ decision-making processes. For example, many people feel ambivalent about emotional problems being conceptualized and labeled as illness, and prescribing medications to treat them reinforces the idea that these symptoms are manifestations of medical illness. There is also a belief held by some people that medications can make symptoms worse, and this may raise fear about the idea of taking medication. Careful consideration of the concerns and behaviors of patients and important others presents an opportunity for education and for reducing resistance to medication in the present and later.

The APPN must know as much as can be known about the patient, but that is only one aspect of the expertise that is needed. The APPN must also be firmly grounded in knowledge about the medications. This includes knowing similarities and differences among agents of the same and different classes, the mechanisms of action, side effects, adverse effects, interaction effects, and other variables essential in the risk–benefit assessment that must precede the prescribing of any medication (Bailey, 1999). APPNs need depth of knowledge and skill in performing all these functions to identify the findings that provide the basis for diagnosis and treatment planning. After initial treatment planning and treatments are in place, the APPN continues until termination of treatment to monitor target symptoms, medication effects, and level of function.

Short- and long-term maintenance care, or follow-up, requires its own set of skills and may be at least as challenging as the initial assessment and treatment plan. Essential to follow-up care is the APPN’s ability to interpret data from ongoing drug monitoring, including objective assessment of target symptoms, laboratory values, patient and family reports of drug response and level of function, and rating scales (Bailey, 1999). Competency in identifying indicators for medication modifications or tapering and clinical expertise to choose alternative medications strategically are needed (Bailey, 1999). The APPN prescriber understands potential withdrawal consequences of discontinuing medications and is able to distinguish among recurrence of illness, drug rebound effects, environmental effects, and personality characteristics when the patient reports changes or when medications are tapered. Patient education on all aspects of the illness and treatment, rehabilitation measures, and other health promoting interventions are inherent and ongoing components of long-term care (Bailey, 1999). All of these require ongoing assessment and intervention, because it is almost inevitable that there will be changes in mental state, functioning level, and interpersonal and environmental stressors over time. See Box 15.2 for 11 basic principles for psychopharmacology practice that have been identified.

BOX 15.2

PRINCIPLES OF PSYCHOPHARMACOLOGY PRACTICE

1. Identify target symptoms and diagnosis 2. Screen for medical problems and drug interactions 3. Obtain a detailed history 4. Recognize signs of impending relapse 5. Form a therapeutic alliance 6. Know one or two drugs per class well 7. Administer a full trial of a new medication before identifying it as a failure 8. Keep the regimens simple 9. Be aware of the financial cost of drugs

10. Adhere to legal and ethical standards 11. Seek consultation

Off-label prescribing and distribution of samples are two situations that the APPN should understand require special consideration. Off-label prescribing refers to the prescribing of certain drugs that are not approved by the U.S. Food and Drug Administration (FDA) for psychiatric use at all or are

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approved for a particular psychiatric treatment but are prescribed for a different purpose. For example, certain anticonvulsants sometimes are used as mood stabilizers, but may never have been approved as mood stabilizers. Another example is that of an atypical antipsychotic used for anger management, impulsivity, or certain instances of insomnia. The APPN must have a clear rationale for prescribing such a drug and document in the record why it is the drug of choice. The patient must be informed of the drug’s off-label status and agree to a trial of the medication. Informed consent must be documented in the record.

Samples of brand-name medications are distributed to APPNs by pharmaceutical representatives, and each APPN must decide about the appropriateness and timing of providing samples to patients. One model is to provide a starter pack of the medication or its equivalent to see whether the patient can tolerate the medication and thereby save the patient the copayment if the drug is not tolerated. After that trial has been successfully completed, patients receive a prescription for ongoing use. Patients sometimes may be given samples of medication change for the same purpose, and some patients may need help with samples when copayments are excessive or when they have no insurance. Providing starter medication is acceptable but should always be discussed in the context of the therapeutic relationship and should not be a permanent solution in most cases. Some prescribers work with the patient and drug company to ensure an ongoing supply of medication when the patient is financially unable to afford it. Casual dispensing of samples can be driven by relationship issues, such as the prescriber’s feelings for the patient, and the patient may attribute meanings to this act that are not intended. APPNs who develop a structured plan for dispensing samples may avoid misunderstandings and expectations that cannot be fulfilled.

THERAPEUTIC RELATIONSHIP

The therapeutic alliance is arguably the most important determinant of adherence to pharmacologic treatment, and adherence to the pharmacologic regimen is vital to success of treatment in terms of feelings of well-being and level of functioning, regardless of the diagnosis (Bailey, 1999). Relationship factors are first among the many aspects of the art and techniques of prescribing that are discussed in this chapter. The emphasis on what to prescribe in contemporary practice has overshadowed focusing on how to prescribe (Mintz, 2005). Many of the components of effective prescribing beyond the neurobiologic sciences and assessment skills belong in the realm of the therapeutic relationship. Interpersonal skill in prescribing can affect all aspects of the treatment. Successful outcomes of prescribing recommendations are often related to the therapist’s knowledge and skill in presenting himself or herself and the recommendations to the patient and in careful listening to the patient. Prescribers have thought about patients’ willingness to comply with medication orders in terms of degree of patient compliance, a word that suggests that patients should obey orders. Snowden and Tusaie (2013) suggest that achieving concordance should be the goal. It requires a collaborative process between prescriber and patient that includes use of the concepts of choice, self- determination, and empowerment. The aim of concordance is to achieve a successful therapeutic effect from medicine the patient has come to accept through the collaborative process rather than simply achieving compliance. This prescribing process is in keeping with the goals of many modalities of psychotherapy and working in this way in the prescriber role strengthens the therapeutic relationship and reduces the divide between the autocratic directive prescriber and the nondirective exploratory psychotherapist.

Nursing is a therapeutic interpersonal process, an educative instrument, and a maturing force that moves personality toward creative constructive, productive personal, and community living (Peplau, 1952). These words have guided psychiatric nursing practice for many years and apply to prescribing practice within psychiatric nursing. The challenge for the APPN in any prescribing practice is to maintain a sense of professional self as a therapeutic interpersonal educative instrument while performing what is an essentially technical treatment task that is heavily dependent on theories in the neurobiologic sciences. The high value placed on medication treatment by medical insurers, pharmaceutical companies, and much of the consuming public, together with the rewards for being a provider who has expertise in biologic psychiatry and has the legal authority to prescribe, can powerfully influence APPN practice patterns and content. There is pressure from multiple directions to assess quickly, prescribe immediately, and keep meetings with patients short and infrequent.

Many APPNs believe that the biologic component of pharmacotherapy needs to be balanced with a firm grounding in the essence of nursing, which may also be seen as the essence of prescribing: psychological understanding of human behavior, interpersonally focused assessment, therapeutic relational skills, and therapeutic use of self. Both the biologic and psychological expertise contribute and are essential to knowing

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what and how to prescribe. The psychotherapeutic interpersonal processes are the core of psychiatric advanced practice nursing and essential to prescribing successfully. The therapeutic relationship is essential to a positive medication treatment experience for the patient, and it is essential to successful outcomes in medication treatment.

Transference and Countertransference

There exists in all the phases of psychopharmacotherapy and in psychotherapy the phenomena of transference and countertransference. Transference is the phenomenon in which the patient reacts to the APPN according to what that APPN is actually saying or doing and according to what that APPN represents for the patient. For example, a patient consistently took a strong and very vocal oppositional position to the APPN’s suggestions about medications and told the APPN she was being too controlling. The APPN could not see herself as the patient did and spent time in clinical consultation discussing this situation and receiving validation for her perception that she had not been controlling in her approach to proposing medication. It was suggested to the APPN that she explore transference possibilities. The patient ultimately revealed that all recommendations that his father made were arbitrary and that the consequences of not following them were harsh. Consequently, he felt powerless and frightened whenever he was at the mercy of an authority figure, regardless of how the recommendations were presented. He always felt compelled to comply and the need to strongly resist. The APPN and the patient were able to explore this issue and work this through. The patient became better able to articulate his feelings, separate the past from the present, and work on solutions to the medication recommendations. Patients can also experience transference reactions to medications. Medications can be personified as little helpers or monstrous controlling enemies. More power can be attributed to them than they deserve, or medications can be disparaged as cruel jokesters full of empty promises. They can instill great fear or great hope. Recognition, understanding, and mindfulness of the transference and countertransference reactions require APPN expertise and experience and can assist in understanding the meanings the patient attaches to the prescriber and to the medications.

Countertransference occurs when the APPN reacts to the patient according to what the patient is saying or doing in the present and according to what the patient represents for him or her. For example, one prescriber who had worked very hard to help a patient with medications felt unreasonably angry when the patient seemed to sabotage her effort to help. Through exploration, the APPN realized that she had made a great effort to be a very good and helpful daughter to her father, who showed her no appreciation. It is useful for the APPN who reacts with great intensity to consider the possibility that the feelings activated by the patient may be related to old relationship issues of his or her own. This can help to gain control over reactions and be more helpful to the patient in the current situation. The concepts of transference and countertransference emerged from psychoanalytic literature and have been a way of understanding some aspects of human behavior. Recognition of transference and countertransference phenomena by the APPN can be used therapeutically to enhance awareness of behaviors related to the progression of the relationship in psychotherapy and/or pharmacotherapy and to facilitate change in the direction of a more productive pharmacotherapeutic alliance and treatment.

Meaning of Prescribing for the APPN

Prescribing medications can serve many functions for prescribers in any configuration of prescribing treatment (Mintz, 2005). For example, one of these functions could be defensive in nature, with the prescriber feeling in control of the treatment or of the patient as he or she acts in the powerful position of prescriber. Prescribing may give a prescriber who lacks confidence in therapeutic skills a sense of purpose, a task to do. It may generate a feeling of omnipotence in the prescriber, allowing the prescriber to keep emotional distance from the patient while feeling very powerful and helpful, and having control of the medications a patient knows help in his or her recovery can encourage the patient’s dependency and, consequently, the prescriber may feel even more needed and powerful.

These functions of prescribing must be recognized and eliminated if the prescriber is to use self therapeutically. Treatment philosophy, knowledge, and comfort level with prescribing are communicated to patients, and the APPN who is self-aware in these areas can be more understanding of patient behaviors and

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more aware of his or her role in contributing to them (Mintz, 2005). For example, patient behaviors that may benefit from APPN self-awareness and from flexibility can include the degree of the patient’s willingness to come to appointments, to take medications, and to share in prescribing sessions and the number and content of contacts the patient initiates with the prescriber outside sessions. Expert knowledge of medications and assessment and skill in the techniques of prescribing can be lost on the patient, and the goals of successful prescribing will not be achieved if implicit or unconscious communications and behaviors of the prescriber impede or prohibit the formation and maintenance of a pharmacotherapeutic relationship.

The therapeutic relationship can be divided into the orientation, working, and termination phases, and the pharmacotherapeutic alliance can be conceptualized in the same way. The orientation phase must define and clarify the relationship. This includes identifying patient issues, the goal of the work together, and the relationship between the patient and the APPN. It must also define the limits of the relationship and the boundaries of the work. The working phase includes understanding the problem together and helping the patient use this understanding to make changes that help him or her. The termination phase is a period of ending the relationship and helping the patient take responsibility for his or her own safety and actions.

The APPN and patient may enter the orientation phase of the therapeutic prescribing relationship through any number of settings, including the hospital, partial hospital program, and outpatient office. One of the first concerns for the APPN and patient, regardless of the orientation phase setting, is to ensure that there is clarity between the patient and the APPN about whether this will be an integrated or a split treatment plan (Riba & Balon, 2005) with respect to prescribing.

SINGLE-PROVIDER INTEGRATED TREATMENT

The term integrated can be thought of as combining parts into a whole. “Integrated” psychopharmacologic and psychotherapy treatment means combining the two approaches to treatment. More specifically, integration in this context means the weaving together of the two treatments in a synergistic mutually facilitating way with a goal of having a more successful outcome than would be had by either treatment alone or if administered in a separate or parallel way (Sussman, 2009; Szigethy & Friedman, 2009; Tusaie, 2013). Each treatment process can provide information for the other that can in turn be used to improve the APPN and patient insight and assist in achieving mental health goals.

Data on outcomes in combining these two treatment modalities has been positive for some diagnostic categories but is not definitive for all. Compared to monotherapy with either modality, combined treatment with psychotherapy and pharmacotherapy does not consistently produce additive results across diagnoses (Summers & Barber, 2010; Szigethy & Friedman, 2009). Making a decision about which treatment or combination treatment to propose is often based on clinical judgment after a thorough assessment and several authors (Busch & Sandberg, 2007; Gabbard, 2007; Sussman, 2009; Szigethy & Friedman, 2009) have summarized disorders with the most empirical support for combination treatments. Szigethy and Friedman (2009) state that Axis 1 diagnoses should be considered a primary indication for evidence-based pharmacotherapy to treat/stabilize symptoms. However, the degree of severity of symptoms, level of function, quality of life, safety, and patient wishes are also considered in the decision making. Pharmacotherapy is commonly used with or without psychotherapy for patients with other diagnoses and/or milder symptoms when the assessment justifies this treatment approach.

Medication treatment for psychiatric disorders has risen steadily over time and is now the most widely utilized treatment in the field (Snowden & Tusaie, 2013), but there are those who suggest that psychotherapy can be too often overlooked as monotherapy initially in mild to moderately severe depression (Markowitz, 2008). The concern is that “if you believe you have a great hammer, everything may begin to resemble a nail” (Markowitz, 2008, p. 452). He says that when psychotherapy is the patient preference, when there are contraindications to pharmacotherapy, there is a psychotherapy single treatment history, symptoms occur in a psychosocial context or during a life crisis, where control is an issue in the emergence of the depressive symptoms, and when new and lasting skills can positively affect the symptoms or there is an issue of complicated grief, psychotherapy alone may be the treatment option of choice. Breggin (2013) says that prescribers and therapists need to reduce medication use and respond positively to patients’ wishes to take little or no medication. He contends that drugs are harmful and create more symptoms that disempower the patient, and that medications are not the answer to emotional problems. Further he posits that psychiatric medications undermine motivation and determination and says that psychotherapy should be the first approach to treatment regardless of the level of severity of symptoms.

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Alternatively, there is the position that there may be a top-down biological role for psychotherapy’s influence on the brain but also a bottom-up biological role for medication (Busch & Sandberg, 2007; Gabbard, 2007; Summers & Barber, 2010). This model would suggest that both treatments have a biological impact on both pathways. Theoretically this may help to integrate the psychological and biological conceptualizations of mind and brain treatments and can theoretically establish a rationale for combined treatment. Szigethy and Friedman (2009) suggest the Cognitive Biological Model, based on a systems approach, as a theoretical basis for combining psychotherapy and pharmacotherapy. They state that there are many influences, including cognitive, interpersonal, behavioral, social, cultural, and biological, that may contribute to mental illness, and integrated pharmacotherapy and psychotherapy might target more of these contributing factors than monotherapy alone could accomplish.

Although there are no definitive criteria that establish the need for combined treatment to effect therapeutic change, many authors suggest that medication may reduce symptoms to the point that the patient can participate in treatment and function safely in daily life and may be able to have a positive effect far faster than psychotherapy can. Psychotherapy may be able to lower resistance and help the patient be open to the medication option. All clinical work in psychiatry requires close attention to the development of the therapeutic alliance (Gabbard, 2007). Psychotherapy can provide a focused, goal-directed means to achieve that alliance as well as recognition of transference issues, defense mechanisms, and countertransference issues that may be serving as impediments to successful treatment with medications. At the same time, interactions with patients and observations of patient behaviors/attitudes toward medications that are being suggested or prescribed can facilitate the work in psychotherapy. Integrated treatment requires skill in both fields of knowledge and a balanced approach to interventions in both spheres, depending on the interpersonal dialogue, manifestation of symptoms, and established goals of treatment (Murawiec, 2009).

Orientation Phase

During the orientation phase of treatment, introductions, getting acquainted, and completing paperwork are required tasks. Boundaries are established, and the first and very important threads of a therapeutic relationship are being forged. Paperwork often is completed by patients ahead of time by mail or in the waiting room. However, this is important foundation work and requires the interest and attention of the APPN. The patient must understand policy matters concerning billing, insurance, confidentiality, and cancellation. It is important to explain APPN prescribing arrangements in a given state so that the patient is informed about the involvement of any physician or other professionals in the prescribing practice, even when it does not directly affect him or her. It expedites matters to have all of these items explained in writing and ready for the patient to read and sign if acceptable before the first session begins. The APPN assesses the patient’s symptoms, formulates a working diagnosis, and considers medication while getting to know the person’s hopes and concerns about psychiatric treatment, the APPN, and mental health and illness. The APPN is concerned with how the patient presents but must remember that the patient is also evaluating the APPN.

Presentation is important in the early moments of interaction and includes appearance, handling of introductions, mood projected, and confidence and empathic understanding demonstrated. Asking what influenced the patient to make the appointment at this time and then what the patient hopes to get from treatment conveys interest in the patient’s thinking and will be useful in assessing needs in treatment later. It also helps to establish the boundaries of the treatment and helps the APPN explain clinical reasoning in recommendations for treatment(s) later. Sometimes a primary care provider (PCP) is already prescribing medication, and the patient or PCP wants an assessment and prescribing of medication to continue under the care of a mental health provider. The medication the patient is taking may not be helpful or has side effects, and he or she wants another opinion. The patient may feel miserable and has never been on medication or may be in psychotherapy with a nonprescribing provider who thinks an evaluation for medication is called for. Other reasons for seeking an appointment may be that the person wants to talk out and solve a problem or wants only the quick fix of medication. Sometimes, the person is against using medication, even though there are significant symptoms and functional impairments that would benefit from medication. The patient should be invited to give feedback and ask questions throughout the session. The attentiveness of the APPN, the thought put into drawing the patient out in the session, and the perceptiveness of the responses made to patient comments set the pharmacotherapeutic alliance in motion when perhaps only very preliminary thought has been given to any possibility of medication by the patient. Many patients value

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reciprocity in interviews, and structuring a reciprocal interview style can be helpful. Others want a focused, businesslike interview with as little talk as possible. Part of the art of the intake interview is to ascertain through the process which style best suits the patient and helps the interviewer to obtain the most information. It is also an opportunity for the APPN to observe how the patient handles interpersonal interchanges and how successfully interpersonal exchanges are executed.

Timing with respect to scheduling appointments and introducing treatment options is important. It is useful to reflect to the patient the symptoms that have been articulated or the problems that have been identified. Conceptualizing the difficulty in diagnostic terms is done immediately, because a diagnosis must be made quickly in the current reality of insurance billing and payments. It is valuable to allow the patient as much opportunity to react to APPN diagnostic considerations as possible and to be as flexible as possible in response to the patient’s ideas. A patient in an emergency room or inpatient setting who is newly diagnosed and flagrantly psychotic may need medication first to help him or her regain emotional and behavioral control. A therapeutic interpersonal communication process can be conducted, and the manner in which this is done may aid the development and progression of a therapeutic prescribing relationship later. Even the sickest patient can eventually understand and remember caring and respect. A successful therapeutic relationship in the hospital can facilitate the patient’s transition and participation in outpatient treatment.

Outpatient settings may allow the APPN to be the most flexible with scheduling, choice of medications, and timing for medication changes. For example, the APPN may suggest that in view of certain symptoms that have been identified, a trial of a particular class of medications may be helpful and give the patient the opportunity to use psychotherapy more comfortably and successfully. It may also help the patient work with more confidence on some of the environmental or interpersonal issues identified in the session without the intense symptoms. The patient may disagree. The APPN may agree to give the patient time to consider the proposal if in his or her clinical judgment this is a safe option and the patient is willing. There is no time limit on waiting to prescribe, but the APPN must use clinical judgment in deciding how long to wait. Safety is the first priority. When psychotherapy is helping to alleviate symptoms and the patient’s functioning is demonstrably improving, the APPN may wait indefinitely. When it is clear that symptoms are increasing and the patient is deteriorating, the APPN may realize that the choice regarding whether to take medication is no longer an option.

Each state has its own laws governing mandatory commitment and mandatory use of medication (i.e., forcing the patient to take medication against his or her will if the risk indicates that this is necessary). It is important for the APPN to know the law in his or her state and to inform the patient in the initial assessment period that there are such laws made to protect patient safety and the safety of others. It is important that the patient understands from the outset that hospitalization may be required if medication is necessary to ensure the safety of the patient or others or in the event that medication is not successful in ensuring safety or the patient refuses to be treated with it. It is important to explain to patients that an agreement to proceed with treatment without the use of medication can change because there is interaction between internal physiology and the external stressors and because assessment of safety can change depending on the patients’ responses to those stressors.

One way for the patient to take control and participate in treatment is to make choices and changes through psychotherapy. Relief of symptoms through use of medication to treat physiologic symptoms may allow the patient to focus more on the work of psychotherapy, leading to a greater sense of empowerment. This approach can help to reframe medication and make it a means of empowerment rather than an instrument of outside control. The APPN who takes this approach is teaching the patient about the reciprocal action between psychotherapy and medication while also sharing power and information, conveying expertise and respect for the patient’s symptoms, and lending support to the choices the patient has made. Many authors have expressed concern that adding medication could reduce motivation to work on psychological understanding and changes as medication can reduce stress, depression, anxiety, and even psychosis, leaving the patient unwilling to work on changes.

The APPN should have completed a medical history in the assessment and can emphasize the positive aspects of that history and the areas for concern and the benefits and necessity of exercise, sleep, hygiene, healthy eating habits, and routine physical examinations. This can help prepare the patient for immediate or future medication usage while conveying concern about the patient’s physical as well as mental health and well-being. The patient who has had this type of initial interactive intake process may agree to try medication or may not but is more likely to come back to treatment and be willing to keep the options open because the APPN has used multiple relationship-building skills in the discussion. That is a big step for many patients entering psychiatric treatment. Patients are often already anxious about psychiatric treatment and may have many questions if the idea of medication is introduced—questions about side effects and other dangers, what

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people will think of them taking medication, and whether it will change their personality. Sometimes, the person needs validation or permission to take medication and may feel that he or she should be able to handle the problems without it.

When the patient agrees to take medication, it is necessary to provide information about the specific medicine, order preliminary or ongoing laboratory or other testing, instruct how to reach the APPN with questions or in an emergency, and explain what to expect during the medication trial process. All of this takes time, and the luxury of time is no longer available in health care. It may take two sessions to exchange all the information necessary in the orientation phase, but the goal is to reach a diagnostic impression and treatment recommendations at the first session. The optimal time for this assessment interview using the relationship- building skills in concert with the interview process should be no more than 75 minutes. This includes a cursory assessment of family history for medical, psychiatric, developmental, and substance abuse problems but does not include time for a full family dynamics assessment. The session needs to be focused but still allow time for some spontaneity and opportunity for the patient to interact with the APPN. Taking the extra time will save the patient a possibly negative experience and will make medication regimens more positive, acceptable, and successful.

The patient who has had medication prescribed should leave the office fully apprised of the plan negotiated by the APPN and the patient together, with written directions if wanted and a written date for the next visit. The timing of treatment sessions is established with the patient. The patient leaves with a sense of safety and trust in the competence and attitude of the APPN; a clear sense of boundaries in the session; a treatment plan for psychotherapy, if indicated; laboratory or other testing and referrals; medication treatment or recommendations for future medication; and a sense of being a valued person with reasonable ideas and questions. The patient who elects to wait before agreeing to take medication should leave feeling that the APPN accepts and respects his or her position. When the patient suggests that family members are opposed to medication or will think the patient is weak or otherwise hold negative ideas that influence the patient to reject medication, a goal of treatment would be to discuss the possibility of a family educative session. Patients can feel relieved to have a therapist/prescriber take on that sort of supportive role. It is also telling when the patient rejects that proposal and it indicates a need for further exploration over time.

Ongoing medication appointment scheduling occurs thereafter in response to an agreement that emerges from the APPN assessment of need, the patient’s agreement to take medication, and schedule demands. Payment mechanisms may play a role in this, and the APPN often sees the patient for short medication sessions, 15 to 30 minutes, after the initial full assessment if it is decided that psychotherapy will not be included in the treatment plan or when the patient has a psychotherapist elsewhere. Medication discussions may be incorporated into a 50- to 60-minute psychotherapy session as an integral part of the therapy or set off as a separate discussion at the beginning or end of a psychotherapy session. If the medication treatment is going well, with symptoms in remission, and the patient is accepting treatment, little discussion is needed during the session. However, it is always necessary to be aware of and reassess medication response, side effects, and the patient’s feelings and behaviors related to the diagnosis and medication treatment and any external events that may be affecting stress levels.

The pharmacotherapy session is an excellent opportunity to observe affect and to assess thought content. These sessions may need to occur weekly according to symptoms, prescribing needs, personality characteristics, and level of engagement of the patient. It is possible that prescribing sessions may be scheduled less and less frequently, until the time between appointments may be as much as 3 to 4 months. Boundaries must be established and monitored carefully in sessions that are planned for medication monitoring and assessment only. The content of these short sessions must be discussed with and agreed to by the patient because it is not uncommon for patients to expect more than can be delivered in such sessions.

Some patients want to be seen as infrequently as possible; some want to limit visits to once each year. Decisions are made on an individual basis beginning in the orientation phase of treatment and should be reconsidered in an ongoing manner thereafter. Patient wishes are considered as scheduling decisions are made as well as patient safety, reliability, trustworthiness, the extent and intensity of symptoms, comorbidities, safety factors related to the particular medications, the number of medications being prescribed, and engagement in other psychiatric treatment, when agreeing to long periods between visits. The timing of visits is based on the patient’s response to the medication as it affects mental status, level of function, and quality of life, and the willingness of the person to contact the APPN if problems develop. Justification for treatment plans, including the scheduling of medication visits, must be documented in the record.

The APPN needs to be cognizant of the fact that many managed care plans allow only a given number of psychiatric or mental health visits per year, and medication visits may or may not be part of that total number. It is important to educate the patient about the importance of knowing the terms of his or her own insurance

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plan and then to plan with the patient so that the total number of psychiatric or mental health visits does not exceed the total number allowed. Patients who have more than one provider of mental health services may not realize that the total number of sessions is cumulative across providers and can be devastated to realize that they have no more visits available for the year well before the year is through.

APPNs use the physician’s current procedural terminology (CPT) codes to get reimbursement for the type of treatment intervention that has been conducted (AMA, 2013). The CPT codes for psychiatry changed in 2013 and it is thought the new coding will better reflect the actual work that is conducted in treatment sessions. There are currently four 2013 CPT coding book publications authored by the American Medical Association (AMA) and available from AMA publishing as well as a data file on CD-ROM. The professional and standard coding books are all inclusive for the practice of medicine including psychiatry. For example, the professional edition has 912 pages and the standard edition has 690 pages. Chapter 19 provides information on reimbursement and documentation.

Working Phase

The working phase of the therapeutic prescribing relationship is short with hospitalized patients, and the orientation and working phases of treatment often are merged. Listening to difficulties associated with concerns about medications and helping to solve problems may be all that there is time for as well as encouraging feedback and questions and providing ongoing education to the extent that the patient is able and ready to receive it. It is important to know what the patient knows and still needs to know about the medications, their potential immediate effects (positive and negative), and the psychological reactions that may occur in response to them. Preparation for outpatient treatment may be facilitated by preparing a list with the patient of concerns and questions for the outpatient provider. Pharmacotherapeutic relationship work must be developed during this phase in preparation for engagement with an outpatient pharmacotherapist.

The working phase in outpatient treatment may go on for very long periods, with its intensity ebbing and flowing. The goals of treatment are articulated collaboratively and are redefined each time a change in treatment is contemplated, a patient change occurs, or problems develop. Patients may go along successfully for months or years taking maintenance doses of medication. They may be seen frequently at first in the working phase to work on psychotherapy issues and to closely monitor responses to medication and medication changes. The patient newly on medication and with interpersonal or environmental issues may need to be seen once weekly initially, and the frequency can be adjusted over time as responses and needs are reassessed together. The APPN must continue to exercise listening and observing skills and always be ready to readdress goals as patients experience remission and exacerbation of symptoms over time.

Patients may need medication adjustments: new titrations of existing medication, addition of a drug of a different class to treat new or more intense symptoms, a short course of minor tranquilizers, sleeping medications, or medications to reduce side effects during this phase of treatment. Sometimes, patients need only to talk about the way they are feeling and gain some mastery over life circumstances. Distinguishing between symptoms that require medication intervention and symptoms that can be dealt with psychotherapeutically requires technical skill, understanding of the patient’s personality dynamics, a sound relationship, and an ongoing dialogue with the patient. Some pros and cons of deciding to utilize pharmacotherapy to address emotional or behavioral distress and the pros and cons of deciding to add a psychotherapy method have been delineated by Szigethy and Friedman (2009). Adding pharmacotherapy can relieve symptoms and improve ego functions so that patients can engage in therapy, and benefits of pharmacotherapy could increase positive expectations of psychotherapy.

Some possible negative effects of introducing medication at the outset include patient concern that they cannot handle the problem, decreased motivation for psychotherapy when acute symptoms have been relieved with medication, and negative transference reactions. Medications can have negative impact on cognitive abilities and the risk of relapse on discontinuing can interfere with ongoing progress in psychotherapy. The authors suggest that adding psychotherapy can help with medication management, may increase expectations of medications, improve functioning, and decrease the effect of outside stressors as the patient gains self- understanding and more successful coping strategies. The APPN must consider the possible negative impact of utilizing psychotherapy exclusively, placing excessive stress on patients with biologically based illnesses and possibly leading the therapist to ignore or not notice biological symptoms, placing too much responsibility for change on the patient’s cognitive abilities.

It might be concluded over time that both interventions are necessary or that the patient can continue to

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make the determination within reasonable parameters. It may be that the degree of distress will be the deciding factor. One of the criticisms of psychiatric treatment has been the perception that medications are thrown at every symptom, and this is not an empty criticism. System settings and payment mechanisms often encourage medication as the first choice for treatment, and it may be the simplest solution in the short run. Clinical consultation in concert with dialogue with the patient is a useful and often a necessary means of exploring the best choice for intervention in these situations.

An appropriate model of psychotherapy must be chosen if the patient and therapist agree that talking therapy will facilitate recovery. During therapy the therapist/prescriber observes the patient’s ability to use the therapeutic relationship, respect the boundaries that have been set, the transference/countertransference issues that arise, the defense mechanisms that the patient employs, and the ways in which emotion is manifested. This is important not only as these relate to the patient’s life story and the relationship with the therapist/prescriber in the present context, but the degree of emotional and cognitive control the patient exhibits through this process can provide information about the need or the value of adding or changing medication in the treatment plan.

When medication has been chosen as the primary treatment it is best to add or change only one drug at a time if possible to see the results and prevent confusion about what is affecting change in the patient. It is useful to consider a different medication, if that is an option, before adding more medications to combat a side effect of a current medication. These options are discussed with the patient along with the risks and benefits of change versus adding another medication. A study conducted by Linden and Westram (2011) revealed that in the course of prescribing activity the content of conversation between the prescriber (psychiatrist) and the patient was primarily about case management, supportive reassurance, and alliance building. They call the content “psychiatric counseling and psychotherapy” and differentiated it from any specific psychotherapy which was uncommon in the pharmacotherapy sessions. They suggest that this might be a supportive encounter during the course of prescribing but not specific treatment. However, when medication assessment and prescribing are the main treatment modality it is quite possible that support and education and active listening may be the most important adjunctive treatment that can be offered.

All medication changes must be recorded and rationale given about why a medication was added or changed. It is easy in the often long and sometimes tumultuous working phase to forget to record seemingly minor events, such as those that may have been addressed by telephone. However, patient safety, treatment progress, and liability issues demand that this be done. Target symptoms and expected outcomes of the treatment should be included in the record, along with health status over the course of treatment and education that was provided for the patient about the drugs and the potential side effects.

Termination Phase

It is a commonly held idea that termination begins at the point of entry into treatment, and this principle holds in the case of integrated prescriptive and psychotherapy treatments. It may not be possible to predict the necessary duration of psychotherapy and pharmacotherapy because it depends on multiple variables, including diagnosis, history, interpersonal, and environmental factors, the individual taking the medication, the prescriber, and the time it takes for the illness to remit or improve. It also depends on whether the patient can remain in remission if the medication is discontinued for a trial period. However, it is possible to discuss patients’ expectations regarding the timeframe and to educate the patient about the usual duration of pharmacotherapy for different diagnoses and treatment regimens. This should be done from the outset. Patients often are concerned about having to take medication for the rest of their lives and the meaning and motivation behind that worry need exploration. This will be an ongoing issue for many patients through every phase of treatment, and a correct answer to the question does not exist.

The APPN must be cognizant of recommendations for the course of treatment for each class of drugs and should apprise the patient of them, but nothing of this complexity should be answered with certainty. It is quite certain that a diagnosis of schizophrenia or bipolar I disorder predicts the need for very long-term medication, perhaps for a lifetime, depending on mental status and level of function. Practice guidelines suggest that people diagnosed with major depression for the first time should plan to take medication for a year; for a second episode, 2 years, and for three episodes, with a strong family history, or other complicating factors, 3 or more. These recommendations have come under scrutiny as more is learned about the effect on the brain of disruption in neurotransmitters involved in mood disorders. Exploring the question is key to understanding patients and their ambivalences and expectations. The final answer is that no one knows for

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sure, but after weighing what is known about the illness and treatments, the safest answer may be that the medication should be taken for the foreseeable future and that the patient can be kept informed as the science evolves and as the patient progresses through treatment.

The patient may decide unilaterally to discontinue medication and it is important to consider the response to such an event according to diagnosis, symptoms, including judgment and insight, other ongoing treatment, stressors and coping status, quality of life, and strength of support system. For example, the APPN confronted with a patient with unremitting schizophrenic symptoms may, after exploring the patient’s reasons, educate the patient about potential pros and cons of this decision and suggest a second opinion before proceeding further in discontinuing the drug, or may work with the patient to make changes in offending medications and may also recommend a meeting with members of the patient’s support system to ensure adequate understanding and safety. The APPN may work with a depressed or anxious patient who wants to proceed without medication in some of the same ways but may be able to support the patient’s decision more readily once the patient clearly understands pros and cons, possible rebound effects, recurrent symptoms to watch for, and safety has been ensured. Breggin (2013) strongly supports discontinuation of psychiatric medications if possible and states that it is often patients’ and others’ anxieties about discontinuation that prolong drug treatment. He states that the success of therapy depends on patients being able to engage in responsible decision making about their own treatment and suggests several psychotherapy principles that are needed to help a patient in making such a decision and in working through the discontinuation process: a healing presence, empathy, and working with significant others. A plan for working through the emergence of any problems in a safe and effective way is also important and it is always highly recommended to have clinical consultation through the process.

Just as the APPN speaks to a patient in the engagement phase of psychotherapy by stating “for as long as I am working with you” the prescriber addresses time boundaries in the prescribing relationship in the engagement phase of the relationship by saying, “for as long as I am prescribing for you.” Questions about this comment deserve discussion and straightforwardness; for example, “Neither of us can say with certainty that we will work in or receive treatment in this setting forever, but I will inform you and give you 6 months’ notice to the best of my ability if I am going to leave so that we will have time to talk about it and make plans for you. I hope you also will give me some notice if you plan to leave.” Patients need explanation in integrated treatment that there may be different timelines and frequencies of sessions for conducting psychotherapy and psychopharmacology. For instance, the plan for psychotherapy may be short term or intermittent, and pharmacotherapy may be long term and constant.

The decision may be made by the APPN and the patient to end psychotherapy and medication based on achievement of goals. In that case, termination means an end of treatment altogether. The timing of termination of the two treatments is important, and they should not be terminated simultaneously if possible. Commonly, psychotherapy is phased out gradually as the patient successfully uses what has been learned in the treatment and demonstrates and feels mastery in his or her outside life. After that is accomplished, the process turns to the medications, and the patient may come in monthly for short, medication-focused visits. Medication changes should not occur as the termination process nears its conclusion. Termination should be a time for reviewing what the patient has accomplished with the medication, about what the possible outcomes of discontinuing the medication may be, feelings about experiences in medication treatment, and about termination. The patient should be encouraged to discuss fears and hopes and should understand that many mental illnesses can exacerbate after a period of remission, that there is no way to predict with complete accuracy the likelihood of a recurrence, and that a prompt return to treatment is valuable if illness recurs.

Serious symptoms during the termination phase may be an indication of feelings about terminating or may be an exacerbation of symptoms as medication is being discontinued. This requires further assessment, and if it is determined that symptoms are increasing in response to decreasing medication, the discharge plan should be reconsidered. The decision may be made to resume treatment and go back to the working phase of pharmacotherapy treatment or to discharge the patient to the PCP for longer-term medication management if the PCP is willing and the patient has an adequate relationship with him or her. This is a decision that can be made only in concert with the patient, and it may take weeks to decide. When symptoms in the termination phase are assessed and found to be related to the therapy termination with the prescriber or feelings about being well and not needing medication, the issues need to be addressed in time-limited, goal-directed psychotherapy before discharge.

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PRACTICE GUIDELINES

Practice guidelines for some psychiatric diagnoses have been created to help in clinical decision making, and they include strategies for prescribing psychotropic drugs. The American Psychiatric Association (APA) has developed practice guidelines, which may be helpful to prescribers and patients because they educate and answer questions about the purpose and duration of medication regimens (APA, 2006). The most recent edition of the practice guidelines is available in full text (APA, 2006), and a quick reference guide also is available (APA, 2006). The development of these guidelines is ongoing, and new and revised guidelines are regularly published by the APA. Guideline watches, which update and augment specific guidelines based on new and scientific developments, are available online on the Practice Guidelines page in the Psychiatric Practice section of the APA website (www.psych.org). APPNs may find these guidelines useful references in treatment decision making. The development process for each guideline seeks to ensure a reliable and valid product through rigorous scientific review of available literature, widespread review of drafts, and final approval by the APA Assembly and Board of Trustees (APA, 2006). However, these are guidelines, not standards of care. Ultimately, the prescribing plan must be based on clinical data and clinical judgment.

Psychiatric prescribing algorithms are useful sources of information about psychotropic medications. A Google search for these algorithms produced as many as 337,000 algorithm references for psychiatric medications. Knowing the source and the scholarship behind any algorithm that an APPN prescriber may consider is critical. One well-known and respected algorithm system is the Harvard Psychopharmacology Algorithm Project. Multiple references to this algorithm system and many others may be obtained by using Google to search under psychiatric medication algorithms. Box 15.3 provides three helpful websites.

BOX 15.3

SELECTED WEBSITES FOR PRACTICE AND PSYCHOPHARMACOLOGY

Texas Medical Algorithm Project: www.dshs.state.tx.us/mhprograms/TMAPtoc.shtm

Harvard Psychopharmacology Algorithm Project: http://mhc.com/Algorithms

American Psychiatric Association Practice Guidelines: www.psych.org

Pitfalls of Integrated Treatment

Integrated treatment presents its own unique treatment issues because the prescriber/psychotherapy is functioning in dual roles. The following example illustrates a particular type of problem. A long-term psychotherapy outpatient, for whom the therapist was also prescribing medication, was no longer making any progress in treatment or in daily life. There had been trials of many medications, and over time the patient had found a reason to stop each and every medication. The patient and APPN disagreed about the need to continue medication, with the APPN believing that the medication should be continued and having observational data to support that position and the patient insisting that the medication was of no value and was actually increasing the symptoms. An effort was made by the APPN to avoid a power struggle and negative outcome. The APPN suggested that an outside consultation for medication might be useful so that fresh eyes could examine the situation and make recommendations. The patient responded with the proposal that he transfer to the consulting prescriber for medication and continue to work in therapy with the APPN. His reason was that he liked the psychotherapy APPN because she was trying to get him to assert himself, and he felt understood and cared about, but he did not like the prescriber APPN because she was trying to get him to do what she wanted without regard for what he thought he needed.

The patient was clearly trying to find a way to get the treatment he wanted but might also have been picking up on a phenomenon that can be a problem when the psychotherapist is also the prescriber. Gutheil (1982) described this phenomenon as the mind–brain barrier when the prescriber psychotherapist must consider medication needs during psychotherapy. He said this was shifting gears from the psychotherapy role

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http://www.dshs.state.tx.us/mhprograms/TMAPtoc.shtm

http://mhc.com/Algorithms

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of nondirectedness to a prescribing role that is traditionally authoritarian and directive in nature. He suggested using the alliance with the patient to process differences and find mutually shared goals in meeting prescribing needs rather than becoming autocratic when the patient disagrees or is noncompliant with the plan. Ideally, those shared goals should be established in the engagement phase of therapy, but even when the goals are mutually established at that early stage, these issues can arise later on. The APPN must reflect on these occasionally conflicting roles in integrated treatment and be able to strike a balance that the patient can understand between the structured and sometimes authoritative stance required for pharmacotherapy and the more accepting exploratory role necessary for successful psychotherapy. The APPN in the previous example continued to clarify the issues, the differences in her style in addressing prescribing and psychotherapy, and worked toward teaching the patient that prescribing requires a more directive approach to ensure safety and progress in the context of care and support. Although these were difficult concepts for the patient to hold at the same time, he agreed to learn more about this way of thinking and to take the medication.

SPLIT TREATMENT

There is a frequent requirement in work places for advanced practice psychiatric mental health nurses to assume a prescriber role in what is commonly known in the mental health community as split treatment (Riba & Balon, 2005). Split treatment refers to a model in which one person manages medication and another manages other aspects of treatment (Tasman et al., 2000). This model of care and treatment occurs in many different settings, ranging from highly structured inpatient services to minimally structured outpatient settings. It has existed as a treatment model for many years in some settings. Historically, the physician or psychiatrist has been on the prescribing side of the split, and the APPN has been on the psychotherapist or other psychosocial care side of it. However, as nurses moved into the pharmacotherapist role in the 1990s, there was a switch to the prescribing side of the split. There is great challenge in successfully integrating psychotherapy and pharmacotherapy into an integrated model as described previously. Creating a successful collaborative/integrative model of delivering therapies in split treatment also has challenges. The triangular configuration in this model creates challenges in use of time, in finding ways to ensure clear and mutually agreed on goals and planning processes, and in recognizing the seemingly endless possibilities in which the players in the triad can interface and react to one another.

History of Split Treatment

The terminology on combining or integrating treatments originally came from the psychiatry literature, and it was first applied to the conceptual issues involved in combining pharmacotherapy with psychotherapy (Docherty et al., 1977; Karasu, 1982; Kay, 2001; Riba & Balon, 2005; Roose, 2001). The challenge then was integrating schools of psychotherapy, accepting pharmacotherapy as appropriate treatment, and finding ways to incorporate it into an integrated conception of psychotherapy (Beitman, 1991). Psychoanalysis and psychoanalytic psychotherapy were generally considered the ultimate approaches to mental health treatment, and the common wisdom in the psychoanalytic community was that medication would disrupt or destroy the psychoanalysis or psychotherapy process, preventing the patient from recovering. Some proponents of pharmacotherapy held that breakthroughs in the field of neurophysiology demonstrated that all that would be needed to treat mental illness was medication and that psychotherapy was totally unnecessary (Klerman, 1991; Roose, 2001).

Gradually, clinicians and researchers began to observe and collect data indicating that the two forms of treatment produced positive responses and that they could be mutually enhancing. Combining the two forms of treatment became common practice in most settings. Karasu (1982) discussed the benefits and possibility of delivering the two treatments in an integrated, mutually enhancing way, rather than a parallel or hierarchical way. Medication came to be viewed as improving interpersonal accessibility. It showed evidence of contributing to initiation and continuation of a therapeutic relationship and to other psychotherapeutic interventions.

Combining pharmacotherapy and psychotherapy has become a frequently used approach for the treatment of many mental illnesses. The combining of these two treatments has evolved in unanticipated ways. Original models for the delivery of the two forms of treatment were conceptualized as one person, a

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psychiatrist, delivering both services. The psychiatrists, the only prescribing professional group at the time, would be the providers for their patients psychotherapeutically and pharmacologically. This was not a workable model in many inpatient, partial hospitals, and other programs from the very beginning. Split treatment began to emerge early in those settings, albeit often informally and always in the context of a hierarchical model, with the psychiatrist as the final arbiter of all treatments. Today, split treatment is a common form of treatment delivery in most practice settings.

Collaborative Versus Parallel Split Treatment

Split treatment has often been administered in a contemporaneous or parallel but unintegrated manner, frequently with one of the treatments viewed as adjunctive to the other. Collaborative split treatment, defined as treatment provided by two or more clinicians who actively try to coordinate and integrate their respective treatments, could be expected to provide more effective outcomes in the split model (Ellison, 2005). Clinicians engaged in collaborative treatment must work with each other and with the patient to maximize benefits. It is even more challenging to integrate the treatments.

It is common to see split treatment in its unintegrated or noncollaborative form in outpatient practice because it can evolve almost unconsciously and easily, despite good intentions in many cases. For example, a psychotherapist may assess the need for medication in the course of psychotherapy and refer to an APPN pharmacotherapist who is already seeing a number of patients for medication and may want to continue to expand that part of practice. An agreement is reached that the APPN pharmacotherapist will assess the patient for medication, which is then independent of the psychotherapist. Medication may be prescribed if the assessment so indicates. There may be calls back and forth between the two therapists, and an informal plan for collaboration often is established. System issues and the business of busy practices often interfere with the two clinicians’ plan and good intentions, and they go on to function in a parallel but unintegrated way. Treatment can deteriorate under these circumstances; the patient becomes confused about goals and treatments and may be left to make decisions based on conflicting messages.

For example, a patient, referred to an APPN prescriber for medication assessment without any preliminary conversation between the psychotherapist and the APPN, was diagnosed by the APPN after the assessment was complete. The APPN suggested that the patient review literature on particular medications to treat this illness. The patient reported this information to his therapist, whom he has known for 1 year, and did this before the APPN initiated dialogue with the psychotherapist. She disagreed with the new diagnosis. The patient then did not follow through with the plan agreed to with the APPN and was not be willing to come back for the next appointment, a meeting in which there would have been an extensive review of the diagnostic and treatment proposals. In retrospect, the APPN realized that she should have discussed with the therapist their separate assessments and agreed on a diagnosis in a coherent, collaborative approach in order to engage the patient in a treatment plan. Time and even the treatment itself can be saved and anxiety vastly reduced for all parties when the dialogue occurs before the first visit to the second provider and before recommendations are shared with the patient.

There are other pitfalls of parallel split treatment. Among them are the dangers of misunderstandings among the providers and long lapses of time before they are identified and resolved as well as actual instances of splitting behaviors by certain patients.

Although a collaborative approach to split treatment is preferred and must be the goal in this model, it is often difficult to establish and maintain. There must be a concerted effort on the part of both providers and even patients when collaborative treatment is attempted, particularly in unstructured treatment settings such as in outpatient treatment. Systems issues, including time constraints, geography, and payment structures, can all create obstacles as multiple treaters attempt to provide collaborative split treatment. Resistance to acceptance of one or the other of these treatments by one or both providers still exists in subtle and not so subtle ways. These obstacles interfere with viewing prescribing and psychotherapy as two equally important and interreactive means of providing psychiatric and mental health treatment. The mind–body split has not been entirely healed (Kay, 2001) and Gabbard (2007) described split treatment as reinforcing Cartesian dualism where mind and body are artificially divided. Successful collaborative and integrated split treatment practice requires that the providers conceptualize mind and body in an integrated way. It demands placing equal value on psychological therapy and biologic therapy and taking time to ensure interaction, balance, coherence, and consistency between them.

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Choosing Split Treatment

The need for medication evaluation, prescribing, and management in addition to psychotherapy often exceeds the resources available to meet it. APPNs and physician groups are usually the licensed prescribers in a given state, and it may, in certain instances of patient demand or in certain settings, be a better distribution of prescriber time to meet the demand for medication evaluations than for the prescriber to try to meet the complete treatment needs of each patient. From a therapeutic standpoint, no single professional group can be trained in depth in all the psychotherapeutic, or pharmacologic treatments, and patients who are in need of specific treatment modalities such as cognitive behavioral therapy, dialectical behavioral therapy, psychodynamic, or interpersonal psychotherapy may need to see therapists other than the APPN if he or she does not specialize in that modality. However, psychotherapeutic skills must remain an integral part of split pharmacotherapeutic practice, just as they are for the APPN who only practices with an integrated approach.

Split treatment is commonly thought to be more cost-effective than the one-person model of treatment, but there is no clear evidence that this is so (Ellison, 2005; Gabbard, 2001). Although research has shown that the combination of psychotherapy and medication is more effective than monotherapy for some diagnoses (Riba & Balon, 2005; Weissman & Klerman, 1991), clinicians and researchers continue to examine the question of when split treatment should be considered the appropriate therapeutic choice rather than both psychotherapy and pharmacotherapy being delivered by one prescriber. Some study authors have suggested therapeutic rationale for choosing split treatment, but there are no fast rules about which patients are best served in split treatment, and practical reasons often are the deciding factors (Chiles et al., 1991; Ellison, 2005; Kay, 2001; Riba & Balon, 2005).

Characteristics of Split Treatment

Split treatment has been described as a two-person treatment model (Gabbard, 2001), the pharmacotherapy– psychotherapy triangle (Chiles et al., 1991), and the triadic alliance (Mintz, 2005). The players in this model include the patient, the psychotherapist, and the pharmacotherapist. It is common to think of split treatment as only three sided, but other combinations can occur (Tasman et al., 2000). For example, a patient may be in need of a group therapist and an individual therapist as well as a pharmacotherapist. Another possible split is a PCP who manages medical problems for a patient, who may also be in treatment with a pharmacotherapist and psychotherapist and be enrolled in a partial hospital program. An APPN pharmacotherapist may be working with one patient and one psychotherapist or may be working with many patients and psychotherapists in multiple permutations of the split treatment model.

The APPN works in collaboration with the PCPs, who are usually the primary care physician or primary care nurse practitioner. Helping the patient understand the need for information sharing and obtaining informed consent to share information back and forth is one of the first goals of treatment in both integrated and split treatment. It is educative for the patient when the APPN includes discussion of primary care and how to use those caregivers to ensure holistic care. Patients sometimes keep different aspects of health care separated and can greatly benefit in terms of seeing themselves more holistically and reaping the benefits of safe and integrated care when the caregivers in all specialties have a full-spectrum view of their health status. It is useful for the APPN to review medications, side effects, health status, and new health issues with PCPs. It is often helpful when considering medications to review a plan with the PCP for possible consequences of interaction with other medical conditions or medications, and it is always imperative to take any comorbid conditions that the PCP can elucidate into consideration in diagnostic decision making and treatment. Another perspective on patient symptoms from a PCP who may have known the patient well over time can be validating or raise new questions to examine. Patients often are able or become able to share information with PCPs themselves, and this is usually an action to be encouraged as they assume responsibility for their health, feel comfortable revealing psychiatric treatment they previously found embarrassing, and appreciate the need for integration of their health care.

Patients may be addressing multiple other health problems with other categories of providers and may be engaged in health promoting activities that involve complementary/alternative interventions or activities. The patient’s health and wellness care may be split in many ways among many providers. Securing information about the patient’s efforts in these areas is important in understanding the patient’s physical and mental status, degree of taking responsibility for health and well-being, and any efforts that may be deleterious to progress in regaining health. Tusaie (2013) describes weaving complementary/alternative approaches together with

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biomedical approaches to create a synergistic holistic way to maximize health. When either single-provider or split treatment is the chosen approach to delivering prescribing and psychotherapy services the provider(s) must be mindful of how many additional providers and treatments are involved with the patient. Sometimes discussion and goal setting with the patient and possibly family can result in coordination or prioritizing and even integrating multiple services.

APPN Practice Status in Split Treatment

The APPN is educationally and experientially prepared to provide expert pharmacotherapy and psychotherapy to patients. Nursing’s professional organizations have provided extensive and ongoing work on APPN scope and standards of practice in psychotherapy and pharmacotherapy (ANA, 1994). However, there is little available in the nursing literature on practice guidelines for split treatment in which the APPN serves as the pharmacotherapist. Split treatment demands awareness and skills that may be somewhat different or in addition to the basic expertise with which APPNs come to the psychotherapy or prescribing role. Riba and Balon (2005) have described competencies needed for delivering pharmacotherapy in split treatment for psychiatric residents, which may be useful for the APPN prescriber.

Skills of the Pharmacotherapist in Split Treatment

Split treatment can be a prescribing challenge for the APPN prescriber, who often sees the patient infrequently and for short medication visits after the first assessment. The prescriber may be only minimally aware of the patient’s activities of daily living, interpersonal relationships, and level of functioning. Patients can object to frequent pharmacotherapy visits when they are engaged in frequent psychotherapy visits, or they can begin to neglect the psychotherapy visits to make time to comply with medication appointments. There may be legitimate concerns about costs and insurance payments for these visits. Insurers have in some instances indicated a preference for pharmacotherapy over psychotherapy by paying more generously for medication visits and by making it easier to secure visits for prescribing than for psychotherapy.

Collaborative split treatment prescribing requires specialized core skills and treatment philosophy (Ellison, 2005). These skills include receptive attitudes, complementary approaches to treatment, and an understanding of and commitment to collaboration (Ellison, 2005). The APPN pharmacotherapist and the psychotherapist must be mutually and actively respectful of the work of the other and be flexible while at the same time being able to maintain clear boundaries to achieve this complementarity. Both clinicians need to appreciate and value both forms of treatment and understand how the treatments can complement and be synergistic with each another. Both respect the patient’s point of view.

Ellison (2005) suggests that the prescribers who propose to practice collaborative split treatment with each other learn the training, experience, and approaches of the other. In the course of the dialogue between them, the two clinicians can become more familiar with each other’s practice characteristics and more receptive to ongoing dialogue about the patient’s treatment plan. Alternatively, the two providers may decide that their practice styles or philosophy of treatment are too disparate. They may then agree that they cannot work together and make alternative plans before engaging a patient in a treatment process that could fail or be destructive.

One concern that must be clarified at the formation of every therapeutic triad in split treatment is the identification of the primary provider. There must be a person who can envision the whole picture and explain it to the patient, the person who makes the referrals and follows up on services and records. Sometimes, the distribution of responsibility for patient care and treatment is shared, but it is common practice for the psychotherapist to assume responsibility for much or all of the treatment, except in the medication domain. The pharmacotherapist has often functioned in an adjunctive role rather than as integral to the treatment and has assumed little involvement except to prescribe medications and often served as final arbiter in the decision-making process. Whatever model is chosen, the way it is set up and the accompanying responsibilities must be communicated to the patient, and the responsibilities of each must be clear to the patient and documented.

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Tools of Split Treatment

Tools used to operationalize and facilitate collaborative split treatment include the consultation request form and the collaborative treatment contract (Ellison, 2005). The collaborative treatment contract may be developed to describe the responsibilities of each clinician in the collaborative practice and to help establish clear and open communication. For example, after the medication consultation, a phone conversation between the APPN prescriber and the psychotherapist can be formalized in written form, delineating what each provider will be responsible for. This contract can then be shared with the patient and the referring psychotherapist for any modifications, and agreement should be procured with signatures of the APPN prescriber, the psychotherapist, and the patient. Clarity of treatment responsibilities in all types of prescribing practices is necessary for the patient and can relieve patient and provider anxiety. This protects the patient and the clinicians clinically and in terms of liability. It is particularly important to maintain practice clarity when two providers are involved in treating the same illness by different but complementary means. It is always necessary to have clear documentation and a paper trail if liability issues arise in any treatment process, and a meticulous paper trail is especially necessary in clarifying roles and responsibilities between the collaborating clinicians in split treatment.

Some of the documentation proposed in this chapter may be seen as too formal for some clinicians, but some means of establishing a plan for division of treatment responsibilities, ongoing communication arrangements between the clinicians, and the coverage plans that each has made for periods of unavailability should be established and documented. The patient is educated about the treatment model, the role of each clinician, and his or her own role. It is particularly important that clinicians are clear with each other and with the patient about channels of communication and the types of communication each will handle (Riba & Balon, 2001). The patient must be informed that the clinicians will engage in treatment discussions and planning, and a consent document agreeing to that communication should be introduced for signature. This would be an appropriate time for a discussion of confidentiality in general. Appendix 15.3 provides the consultation request form.

Timing

Timing, sometimes referred to as sequencing (Riba & Balon, 2005; Roose, 2001), of treatment modalities is carefully calibrated to achieve the goals of treatment. Timing of medication changes and other alterations must be based in part on the patient’s mental status, behaviors, and other communications as well as the events of the patient’s daily life, just as they are in any pharmacotherapy. These factors also are considered in relation to the progress and status of psychotherapy that is occurring simultaneously with a psychotherapist in another setting. The only way to orchestrate the timing of medication changes successfully in split treatment is to maintain open, frequent, and detailed communication with the psychotherapist and the patient as these changes are considered. Timing of visits can be established based on the factors discussed earlier. However, there must be particular attention in split treatment to boundary issues so that medication visits do not drain energy or material from psychotherapy. A patient’s requests for more or fewer visits than have been deemed necessary require exploration for meaning with the patient and may require discussion with the psychotherapist.

The psychotherapy and the pharmacotherapy affect each other as both are simultaneously affecting the patient. Cooperative communication between providers in coordinating care can enhance each treatment and enhance the quality of the combined treatments. The psychotherapist can greatly facilitate the patient’s engagement and continuing participation in pharmacotherapy and can refer the patient for more frequent monitoring if problems develop.

Shared Communication

Some patients may not want communication between therapists. A discussion with the patient about the need for mutual communication among all parties, including the patient, at the point of referral to or from the other therapist is mandatory because a patient’s negative response to it may necessitate finding alternatives to the collaborative treatment approach. The collaborating clinicians must agree on which one of them will

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present the terms of the triadic treatment relationship to the patient, and both must agree on the other’s approach to the treatment and support each other while remaining open to the patient’s input and questions.

Some clinical communications must be limited or redirected in split treatment (Ellison, 2005). For example, each of the therapists in the shared relationship respects and adheres to role boundaries established before this treatment model was operationalized. The APPN pharmacotherapist concentrates on medication-related issues and does not get involved in other issues that are meant for psychotherapy. Unseasoned APPN prescribers may assume that this means that questions about the person’s life should not be asked or that they should not allow the patient to digress from a single-minded discussion of medications. However, the APPN’s interest in the patient sharing something about his or her life facilitates engagement in a pharmacotherapeutic relationship, and it is a way for the APPN to unaffectedly assess the patient’s spontaneity, ability to relate, and ambivalence about treatment. This can be done in a relational and validating manner while maintaining the boundaries of the prescribing relationship. This type of relating can be very helpful in assessing the medication needs and attitudes of the patient and significant others about medications.

Patients may share information that the APPN prescriber believes belongs more appropriately in the psychotherapy. However, the APPN can redirect the patient and get his or her permission to inform the psychotherapist. The APPN must know the law with respect to sharing information among providers and the patient must be fully apprised of the law and clear about what and how information will be shared. This discussion must be documented in the record. When a patient will not allow sharing, the APPN must decide whether this precludes working in a split model of treatment. The psychotherapist would not be expected to advise on medications except to listen and support the patient’s concerns, refer the patient to the APPN prescriber, and discuss issues with the APPN prescriber when necessary and with the patient’s permission. It is also important for both clinicians to reflect on and explore the contribution of interpersonal dynamics in the triad when issues come up that are related to medications or psychotherapy. This can be a fruitful but difficult aspect of the split treatment model, and it demands good communication and good boundaries between the therapists and between therapists and patient. The patient must understand the clinicians’ boundaries with respect to the combined treatment before he or she can reasonably be expected to respect them.

Boundaries

The importance of boundary clarity can be demonstrated when a patient wants to communicate a secret to one of the therapists and wants it to be kept confidential between them. It may be that the patient is embarrassed to have the other therapist know certain symptoms, behaviors, thoughts, or feelings. There may be transference issues involved, or a medication problem or reaction may be shared in a medication session that the patient believes belongs with a medical person only. It could be a means of testing the APPN to see whether the information and the request for secrecy will be honored.

Whatever the motivation, an issue of this nature must be addressed immediately. A secret kept between two of three people in a triad creates one dyad and one outsider and can destroy trust and balance among the three, and that situation can destroy treatment. APPN prescribers and psychotherapists who have positioned themselves from the outset to deal with such a situation before it occurs will be able to deal with it in a therapeutic manner immediately. For example, the therapist asked to keep a secret can remind the patient of the agreement that information will be shared if it is seen as necessary to the treatment process or to the safety of the patient or others. When no contract regarding communication has been established, the time necessary to process the request for secrecy is often more than an APPN prescriber can give in the appointment time allotted. The issue can then go unresolved if the short answer or no answer is misunderstood by the patient. The psychotherapist is left out of the special dyad created by the secret shared by the other two and cannot be part of the problem-solving effort. One short-term solution is to again explain the nature of collaborative treatment arrangements in the hope of persuading the patient that sharing the information is important to the collaborative treatment process, assure the patient that his or her wish to maintain confidentiality will be respected if that remains his or her decision, and urge the patient to share with the psychotherapist, at a minimum, the fact that the request for secrecy has been made.

Life-threatening revelations must be revealed and dealt with immediately and create an exception to the plan described previously. Such measures handled in haste and after the fact have the potential to diminish the patient’s trust and confidence and can undermine the treatment process. In some cases, one episode can be instructive and will not destroy the treatment relationships, but these issues can be extremely destructive if

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such patterns continue. The APPN and psychotherapist can learn from one episode and establish boundaries and rules for the split treatment from that point on. Patients who are brought into the treatment-planning process from the outset, kept informed, encouraged to contribute, and agree to the treatment plan are more likely to understand the triadic relationship and have greater incentive to participate in the plan.

Psychological and Relational Aspects of Split Treatment Prescribing

Proficiency in the procedural aspects of split treatment prescribing is necessary to set up a collaborative split treatment plan to ensure clarity of boundaries, safety for the patient and clinicians, and to maximize the opportunity for a positive treatment process and outcome. Just as in integrated single-provider treatment, the APPN prescriber must be skilled in the psychological and relational aspects of prescribing. The APPN must convey in all prescribing scenarios the same sense of trustworthiness, safety, and competence. There must be expertise in listening skills, the ability to acknowledge the patient’s pain, in being empathic, and in encouraging, listening, and responding to feelings about illness and about medications to have a successful APPN–patient relationship. The split treatment model draws heavily on the APPN expertise in and exquisite appreciation of the art and science of collaboration. Collaborative skills are essential to ensure a successful triadic relationship, in part because there are three people wanting to achieve the same goal in very different ways and in part because of the possible transference–countertransference reactions among the three people. The ability and willingness to use these skills in a medication-focused role, to understand and work within a triadic relationship, and to keep that relationship central to the treatment, even during dyadic medication sessions, can be a challenge.

The APPN pharmacotherapist may find the split treatment role uncomfortable or frankly disagreeable at first, feeling that he or she must stay out of the relationship-building role as the prescriber. Understanding the psychological components of prescribing, using therapeutic relationship skills to maximize success in prescribing, and practicing within a strong collaborative model turn prescribing in collaborative split treatment into a distinctly nursing intervention.

Hierarchy or Mutuality Among Therapists in Split Treatment

There is a long history of physicians making split treatment a hierarchical model of treatment, with themselves at the top of the hierarchy. Physicians served as the final arbiter in all treatment-planning decisions but were generally distant from day-to-day treatment or involvement with patients aside from prescribing. Few challenges or questions were allowed or considered. Collaboration in the sense of sharing and planning among different but equally qualified professionals was unusual. The APPN in the prescriber role has the opportunity to contribute to and enhance the more collaborative model that has been evolving in split treatment and to better serve patients by maximizing contributions of all the clinicians involved, while being realistic about what is possible in the health care environment.

Model for Integrating Psychotherapy and Pharmacotherapy

A model that helps integrate psychotherapy and pharmacotherapy in single-person delivery of the treatments or in split treatment was proposed by Beitman (1991). This model clarifies and helps to structure the reciprocal relationship between the process of psychotherapy and using medications during psychotherapy. Medications function in ways that can support or inhibit development of a psychotherapeutic relationship and its objectives (Beitman, 1991). Four stages of psychotherapy are delineated: engagement, pattern search, change, and termination. He described six elements that occur in each stage: goals, techniques, content, resistance, transference, and countertransference. Medications are one of the techniques that may be used to help reach goals at every stage. For example, the patient may need effective medications or the hope of them to reach the goal of becoming engaged in treatment. Other patients may need time to engage before considering medication. Sometimes, discussions about medications can provide the means of engagement.

The pharmacotherapist watches for the patient’s unique emotional or intellectual reactions to

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medications to find a pattern. Personality characteristics and defensive positions in response to the variety of possible events and outcomes during medication trials can help to identify the patient’s typical patterns of behavior and relating and set the stage for introducing change possibilities. Medication-induced change occurs as medicine reduces symptoms and makes other changes possible and by using the meanings patients attribute to the medication to help them understand and change their behaviors. The ways that the patients deal with medication at the termination stage can contribute to insights into patient dynamics and behaviors. Patients can bring about termination over disagreements about medications. Sometimes, a therapist can orchestrate an early termination through aggressive use of medication, and medications sometimes are used to assist in the painful process of termination. The patient’s responses to medication at each stage and the resistance, transference, and countertransference related to medication that are observed at each of the four stages help establish a coherent conceptualization of the patient’s thinking and behaviors and give direction to all participants in the triadic relationship.

This model can be particularly useful in collaborative split treatment because it provides a common way to understand, organize, and share observations; creates a common language for understanding the patient’s current status in treatment; facilitates communication between the therapists; and guides them in working together in treatment planning. Other models may be developed to further integrate the two treatment modalities and facilitate the triadic relationship. The following case example introduces a patient to split treatment.

CASE EXAMPLE

Ms. T, a 45-year-old, single woman diagnosed with major depressive disorder, was referred to the APPN by her psychotherapist for medication evaluation. As reported to the APPN by the therapist, Ms. T was very attached to her psychotherapist, hostile to the APPN pharmacotherapist, and hostile to the idea of medication treatment. Anticipating a difficult period of engagement, the APPN invited feedback on the patient’s understanding of the purpose for the visit, feelings about the psychotherapist sending her in for a medication evaluation, and feelings about the APPN prescriber and medications. The entire first visit was devoted to this discussion, with some preliminary and very broad questions about the way she had been feeling and what measures she had taken to eliminate the feelings that had led the psychotherapist to suggest a medication evaluation. The APPN shared some information about how she works and how she thinks about medication use. She showed Ms. T the consultation/collaboration form that she uses to share information with the psychotherapist and emphasized the fact that the psychotherapist and she would be working closely if she would be willing to sign a consent form. The patient snapped that the psychotherapist had already shown her this form and that she had agreed to the collaboration. She signed the consent form for the APPN prescriber to collaborate. The APPN’s last comments in the session included an explanation about a mental status examination if Ms. T was willing to consider medication treatment. The APPN explained that this was necessary to do a complete medication needs assessment and urged Ms. T to think about the conversation and schedule a return visit after further discussion with her psychotherapist.

It was extremely helpful for the APPN to have had a preliminary conversation with the patient’s psychotherapist, who, in addition to diagnosis and history, described the hostility and explained that it had erupted just after the recommendation for the referral for medication evaluation. The psychotherapist had not gleaned the basis for the reaction from Ms. T. This conversation prepared the APPN for the difficult pattern of behavior and allowed her to prepare herself to be friendly, to be businesslike, and to interact without defensiveness. The APPN realized from the session that Ms. T needed to discuss the session with the psychotherapist and needed to get to the bottom of her hostile feelings before she could productively engage in a psychopharmacologic assessment or intervention. After Ms. T explored her thinking and reactions with the psychotherapist, she became much more open and available. Hostility was not her usual pattern of behavior. Ms. T did return for a second visit with the APPN prescriber, and instead of hostility, she presented with an explanation for her previous behavior. A grandparent had died in a psychiatric hospital after years of illness and multiple medications, and she feared that taking medications would mean that she was as ill and as powerless as her grandmother.

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The APPN began to understand the patient’s behavior patterns in terms of a defensive style when feeling threatened and her thoughtful and helpful explanation later after exploration with her psychotherapist. Ms. T was ready for the medication discussion, willing to engage in a mental status examination, and prepared to discuss alternative medications for treating the symptoms she revealed. She was given literature on the medications, complete answers to her questions about them, and some websites to investigate. Her psychotherapist reported to the APPN a day or two later that after a review, she was ready to use medication treatment, and Ms. T did return for the prescribing visit. The APPN worked in concert with the psychotherapist and the patient through the engagement phase, the emerging patterns of behavior, and the change phase of medication evaluation and treatment.

CONCLUDING COMMENTS

A competent prescribing APPN psychotherapist must have expertise in interviewing, assessment, diagnosis, prescribing, and psychotherapy. Knowledge about when to combine psychotherapy and medication and how to expertly combine/or integrate them into a synergistic whole that maximizes the benefits of both for the patient, is essential. The when and the how require knowledge of the empirical data available, a thorough evaluation of contributing factors including comorbid conditions, intensity of symptoms and suffering, accurate diagnoses, and a great deal of clinical judgment. There is an art to the if, when, and how to prescribe that can be nurtured and flourish by being firmly grounded in the intellectual knowledge above, engaging in ongoing clinical consultation, and by listening, observing, and engaging in therapeutic interpersonal dialogue with the patient. At the heart of every prescribing encounter is the APPN’s understanding of the strengths and pitfalls of integrated single-provider treatment; collaborative split treatment; and parallel split treatment, the ability to engage in a collaborative and reciprocal relationship with another therapist and a patient in a treatment triad; and skill in the art and science of creating and maintaining the therapeutic relationship. The goal of integrating treatment in split collaborative treatment requires continual time and attention; split parallel treatment is a great challenge to providers. The key to success in this form of triadic treatment is attention and openness to patient verbal and nonverbal communications and an agreement with the other provider that defined periodic updates in the interest of synergistic integration will be maintained.

McBride (1996) described psychiatric nursing as a means of helping the patient move toward mental health. Prescribing medications is an APPN intervention that can help patients move toward that goal. Medications can be prescribed in ways that enhance that movement or impede it. The APPN prescriber has the opportunity and responsibility to move the patient toward mental health holistically when serving the patient in a pharmacotherapist role only or when the APPN is the single provider for both psychotherapy and pharmacotherapy. Patients can be guided toward mental health mechanisms in both pharmacotherapy and psychotherapy through use of the therapeutic relationship, assessment of and education on maintaining boundaries, recognition of and working through transference, countertransference reactions, and defense mechanisms. An integrated synergistic psychotherapeutic delivery of the two treatments can improve the effect of both.

The discussion and recommendations in this chapter imply the luxury of infinite time to deliver the services that have been proposed and infinite financial resources to pay for them. That is in direct contrast to the reality of health care delivery thus far in the 21st century. Although compromises may have to be made, the APPN’s awareness and knowledge of the components necessary for successful psychotherapeutic prescribing can contribute to reshaping the delivery system into one that facilitates patient movement toward mental health. APPNs are an invaluable resource to the mental health care system in the successful delivery of these services. Shaping a delivery system that allows the APPN to deliver safe, effective integrated treatment that moves the patient toward mental health may ultimately require an increasingly proactive APPN approach to the delivery environment and to the sources of payment for the services.

DISCUSSION EXERCISES

1. Discuss advantages and disadvantages of single-provider, integrated psychotherapy and

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pharmacotherapy. 2. Discuss advantages and disadvantages of collaborative split treatment. 3. Discuss ways to ensure the patient the pharmacotherapy and psychotherapy he or she needs when

number of visits and fee schedule are limited by an insurance plan. 4. Discuss the practice constraints that interfere with collaborative treatment planning with other

providers in integrated, single-provider treatment and split treatment, and propose ways to successfully overcome those impediments.

5. Discuss the pros and cons of statutory requirements for collaboration or supervision with physicians.

6. Discuss the pressures on the APPN to serve patients in the prescriber role and the effect on the APPN role as nurse psychotherapist.

7. Discuss the use in APPN practice of core competencies and prescribing algorithms designed for physicians and psychiatrists. Should APPNs be developing their own competencies and algorithms?

8. Discuss the value and adequacy of the Standards of Psychiatric-Mental Health Clinical Nursing Practice (ANA, 2004; in press) for guiding APPN prescribing practice.

9. Discuss Beitman’s model as a means of providing reciprocity between psychotherapy and pharmacotherapy and common language between providers in split treatment. Design a nursing model to achieve these goals.

REFERENCES

American Medical Association. (2013). Current procedural terminology handbook (Standard Edition). Washington, DC: American Medical Association.

American Nurses Association, American Psychiatric Nurses Association, International Society of Psychiatric-Mental Health Nurses. (2007). Psychiatric-mental health nursing: Scope and standards of practice. Silver Spring, MD: American Nurses Association.

American Nurses Association Council on Psychiatric and Mental Health Nursing, American Psychiatric Nurses Association, Association of Child and Adolescent Psychiatric Nurses, Society for Education and Research in Psychiatric Mental Health Nursing (ANA). (1994). A statement on psychiatric-mental health clinical nursing practice & standards of psychiatric-mental health clinical nursing practice. Washington, DC: American Nurses Publishing.

American Psychiatric Association (APA). (2006). Practice guidelines for the treatment of psychiatric disorders compendium. Arlington, VA: American Psychiatric Publishing.

APA. (2006). Quick reference to the A.P.A. practice guidelines for the treatment of psychiatric disorders compendium. Arlington, VA: American Psychiatric Publishing.

Bailey, K. (1999). Framework for prescriptive practice. In C. Shea, L. Pelletier, E. Poster, G. Stuart, & M. Verhey (Eds.), Advanced practice nursing in psychiatric and mental health care (pp. 297–313). St. Louis, MO: Mosby.

Beitman, B. (1991). Medications during psychotherapy: Case studies of the reciprocal relationship between psychotherapy process and medication use. In B. Beitman & G. Klerman (Eds.), Integrating pharmacotherapy and psychotherapy (pp. 21–44). Washington, DC: American Psychiatric Publishing.

Breggin, P. (2013). Psychiatric drug withdrawal: A guide for prescribers, therapists, patients and their families. New York, NY: Springer Publishing Company.

Busch, F., & Sandberg, L. (2007). Psychotherapy and medication. New York, NY: The Analytic Press. Chiles, J., Carlin, A., Benjamin, G., & Beitman, B. (1991). A physician, a nonmedical psychotherapist, and a patient: The pharmacotherapy-

psychotherapy triangle. In B. Beitman & G. Klerman (Eds.), Integrating pharmacotherapy and psychotherapy (pp. 105–120). Washington, DC: American Psychiatric Publishing.

Docherty, J., Marder, S., Van Kammen, D., & Siris, S. (1977). Psychotherapy and pharmacotherapy: Conceptual lenses. American Journal of Psychiatry, 134(5), 529–533.

Ellison, J. (2005). Teaching collaboration between pharmacotherapist and psychotherapist. Academic Psychiatry, 29(2), 195–202. Gabbard, G. (2001). Combining medication with psychotherapy in the treatment of personality disorders. In J. Gunderson, G. Gabbard, J.

Oldham, & M. Riba (Eds.), Psychotherapy for personality disorders. Review of psychiatry (Vol. 19, pp. 65–94). Washington, DC: American Psychiatric Publishing.

Gabbard, G. (2007). Psychotherapy in psychiatry. International Review of Psychiatry, 19(1), 5–12. Grimaldi, D., & Cousins, A. (1998). Establishing a collaborative psychopharmacology practice: Practical considerations. Journal of Psychosocial

Nursing and Mental Health Services, 36(10), 32–35. Gutheil, T. (1982). The psychology of psychopharmacology. Bulletin of the Menninger Clinic, 46(4), 321–330. Jones, M., Bennet, J., Grey, R., Arya, P., & Lucas, R. (2006). Pharmacological management of akathisia in combination with psychological

interventions by a mental health nurse consultant. Journal of Psychiatric and Mental Health Nursing, 13(1), 26–32. Kaas, M., & Markley, J. (1998). A national perspective on prescriptive authority for advanced practice psychiatric nurses. Journal of the American

Psychiatric Nurses Association, 4(6), 190–198. Karasu, T. (1982). Psychotherapy and pharmacotherapy: Toward an integrative model. American Journal of Psychiatry, 139(9), 1102–1113. Kay, J. (2001). In J. Oldham & M. Riba (Eds.), Integrated treatment of psychiatric disorders. Review of psychiatry (Vol. 20, pp. xxi–xxii),

Foreword 1–27. Washington, DC: American Psychiatric Publishing. Klerman, G. (1991). Ideological conflicts in integrating pharmacotherapy and psychotherapy. In B. Beitman & G. Klerman (Eds.), Integrating

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nursing: Integrating the behavioral and biological sciences (pp. 1–9). Philadelphia, PA: W. B. Saunders. Markowitz, J. (2008). When should psychotherapy be the treatment of choice for major depressive disorder? Current Psychiatry Reports, 10, 452–

457. Murawiec, J. (2009). Psychodynamic psychotherapy concept by D. Mintz and B. Belnap–discussion of the discipline in relation to treatment

resistant patients. Archives of Psychiatry and Psychotherapy, 1, 61–68. Mintz, D. (2005). Teaching the prescriber’s role: The psychology of psychopharmacology. Academic Psychiatry, 29(2), 187–194. Peplau, H. (1952). Interpersonal relations in nursing. New York, NY: Springer Publishing Company. Phillips, S. (2006). A comprehensive look at the legislative issues affecting advanced nursing practice. The Nurse Practitioner, 31(1), 6–38. Phillips, S. (2013). Evidence-based practice reforms improve access to APRN care. The Nurse Practitioner, 38(1), 18–42. Riba, M., & Balon, R. (2001). The challenges of split treatment. In J. Oldham & M. Riba (Eds.), Integrated treatment of psychiatric disorders.

Review of psychiatry (Vol. 20, pp. 113–116). Washington, DC: American Psychiatric Publishing. Riba, M., & Balon, R. (2005). Competency in combining pharmacotherapy and psychotherapy: Integrated and split treatment (core competencies in

psychotherapy). Washington, DC: American Psychiatric Publishing. Roose, S. (2001). Psychodynamic therapy and medication: Can treatments in conflict be integrated? In J. Kay, J. Oldham, & M. Riba (Eds.),

Integrated treatment of psychiatric disorders. Review of psychiatry (Vol. 20, pp. 31–49). Washington, DC: American Psychiatric Publishing. Snowden, A., & Tusaie, K. (2013). Shared decision-making: Concordance between psychiatric mental health advanced practice nurse and

client. In K. Tusaie & J. Fitzpatrick (Eds.), Advanced practice psychiatric nursing: Integrating psychotherapy, psychopharmacology and complementary and alternative approaches (pp. 12–25). New York, NY: Springer Publishing Company.

Sussman, N. (2009). General principles of psychopharmacology. In B. Sadock, V. Sadock, & P. Ruiz (Eds.), Kaplan and Sadock’s comprehensive textbook of psychiatry (9th ed., Vol. II, pp. 2965–2988). New York, NY: Wolters/Kluwer/Lippincott Williams Wilkins.

Szigethy, E., & Friedman, E. (2009). Combined psychotherapy and pharmacology. In B. Sadock, V. Sadock, & P. Ruiz (Eds.), Kaplan and Sadock’s comprehensive textbook of psychiatry (9th ed. Vol. II, pp. 2923–2932). New York, NY: Wolters/Kluwer/Lippincott Williams Wilkins.

Summers, R., & Barber, J. (2010). Psychodynamic therapy: A guide to evidence-based practice. New York, NY: Guilford Press. Tasman, A., Riba, M., & Silk, K. (2000). The doctor-patient relationship in pharmacotherapy: Improving treatment effectiveness. New York, NY:

Guilford Press. Tusaie, K. (2013). Synergy of integrative treatment. In K. Tusaie & J. Fitzpatrick (Eds.), Advanced practice psychiatric nursing: Integrating

psychotherapy, psychopharmacology and complementary and alternative approaches (pp. 27–35). New York, NY: Springer Publishing Company. The National Panel. (2003). Psychiatric mental health nurse practitioner competencies. Retrieved from www.nonpf.com Weissman, M., & Klerman, G. (1991). Interpersonal psychotherapy for depression. In B. Beitman & G. Klerman (Eds.), Integrating

pharmacotherapy and psychotherapy (pp. 379–394). Washington, DC: American Psychiatric Publishing.

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Collaborative Agreement

The following mutually agreed on collaborative agreement shall form the basis of a prescribing relationship between _____________ APRN and __________ MD, wherein the APRN may prescribe and administer medical therapeutics and corrective measures, and may dispense drugs in the form of professional samples.

1. The categories of medical therapeutics, corrective measures, laboratory tests, and other diagnostic procedures, which may be prescribed, dispensed, or administered by the advanced practice registered nurse (APRN) are as follows: (a) Medications, which may include but are not limited to antidepressants, antipsychotics,

anxiolytics/hypnotics, mood stabilizers, antihistamines, and antiparkinsonian drugs. (b) Laboratory tests, medical therapeutics, diagnostic procedures, and treatment that are commonly

performed in the assessment and treatment of psychiatric disorders. 2. Periodically, the APRN will randomly select cases for review with the collaborating physician. The purpose

will be to review patient outcomes including a review of medical therapeutics, corrective measures, laboratory tests, and other diagnostic procedures that may be prescribed, dispensed, and administered by the APRN.

3. Schedule II and III drugs may be prescribed by the APRN. Patients receiving these medications will be reviewed in the same manner as in Section 2.

4. A registered nurse may take orders for medical therapeutics, corrective measures, laboratory tests, and other diagnostic procedures from an APRN under the supervision of a collaborating physician.

_____________________APRN Date:_______ _____________________MD Date:_______

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Collaborative Agreement (Optional Language Added)

Advanced practice registered nurse (APRN) collaborative agreement for the outpatient setting. This form is proposed as a guideline for advanced practice registered nurses in developing a collaborative

agreement for their prescribing practices. It is not an authorized standard of practice, nor is it a legal document. The Connecticut Society of Nurse Psychotherapists bears no responsibility for its use.

The following mutually agreed on collaborative agreement shall form the basis of a prescribing relationship between _________ APRN and _____________ MD, wherein the APRN may prescribe and administer medical therapeutics and corrective measures, and may dispense drugs in the form of professional samples.

1. The categories of medical therapeutics, corrective measures, laboratory tests, and other diagnostic procedures, which may be prescribed, dispensed, or administered by the APRN are as follows: a. Medications, which may include but are not limited to antidepressants, antipsychotics,

anxiolytics/hypnotics, mood stabilizers, antihistamines, and antiparkinsonian drugs. b. Laboratory tests, medical therapeutics, diagnostic procedures, and treatment that are commonly

performed in the assessment and treatment of psychiatric disorders. 2. Periodically, the APRN will randomly select cases for review with the collaborating physician. The purpose

will be to review patient outcomes, including a review of medical therapeutics, corrective measures, laboratory tests, and other diagnostic procedures that may be prescribed, dispensed, and administered by the APRN.

3. Schedule II and III drugs may be prescribed by the APRN. Patients receiving these medications will be reviewed in the same manner as in Section 2.

4. A registered nurse may take orders for medical therapeutics, corrective measures, laboratory tests, and other diagnostic procedures from an APRN under the supervision of a collaborating physician.

5. Consultation and referral shall be on a case-by-case basis as deemed appropriate by the APRN. 6. Coverage for patients during nonoffice hours and vacations will be arranged by the APRN. 7. There will be a method of disclosure to the patient of the MD–APRN collaboration.

_____________________APRN Date:_______ _____________________MD Date:_______ Connecticut Society of Nurse Psychotherapists (2000).

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Pharmacotherapy Consultation and Collaboration Request Form

_______________________________________________________ Psychotherapist’s request: Date of consultation request:________________________________________ Patient’s name:________________________________________ Date of birth:________________________________________ Patient’s phone number:________________________________________ Psychotherapist/requester name:________________________________________ Psychotherapist address:________________________________________ Psychotherapist’s phone number:________________________________________ Symptoms of concern leading to consultation request: Pertinent history: Desired outcome of consultation:

Assessment for appropriateness of pharmacotherapy? Second opinion on current pharmacotherapy? If so, how has current pharmacotherapist been involved in planning this consultation? Request for collaborative follow-up treatment?

_________________________________________________________ Psychotherapist’s signature and date: Consultant’s response: Brief history of present illness (can include data such as target symptoms, pertinent negatives, current treatments): Pertinent past psychiatric history (can include such data as past psychiatric hospitalizations, medication history, substance abuse history, past suicidal or violent behavior): Medical history (can include such data as current medications, known illnesses, past operations, use of caffeine/tobacco/alcohol, diet, activity, allergies, PCP, and recent examinations or labs): Family history of mental illness: Current mental status examination (can include comments on appearance, alertness, language, affect, mood, thought process, and content, any specialized examinations or rating scale scores, assessment of dangerousness or of risk for suicidal behaviors): Consultant’s diagnostic assessment: Consultant’s recommendations regarding treatment: Discussion of follow-up and medication instructions with the patient (can include data such as which side effects were discussed, whether consent was obtained for discussion with psychotherapist/PCP/others, any limitations on communications requested by the patient, and follow-up plans): Signature of consultant:____________________ Date:__________________ Printed name of consultant:________________________________________ Consultant’s phone number:________________________________________

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Psychotherapeutic Approaches for Addictions and Related Disorders SUSIE ADAMS DEBORAH ANTAI-OTONG

oping with life stressors is an inevitable part of the human experience. Anxiety, depression, loss, neglect, illness, chronic pain, trauma, or other life stressors can result in dysregulation of the individual—

physiologically, emotionally, cognitively, interpersonally, and spiritually. From infancy onward, biopsychosocial factors drive one’s attempts to “self-soothe” or self-regulate feelings, thoughts, and emotions in response to the world around us. The use of mood altering substances and mood altering behaviors can be viewed as the individual’s attempts to “self-soothe.”

The cultural, social, and legal context frame the degree of acceptance of any given behavior or use of substances. Nicotine, caffeine, and alcohol are legally and socially accepted. The use of prescription anxiolytics, analgesics, opioids, sedatives, hypnotics, and stimulants is condoned when properly prescribed and used as directed to manage various conditions. Gambling, computer gaming, sexual intimacy, running marathons, Internet use, and shopping are socially acceptable behaviors. Although heroin and cocaine remain illicit substances, the legalization of marijuana for first medical use in over 17 states and more recently legalization for recreational use in Colorado and Washington are shifting the boundaries of what are considered illicit substances of abuse and addiction. It is the misuse, excessive use, dependence, and ultimately the inability to control one’s use of mood altering substances or mood altering behaviors that are problematic.

Historically, addiction has been defined as the compulsive need for and use of a habit-forming substance (such as heroin, nicotine, or alcohol) characterized by tolerance and physiological symptoms of withdrawal and recognized to be physically, psychologically, or socially harmful (Merriam-Webster, 2012). There is growing recognition among researchers that a compulsive behavior can stimulate the same reward system in the brain that leads to pleasurable or “self-soothing” sensations similar to mood altering substances (Grant, Brewer, & Potenza, 2006). The individual becomes addicted to the behavior and the associated pleasurable feeling brought about by the particular behavior such as gambling, Internet pornography, exercise, or sexual behaviors. These compulsive behaviors are sometimes categorized as process addictions.

The purpose of this chapter is to present an integrated model of care supported by evidence-based psychotherapeutic interventions that facilitate lifelong recovery for individuals with substance and behavioral addictions. Pharmacological interventions for substance addictions, while well supported by research and clinical practice, are beyond the scope of this chapter. An overview of the prevalence, health risks, and the financial burden of addictive disorders provides a compelling context for addressing this global health problem. A discussion of DSM-5 criteria for addictions and related disorders provides a new context for understanding what was previously confined to substance use disorders (SUDs) in the DSM-IV- TR (American Psychiatric Association [APA], 2013). Definitions of key terms including addiction, SUDs, behavioral addiction, relapse, and recovery are followed by a brief synopsis of causative factors (neurobiology, behavioral, and psychosocial factors). Principles of comprehensive treatment components are presented followed by screening and assessment tools and a discussion of evidence-based psychotherapeutic interventions. The chapter concludes with a case study that demonstrates an integrated person-centered treatment approach.

OVERVIEW OF ADDICTIONS

Prevalence

The abuse of illicit and licit psychoactive substances is a serious U.S. and global public health problem. Table

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16.1 and Table 16.2, respectively, provide a synopsis of the prevalence, health risks, and economic burden of addictions worldwide and in the United States. Despite regional differences, worldwide, alcohol causes greater harm to men (6% of deaths, 7.4% of disability-adjusted life years [DALYs]) than women (1.1% of deaths, 1.4% of DALYs) reflecting gender differences in quantity, frequency, and patterns of drinking (WHO, 2009; Wu, 2010).

TABLE 16.1 Worldwide Prevalence, Health Risks, and Economic Burden of Addictions

1WHO (2009). 2Institute of Alcohol Studies, UK (Baumberg, 2006). DALYs, disability-adjusted life years.

According to data from the U.S. National Survey on Drug Use and Health (NSDUH), the use of illicit and licit psychoactive substances has been on the rise between 2002 and 2011 across most age categories and for most substances (Substance Abuse and Mental Health Services Administration [SAMHSA], 2002, 2012). The steady rise in the amount of use, binge use, and heavy alcohol use from high school into the college years is significant. See Figure 16.1 for current alcohol use, binge drinking, and heavy drinking patterns by age group. Epidemiological studies indicate that delaying the age of initial alcohol use until after the age of 14 years can significantly decrease lifetime risk of subsequent alcohol abuse and dependence (DeWitt, Adlaf, Offord, & Ogborne, 2000). Individuals who start to drink at age 11 or 12 years are nearly 10 times more likely to become alcohol dependent than those who started drinking later (ages 19 and older) (DeWitt et al., 2000). Other researchers have found that individuals who experienced two or more adverse childhood events also have a 1.37 greater lifetime risk for lifetime alcohol dependence than individuals who had no adverse childhood events (Pilowsky, Keyes, & Hasin, 2009).

TABLE 16.2 U.S. Prevalence, Health Risks, and Economic Burden of Addictions

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*Binge drinking is defined as having five or more drinks on one occasion at least one time during the past month. **Heavy drinking is defined as having five or more drinks a day with binge drinking during the past month. 1SAMHSA (2012). 2Kessler et al. (2005). 3Chou, Huang, Goldstein, and Grant (2013). 4Surgeon General’s Report (2004). 5ONDCP (2004).

There are a number of “at-risk” populations within the United States where even higher prevalence of SUDs occurs. These include survivors of emotional, physical, and sexual abuse, people with physical, sensory, or cognitive disabilities, people who live with chronic pain, people with depression, people who are unemployed, have limited education and low socioeconomic status, and people with military combat service (SAMHSA, 2011a). Since the U.S. financial crisis in 2008, unemployment rates have soared along with concomitant home foreclosures, loss of health care coverage, and economic insecurity. These socioeconomic stressors have historically been associated with increased risk for alcohol and substance use problems. Increasingly, news reports highlight the increasing suicide rates, posttraumatic stress disorder (PTSD), traumatic brain injury, substance abuse, and domestic violence among returning military and veterans serving in over a decade of war in Iraq (Operation Iraqi Freedom [OIF]) and Afghanistan (Operation Enduring Freedom [OEF]). A recent Institute of Medicine (IOM) report on military personnel found that 20% engage in heavy drinking and 47% in binge drinking (Pittman, 2012).

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FIGURE 16.1 Current, binge, and heavy alcohol use among persons (age 12 years and older) by age group. Adapted from NSDUH (2011).

Coexisting SUDs, psychiatric and medical disorders are linked to adverse or poorer treatment outcomes, decreased quality of life, marked disability, and higher health care utilization including emergency and crisis services. Predictably, coexisting disorders destroy social and work relationships; correlate with increased intimate and family violence; and contribute to unstable housing, legal problems, and poverty, particularly when compared to having a single diagnosis (Prisciandaro et al., 2012).

The complexity of coexisting SUDs, and psychiatric and medical disorders makes detection, accurate diagnoses, and formulation of appropriate treatment planning a challenge for both primary care providers and mental health specialists (Hasin & Kilcoyne, 2012). Failure to accurately diagnose these conditions is a barrier to timely access and specialized treatment for SUDs. These diagnostic challenges coupled with the stigma associated with SUDs are reflected in the disparity among the 21.6 million Americans (8.4% of the population) who reported alcohol and drug intake, indicating the need for specialized SUD treatment, and the 2.3 million (10.7% of the population) who actually received treatment in 2011 (SAMHSA, 2012).

Prevalence statistics and comorbidities can never aptly convey the emotional, physical, financial, and spiritual toll on the individuals and their families who struggle with addictive disorders. Substance abuse erodes the fabric of family life, meaningful relationships, and sows the genetic, psychosocial, and intergenerational seeds of addiction within the family. Although no single model has been identified for treating SUDs, three decades of research in this field provide increasing evidence of positive outcomes related to integrated treatment approaches that focus on principles of cognitive behavioral therapy (CBT), contingency management (CM), mindfulness, motivational interviewing (MI), and couple and family therapy along with pharmacotherapy. Early screening and detection of SUDs, assessing and encouraging motivation to change, and engagement in person-centered approaches that facilitate active participation in treatment planning and lifelong recovery are critical components of an integrated recovery model.

Addiction Concepts and Definitions

As previously mentioned, the concept of addiction has expanded to include both substance and behavior addictions. While sources such as the National Institute on Drug Abuse (NIDA) and the National Institute of Alcohol Abuse and Alcoholism (NIAAA) adhere to definitions focused solely on SUDs, the American Society of Addiction Medicine (ASAM) has broadened their definition of addiction to include substance use and other behaviors.

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. (ASAM, Public Policy Statement, 2011)

DSM-5

Although the DSM-IV-TR (2000) diagnostic criteria focused exclusively on drug or substance use and distinguished between disease categories of substance abuse and substance dependence, the DSM-5, released in May 2013 by the American Psychiatric Association, eliminates the distinction between abuse and dependence and broadens the diagnostic criteria to include “substance-related and addictive disorders” that includes the new category of “behavioral addictions.” Pathological gambling is the only currently recognized behavioral

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addiction in the DSM-5, although this suggests that other behavioral disorders may be added in the future. Other behaviors such as sex, eating, shopping, and Internet use have the potential to become addictive and destructive. They were considered for inclusion in the DSM-5 (APA, 2013); however, these behaviors have been referenced within the appendix pending further research (Bickman, 2011; Curley, 2010; Markel, 2012).

The DSM-5 criteria for addiction combine the 11 criteria previously used for abuse and dependence in DSM-IV-TR, while eliminating the criterion of “substance-related legal problems” because this can no longer be uniformly applied across different states in the United States and internationally. The DSM-5 lowers the diagnostic threshold requiring that only two of the criteria be met to satisfy the diagnostic category of “substance use disorders,” although there must be a maladaptive pattern of substance use or behavior that leads to clinically significant impairment or distress occurring at any time in the same 12-month period and two of the other diagnostic criteria from DSM-IV-TR:

Failure to fulfill major role obligations at work, school, or home Recurrent substance use or behavior in situations in which it is physically hazardous Continued use or behavior despite having persistent recurrent social or interpersonal problems caused or exacerbated

Tolerance Withdrawal Substance use in larger amounts or substance/behavior used over longer periods than intended Persistent desire or unsuccessful efforts to cut down or control use Great deal of time spent obtaining or pursuing Cravings or urges to engage in behavior or use substance Important social, occupational, or recreational activities are given up or reduced Behavior or substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that interferes with functioning

The criteria of “tolerance” and “withdrawal” in the DSM-IV-TR, respectively, denote increasing amounts of a substance needed to achieve the same desired effect and characteristic signs and symptoms when a particular drug/substance is discontinued. However, withdrawal symptoms can also be seen when medications such as beta-blockers or antidepressants are discontinued. Pharmacological withdrawal is a normal physiological response to the discontinuation of the medication and not the same as addiction, which refers to the loss of control over the intense urges to take the drug even at the expense of adverse consequences (O’Brien, Volkow, & Li, 2006). There is considerable debate about unintended consequences that may ensue from lowering the diagnostic threshold for addictions, the implications for screening and access to treatment services, and the use of the term addiction versus the more neutral terms of abuse or dependence (Bickman, 2011; Curley, 2010; Markel, 2012).

Allen Frances, who chaired the DSM-IV task force and was a member of the DSM-III-R Task Force, voices his concern about collapsing the previously separate categories of substance abuse and substance dependence into one category of substance use disorders. Allen suggests that beyond increasing stigma, this collapsed label sends the wrong message to individuals who abuse substances that they are among the “addicted” (Frances, 2013). This message connotes that the substance already controls his or her life; that it will be quite difficult to give up the substance; that this is biologically determined by genetic fate and beyond an individual’s control, thereby diminishing personal responsibility for substance use and its consequences (Frances, 2013). Frances suggests that clinicians continue to use the approved ICD-9 codes or ICD-10 to be implemented by 2014, which continue to distinguish between substance abuse and substance dependence codes (Frances, 2013).

Relapse

Relapse is the recurrence or return to substance use or addictive behaviors after periods of abstinence. Relapse is a persistent risk in addiction and can be triggered by exposure to the addictive/rewarding substances and behaviors, exposure to conditioned environmental cues, and by exposure to emotional stressors that trigger increased activity in the brain circuitry and the neurotransmitters involved. These three modes of relapse are supported by a body of neuroscience research: (a) drug or reward-triggered relapse, (b) cue-triggered relapse, and (c) stress-triggered relapse (ASAM, 2011).

It is important to recognize that relapse is not unique to addiction disorders; rather it is

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characteristic of all chronic medical diseases. The relapse rate for drug addiction at 40% to 60% compares as well or better to the relapse rates for other chronic diseases when considering adherence to medication: type 1 diabetes at 30% to 50%, hypertension at 50% to 70%, and asthma at 50% to 70% (McLellan, Lewis, O’Brien, & Kleber, 2000). Relapse is not a treatment failure but an indicator that renewed and tailored intervention is needed.

Recovery

Although initial definitions of recovery applied to alcohol and drug problems, the most recent definition applies to recovery from mental disorders and SUDs and aptly applies to behavioral addictions as well:

Recovery is a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. (SAMHSA, 2011b)

According to behavioral health leaders including individuals in addiction recovery and mental health consumers, recovery is considered a lifelong process that encompasses four major dimensions:

1. Health—overcoming or managing one’s disease(s) as well as living in a physically and emotionally healthy way

2. Home—a stable and safe place to live 3. Purpose—meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative

endeavors, and independence, income, and resources to participate in society 4. Community—relationships and social networks that provide support, friendship, love, and hope

(SAMHSA, Recovery Support Strategic Initiative, 2011b)

During the past decade, SAMHSA and Center for Substance Abuse Treatment (CSAT) have convened summits and national conferences to develop and refine a consensus understanding of the recovery process (CSAT, 2009; Gaumond & Whitter, 2009; SAMHSA, 2011b; Sheedy & Whitter, 2009) informed by the Guiding Principles of Recovery (see Table 16.3).

Etiology

There are many pathways to addiction and multiple interacting factors that contribute to the etiology of both substance use and behavioral addictions. Although addiction is now recognized as a primary disease of the brain’s neurocircuitry (Feltenstein & See, 2008; NIDA, 2010), genetic factors account for roughly half the likelihood that someone will develop an addiction (Prescott & Kendler, 1999; Schuckit et al., 2001). Environmental factors, culture, and an individual’s personal resilience all interact with predisposing genetic vulnerabilities to further influence the likelihood and emergence of addictive behaviors or substance use. Many people experiment with alcohol and substance use in their teens and early 20s with the majority using alcohol in moderation, typically in social settings over the course of a lifetime. An estimated 15% to 20% of users adopt regular or frequent use of alcohol and/or drugs, such as marijuana, cocaine, or other illicit drugs several times a week to cope with stress, and mask or manipulate undesired feelings such as guilt or sadness. This second stage pattern of use has been recognized as “abuse” but did not meet criteria for “dependence” in the DSM-IV-TR. An estimated 5% of substance users’ progress to the third stage pattern of use, or “dependence,” entails daily or nearly daily use, life centered on obtaining the alcohol or substance, using it, or recovering from its effects (withdrawal symptoms) to the detriment of family, work, school, and other social obligations despite increasing negative consequences. In this final stage of addiction, recognized as “dependence,” the person’s life and use of the alcohol or substance are entirely out of control. The cravings and urges are biologically and psychologically driven at this stage. They have lost their sense of personal integrity and self- esteem. They will resort to any means to obtain the alcohol or drugs, including prostituting, pimping, selling drugs, selling their children for adoption, prostituting their children … anything to get the next fix. The personal despair, self-loathing, and sense that God (or higher power) could never forgive them or love them as human beings are common. Thus, we have come to appreciate the bio-psycho-social-spiritual factors that contribute to the development of addictions.

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572TABLE 16.3 Guiding Principles of Recovery Recovery emerges from hope: The belief that recovery is real provides the essential and motivating message of a better future—that people can and do overcome the internal and external challenges, barriers, and obstacles that confront them. Recovery is person driven: Self-determination and self-direction are the foundations for recovery as individuals define their own life goals and design their unique path(s). Recovery occurs via many pathways: Individuals are unique with distinct needs, strengths, preferences, goals, culture, and backgrounds including trauma experiences that affect and determine their pathway(s) to recovery. Abstinence is the safest approach for those with substance use disorders. Recovery is holistic: Recovery encompasses an individual’s whole life, including mind, body, spirit, and community. The array of services and supports available should be integrated and coordinated. Recovery is supported by peers and allies: Mutual support and mutual aid groups, including the sharing of experiential knowledge and skills, as well as social learning, play an invaluable role in recovery. Recovery is supported through relationship and social networks: An important factor in the recovery process is the presence and involvement of people who believe in the person’s ability to recover; who offer hope, support, and encouragement; and who also suggest strategies and resources for change. Recovery is culturally based and influenced: Culture and cultural background in all of its diverse representations including values, traditions, and beliefs are key to determining a person’s journey and unique pathway to recovery. Recovery is supported by addressing trauma: Services and supports should be trauma informed to foster safety (physical and emotional) and trust as well as promote choice, empowerment, and collaboration. Recovery involves individual, family, and community strengths and responsibility: Individuals, families, and communities have strengths and resources that serve as a foundation for recovery. Recovery is based on respect: Community, systems, and societal acceptance and appreciation for people affected by mental health and substance use problems—including protecting their rights and eliminating discrimination—are crucial in achieving recovery. For further detailed information about the new working recovery definition or the guiding principles of recovery, please visit www.samhsa.gov/recovery

Neurobiology of the Reward System

During the last several decades, progress in neuroimaging studies has enabled scientists to examine the brains of individuals with SUD in real time and garner a better understanding and insight into neurobiological underpinnings of these complex disorders (Goldstein & Volkow, 2011; Koob & Volkow, 2010). The basic neurobiological pathways of the reward system in the brain include projections from the ventral tegmental area (VTA), through the median forebrain (MFB), and terminate in the nucleus accumbens (NA) or the pleasure center of the brain, where there is a proliferation of dopamine (DA) neurons. The NA plays a central role in reward, fear, and aggression and is modulated by DA and other neurotransmitters, including norepinephrine (NE) and serotonin (5-HT). Together the NA, 5-HT, and DA modulate inhibitory behaviors (impulse control), learning, cognition, motivation, and the reward stimuli and play principal roles in the genesis of SUDs and behavioral addictions (Grant, Brewer, & Potenza, 2006; Potenza, 2006). Most drugs of abuse and behavioral addictions flood the reward circuitry with DA, which appears to be the final common neurotransmitter in the reward pathway.

Chronic activation of the reward pathway by use of substances or behavioral addictions has been linked to neuroadaptive effects occurring in the brain. Over time there is a generalized decrease in DA neurotransmission, induced by the intermittent increases in DA from substances or addictive behaviors. Chronic substance use and addictive behaviors also result in release of corticotropin releasing factor (CRF), implicated in activation of central stress pathways. Sensitization occurs when there is an increased response to the repeated administration of the substance or behavior and can be associated with increased “wanting” or “craving” after repeated intermittent use. This is followed by counteradaptation where the initial positive reward feelings are followed by the development of tolerance. Greater amounts of the substance or behaviors are required to achieve a diminishing level of positive rewards (Koob et al., 2004). Recent neurobiological findings support what previous addiction researchers had hypothesized, a “reward deficiency syndrome,” where a hypodopaminergic state involving multiple genes and environmental stimuli puts individuals at high risk for multiple addictive, impulsive, and compulsive behaviors (Blum et al., 1996).

Memory consolidation is the process in which newly formed memories mediated by the hippocampus are pliable and subject to modification or updating by diverse processes including inhibition of new protein synthesis and gene expression and subject to subsequent reminders. Over time hippocampus-dependent memories are believed to become less pliable and resistant to updating new information to an established memory for relevance through consolidation, which is surmised to occur within 1 to 2 days, although these memories can be reactivated by subsequent reminders, such as triggers (Alberini, 2009). Reactivated memories

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are again pliable and restabilize through retrieval-dependent reconsolidation. Memory consolidation and reconsolidation are implicated in acute and chronic symptoms of addictive disorders and PTSD. Specifically, intense memories, such as a drug-related trauma intensify NE hyperactivity, and stress hormones (e.g., CRF) are believed to play a role in the encoding and consolidation of these memories.

Of clinical importance is the role of memory consolidation in the treatment of addictive disorders and PTSD. Memories are dynamic and subject to updating with new information. Memory reconsolidation is believed to mediate memory updating as new memories to sustain their relevance. Evolving research indicates that the progressive benefit of reconsolidation is that newly formed and pliable memories of the drug-related or traumatic event may be modified through various therapies including CBT (e.g., eye movement desensitization and reprocessing [EMDR]), relapse prevention, and/or pharmacological interventions (e.g., receptor antagonists) that facilitate memory extinction (Koob, 2009; Lee, 2008, 2009; Soeter & Kindt, 2011).

Although the neurobiology of the reward system in the brain has been understood for decades, recent research has implicated a wider network of bidirectional brain circuitry involving the basal forebrain, frontal cortex, and midbrain structures with the reward circuitry that collectively mediate memory, motivation, impulse control, delayed gratification, cognitive appraisal of risks and rewards, selection of certain rewards, response to triggers or cues, altered judgment, and the dysfunctional pursuit of rewards seen in addiction (ASAM, 2011). There is mounting evidence that supports neurobiological, genetic, and phenomenological links between behavioral addictions (classified as impulse-control disorders in DSM-IV- TR) and substance addictions (Blanco, Moreyra, Nunes, Saiz-Ruiz, & Ibanez, 2001; Grant & Potenza, 2005; Kalivas & Volkow, 2005; Potenza, 2006, 2008). Alcohol, marijuana, nicotine, other drugs, and compulsive behaviors such as pathological gambling act on the same reward circuitry in the brain. Understanding the similar neurobiology of SUDs and behavioral disorders can inform clinical efforts of prevention and treatment.

TREATMENT APPROACHES

The overall goals of addiction treatment are to: (a) decrease the frequency and intensity of relapses, (b) sustain periods of remission, and (c) optimize the person’s level of functioning during periods of remission (ASAM, 2011). Central to these three goals is the personal awareness that through the recovery process one can experience hope, even for those who initially may not perceive hope. In addition to the Guiding Principles of Recovery (Table 16.3), the NIDA synthesizes the latest evidence on addiction treatment in an ongoing effort to influence health care policy by informing the public, health care providers, and decision-making bodies on best practices (NIDA, NIH, 2012). Recognizing that addiction is a complex yet treatable disease that affects brain function and behavior, that no single treatment approach is appropriate for everyone (NIDA, 2012), and that treatment must be safe, effective, patient-centered, timely, efficient, accessible, and equitably available (IOM, 2001), principles of effective treatment of addiction continue to be refined. Table 16.4, Principles of Effective Treatment for Addictions, and Figure 16.2, Components of Comprehensive Drug Abuse Treatment, summarize the latest knowledge, research, clinical practice, and evidence-based treatment approaches in the field of addiction. Although these documents predate the release of the DSM-5 in 2013 and focus on drug addiction, the principles and components of comprehensive treatment largely apply to behavioral addictions as well.

Particularly relevant to the consideration of behavioral and psychotherapy approaches are the need to address the motivation to change, providing incentives for abstinence, building skills to resist behavioral or drug use, replacing behavioral or drug-using activities with constructive and rewarding activities, improving problem-solving skills, and facilitating better interpersonal relationships (NIDA, 2012). Participation in group therapy and other peer support programs such as 12-step programs during and following treatment helps maintain abstinence when that is the desired goal, particularly in substance use more so than behavioral addiction where the goal is to have a normal or healthy level of a given behavior, not complete abstinence.

Person-Centered Care

Substantial progress in the treatment of SUD alone or with concurring psychiatric disorders has occurred during the last 30 years. During this period, there has been a compilation of research and practice guidelines that indicates that the most effective treatment for SUD with and without concurrence with psychiatric

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disorders is one that is multidimensional and incorporates and addresses medical, psychosocial, and mental health issues. As a rule, these strategies are person centered and integrate individual assets, wishes, abilities, and personal choices that promote an understanding and awareness of the detrimental course of sustained drug use; mitigate drug use; facilitate a drug-free lifestyle; and attain an optimal level of functioning.

TABLE 16.4 Principles of Effective Treatment for Addictions 1. Addiction is a complex but treatable disease that affects brain function and behavior 2. No single treatment is appropriate for everyone 3. Treatment needs to be readily available 4. Effective treatment attends to the multiple needs of the individual, not just his or her drug abuse (or behavior) 5. Remaining in treatment for an adequate period of time is critical 6. Behavioral therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse (and

behavioral addiction) treatment 7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral

therapies 8. An individual’s treatment and services must be assessed continually and modified as necessary to ensure that it meets his or her changing

needs 9. Many drug-addicted individuals also have other mental disorders

10. Medically assisted detoxification is only the first stage of (drug) addiction treatment and by itself does little to change long-term drug abuse

11. Treatment does not need to be voluntary to be effective 12. Drug use during treatment must be monitored continuously, as lapses during treatment do occur 13. Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases, as

well as provide targeted risk-reduction counseling, linking patients to treatment if necessary Source: NIDA (2012).

FIGURE 16.2 Components of comprehensive drug abuse treatment. Adapted from NIDA (2012).

CULTURE Person-centric care encompasses various factors including degree of self-efficacy, culture and level of acculturation, ethnicity, preferred language, age, sexual orientation, socioeconomic status, and spiritual and religious beliefs. Patients and families seeking SUD treatment must be assessed for individual uniqueness that comprises socioeconomic status; personal strengths, needs, abilities, and choices. Secondly, assessing cultural influences necessary to facilitate community integration, support the role of family, and access to social support and natural resiliencies of various cultures provides a greater understanding of the person’s experiences associated with SUD.

In a study involving the cause of alcohol and substance use in American Indian and Alaskan Native (AI/AN) (Legha & Novins, 2012) communities, researchers emphasized the unique role culture has on

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treatment planning by underscoring the significance of community, family, and strong relationships with respect to cultural diversity and socioeconomic challenges. In another study, researchers highlighted additional areas that enhance cultural competency, including cultural knowledge and skills; culturally sensitive attitude and appropriate behaviors; and community integration. They also stressed the importance of understanding family communication styles, perception of drug abuse and trauma, and culturally specific linguistics such as idioms, colloquial expressions, dialects, and nonverbal expressions (Rieckmann et al., 2012; Siegel, Haugland, Reid-Rose, & Hopper, 2011). Cultural, role delineation, and socioeconomic factors also have a significant impact on women with SUD and coexisting psychiatric conditions. Lastly, with changing societal demographics moving from a majority culture to a minority culture, it is imperative for psychiatric nurses to be mindful of their own culture, beliefs, and personal biases and their potential impact on how they evaluate symptoms, diagnosis, and treat individuals seeking treatment for SUD.

WOMEN Women seeking treatment often present with great social and psychological challenges, including psychiatric disorders and psychological distress, high rates of history of trauma and interpersonal violence, few vocational skills, and low income (Hunter, Robison, & Jason, 2012). Additional social challenges faced by women include childcare, homelessness with minor children, pregnancy, and financial instability and transportation problems. Women seeking treatment for SUD are more likely than men to have experienced traumatic events and present with untreated PTSD. Due to the inordinate prevalence of PTSD in women with SUD, integrating trauma-focused treatment in substance abuse treatment programs is critical in decreasing symptoms during active treatment and community integration (Greenfield et al., 2011; Hien et al., 2009).

According to the Center for Substance Abuse (2009), women are more apt than men to continue treatment once it begins, particularly if treatment is supportive, collaborative with the provider, and includes on-site child care. Women are also more willing to participate in group therapy and seek professional mental health services than men. Positive treatment outcomes unique to women can be strengthened by the following:

Valuing the significance of relationships Embracing unique psychobiological attributes and health care needs Understanding the importance of and influence of lifelong caregiver roles they assume Appreciating the meaning of societal roles and gender expectation across cultures, specifically about women who have SUD

Accepting and using a trauma-competent perspective Integrating strengths into the evaluation, treatment, and symptom management Employing a strength-based treatment approach

Increasingly as more women seek treatment for SUD and coexisting psychiatric disorders, psychiatric nurses are poised to evaluate potential barriers to treatment and utilize resources to develop gender- specific and trauma-focused approaches to ameliorate symptoms and facilitate an optimal level of functioning and integration into the community.

OLDER ADULTS (AGE 50 YEARS AND OLDER) There is mounting evidence of an inordinate prevalence of older adults who will seek SUD treatment for prescription and illicit drugs in the upcoming decades. Of particular concern is the increased use of nonprescription opioid use. Mental health and primary care providers contend that this dangerous disorder presents a challenge and requires early and routine screening to ensure accurate diagnosis and treatment. A major barrier to screening for SUD in older adults is that mental health providers are more likely to view these conditions as an afterthought rather than routine.

Age-related factors must also be considered when developing a person-centered treatment plan. Substance use disorders are predicted to rise significantly among older adults in the next 20 years. The prevalence of Americans older than 50 years of age with an SUD is estimated to double from 2.8 million in 2002 to 2006 to 5.7 million in 2020 (SAMHSA, 2012).

Older adults differ from their younger counterparts in several areas that include unique features of older adults such as age- and drug-related cognitive function and physiological changes and psychological, emotional, and socioeconomic factors. Clinical concerns associated with these changes include impact on learning or developing new coping skills to enhance relapse prevention; heightened sensitivity to psychoactive

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drugs and interactions between them and medications used to treat coexisting psychiatric and medical conditions (Arndt, Clayton, & Schutz, 2011; Wu & Blazer, 2011). Outcomes studies also indicate that older adults are most likely to require lower doses of medications, such as methadone, have fewer legal problems, and remain in treatment longer than younger patients.

Treating older adults with an SUD and most likely coexisting medical and psychiatric disorder requires expertise in age-related physiological and psychological changes and socioeconomic challenges. Unique age- related changes include diminished biological (e.g., slowed metabolism), cognitive, and neurobiological changes; disability along with reduced physical stamina; sensory deficits; financial constraints; few social support networks, and impaired driving and transportation issues. Due to a higher incidence of adverse effects of SUD in older adults, coexisting medical and psychiatric conditions require continuous monitoring and collaboration with primary care providers to minimize serious and adverse treatment outcomes. Treatment considerations for older adults include a candid and honest discussion about drug-related problems and treatment options.

Co-Occurring Disorders

Co-occurring disorders is a term used to describe the simultaneous occurrence of a substance use/abuse related disorder and a non-substance-related mental health disorder based on DSM diagnostic categories (CSAT, 2006). Based on the recent National Survey on Drug Use and Health (2009), an estimated 45 million adults experienced mental illness in the past year, 20.8 million adults experienced an SUD, and among those, 8.9 million adults had co-occurring disorders. Among the 8.9 million with co-occurring disorders, 44% received substance use treatment or mental health treatment, only 7.4% received treatment for both conditions, and 55.8% received no treatment at all (NSDUH, 2009). Although there is greater understanding for the need to treat both substance use and mental health disorders in an integrated approach rather than separately or sequentially, the limited access to care for integrated services results in fragmented and inadequate care for most people.

FIGURE 16.3 Co-occurring disorders by severity. Adapted from NASMHPD and NASADAD (1998).

A classification system developed by the state program directors of mental health associations and alcohol and drug abuse programs provides a four-quadrant model to coordinate care for individuals with co-occurring disorders (see Figure 16.3 on co-occurring disorders by severity). As the severity of both disorders increases, the level of care, setting of care, and coordination of services intensify. In Quadrant I with low severity of both mental illness and alcohol/drug abuse, care is typically provided in primary health care settings with some consultation with specialized care providers. Patients in Quadrant II having greater severity of mental illness and mild substance use issues typically are seen through the mental health system of care. Those in Quadrant III with greater severity of substance abuse problems and mild or moderate mental health problems are typically seen in the substance abuse treatment system. Patients in Quadrant IV with high severity of both addiction and mental illness problems are typically seen in state psychiatric hospitals, jails, prisons, emergency

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rooms, or criminal justice systems on parole or probation. The greater the severity of the co-occurring disorders, the greater the need for integrated and trauma-informed services (COCE, 2006; SAMHSA, NASMHPD/NASADAD, 2002).

Trauma-Informed Care

During the past 20 years, there has been increasing recognition of childhood abuse, childhood neglect, exposure to violence, and subsequent revictimization as adolescents and adults as risk factors and correlates for developing substance abuse and mental health disorders (Najt, Fusar-Poli, & Brambilla, 2011). There is an association that the younger the age of abuse/neglect/violence and the more prolonged the duration, the greater the likelihood of developing substance abuse and mental health disorders (Brems, Johnson, Neal, & Freemon, 2004; Dube et al., 2003).

Research indicates that women substance abusers have higher rates of comorbid PTSD than women in the general community and two to three times the incidence of comorbid PTSD than substance abusing men who are in treatment (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Kessler et al., 2005). Among women seeking substance abuse treatment, the rates of emotional, physical, and sexual abuse ranged from 55% to 99% (Adams et al., 2011; Najavits, Weiss, & Shaw, 1997). For these women, substance abuse became a means to dull the emotional pain of prior traumas or cope with ongoing trauma.

With the increased exposure to violence in combat zones during the wars in Iraq and Afghanistan, there has been a dramatic increase in rates of PTSD, substance abuse, and suicide among U.S. military servicemen and women and veterans (DVA, 2011). Three out of every four Vietnam combat veterans with PTSD had co- occurring SUDs. One in five veterans of the Iraq and Afghanistan wars has PTSD or depression. Although rates of co-occurring substance use have not been established, these veterans are at greater risk for experiencing SUDs due to combat exposure (SAMHSA, 2013).

Regardless of whether the trauma is childhood abuse, domestic violence, combat exposure, natural disasters, or other forms of trauma, understanding the risk for using alcohol or drugs to “numb” the pain or “avoid” the bad memories, dreams, people, or places increases and thereby makes the PTSD symptoms worse. Clinicians need to learn evidence-based treatment approaches to simultaneously treat the underlying trauma and PTSD while addressing the alcohol and drug use. Addressing trauma-related symptoms early in treatment can increase the likelihood of recovery from SUDs because most individuals report using alcohol or drugs to manage PTSD symptoms such as flashbacks, sleep problems, nightmares, avoidance of trauma memories, and hypervigilance. A few studies suggest that using a selective serotonin reuptake inhibitor, such as sertraline, among those who have PTSD before the onset of the SUD results in a better treatment response (Brady, Sonne, Anton, Randall, Back, & Simpson, 2005; Labbate, Sonne, Randall, Anton, & Brady, 2004). A manualized CBT approach to increase coping skills for women with co-occurring PTSD and SUDs called “Seeking Safety” has demonstrated efficacy in treatment retention, reducing PTSD symptoms, and reducing relapse rates (Najavits, 2002). Other integrative therapies such as EMDR, dialectical behavioral therapy (DBT), and mindfulness practice offer additional promising treatment approaches useful in addressing the underlying trauma, but empirical testing of their treatment efficacy needs to be further strengthened.

12-Step Peer Support Groups

The 12-step program is a set of guiding principles that outlines actions for recovery from addictions, compulsions, or other behavioral problems. These principles were initially proposed by Alcoholics Anonymous in 1939 as a method to recover from alcoholism and subsequently adapted as the foundation for other 12-step groups throughout the world. The guiding principles include:

Admitting that one cannot control one’s addiction or compulsion Recognizing a higher power that can give strength Examining past errors with the help of a sponsor (experienced member) Making amends for these errors Learning to live a new life with a new code of behavior Helping others who suffer from the same addictions or compulsions

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Participation in 12-step groups during and after formal substance abuse treatment has been associated with positive outcomes among substance users. However, high attrition rates and low participation limit the effectiveness of 12-step groups. Common barriers to participation cited by patients are the religious aspect and emphasis on powerlessness. Clinicians cite convenience, scheduling issues, and finding the right “patient fit” for a particular 12-step group as barriers. Studies have found that the person’s readiness to change, perceived need for help, and motivation are more critical factors in 12-step group participation (Laudet, 2003; Smith, Buxton, Bilal, & Seymour, 1993). Positive attitudes by clinicians about 12-step groups and their role in supporting recovery were associated with greater rates of referral, while resistance to the concepts of spirituality and powerlessness was associated with lower rates of referral by clinicians (Laudet & White, 2005).

Participation in 12-step groups can be viewed as a complementary treatment approach that helps the person to build a support network. Advanced practice psychiatric nurses (APPNs) who can address concerns about entering a new group, explain the concept of powerlessness and spirituality within the 12-step tradition, and use MI to contract for attendance at different groups to find the right “fit” and encourage attendance are more likely to successfully engage their patients in 12-step group participation as one aspect of their lifelong journey in recovery.

Screening and Assessment

Recent results of the National Health Interview Survey revealed increasing use of alcohol with 52% of adults reporting regular alcohol use, 14% current infrequent drinkers, 6% former regular drinkers, 9% former infrequent drinkers, and only 20% abstainers (Schiller, Lucas, & Peregoy, 2012). These prevalence rates of drinking have increased since 2004 when 49% of adults in the United States were abstainers, 22% reported light or occasional drinking, and 29% reported “risky drinking” or individuals who regularly or occasionally exceed screening guidelines (U.S. Surgeon General, 2004). Rising alcohol-related emergency room visits and motor-vehicular deaths as well as rising prevalence of alcohol use in teens and adults have prompted ongoing efforts to train health care providers across disciplines to screen and assess patients for alcohol and drug use.

The Screening, Brief Intervention and Referral to Treatment, known as SBIRT, has been a public health approach supported by SAMHSA since early 2000 to train the health care workforce to deliver screening and early intervention for individuals with SUDs and those at risk for developing these disorders. SAMHSA has funded numerous and ongoing efforts to train current health care providers and integrate SBIRT skills into the education and curriculum of all health professionals as well as universal screening across health care settings. SBIRT is intended for widespread use in primary care centers, hospitals, emergency rooms, trauma centers, and other community settings for early interventions with at-risk substance users before more severe consequences occur. The SAMHSA SBIRT website (www.samhsa.gov/prevention/SBIRT/index.aspx) provides information and resources on SBIRT grant funding, billing and coding, and training materials. The NIAAA has additional SBIRT resources and clinician guidelines for adults (NIAAA, 2005) and for youth (NIAAA, 2011). For individuals who screen positive for risky alcohol and drug use, health care providers can use an MI approach in ongoing brief periodic interactions to engage the patient in steps to reduce his or her risky alcohol use to safe cut points over time. For patients who meet criteria for more advanced alcohol use or dependence, clinicians are advised to refer those patients for specialized addiction treatment. Information on additional screening tools for age-specific and special populations such as pregnant women is provided in Table 16.5.

Clinicians who treat patients with SUDs or co-occurring disorders beyond the primary care setting understand the importance of establishing a therapeutic relationship; conducting a comprehensive biopsychosocial assessment including the risk for any urgent medical or psychiatric crisis; making differential diagnoses; and implementing and evaluating a person-centered, trauma-informed treatment plan (see Table 16.6 on biopsychosocial addiction assessment). A mental status examination must be used initially as part of the assessment and continually throughout the treatment process to monitor symptom management and level of dangerousness to self and others. Evidence of acute psychiatric or SUD symptoms must be referred to the emergency room or services for further evaluation, detoxification, and psychiatric and medical stabilization. In the absence of active or acute symptoms of SUD and psychiatric conditions, an evaluation of the person’s readiness and motivation to engage in treatment must be determined. Stressful life events, ineffective coping, or adaptive coping skills contribute to the chronic nature of SUDs. A critical concept of treatment is helping individuals understand that recovery is an ongoing process that requires a lifetime commitment. Recovery is not simply achieving sobriety or being drug free. Recovery establishes goals and supports steps to improve

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overall health, happiness, self-sufficiency, and a meaningful life without substances through education, employment, volunteerism, and developing a strong social network.

TABLE 16.5 Screening Tools for Alcohol and Drug Use

*Public domain. 1Copyright by Boston Children’s Hospital; no cost, need approval of Center for Adolescent Substance Abuse Research (www.ceasar- boston.org). 2Copyright by Harvey Skinner, PhD; no cost, need approval through [email protected].

TABLE 16.6 Biopsychosocial Addiction Assessment

Integrative Theoretical Framework

The feeling-state therapy (FST) of behavioral and substance addictions offers an integrative theoretical

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framework for treating an individual with addictions (Miller, 2010, 2011). This theory posits that a “feeling state” comprises a sensation plus an associated emotion plus an associated cognition with a behavior that causes the urges and cravings for both substance and behavioral addictions. The FST hypothesizes that feeling states associated with addictions develop from intensely positive events and create positive, although rigidly applied, beliefs. These positive feeling states may mask a defense that serves to ward off anxiety or depression. Miller (2011) cites the example that a feeling state linked to compulsive shopping might be composed of the sensations and emotions of excitement and the anticipation of “getting what I want.” The urge or craving is not the feeling that the person seeks but rather the drive for the feelings associated with the behavior linked with them. In this example, the urge to buy clothes was not the desired feeling, but it was the need to feel excitement and anticipation. If the therapist focused only on the craving or urge to shop, the therapist would miss the underlying need for excitement and anticipation and fail to break the feeling/behavior connection (Miller, 2011). In behavioral addictions, the goal is to enable the person to return to a normal system of functioning, not to totally abstain from the behavior. Shopping, eating, exercising, sexual intimacy, and even recreational gambling are normal behaviors. Once the “feeling-state” link is broken the individual automatically begins to use more appropriate ways to satisfy needs (Miller, 2011).

Behavioral and some substance addictions may also form as a response to a preexisting intense psychological need such that the use of the substance is associated with avoidance of undesirable emotional feelings such as dysphoria, depressed mood, and emptiness. This is most easily illustrated by the urge or craving for substances such as alcohol, cocaine, or opioids when these substances are associated with the “feeling state” of “chilling out” on alcohol or opioids or “being productive” or having “great sex” on cocaine. The underlying drive may be avoidance of dysphoria or boredom by using alcohol or the need to feel alert, aware, and highly stimulated by using cocaine. Additionally, the physiological reaction to the drug also contributes the desired “feeling state” of euphoria. Thus, the compulsion to take the drug to achieve a euphoric state can and does occur even if there is not a preexisting psychological need the individual wishes to avoid. Because substance addictions can create intense experiences for the development of a “feeling state,” the treatment goal is abstinence. It is also important to recognize that if you successfully eliminate a substance addiction, the underlying depression or anxiety disorder may emerge (Miller, 2011).

Individuals who struggle with addictions often have core beliefs that are shame based, meaning they perceive themselves as “losers,” “failures,” and “hopeless.” Shame drives a person to hide, withdraw, and avoid treatment. Guilt over actions taken while under the influence of substances or during compulsive, addictive behaviors is more event specific. The individual typically feels guilty that his or her behavior may have been embarrassing or inappropriate while intoxicated or overspending while compulsively shopping, does not feel that he or she is inherently a “bad person” or a “loser.” Guilt often motivates a person to seek treatment. A turning point for many people with addictions is when they feel guilty about their actions and want to repair interpersonal relationships and stop the destructive behavior patterns created by their addiction. Understanding the difference between guilt and shame and its impact on an individual’s motivation or avoidance of treatment is critical to hope and the recovery process (Dearing, Stuewig, & Tangney, 2005).

Feeling-state addiction therapy (FSAT) combines the FST of behavioral and substance addiction (Miller, 2012) with a modification of EMDR (Shapiro, 2001). Guilt and shame are reactions to the behaviors caused by the “feeling state.” In the Feeling-State Addiction Protocol (FSAP), the “feeling state” is the target for therapy. The theoretical basis of EMDR is the adaptive information processing (AIP) model (Shapiro, 2001), which posits that the innate information processing system of the brain may become imbalanced as a result of high arousal from events perceived as traumatic. The memory of the event is encoded within an isolated neural network containing the heightened emotions, bodily sensations, and the associated cognitive appraisals at the time of the event. The memory node becomes fixed and isolated from linking the experience to more adaptive information forming the basis for pathology. When the memory is triggered by current environmental stimuli, dysfunctional reactions and affects emerge. EMDR facilitates the adaptive reprocessing of such pathological memories (see Chapters 2 and 6 for further discussion of AIP and EMDR).

The primary modification of the EMDR protocol for FSAP is the identification of the specific positive FS (sensation + emotion + cognition) linked with the addictive behavior and its Positive Feeling Scale (PFS) level (0–10) and associated body sensations. Eye movement sets are then performed while the patient visualizes the addictive behavior until the PFS level drops to 0 or 1. Once the FS associated with the addictive behavior has been processed, the negative belief underlying the FS is determined, and the positive belief is chosen and installed using the standard EMDR protocol. See Table 16.7 on FSAP (Miller, 2012). Another EMDR approach is the Desensitization of Triggers and Urge Reprocessing (DeTUR) Model (Popky, 2005) that uses bilateral eye movements or bilateral stimulation component of EMDR to process the triggers, urges, and cravings associated with addiction using the Level of Urge (LOU) scale. Although promising, the use of

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EMDR for behavioral and substance addictions needs to be further researched.

Evidence-Based Psychotherapeutic Interventions

During the past decade, the implementation of evidence-based practice (EBP) has permeated all health care systems, including substance abuse treatment. Despite the promulgation of practice guidelines, protocols, and manualized psychosocial interventions such as the Treatment Improvement Protocol (TIP) series for addictions developed by SAMHSA in the 1990s and 2000s, demonstration of improved treatment outcomes in the addiction field remains inconsistent across treatment settings and geographic areas. Some argue that a focus on specific evidence-based core skill sets that are broadly applicable and easily learned replaces the emphasis on manualized psychosocial interventions (Glasner-Edwards & Rawson, 2010). Critical goals of EBPs in addiction treatment involve (a) improving impulse control, (b) reducing craving, and (c) promoting an adaptive social environment (Glasner-Edwards & Rawson, 2010). Evidence-based skills that can best impact these three goals include (a) principles of CM, (b) MI and brief intervention skills training, (c) core cognitive behavioral coping skills and relapse prevention strategies, and (d) couple and family counseling techniques (Carroll & Rounsaville, 2006; Glasner-Edwards & Rawson, 2010).

TABLE 16.7 Feeling-State Addiction Protocol 1. Obtain history, frequency, and context of addictive behavior. 2. Evaluate the person for having the coping skills to manage feelings if he or she is no longer using the addictive behaviors to cope. If not,

do resource development before continuing. Install future template if necessary. 3. Identify the specific aspect of the addictive behavior that has the most intensity associated with it. If the addiction is to a stimulant drug,

then the rush/euphoria sensations are usually the first to be processed. However, if some other feeling is more intense, process that first. The starting memory may be the first time or the most recent—whatever is most potent.

4. Identify the specific positive feeling (sensation + emotion + cognition) linked with the addictive behavior and its Positive Feeling Score (PFS) level (0–10).

5. Locate and identify any physical sensations created by the positive feelings. 6. Have the client visualize performing the addictive behavior—feeling the positive feeling combined with the physical sensations. 7. Eye movement sets are performed until the PFS level drops to 0 or 1. 8. Install future templates of how the person will live without having that feeling. 9. Between sessions, homework is given to evaluate the progress of therapy and to elicit any other feelings related to the addictive behavior.

10. In the next session, the addictive behavior is reevaluated for both the feeling identified in the last session as well as identifying other positive feelings associated with the behavior.

11. Steps 3 to 9 are performed again as necessary. 12. Once the FSs associated with the addictive behavior have been processed, the negative beliefs underlying the FSs are determined, and the

desired positive beliefs are chosen. Source: Miller (2012).

CONTINGENCY MANAGEMENT CM is a behavioral-reinforcement-based approach within the CBT model that employs positive or reward reinforcement that has proven efficacy in the treatment of SUD as evidenced by facilitating effective and adaptive behavioral changes based on four decades of research (Hser, Li, Jiang, Zhang, & Du, et al. 2011; Stitzer, Petry, & Peirce, 2010). Promising outcomes from these data consist of reduced substance use, increased group participation, and improved adherence to medication regimens (Schmitz, Lindsay, Stotts, Green, & Moeller, 2010).

Similar to CBT, CM is likely to be a part of an integrated treatment plan for SUD to reinforce homework completion and session participation to strengthen CBT through exposure to adaptive coping skills training by reinforcing abstinence and relapse prevention. Building coping skills enables the individual to sustain and maintain new behaviors primarily because they reinforce the brain’s self-regulatory or impulsivity capacity. Typically, reinforcement involves provision of monetary-based reinforcers, such as vouchers for retail purchases for abstinence incentive (Hser et al., 2011). How one manages money is further influenced by culture and perception of money management and prudent use of one’s money through impulse control (Hamilton & Potenza, 2012). Other forms of reinforcement may include treatment attendance, adherence to treatment goals, and medications.

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Effectiveness of CM using reinforcement can be established using various reinforcers, such as monitoring drug screens and previously mentioned money-management tasks. Collecting and monitoring drug screens several times a week to identify brief episodes of abstinence, reinforces adherence to pharmacological and psychotherapeutic interventions; reduces cravings and/or psychiatric symptoms; and promotes relapse prevention (Carroll et al., 2012). Positive reinforcement manifested by negative drug screens, adherence to treatment, reduced cravings, and absence of psychiatric symptoms expand with continuous lengths of abstinence. Positive reinforcement is also strengthened by incorporating additional psychotherapeutic interventions, such as MI, mindfulness and social skills training, and couple and family therapy to target high-risk behaviors associated with impulsive drug use and relapse.

MOTIVATIONAL INTERVIEWING MI was initially developed within the addiction field to motivate individuals to commit to healthy drug-free lifestyle change (Miller & Rollnik, 1991, 2002). See Chapter 7 for detailed discussion and applications of MI beyond the addiction field. The specific treatment goal of MI centers on identifying the opportunity to guide the individual in change talk and enhancing the motivation to change. This approach affords the APPN an opportunity to join and appreciate the person’s experience that begins when treatment is started irrespective of stage of change. Motivation to change is potentiated through the therapeutic alliance and specific communication strategies that direct the discussion. By encouraging the person to appraise problems linked to his or her addiction, the nurse can actively frame and use the individual’s “own words” as a basis for adaptive change. Change talk reflects the motivation to change, the incentive to remain abstinent, and forecasts positive outcomes (Hallgren & Moyers, 2011; Miller, Moyers, Amrhein, & Rollnick, 2006).

Motivational interviewing also requires the APPN to avoid challenging the person’s resistance and ambivalence and “roll with the resistance,” accepting that ambivalence and resistance to change are a natural part of change and growth. Eventually resistance to change diminishes, as the individual discovers personal options, accountability, and solutions to the current situation, while promoting autonomy and self-efficacy (Marlatt & Gordon, 1985). As the person becomes more confident through change talk and discovers healthy solutions to everyday problems, these sessions can be used to sustain motivation and support newly found self- esteem, hope, and self-efficacy. The most successful approaches for an SUD are likely to be those that encourage self-efficacy.

COGNITIVE BEHAVIORAL COPING SKILLS AND RELAPSE PREVENTION Typically CM, MI, and CBT are integrated to help individuals increase coping skills and develop a relapse prevention plan by focusing on cognitive, behavioral, and lifestyle choice that might be changed or reinforced (Marlatt, 2006). One of the central components of this approach is identifying relapse triggers and developing a variety of coping strategies to successfully avoid or manage different triggers without reverting to substance use or addictive behavior pattern such as gambling. See Chapter 8 for detailed discussion and applications of CBT beyond the addiction field.

INTEGRATED FAMILY THERAPY Quality family interactions and relationships and mental health of members are strongly correlated. Likewise, long-lasting committed relationships afford the most important form of social support for many individuals with an SUD. Conversely, distant, impaired, and dysfunctional family relationships typically result in divorce and separation and have a long-standing destructive impact on couples and families and their children and communities and overburden health care systems and resources. It is widely understood that abstinence and healthy communication and relationship functioning curtail societal costs, familial violence, and lifelong emotional and behavioral problems of children (O’Farrell & Clements, 2012; Rowe, 2012). Couple and family therapy is a necessary component of the integrated plan and a proven asset to helping individuals and their families and communities restore severed interpersonal relationships and improve social and occupational functioning related to SUD. Research findings consistently indicate couple and family therapy approaches among the most effective modalities in the treatment of adults with an SUD (Rowe, 2012).

Couple and family therapy offers venues for individuals and families to understand the impact of SUD within a social context and developing communication and social skills that restore trust, self-efficacy, and confidence and strengthen dysfunctional relationships associated with an SUD. These skills also help families

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and individuals appraise the role of high-risk situations and drug-induced triggers and develop coping techniques that restore healthy interactions and support relapse prevention. Specific communication and social skills training include assertiveness, anger and stress management, and active listening skills necessary to heal and repair family relationships through effective quality support and empathy. Furthermore, couple and family therapy plays key roles in moderating substance use; promoting higher levels of relationship satisfaction; improving child and marital functioning; reducing family and partner violence; sustaining sobriety; and facilitating community integration (CSAT, TIP #39, 2004).

COMPLEMENTARY AND ALTERNATIVE THERAPIES Mindfulness is often part of an integrated plan of care utilizing other cognitive behavioral approaches. This approach necessitates awareness or mindfulness of triggers and high-risk situational cues and readiness to do something about it. Awareness and readiness enable the individuals to explore and develop an array of relapse prevention interventions, such as “stepping back” and appraising the trigger-related situation, which historically was deemed automatic, and using more adaptive coping behaviors to modulate triggers (Witkiewitz, Lustyk, & Bowen, 2012). Together, these proactive techniques reinforce adaptive coping behaviors and greater control over trigger-related situations, specifically physical and emotional responses. Similar to other cognitive behavioral techniques, mindfulness is most appropriate for individuals who have completed initial treatment, including symptom management of psychiatric conditions and are clearly motivated to sustain treatment gains and formulate healthy lifestyles and recovery.

MAINTAINING THE THERAPEUTIC FRAME Although the concept of the therapeutic frame originated from psychoanalytic therapy, it has been widely adopted by most psychotherapy schools including interpersonal, object relational, cognitive behavioral, and self-psychological theories (Cherry & Gold, 1989). The therapeutic frame consists of the conditions required to support a professional counseling relationship. Typically this includes setting and maintaining clear boundaries and role expectations to provide the patient with a secure, safe “holding” environment that facilitates personal growth and development (Modell, 1976). Conversely, the therapeutic frame also supports the clinician in maintaining a therapeutic stance of neutrality (nonjudgmental), anonymity (avoiding unnecessary self-disclosure), and nonintrusiveness, thereby keeping the focus on the person’s thoughts, concerns, and needs. The “traditional” treatment frame consists of rules regarding:

Making and keeping regular appointment times Enforcing established starting and ending times for each session Declining to disclose a home or cellular phone number or address Canceling sessions if the patient arrives under the influence of alcohol or psychoactive drugs Not having contact outside of therapy sessions Having no sexual contact or interactions that could reasonably be interpreted as sexual Terminating counseling if threats are made or acts of violence are committed against the counselor Allowing patients to explore thoughts and feelings without “acting out” thoughts/feelings of harm to self or others, or damaging property within a session

Establishing and enforcing a clear policy in regard to payment

Exceptions to a particular rule may be supported by a particular treatment approach. For example, the use of telephone contact outside the therapy session may be appropriate within the context of DBT managing suicidal feelings. Patients may feel abandoned if a telephone call is not returned, thereby damaging the therapeutic alliance (CSAT, TIP #36, 2000).

Clinicians working in the addiction field must attend to issues of transference, countertransference, secondary traumatization, and burnout. Alcohol and drug counselors, as well as other mental health professionals, work with people who have often suffered abuse and neglect as children and revictimization as adolescents and adults. This is even more complex when the clinician may also be in recovery from SUDs and/or suffered abuse or neglect themselves. Clinicians must be mindful of their own feelings to avoid countertransference that can lead to negative judgments and rejection of certain patients or to “rescuing” helpless or defenseless patients. Finding the appropriate balance of providing support and distance to facilitate growth and recovery is an ongoing process. Supervision and consultation are useful strategies to provide the clinician with objective feedback and recognize or prevent boundary crossings or countertransference issues.

Patients with SUDs and especially those with a history of abuse are often mistrustful while at the same

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time seeking a trustworthy relationship. At times they may project intense feelings onto the clinician, which results in a “push–pull” dynamic. The person may test the clinician’s limits, breach trust, act out, avoid engaging in meaningful counseling, or relapse. APPNs must be mindful of these dynamics and develop strategies to ensure effective care. Because child abuse and neglect represent the ultimate violation of trust, the therapeutic frame must be maintained with appropriate boundaries and limitations to provide a safe, trustworthy relationship and the opportunity to heal (CSAT, TIP #36, 2000).

By contrast, some patients may idealize the clinician as they experience perhaps the first relationship with a consistent trustworthy person who offers positive regard and validates their value and positive self-esteem. In those who have recently stopped abusing alcohol or drugs, tension may be reduced through obsessive romantic or sexual fantasies about the clinician. Patients who have used sex as their primary way of relating may misinterpret cues from the clinician and believe the clinician is sexually interested in them. The patient who is “in love” with his or her therapist/clinician poses a challenge and an opportunity for therapeutic growth. While the APPN must be alert to potential “romanticized” patient perceptions and avoid seduction, the situation presents the opportunity for the person to learn to examine the feelings, rather than act on them, and explore the underlying meaning. By maintaining the professional boundary of the patient–counselor relationship, the clinician can guide the patient to examine whether he or she is replacing substance use with romantic fantasies to reduce tension. The clinician may also guide the person to explore what he or she values about the therapeutic relationship—feelings of trust, safety, and positive regard—and how to seek this experience in nonsexual relationships with others who listen. This is potentially a “teachable moment” where the patient uses reflection to learn to better differentiate his or her own feelings (CSAT, Tip #36, 2000).

The ongoing daily stress of working with those who have experienced abuse, neglect, and violence can take a toll on clinicians. When repeatedly listening to disclosures of abuse, neglect, violence, and victimization, especially when perpetrated by parents or family members on their own children, the clinician may experience symptoms of trauma in the form of disturbing dreams, anxiety, irritability, withdrawal, and problems in interpersonal relationships. This phenomenon is recognized as secondary trauma. Untreated or ignored, this can progress to symptoms of PTSD and burnout. Clinicians experiencing these symptoms lose perspective and effectiveness in working with traumatized patients. The APPN may unintentionally minimize, negate, or fail to inquire about a person’s abuse history, thereby unconsciously avoiding the distress raised by listening to disclosures of abuse or neglect. By contrast, the clinician may become overly focused on probing for histories of abuse or neglect seeking detailed histories when the person may not be a survivor of abuse or may not feel safe or ready to disclose or have no memories of abuse. These clinicians are vulnerable to become overly involved with the desire to “rescue” the patient, and may direct anger at parents, mental health clinicians, former therapists, or child protective services (CPS) workers who had missed the abuse. When this loss of professional objectivity occurs, the relationship ceases to be therapeutic or beneficial to the patient (Briere & Scott, 2006).

CASE STUDY

Ms. B, a thin, cachectic, 27-year-old woman, entered residential treatment for co-occurring cocaine, marijuana, and alcohol addiction, substance-induced mood disorder, and chronic PTSD immediately following release from 30 months incarceration for prostitution and drug trafficking. She has lost custody of her 5-year-old daughter as a result of her incarceration. The biological father is unknown and her daughter is in the custody of her aging parents since she was incarcerated. She relates a history of childhood neglect and physical abuse by her mother and stepfather, who were both reportedly alcoholics. The youngest of three girls, she denies sexual abuse until she dropped out of high school and left home at age 16 to live with her older boyfriend, age 24. He was emotionally, physically, and sexually abusive, and turned her onto alcohol, marijuana, cocaine, and opioids within their first year together. She began prostituting and selling drugs to get out of the abusive relationship, quickly finding herself victimized by johns and a series of pimps over the next 7 years. She was in and out of jail 3 to 5 times a year for prostituting until she ended up in the state prison for women for multiple violations and the drug-trafficking charge, a felony offense. She did engage in prison-based drug treatment, which included 12-step groups, trauma-informed group therapy, and psychoeducation during the past 8 months affiliated with the current residential treatment program for women with addictions in an urban setting. This was her first exposure to addiction and recovery services.

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Ms. B entered residential treatment with trepidation, fearing she would be unable to adhere to the treatment program’s expectations. An initial comprehensive intake evaluation was completed by a licensed addiction counselor, an educational and workforce evaluation by her case manager, a comprehensive mental health history and evaluation by the psychiatric nurse practitioner, and she was assigned a “Big Sister” peer mentor in the 12-month residential program. The first month in the program provides all residents with an individual therapist for weekly counseling, a case manager for coaching and navigating program expectations, daily series of trauma-informed group counseling based on the “Seeking Safety” program (Najavits, 2002), 12-step groups on-site twice weekly and off-site once weekly, and a weekly faith-based group with the option of a prayer-partner volunteer through local church affiliation. The second month focuses on job placement in a position that provides a living wage while continuing all of the program elements through evening programming on completion of the eight-session “Seeking Safety” group series. Within the context of this residential program, Ms. B engaged in all of the treatment components as she eventually pursued part-time and eventually full-time employment by the fourth month. She saw the psychiatric nurse practitioner who prescribed escitalopram 20 mg orally daily, which resolved her anxiety and improved her mood, energy, motivation, and sleep.

The case manager and individual therapist consistently used MI approaches. After a 6- month period of stabilization in the program and in weekly individual therapy, her individual therapist, trained in EMDR, used this approach to process many of the traumatic memories of abuse by johns and pimps while prostituting and to process and reduce cravings and urges to use cocaine in particular. She did not experience cravings or urges for alcohol or marijuana even at times when other residents relapsed and were either reincarcerated or discharged from the program. Ms. B maintained clean urine drug screens throughout her year in residence, faithfully engaged in all aspects of the program, attended 12-step meetings, rarely missed an individual therapy session, mentored new program residents as a “Big Sister” during her final 6 months in residential treatment, and maintained employment with one of the large hotels where she worked in the catering department.

On graduation from the 12-month residential treatment program, Ms. B transitioned to one of the program’s apartment complexes dedicated to ongoing recovery. She was able to continue seeing her therapist monthly and ongoing medication management through the aftercare services. Therapy focused on reunification with her then 6-year-old daughter, referral to pro bono legal services to begin steps to regain custody of her daughter, and supportive counseling to manage daily work and life stressors without relapsing to drug or alcohol use. She received promotions at work over the next 2 years, enjoyed regular visitation with her daughter, and was engaged in therapy regarding issues of reconciliation with her aging parents. She was active in 12-step recovery groups and joined a church community where she was baptized. She attributes her recovery to the women and program staff who believed in her, her rekindled faith in God whom she thought had abandoned her long ago as a teenager, her unwavering desire to be a “good mom” to her daughter, her employer “who took a chance on a woman with a felony conviction,” and the recovery community she relies on daily. Her future challenges will be the decision on whether or when to engage in a significant monogamous relationship. She anticipates ongoing work with her therapist as she embarks on that journey.

POSTMASTER’S ADDICTION NURSING TRAINING AND CERTIFICATION

Specialized certification as an addiction nurse is offered by the Addictions Nursing Certification Board (ANCB), an affiliate of the International Nurses Society on Addictions (IntNSA). The organization offers two levels of certification: Certified Addictions Registered Nurse (CARN) and Certified Addictions Registered Nurse–Advanced Practice (CARN-AP).

Eligibility for the CARN-AP requires:

Current, full, unrestricted license as a registered nurse (RN) in the United States or Canada

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A master’s degree or higher in nursing Documentation of a minimum of 500 hours of supervised, direct patient contact in advanced clinical practice working with individuals and families impacted by addictions/dual diagnoses. All 500 hours may be earned while in the master’s program

Submission of master’s program transcript verifying the hours of supervised clinical practice, or submission of verification form signed by supervisor/consultant of postmaster’s supervised direct patient contact, which together with hours of supervised practice in the master’s program, equal 500 or more hours

See the IntNSA website for further information www.intnsa.org/home and the ANCB Candidate Handbook for details regarding the certification exam and eligibility at www.intnsa.org/certification/documents/CandidateHandbookApril-2013.pdf.

CONCLUDING COMMENTS

In conclusion, this chapter has provided an overview of the complexity of coexisting substance use, psychiatric, and medical disorders and underscores the importance for all health care providers to accurately screen, identify, provide, and/or link patients to appropriate, person-centered and integrated services. The APPN is uniquely prepared to provide diagnosis and treatment of psychiatric disorders and will find it increasingly important to refine skills in the diagnosis and treatment of substance use and behavioral addiction disorders, given the prevalence and co-occurring nature of these disorders.

DISCUSSION EXERCISES

1. Discuss the potential impact of the DSM-5 diagnostic criteria for addictions that lowers the diagnostic threshold and includes both substance use and behavioral addictions.

2. What neurobiological pathways and neurotransmitters are implicated in both behavioral and substance use addictions?

3. Describe the goals of addiction treatment and the components of comprehensive addiction treatment.

4. Discuss the 10 guiding principles of recovery and how you would integrate these into the treatment of a crack-cocaine addicted pregnant woman who is entering residential treatment that will continue through 90 days postpartum, including care of infant in residence.

5. What screening questions and measures would be most helpful in detecting behavioral and substance use addictions?

6. Describe motivational interviewing and how you would apply this approach to the individual described in the case study for this chapter.

7. Describe integrated family therapy and how you would apply this approach to the individual described in the case study for this chapter.

8. Describe the FSAP and how you would apply this approach to the individual described in the case study for this chapter.

9. Discuss the importance of maintaining the therapeutic frame and the role of boundaries in working with individuals with addictions.

10. Examine your own thoughts, feelings, and attitudes about individuals with substance use and behavioral addictions. How have addictions touched you, your family, or friends that may influence your ability to effectively work with individuals with addictive disorders?

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Psychotherapy With Children KATHLEEN R. DELANEY WITH JANIECE DESOCIO JULIE A. CARBRAY

n this chapter child psychotherapy is discussed in the context of the evolving science of evidence-based practices (EBPs). Viewing all intervention through a lens of supporting evidence is particularly important

for child (unless specified, the term child is used to refer to treatment with both children and adolescents) psychiatric nurses who hold a social commitment with families and children to provide effective treatment that promotes mental health and wellness. As described in the chapters on adult psychotherapy, psychiatric nursing interventions are always initiated in the context of the relationship. In the case of children, that focus broadens to the relationship the advanced practice psychiatric nurse (APPN) establishes with the family/parent/caregiver. The perspective of APPNs who treat children is also shaped by an orientation on prevention and promoting resiliency. Following a historical summary and exploration of underlying assumptions of child intervention, several basic principles of child psychotherapy are described. Three therapeutic evidence-based psychotherapeutic approaches are highlighted, applied to select commonly occurring childhood disorders. As noted in Chapter 1, nurse psychotherapists are on a journey from novice to expert. To provide a sense of this movement, two cases are presented: one involving a novice nurse who uses a solution-focused common elements approach and two other cases detailing the approaches of expert psychiatric nurses who discuss their treatment plans for children exhibiting complex behaviors indicative of comorbid serious emotional disorders (SEDs).

HISTORICAL CONTEXT

What defines the field of child psychotherapy? For anyone over a certain age, a mention of child psychotherapy conjures up an image of play therapy and a dynamic, drive-theory orientation to a child’s behavioral problems. Indeed, the history of child therapy would have most likely begun in the 1930s and early 1940s when the ideas of Anna Freud and Melanie Klein predominated (West & Evans, 1992). While psychodynamic and play-therapy techniques have continued refinement and broadened to include expressive therapies (Chethik, 2000) and short-term models (Trowell et al., 2007) the dominance of the psychodynamic school has subsided (Ritvo et al., 1999). Child psychodynamic practice has drawn consistent criticism for the lack of empirical data on its effectiveness (Barnett, Docherty, & Frommelt, 1991; Marans, 1989; Remschmidt & Quashner, 2001; Ritvo, 2006), but recent reviews, particularly from the United Kingdom, indicate that psychodynamic approaches are effective for some children, especially those dealing with internalizing disorders (Midgley & Kennedy, 2011). Today psychodynamic therapy continues as a significant element of training in psychiatry and is recognized as a portal to concepts critical to the relationship and narrative elements of treatment (Shedler, 2010). The field is also supported by the American Academy of Child and Adolescent Psychiatry (AACAP), which recently published a practice guideline on the implementation of psychodynamic therapy for children aged less than 2 years (Kernberg, Ritvo, Keable, & AACAP Workgroup on Quality, 2012). In children and teens, there is also increasing interest in research that aimed to demonstrate its effectiveness with select populations (Goodyer et al., 2011).

Given that historical background, what propelled the current dominance of behavioral and cognitive- behavioral approaches in child psychotherapy? Hibbs (2001) proposed that a data-based, scientific approach to solving specific behavioral problems contributed to the ascendancy of child behavioral treatments in the 1960s and 1970s. Throughout the 1990s the trend continued toward time-limited interventions aimed at producing symptom-specific outcomes (Bloom, 2002) and child psychotherapy was increasingly defined by techniques and their accompanying school of therapy (e.g., interpersonal, systemic, cognitive behavioral, and family) (Roth & Fonagy, 1996). In their most recent policy statement on child psychotherapy, the AACAP

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endorsed the notion of psychotherapy as treatments residing in these established therapy schools (AACAP, 1998).

At the same time, a shift was occurring in how therapies were organized within these recognized psychotherapy schools, that is, they were increasingly classified by the major childhood disorders: anxiety, depression, attention deficit hyperactivity disorder (ADHD), and conduct disorders (Weisz, Hawley, & Doss, 2004). Organizing intervention by diagnosis was advanced by the work of the American Psychological Association Division 12 (1993), which created a scheme to rate the evidence supporting psychological interventions. In the child field, what followed were extensive treatment reviews for specific childhood disorders such as anxiety disorders, ADHD, and autism (Burns, 2004). This organizational scheme for rating evidence also lent itself to the analysis of clinical trial research, which supplied the data for another emerging movement, defining EBPs (Hibbs & Jensen, 1996). What has emerged from this trend are sets of interventions for particular disorders and child psychotherapy being defined and organized by EBPs for both specific disorders (e.g., Simpson, Suarez, & Connolly, 2012) and common factors of effective treatment approaches that span across disorders, for example, parent management training and problem-solving skills groups (Chorpita, Daleiden, & Weisz, 2005; Garland, Hawley, Brookman-Frazee, & Hurlburt, 2008).

APPN: TRAINING AND CERTIFICATION

Psychiatric nurses are key participants in the coordination of mental health care for children and bring a particular nursing orientation and expertise. The scope of practice for child psychiatric nurses sets down several areas of emphasis: the value of the relationship, a health focus, view of the child in relation to social systems, and the application of science to treatment, that is, both psychological interventions and the neurobiology of illness (American Nurses Association, 1985). Preparation for APPNs occurs at the graduate level and includes training in multiple bodies of knowledge (medical science, neurobiology of psychiatric disorders, health systems, treatment methods, psychopharmacology, and relationship science). APPNs bring this distinct orientation into their work with children by the way they respond and view phenomena.

There are two groups of APPNs who are trained, certified, and licensed to provide child psychotherapy. The first are child and adolescent clinical specialists (C/A CSs) who, since the demarcation of their scope in 1985, have provided comprehensive psychiatric services to children and adolescents. At the start of the decade, there were close to 990 certified C/A CSs, but through the early 2000s fewer C/A CSs sought ANCC certification; thus there has been scant increase in this workforce over the past 15 years (Drew & Delaney, 2009). In 2001, when the psychiatric-mental health (PMH) nurse practitioner (NP) exams were introduced, an adult and a family or life span PMH NP option were offered. The family PMH NP is trained to deliver psychiatric services across the life span and function in a manner quite similar to the C/A CSs, although as noted in a role differentiation study of the two groups there was a greater emphasis on medication management among PMH NPs and therapy with C/A CSs.

At the same time the Advanced Practice Registered Nurse (APRN) Consensus Model was widely endorsed, which set the PMH specialty as a life span population. As a result of an alignment of licensing, accreditation, certification, and education, by 2015 only the PMH-NP (life span) certification exam will be available for new APPNs (Hanrahan, Delaney, & Merwin, 2010). However, the existing C/A CS workforce will continue to practice because, as with any specialty, once licensed an advanced practice nurse (APN) retains that state license and may renew certification by meeting the certifying body’s certification practice requirements (see details at APNA, n.d.). The APRN Consensus Model delineates the positioning of a specialty practice level beyond the basic population/role license. In the near future, the PMH specialty must decide whether creating specialty training would be the optimal path for addressing the mental health needs of particular child/adolescent populations, particularly those with complex SEDs (Hanrahan, Delaney, & Stuart, 2012).

UNDERLYING ASSUMPTIONS AND PRINCIPLES

Three underlying assumptions that differentiate child therapies from adult psychotherapy include developmental considerations, family inclusion, and consideration of the interacting systems in a child’s life. In the adult realm of mental health service delivery the notion of recovery has become a prominent organizing

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principle of mental health treatment. In the child field, a parallel idea is the concept of resiliency. This principle is in direct contrast to the traditional approach to children, which was ground in a problem-based method. Resiliency as an overarching perspective moves the field to a strength-based approach that holds at its center a stance of therapeutic optimism.

The level of a child’s development influences what they can understand and how they understand the world. For instance, depending on a child’s developmental level they may be unable to take another person’s perspective into account and may explain an adult’s action based on an egocentric view of the situation (Moses & Flavell, 1990). By about age 6 this egocentric thinking gives way to a more reasoned interpretation of another person’s intention; thus an APPN should be aware of potential diagnostic issues when egocentric thinking is still apparent in a latency aged child (Begeer, Bernstein, van Wijhe, Scheeren, & Koot, 2012). As the APPN approaches a child’s issues the APPN also considers the developmental norms that the child’s behavior might or might not be violating. Are the parents’ or teacher’s expectations for sustained attention in line with what one might expect of a child of that age? Thus understanding a child’s developmental level of reasoning, perspective taking, language, and social emotional regulation (ER) facilitates treatment planning, therapies and, at times, developmentally sensitive adaption of a particular method (Friedberg & McClure, 2002).

Just as in adult therapies where APPNs consider the notion of the neural integration that can be achieved via intervention, in the child world an overarching framework is the notion of how a child achieves self- regulation via integration of the thinking, emotional, memory, and motivational centers of the brain. The field of developmental neuroscience has accelerated the view of children as striving to achieve integration largely on the heels of experience-dependent growth of critical areas of the brain (Siegel, 1999). This developmental view is particularly important when, after a thorough assessment, the APPN begins to piece together a formulation of the child’s presentation with an eye on both the child’s functioning and how the child/family have attempted to cope with the regulation issues they deal with, be it impulsivity or emotional dysregulation (Blaustein & Kinniburgh, 2010; Southam-Gerow, 2013).

Developmental neuroscience also provides APPNs a platform for combining the emerging neurobiology of illness/treatment with a service system organized around the family-centered approach. In one sense, neuroscience maps ways of helping children and adolescents engage in experiences that will help them reorganize, strengthen, and reconnect with developmental challenges (Arden & Linford, 2009). Similar to the spiral of treatment (Figure 1.8), children engage in life so that they are making decisions that lead to behaviors that promote competence and stabilization, which in turn increases esteem (Basch, 1988). To re-engage with social systems, children must respond to situations with appropriate control of their behaviors and emotions. This critical task is represented by the notion of self-regulation. Box 17.1 provides a brief summary and an example of how research informs efforts to understand childhood illness in the framework of neural integration and self-regulation.

BOX 17.1

SELF-REGULATION

At its most basic level, regulation is conceptualized as a developmental milestone of childhood whereupon the child controls behavior in the service of socially desirable conduct (Kochanska, Forman, Aksan, & Dunbar, 2005). As a simple example, think of the 4-year-old who, as the preschool teacher puts down a plate of cookies, is told to wait for snack time to begin. What prevents that child’s hand from snatching a treat? Neuroscientists would argue that the restraint arises from the development of inhibitory control and the integration of emotion with memory (e.g., What happened last time I snatched a cookie?). These processes help dampen the rush to reward so that the child can comply with the teacher’s request and wait. It is within this almost simultaneous action and reaction of cognitive, emotional, and motor systems that individuals adjust to the demands of a particular situation. Neuroscience researchers illustrate how frontal lobe activities coordinate with limbic system structures to control attention and modulation of emotions which in turn facilitates one’s ability to respond appropriately to particular situations (Eisenberg & Spinrad, 2004).

Self-regulation depicts the pivotal developmental process of integrating emotion, reading the salience of a cue with a memory of past experience. It also has the potential to bridge psychotherapy and neuroscience. Indeed, the future of child psychotherapy may lie in how neuroscience informs the process of creating experiences and surrounds such that the child strengthens neural pathways and develops adaptive ways of thinking, feeling, and behaving (Arden & Linford, 2009). Self- regulation issues are increasingly understood to cut across several dimensions of child psychopathology such as ADHD, PTSD, maltreatment, depression, and anxiety (Anastopoulos et al., 2011; Burns, Jackson, & Harding, 2010; Dahl, Silk, & Siegle, 2012; Lanius, Frewen, Vermetten, & Yehuda, 2010; Tan et al., 2012).

Problems in the preschool child’s self-regulation have also been tied to subsequent issues with aggression, social withdrawal, and conduct problems (Bell & Calkins, 2012). Since it may be one of the pivotal processes that drive several disorders, Racusin and associates (2005) suggest that it should be a component of any therapy program aimed at attention, self- awareness, or cognitive controls.

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601TABLE 17.1 Key Events and Principles in Family-Centered Care Approach CASSP Established (Children and Adolescent Service System Program). The overarching goals of CASSP were to coordinate community services for children with serious emotional needs. CASSP principles also emphasized that parents should be empowered, treated as partners in care, and participate fully in treatment planning (Day & Roberts, 1991).

Systems of Care Approach Is Defined. These principles moved into a broader systems of care approach to treatment (Stroul & Friedman, 1996) with the creation of agencies and funding that ensured comprehensive community-based services would be available for families of children with serious emotional illness. Here the emphasis shifted to establishing networks for delivering individualized service plans embedded in comprehensive, culturally competent, coordinated service networks.

Comprehensive Community System of Care Ideology Is Developed. With these grants, systems of care were developed that held parents as key players determining how services would be developed, delivered, managed, and evaluated to match the needs of the child.

A second underlying assumption of child psychotherapy is that clinicians operate from a norm of family involvement in treatment and treatment decisions. The idea of family involvement has an important history and critical place in child treatment (see Table 17.1). Family involvement begins when treatment is initiated, enlisting the parent’s view of treatment needs and establishing goal congruence (a consensus about the goals of therapy and the means to accomplish those goals). This orientation, sometimes titled family-centered systems of care approach or more recently patient-family-centered care (Conway et al., 2006), should be firmly integrated into all aspects of treatment planning. Focused efforts to involve families in care is also critical as the treatment proceeds because strengthening family’s engagement has been demonstrated to improve outcomes and reduce treatment dropout (Saxe, Ellis, Fogler, & Navalta, 2012).

A family-centered approach does not mean that the family is the focus of treatment. Family treatment is appropriate to improve family interactions, keep families engaged in services, or increase their knowledge about mental health (Hoagwood, 2005). For some children, an individual approach with a family component may be the appropriate treatment combination, particularly if informed by evidence of parent–child interactions that reinforce a problematic behavioral pattern (Kendall, 2012a). Children with conduct issues may require a multisystemic approach where interventions are aimed at the various systems that interact with the child; in this instance, family involvement is a critical element to both setting goals and keeping them involved with the treatment (Henggeler, 2012).

The third underlying assumption of child psychotherapy is consideration of the systems that promote a child’s development (i.e., family, school, peers, and community). Since interaction in these systems is key to ongoing development, a child’s competence in these systems must also be facilitated. As articulated by parents, a guiding principle of child psychotherapy should be a focus on developing a package of services that contribute to a wide band of “real-world” outcomes (Flynn, 2005). For instance, the goals of treatment should include a focus on improvements in critical areas of a child’s life and the socioemotional skills they need to succeed in school and with peers (Aviles, Anderson, & Davila, 2006). In line with a goal of supporting a child’s strengths and reducing risk, treatment should also extend to the development of a community support system that will ensure gains are continued. Guidelines have not been formally written for this type of therapy system, but exemplars exist (Herrick, 2006) as well as statewide models that integrate EBPs into community services within the context of usual care at community-based practice settings (Garland, Hurlburt, & Hawley, 2006). Combining EBPs with coordinated communityservices that assist patients with recovery/resiliency is also at the heart of the government’s plan for a transformed mental health care system (Substance Abuse and Mental Health Services Administration [SAMHSA], 2005).

In the introductory chapter of this book, healing was identified as an outcome of the psychotherapy process. Must child psychotherapy involve healing? Yes, but not healing in the cognitive sense where, as with adults, one comes to piece together a healing narrative. Rather therapy should be healing such that children can regulate their behavior and emotions and thus stay positively connected with their school, family, and peers. Drawing upon regulation skills, children interact with the wider world and build a store of experiences that promote children’s/adolescents’ learning and also practice in how to plan, solve problems, build competencies, and exercise agency. To accomplish these outcomes, therapy should be aimed at helping children build resilience. That may include addressing maladaptive behaviors, but equally important is constructing an environment that builds on children’s strengths and augments their vulnerabilities (Bailey, 2005).

Resiliency was initially conceptualized via a trait approach, isolating characteristics of children who were able to develop, indeed thrive, in the face of significant adversity (Anthony, 1988). Increasingly resiliency is viewed as a grounding conceptual framework for intervention programs that promote competency and minimize stress (Goldstein & Brooks, 2013). In line with this approach, interventions are not primarily

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focused on pathology but on strengths and promoting protective processes in families and systems that interface with the child (Masten, 2006; Olin et al., 2010; Selekman, 2005). A strength-based orientation moves beyond diagnosis-bound approaches to consider accommodations in the environment that will strengthen factors to help children and adolescents deal successfully with the challenges they may face.

This emphasis has been part of child psychiatric nursing since the first standards of practice written in 1985 (ANA, 1985). It is also in line with the current SAMHSA (2005) orientation toward focusing treatment on building recovery/resiliency. This orientation does not discount diagnosis but emphasizes that nurse psychotherapists combine symptom amelioration with building environments that allow for the mobilization of a positive developmental thrust; a potential that resides in all children and is reset in motion in an environment structured to support functioning (Emde, 1990).

This orientation does not discount the need to intervene to help children regulate and/or alleviate distress. Thus any psychotherapist treating children must also know a range of interventions and what is efficacious for the treatment of a particular SED (Davis, May, & Whiting, 2011). For instance, a child dealing with serious anxiety will need to learn regulation skills ground in cognitive behavioral techniques (Kendall, 2012b). It would be an error in clinical reasoning not to initially consider these techniques given the substantial evidence supporting the use of behavioral, cognitive behavioral, and for some anxiety disorders, combined techniques (medication with cognitive behavioral therapy [CBT]) to address anxiety issues (Kendall, Settipani, & Cummings, 2012).

Part of building resiliency might mean addressing the pivotal process that may be driving the disorder. For example, the treatment plan for a depressed adolescent may need to include interpersonal psychotherapy (IPT) when dysfunctional relationships are seen as central to the disorder (Mufson et al., 2004). Chapter 9 contains an excellent outline of the principles and basic techniques of IPT and a summary of the accommodations of the model in IPT protocols designed for adolescents. Alternately, therapy might be focused on cognitive coping skills for an adolescent whose issues with ruminative self-focus are pivotal to the maintenance of the depression (Miller, 2007). Either or both processes (interpersonal and cognitive) that may be at play in adolescent depression and treatment should address the core issue. Combining evidence-based therapies (a traditional deficit approach) with a fundamental strength-based framework may seem like forging a meeting of opposites. What is essential is that the APPN weaves together targeted interventions within a plan for building systems that promote a child’s/adolescent’s competence. In doing so, the nurse aims to help the child get back on the developmental path of agency, choices and, eventually, self- efficacy.

Current EBPs in the Child Field

Therapies and psychological approaches become EBPs via clinical trials where defined groups of participants receive a standardized treatment. Members of this participant group have similar behaviors or presentations such that they meet select diagnostic criteria. Thus a particular EBP often demonstrates efficacy for a particular diagnosis. The convention of linking EBPs to diagnosis is reinforced by publications such as practitioner reviews (Leenarts, Diehle, Doreleijers, Jansma, & Lindauer, 2013), research summaries of treatments for particular disorders (Simpson, Suarez, & Connolly, 2012), practice guidelines, and texts describing specific EBPs in detail (Weisz & Kazdin, 2010).

Based on a review of the literature, it would seem that there was much to choose from when considering an EBP approach for children and adolescents. While the body of evidence-based child practices does not equal those amassed in the adult field, reviews and analysis of effective treatment modalities indicate the growing strength of the child specialty (Chorpita, Daleiden, et al., 2011; Kazak et al., 2010). Organizing child interventions by EBPs and diagnosis envisions a future where the therapist will line up diagnosis and a suitable evidence-based intervention. This would seem a logical approach but this convention is not without complications. Several issues of an EBP-based child psychotherapy therapy system are outlined in Box 17.2. With the advent of web-based searches and dashboard methods for organizing effective treatments, the hope is clinicians will achieve a comfort level with isolating the best available, most effective approach for a child’s presentation (Chorpita, Bernstein, & Daleidan, 2008). Indeed the logical result of this modular effort is moving the child field toward defining child psychotherapy by EBPs in line with a child’s core issues, informed by diagnosis but not necessarily dictated by it (Weisz et al., 2012).

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BOX 17.2

ISSUES OF EBP AND CHILD PSYCHOSOCIAL TREATMENT

There are several issues with building a child therapy system ground in EBPs. One of the issues rests on the assumption that eventually there will be an EBP to match most of the children’s SEDs. While significant strides have been made in developing a menu of evidence-based treatment for children (Weisz & Kazdin, 2010), the child specialty has not built a body of clinical-trial evidence to support psychosocial or combined treatment for every diagnostic category. Reviews of child-specific EBPs demonstrate progress in the treatment of adolescent depression, anxiety, and ADHD but there is much work to be done, particularly in the areas of Pediatric Bipolar Disorder and children who present with elevated symptoms of mania (Findling et al., 2010). Even with the SEDs that have been the focus of significant research, there are issues with the way evidence is reviewed and interpreted, and data are collected, at times calling into question the conclusions of treatment that are considered evidence based (Watson, Richels, Michalek, & Raymer, 2012).

Another assumption of the evolving evidence-based system is that clinicians will proceed in a linear fashion from assessment to diagnosis to locating the appropriate EBP. However, diagnosis in the child and adolescent field comes with a host of considerations (Chorpita, 2003). Children’s psychiatric diagnoses are not static; they can change over the years. The current popular taxonomies do not provide for a youth’s presentation that might be a blend of behaviors, each akin to several disorders (Arnold et al., 2011) or a combination of behaviors that do not fit into any existing diagnostic category. With children comorbid disorders are common; 40% of affected youth report more than one class of mental health disorders (Merikangas et al., 2010). Another issue is the assumption that EBPs, primarily designed and tested as child-centered approaches, will be what families want or need. Speaking for the voice of parents, Flynn (2005) noted families’ issues with EBPs: primarily there are too few, they are poorly translated into “real-world practice,” and they disregard the family’s role in the treatment planning. As Flynn emphasized, children and adolescents must be treated in the context of their school lives, families, and communities. The outcomes families seek (improved school performance, competency, and enhanced peer relationships) are not necessarily the direct outcomes of applying an EBP.

Finally, a therapy model organized solely around EBPs overlooks the reality that children and adolescents with SEDs have a variety of interconnected needs. Research demonstrates that youth with SED are likely to have a comorbid disorder, be severely impaired, and be experiencing problems in multiple areas of their lives (e.g., school and family) (Pottick et al., 2004). Within the population of youth with SED are cohorts of children with particular needs arising from maltreatment, being in foster care, or involvement in the juvenile justice system, children for whom specific EBPs do not exist (Kates, Gerber, & Casey, 2012; Pecora, 2010). Children with complex needs will require an approach that simultaneously addresses their multiple social needs as well as issues arising from their SED. It is beyond the scope of this chapter to review the issues with translation of EBPs with “usual” care in community settings.

PSYCHOTHERAPY WITH CHILDREN: BASIC PRINCIPLES

Initial Contact, Assessment, and Setting Shared Goals

There are numerous psychotherapy interventions, many of which fall within the major schools of therapy (e.g., cognitive behavioral, psychodynamic, and supportive). The text has provided an excellent orientation to the underlying conceptual framework of these major schools, the drivers of change, and theoretically how particular methods achieve these aims. The basic structure of psychotherapy with children aligns with the principles presented for adults. With children and families, as with adults, the APPN mindfully moves through the initial contact, aware that this first meeting sets the stage for the requisite therapeutic alliance. With children, one also considers that it is the parent, not the child or teen, who often initiates the treatment, and thus for the youth there may be a mixture of both fear and resentment at this initial session. Thus beginning with this first meeting it is helpful to take a strength-based approach, for example, praise the teen for his or her efforts at maintaining control of some aspects of his or her life (Cepeda, 2010). All the principles of therapeutic communication also apply here, but the attending and listening are to both the family and the child. Cepeda (2010) also underscores the importance of picking up on the themes or the preoccupations of the child during the assessment process. For the beginning practitioner, several texts exist to guide this initial engagement process (Cepeda, 2010; Greenspan & Greenspan, 2003; Morrison & Anders, 1999).

CHILD ASSESSMENT During initial meetings with a child and his or her family the APPN conducts a thorough assessment. The basic elements are reviewed here because assessment drives treatment planning, which in turn drives the

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psychotherapeutic approach. However, the reader should refer to more extensive texts on child assessment for a comprehensive approach to the process (e.g., Mash & Barkley, 2010). In line with a family-focused, strength-based approach, the APPN does not conduct the assessment to place a label on the child, which might place constraints about how to think about the child and the family goals (Selekman, 2002). Yet while working within a strength-based framework, the APPN is aware that billing, service site treatment records, and at times, communications with other providers, will necessitate that a diagnostic impression be recorded. Parents will also want to know within what category (mood, thought, and behavior) the APPN places the focus of treatment.

The psychiatric assessment should be conducted in an organized fashion with particular categories of information explored, such as details of the current problem, strengths, functioning, psychiatric history, medical issues, emotional/physical development, relationships, and trauma circumstances. The novice APPN might use the AACAP assessment practice parameter, which is currently under revision by the AACAP, and incorporate specialized areas of assessment depending on the child’s presentation. For instance, if a child/parent reports a significant history of anxiety, the student should consult the appropriate AACAP assessment guideline (Connolly, Bernstein, & AACAP Work Group on Quality, 2007) as well as considering a structured interview format appropriate to the presentation (Frick, Barry, & Kamphaus, 2010). Numerous rating scales exist for children; Lee (2012) provides a succinct summary of the gold standard tools and consideration for their use and interpretation.

Finally the assessment process of children requires that the APPN develop a sense of the child’s internal world. In his classic book, The Clinical Interview of the Child, Greenspan (2003) explains how one conducts an assessment of not just a child’s problem behaviors but also how the child is organizing experiences and the developmental level of that organization. These key processes include the developmental level of the child’s regulation and engagement, which is assessed by taking note of how the child attends to the interview and shares attention and focus. The second process involves how the child signals and communicates via gestures. The third has to do with the meaning system of the child and mental images or representations he or she creates, and the last involves how the child connects ideas and feeling and reflects on a global level. Taken together, these processes offer a vehicle for observing the often intangible aspects of children, that is, how they take in reality, how they take in you as an interviewer, how they signal needs, and how they manipulate ideas.

While the basic components of the assessment process in child treatment move in parallel with adults, there are several distinct features. As with adults, the APPN organizes his or her assessment around guidelines that map out the essential content areas. In an integrated approach, the assessment may also include a review of systems to rule out medical issues that may be present and impacting behavior (Johnson & Newland, 2012). The assessment also demands integrating data from multiple informants, parents, child, and school as well as viewing the information through a developmental-systems lens. Finally the APPN considers presenting behaviors in terms of their setting, frequency, variability/consistency, and situational influences (Mash & Barkley, 2010). Considering the known issues of disparities in the treatment of racial and ethnic minority youth, the assessment incorporates ethnic and cultural contexts for both the child’s behavior, the interpretation of the presenting problems as well as the goals and expectations of the family (Alegria, Vallas, & Pumariega, 2010).

Another important element of child psychotherapy involves goal setting with both the parent and child. Through careful listening, the APPN has come to understand the parents’ perception of the core problem as well as how they have come to understand the behavior and what they believe “caused” the problem (Delaney & Sciana, 1996). For teens, collaboration is particularly important as they tend to avoid services if they view the therapists as not understanding their problems and perspective (Draucker, 2005). Parents’ beliefs, attitudes, and expectations about treatment and their sense of the effectiveness of the interventions are critical to their engagement with services (Olin et al., 2010). Among the reasons Horwitz and colleagues (2012) note for parents prematurely leaving treatment are issues around the cultural relevance of services, lack of consideration of family preferences (particularly around medication), and seeing the treatment as irrelevant and/or ineffective. Thus incorporating the family’s ideas into treatment goals not only demonstrates respect but meeting the family’s expectations increases the likelihood that parents/caregiver will stay with treatment (Horwitz et al., 2012). Box 17.3 provides an example of how an expert nurse works within a family-centered approach to align with family goals as well as educate and empower the parents and child.

Following the assessment and discussion of shared goals, the APPN begins to build a formulation of the child’s core issues. The formulation goes beyond diagnosis to explain what is unique about the child’s presentation, how the child/family is responding to situations, as well as the narrative of the illness and events that shaped that interpretation (Crowe, Carlyle, & Farmar, 2008). As Crowe et al. suggest, the nurse also filters the data through the explanatory framework he or she is operating from, that is, a particular therapeutic

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approach (e.g., psychodynamic and cognitive) or a theoretically sound blending of approaches. With children, it is also important to include the developmental context and an understanding of why the child is struggling in particular areas of his or her life and what might be the processing/regulation deficit underlying the behavior (Blaustein & Kinniburgh, 2010). The formulation should take into account the systems the child interacts with, his or her support network, and the cultural dimensions that impact on both the particular SED and a particular orientation to mental health (Alegria et al., 2010; Stewart, Simmons, & Habibpour, 2012).

BOX 17.3

EXPERT NURSING APPROACH TO A CHILD EXHIBITING BEHAVIORS CONSISTENT WITH PEDIATRIC BIPOLAR DISORDER

8-Year-Old Thomas: A Psychiatric Mental Health Nurse Practitioner Approach to Treatment Planning, Medication Management, and Family Support

Julie A. Carbray PhD, PMHNP-BC, PMHCNS-BC, APN

Thomas is an 8-year-old cherubic, energetic, and loud Caucasian boy who presents with his parents to the outpatient clinic. His family is concerned about the level of mood dysregulation Thomas shows at home, where he is always irritable, demanding, and volatile, especially when things do not go as he desires. Thomas has an uncle with bipolar disorder, and his parents note that sometimes they worry Thomas shares similar symptoms to those of his uncle. He does well at school, is proud of his grades, but his intense moods keep peers at a distance. Those who try to be his friend soon abandon him for less intense peers, despite his creative and witty personality. At home, his family feels they are always walking on eggshells anticipating what they say or do might trigger him to explode. When he explodes, he throws shoes, toys, will hit whoever is in his way, and has run out of his home and into the street without paying attention to safety.

In addition to his irritability and rages, Thomas is often hypersexual. His symptoms of hypersexuality, mostly manifest in masturbatory behaviors in inappropriate social environments, talking about sexual feelings out of context, and acting on sexual impulses; recently he has swatted girls at school on the behind at school, which has jeopardized his academic success. Thomas does not have a history of sexual abuse or trauma. Although a more chronic concern exists, Thomas has never been a good sleeper. His parents look forward to when he is finally sleeping each night, but he seldom can fall asleep before 10 p.m. and awakens before the rest of the house each morning and starts his busy day while all are sleeping. Thomas shows intensity and struggles with mood regulation throughout the intake interview with themes of hopelessness, negative cognitions, and frustration fueling his angry responses to questions. Quietly, his parents share that they have been worried that these symptoms will leave Thomas disabled as an adult, like his uncle, and they want to stop the course of these symptoms to prevent the same outcome. Developmentally, Thomas wants to show his parents that he is more independent. They have noticed he has begun to want more privacy especially around talking about his symptoms.

Although Thomas understands what can trigger his anger, he feels frustrated with his inability to articulate what he needs when frustrated or to stop himself. After he has a rage, he is embarrassed, exhausted, and wants his family not to talk about it because he now is better. However, the family does not recuperate as quickly. Thomas had been treated for ADHD previously, but his parents are concerned that his symptoms of mood dysregulation went beyond what they have read about ADHD symptoms. Given his symptoms, his parents were given the Child Mania Rating Scale (Pavuluri et al., 2006) to further illicit any positive symptoms of mania. Thomas’s parents’ responses to the rating scale indicated that his symptoms were likely to indicate mania, and their instincts were correct; his symptoms were beyond his previous ADHD diagnosis and a pediatric bipolar disorder diagnosis seemed likely.

We discussed together the predominant challenges for Thomas, his irritability, mood dysregulation, hypersexuality and arousal, and his struggle with self-soothing especially when he does not get his way. I showed Thomas and his parents a picture of a brain and discussed with them how the emotional center of the brain (amygdala) seems to become so active that it shuts off the part of the brain that helps people solve problems and shift expectations (frontal cortex), allowing the emotions to take over, and how medications and therapy have been designed specifically for children like Thomas to help them regulate better. Thomas and his family were told how chemicals in the body help the brain regulate those actions, and that sometimes medications can help to better regulate the emotions so that a child can work with his or her family on better problem solving and keeping his or her moods (both anger and hyperarousal) more manageable (Pavuluri, Ellis, Wegbreit, Passarotti, & Stevens, 2012). We reviewed medications that had the most evidence for effectiveness with irritability, mania, and hyperarousal, and we discussed what benefits and potential risks were involved with these medication choices (Pavuluri, Henry et al., 2004). After this review, Thomas and his family decided to have preliminary lab work done to rule out thyroid illness, vitamin deficiencies, lead poisoning, and to get a baseline for kidney, liver, and metabolic function, and then to start risperidone 0.25 mg twice daily to control his symptoms.

In addition, we talked about starting a family psychotherapy regimen that would help Thomas track his moods, control his responses to a shift in his mood states or arousal, and would also help his parents better understand techniques they could use to help Thomas when his brain circuits seemed “stuck.” I told them about RAINBOW therapy, specifically designed for children with Pediatric Bipolar Spectrum illnesses (Pavuluri, Graczyck et al., 2004; West et al., 2009), which is designed to help kids understand and regulate their moods and engage with their parents in solving problems due to their illness. As a start, Thomas and his family would begin tracking his moods and collecting information together about triggers for rage episodes and hypersexuality, as well as seeing what helps to soothe Thomas when he begins to become angrier. Most importantly, I shared how evidence consistently demonstrates that early intervention, academic successes, a supportive family (and new evidence that treatments work) all show great promise for Thomas and his family’s recovery. I told the family I would be their coach along the way, and offered my confidence that together we could help Thomas gain better control over his symptoms and for their family

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to see hope and more peace in their everyday living—that the disability of his uncle did not need to be in the future for Thomas. We agreed to meet again the following week.

TREATMENT PLANNING Treatment planning takes into account family goals, preferences, beliefs, as well as the perspective of the child/adolescents on the problem and, for teens, their ideas on how best to address the issue (McCarthy, Downes, & Sherman, 2008; Selekman, 2005). Given the issue, the APPN draws on the evidence supporting a particular approach to formulate the treatment plan. Following an overview of general principles of child psychotherapy, I will discuss three methods of implementing evidence-based psychotherapy. The use of medications is indicated in combination with psychosocial interventions in several child and adolescent SEDs, such as pediatric bipolar disorder, and with moderate to severe levels of particular disorders (ADHD, obsessive–compulsive disorder [OCD], and adolescent depression). A thorough treatment of this topic is beyond the scope of this chapter, so the reader is referred to the practice guidelines and most recent evidence on combined/pharmacological treatment strategies (Greenhill et al., 2001; Kennard et al., 2009).

GENERAL PRINCIPLES OF CHILD PSYCHOTHERAPY

One way to approach child psychotherapy would be to discuss the major schools of therapy and exactly what a child version might entail. In many respects, the therapeutic mechanisms of CBT and IPT discussed in this text apply to work with children and teens. While the goals of CBT with children are in line with the general principles of the therapy school, there are important differences in their implementation with children and teens (Delaney & Hawkins-Walsh, 2012). For instance, the principles of cognitive therapy with children are similar, that is, sessions are problem focused, collaborative, and goal oriented (Friedberg & McClure, 2002). But as Friedberg and McClure (2002) point out, owing to the child’s motivation for treatment and cognitive/verbal abilities, therapy tasks should be constructed in line with the child’s developmental level and an orientation to the here and now. The actual use of CBT techniques with children and teens will also depend on the particular issues and their engagement with a particular CBT technique (Friedberg, McClure, & Garcia, 2009).

For the interested reader, Sharer (2012) provides excellent summaries of the major schools of therapy (e.g., psychodynamic, IPT, CBT), as well as multisystemic and eye movement desensitization and reprocessing (EMDR) in the context of child treatment and specific intervention techniques (e.g., behavioral parent training). For the APPN who decides to offer these therapies in his or her practice, Sharer also provides information about how one enrolls in specific training to become proficient at each particular type of therapy. Since the principles and core techniques of the CBT and IPT for children and teens are quite similar to their presentation in this text, I will spend the rest of the chapter discussing specific ways to implement these strategies within an evidence-based approach to psychotherapy for children.

At the start of one’s advanced practice career, an APPN may not have extensive or specialized training in a mode of therapy. As they begin to practice, APPNs will undoubtedly find that they spend much time providing a full range of psychiatric services including diagnostic evaluations and medication management. Often it is within this framework that one provides the indicated psychotherapeutic or psychosocial interventions. As the novice APPN moves into a particular service sector, depending on the team and how they approach therapy, he or she might seek advanced therapy training in a particular modality such as IPT or psychodynamic therapy. Perhaps the APPN finds that many of the children and teens in the practice are dealing with anxiety and thus finds it appropriate to acquire additional training in both CBT and EMDR. For the beginner or novice APPN who finds that he or she is dealing with directing intervention for a wide variety of children, there are several methods for implementing evidence-based psychosocial therapies. Two that are accessible for the novice APPN are a common factors and a common elements approach. To begin, I discuss a manualized therapy approach so that the reader understands the difference between this and a common factors/common elements approach.

Treatment With Manualized Approach

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In treatment planning, one way to address a child’s issues is to utilize a specific method or manualized approach. For illustration, outlined here is the treatment approach for a child assessed with trauma issues. The treatment is being utilized with a 10-year-old boy who was brought to the mental health clinic with behaviors that began following a 6-month-long exposure to a domestic violence situation. The boy is assessed by the APPN who determines that many of the presenting issues (poor sleep due to nightmares about the violence, irritability and refusal to talk about the domestic violence, minor aggression, and restlessness) began following the domestic violence exposure. After gathering additional information and consultation with the boy’s mother, the team agreed that the evidence-based treatment of choice was trauma-focused CBT (TF-CBT) (AACAP, 2010). TF-CBT is an empirically supported treatment model for children who have experienced some form of trauma. It aims at helping such children practice emotional expression, build emotion–event– cognition connection, and gradually process their abuse experience (Cohen, Mannarino, & Deblinger, 2006). TF-CBT is a component-based treatment where within a relationship-based approach parents and the child learn how to manage emotions, cope with stress, manage and process thoughts related to the trauma, and enhance feelings of safety (Cohen, Mannarino, Berliner, & Deblinger, 2000). The acronym PRACTICE represents the components of TF-CBT (as cited in Child Sexual Abuse Task Force and Research & Practice Core, National Child Traumatic Stress Network, 2004).

The first component psychoeducation begins the process as the child and parent are taught about trauma response, what causes it, common responses (including PTSD symptoms), and how TF-CBT addresses these issues. Also included in this component is a review of the effective parenting skills that will be of use to the traumatized child, such as praise and positive attention. The R stands for relaxation and the skills taught to the child to deal with the physiologic response to the trauma. Affect modulation (A) provides skills such as affect identification and thought interruption that help children control thoughts attendant to anxious feelings. Enhancing safety (E) as well as cognitive coping (C) is critical and includes problem solving to help the child both regulate negative thinking and recognize the relationship between thoughts, feelings, and behavior. In the final components, the child begins to construct the trauma narrative (T), which entails creating a narrative of the experience, correcting distortions about the experiences, and placing the trauma in the context of his whole life. Via graduated exposure to feared stimuli, the therapist leads the child through in vivo (I) mastery of trauma cues. Then in conjoint (C) parent–child sessions the child shares the trauma narrative with parents. Finally the therapist and family work toward enhancing (E) the child’s sense of future safety. In controlled studies, children who completed the TF-CBT program had significantly reduced depression, anxiety, and PTSD symptoms; gains were robust compared to another parent–child treatment, and the TF-CBT gains held over a 1-year period (Cohen, Deblinger, Mannarino, & Steer, 2004; Cohen, Mannarino, & Knudsen, 2005; Deblinger, Mannarino, Cohen, & Steer, 2006).

Common Factors Approach to Therapy

In some settings, TF-CBT may not be available or there might be a delay in the child entering treatment or the child may present with a history of multiple traumatic events in his or her life that have generated a host of behavioral issues (Cook et al., 2005). In this situation, what approach would an APPN take in treatment planning and providing psychotherapy for a traumatized child? For the purpose of this discussion, we will focus on a child who presents with the similar symptoms to our young boy (poor sleep due to nightmares, irritability, minor aggression, and restlessness) but has a history of multiple traumas, early abuse, and significant neglect. This young child with a more extensive trauma history could benefit from TF-CBT (Cohen, Mannarino, Kliethermes, & Murray, 2012), but the APPN must determine how to use the principles and translate them to usual care in the community clinic. One way to conceptualize an alternative method for psychotherapy is the common factors approach. The common factors approach holds that change in therapy depends on patient factors, relationship factors, the specific technique used, and expectancy (Hubble, Duncan, & Miller, 1999). The approach aligns well with a nursing framework because factors highlight the relationship as well as planned use of evidence-based psychosocial interventions (Perraud et al., 2006).

Using a common factors model, the APPN pays particular attention in cultivating a relationship with the family and child. With a child, a straightforward approach to relationship building would be to convey understanding, respect, and wish to be of help (Reisman & Ribordy, 1993). Other critical elements of the child–therapist relationship are the therapist’s use of interpersonal skills (such as warmth and empathy) and influence skills (presenting information clearly with rationale) (Karver, Handelsman, Fields, & Bickman, 2006). The APPN strives to attune with the child’s affect and mirror back that understanding to the child

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(Arden & Linford, 2009). Forming a relationship with the child will, in large part, depend on the nurse therapist’s efforts to develop a bridge of empathy with the child’s meanings: meanings sent via nonverbal behaviors and ones extracted from the youth’s narrative of experiences (DeSocio, 2005).

In child psychotherapy the APPN also focuses on the alliance with the family knowing that this will entail building trust and understanding the family’s dilemma. Caring for a child with emotional difficulties creates stress, particularly in the years that families search for answers and they find none, have problems accessing services or understanding exactly what the services offer (Mendenhall & Mount, 2011; Usher, Jackson, & O’Brien, 2007). Families must also deal with stigma that they sense from relatives and their community (Hinshaw, 2005). Building an alliance with families of traumatized children has been historically difficult and actively addressing barriers to treatment is critical to increasing engagement (Saxe et al., 2012).

In the common factors approach, the techniques to intervene with the child and family should be informed by the assessment data, use of the current practice guidelines, by practitioner review of evidence- based treatment for trauma in children (Leenarts et al., 2013; Silverman et al., 2008), and by the impact of maltreatment and trauma on a child’s development (Burns, Jackson, & Harding, 2010). In drawing these sources together, the APPN realizes that children who have experienced maltreatment have multiple problems with regulation (cognitive/affective balance) (Muller, Vascotto, Konanur, & Rosenkranz, 2013) and manifest behaviors indicative of ER issues, for example, irritability, emotional flooding, or angry outbursts (AACAP, 2010). Research on the ER issues of maltreated youth has focused on its impact on vital parts of the prefrontal cortex (PFC); trauma (including abuse and neglect) influences not just the development of these structures but the neuronal pathways that travel between them (van der Kolk, 2006). On a more profound level, this poor neurocircuitry can lead traumatized children to immobilize in the face of threat as the neurochemical ramifications of fear surge through their systems (McFarlane, Yehuda, & Clark, 2002). The neurobiology that makes the maltreated brain vulnerable to a poor stress response also introduces social information processing deficits that have wider developmental implications (Pollak & Tolley-Schell, 2004; Teicher, Andersen, Polcari, Anderson, & Navalta, 2002).

In treatment planning, the APPN realizes that the family is unaware of the impact of trauma exposure on the child and that the child’s presentation suggests ER deficits. In the delay to access formal TF-CBT, the APPN intervention is based on a trauma systems therapy approach (Saxe et al., 2012) and on the suggestions offered by Cohen et al. (2012) of how to use a phase model of TF-CBT with children whose history and behaviors are indicative of complex trauma. Along with strategies to actively engage the family, the APPN provides psychoeducation around the impact of exposure to trauma and also suggests how the young boy’s behaviors might be related to the trauma exposure. Drawing on ER strategies (Southam-Gerow, 2013) and with an understanding of how to apply the ER and psychoeducational components of TF-CBT (Cohen et al., 2012; Dorsey, Briggs, & Woods, 2011), the APPN also suggests relaxation techniques that help the young boy reduce arousal and learn to accept comfort. Throughout the meetings the APPN also builds the relationship with the child, attuning to how the child is feeling and his state of mind (Arden & Linford, 2009).

There are EBPs for particular child/adolescent SEDs that provide a clear roadmap to the psychosocial interventions and can be used to address specific aspects of a disorder, such as CBT techniques for adolescent depression (Rohde et al., 2005; Spirito, Esposito-Smythers, Wolff, & Uhl, 2011). This clinical example was selected to illustrate how the APPN builds an intervention based on the best available evidence, the neurobiology of the disorder, and combining components of an EBP to direct psychoeducation, family engagement, and provide strategies for relief to the child.

Common Elements Approach

The common elements approach is not to be confused with the common factors approach albeit the similarity in names. The common elements approach has been more than 10 years in development, and while the focus of the program drivers has evolved (Chorpita, Bernstein, & Daleiden, 2011; Weisz et al., 2012), the core idea of the program has remained consistent. The program has its roots in the Child and Adolescent Mental Health Division (CAMHD) of The Hawaii Department of Health where a team of practitioners mapped evidence-based interventions across child diagnoses and some 322 clinical trials to arrive at effective interventions for common childhood mental health problems such as aggression, withdrawn behaviors, and attention problems (Chorpita et al., 2002). Their goal was to conceptualize how the existing evidence on treatment, derived largely from controlled clinical trials, would be best implemented in real-world practice

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where case managers usually select the services a child will receive (Chorpita, 2003). They viewed transportability of interventions would more likely occur when the common elements across diagnoses and the evidence of a particular strategy were isolated. For instance, a problem-solving approach might be contained in a package of CBT elements for adolescent depression (Kennard et al., 2009; Rohde, Feeney, & Robins, 2005), but it is also a component for treatment of children with conduct issues and a wide variety of mental health issues (D’Zurilla & Nezu, 2010). The common elements approach views the evidence-based strategies in light of the actual intervention as well as the diagnostic categories where it fits best. The distillation of methods and matching of models to the best fit of client characteristics have continued (Chorpita et al., 2005; Chorpita, Daleiden et al., 2011) as well as sophisticated decision tree models for moving common elements into practice (Chorpita, Bernstein, & Daleiden, 2008).

Psychotherapy With Medication for a Child Exhibiting ADHD Symptoms: Common Elements Approach

Children coping with ADHD characteristically have problems with inattention, hyperactivity, and impulsivity. Over the last two decades in large scale studies and evidence reviews, medications have demonstrated effectiveness at addressing core ADHD symptoms (Vaughan, March, & Kratochvil, 2012). Behavioral and psychosocial treatments are recommended as an adjunct to medication for moderate to severe ADHD as well as the first-line treatment for mild presentations of the disorder and treatment of ADHD symptoms in preschool children (Greenhill et al., 2006; Pliszka et al., 2007; Vaughan, March, & Kratochvil, 2011). Also, given the common comorbidities with ADHD, psychosocial treatments are often indicated (Pliszka et al., 2007). It is beyond the scope of this chapter to detail the debate surrounding the effectiveness of psychosocial treatments (Sonuga-Barke et al., 2013); suffice it to say that there is support for behavioral classroom approaches, behavioral parent training, and intensive summer camp type of interventions (Pelham & Fabiano, 2008). The promise of cognitive and behavioral interventions to improve behavioral problems has also led to support for several psychosocial interventions (Toplak, Connors, Shuster, Knezevic, & Parks, 2008; Watson et al., 2012).

It is recognized that children with ADHD have a fundamental problem with tasks requiring sustained attention. The problems with ADHD have long been viewed as a fundamental problem in the PFC, particularly the PFC cortices that via projections to the temporal and parietal association cortices regulate so- called “top-down” attention (Arnsten, Berridge, & McCracken, 2009). Visual-spatial working memory has received increased attention as a key mechanism in the pathophysiology of ADHD (Mills et al., 2012) and comes into play when children must hold visual information in mind, retrieve it, and then manipulate that information for an additional task. This temporary storage of information and then its manipulation is used in a range of cognitive tasks such as problem solving and complex thinking. For example, this type of memory might come into play for a child attending to a board exercise involving the five steps of long division.

To help a 9-year-old girl who despite stimulant medication exhibits poor attention in school, in a common elements approach, the APPN would review the best available evidence for a behavioral, cognitive, or psychoeducational intervention to augment the medication and address this core issue. Considering the child and family characteristics, and the parent goals, the APPN might suggest cognitive training aimed at enhancing working memory (WM), which is considered an intervention with good (level 2) support (Holmes et al., 2010). Cognitive training, on the most basic level, helps the child increase the amount of information they can hold in their mind. Knowing that the child enjoys computer-based work, the APPN locates the optimum program for systematic practice at WM tasks (Holmes et al., 2010; Klingberg et al., 2005). While WM training is considered an intervention with only good support, the example illustrates how to combine medication with psychosocial treatment drawing on a common elements approach.

Combining Common Factors and Common Elements Approaches

Since one element of a common factors approach is the particular technique used to address a core issue, it is logical that the two approaches can be combined in everyday practice. Such combinations make sense owing to the importance of the relationship in any treatment setting as well as consideration of individual, family, and systems factors in selection of a common elements intervention (Barth et al., 2012). The case example

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below illustrates how the APPN might combine common factors and common elements approaches in the treatment of a child with ADHD and significant ER issues (Anastopoulos et al., 2011). To demonstrate how the two approaches could be used by expert nurses, another case example is presented that illustrates how the approaches were combined by an expert APPN with a young teenage girl presenting with an eating disorder and obsessive–compulsive behaviors (see Box 17.4).

BOX 17.4

EXPERT NURSING APPROACH TO A CHILD EXHIBITING COMORBID SEDs

9-Year-Old Alicia: A Psychiatric Mental Health Nurse Practitioner Approach to Treatment Planning

Janiece DeSocio, PhD, RN, PMHNP-BC

Alicia, age 9, was referred by her primary care provider (PCP) for a psychiatric evaluation due to a 7-pound weight loss, an increase in hand-washing, and fears of germs over the past 2 months. Her symptoms began following an episode of the flu when she experienced several days of nausea, vomiting, and sore throat. Following her recovery, Alicia weighed 64 pounds and returned to school and swim team but continued to complain of stomachaches when she ingested even small amounts of food. Within the past month, she continued to lose weight. Today she weighs 60 pounds at 4'6" tall with a body mass index (BMI) of 14.5. The most Alicia has ever weighed is 67 pounds at her last physical exam 6 months ago when her PCP noted that Alicia expressed body image concerns related to the onset of puberty. After Alicia’s recovery from the flu, her mother noticed Alicia was washing her hands multiple times a day to the point that her hands are always red and chapped. She is fretful and anxious, and has difficulty falling asleep. Last week, the school called Alicia’s parents to report that Alicia is refusing to use the girl’s bathroom. She has been pulling her sleeves over her hands to avoid touching doorknobs and frequently wipes her desk with antibacterial gel. Her mother found several discarded school lunches in Alicia’s room and when confronted, Alicia acknowledged she does not eat or drink at school because she is afraid she will need to use the bathroom and it is full of germs.

Given this history, the psychiatric-mental health nurse practitioner (PMHNP) identifies several key areas for assessment. Alicia’s presenting symptoms are consistent with obsessive–compulsive disorder (OCD), and her age is within the expected range for anxiety disorder onset (Kessler et al., 2005). The onset of symptoms after a sore throat warrants evaluation for Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus infection (PANDAS), especially if the OCD symptom onset was acute and subsequent to her illness (Sokol, 2001; Storch et al., 2006). Laboratory tests include a complete blood count (CBC), throat culture, anti-streptolysin O titer, and anti-DNase-B titer to evaluate for current or recent strep infection (Sokol, 2001). Alicia’s recent body image concerns, weight loss, and reduction of nutritional intake are also risk factors for the onset of an eating disorder. Essential to evaluating Alicia’s risks is the family medical and psychiatric history to evaluate genetic predispositions for these disorders. The PMHNP also notes that, although Alicia’s resting heart rate today is 70 bpm and does not meet criteria for hospitalization, continuing weight loss could place Alicia at risk for cardiovascular compromise and requires close monitoring in collaboration with Alicia’s PCP (Golden et al., 2003).

As the evaluation continues, the PMHNP identifies a family history of anxiety disorders, a maternal grandmother described as “meticulous about cleanliness,” and a maternal aunt with adolescent-onset anorexia nervosa (AN). The comprehensive psychiatric evaluation includes administration of the Children’s Yale-Brown Obsessive Compulsive Scale and reveals symptoms sufficient for a diagnosis of OCD, a rule out for PANDAS, and an increased risk for early-onset anorexia nervosa. The PMHNP considers treatment options to discuss with Alicia and her parents. This treatment approach is adapted with consideration of the developmental tasks of industry versus inferiority in this school-age child and the normalcy of body image sensitivity associated with the onset of puberty (Dixon & Stein, 2005). The PMHNP recognizes that Alicia’s participation in the swim team may be central to her sense of industry and emerging identity, yet energy-deficient exercise puts her at risk for activity-induced anorexia. Alicia’s complaints of stomachaches with meals are a red flag for the stress-hormone-induced anorectic response associated with energy-deficient exercise (DeSocio, 2013). Psychoeducation will include discussion of the need to compensate energy expended during exercise with adequate nutritional intake, or limit Alicia’s exercise until her weight stabilizes and she returns to a healthy weight. The Practice Parameter for the Assessment and Treatment of Children and Adolescents with OCD (AACAP, 2011) will be a useful reference to share with Alicia’s parents in discussing evidence-based treatment options. Additionally, the PMHNP cites research findings of the Pediatric OCD Treatment Study (POTS Team, 2004) indicating that a combination of CBT and sertraline is more effective than CBT or sertraline alone in treatment of childhood OCD. The PMHNP also reflects on the family’s predisposition for anxiety disorders and the possibility that parental anxiety may be amplifying Alicia’s reactions. Parental education includes a discussion about managing anxiety and avoiding the proliferation of compulsive rituals by calmly withdrawing attention and redirecting Alicia away from the performance of new compulsive routines (March & Mulle, 1998; McKay & Storch, 2009). Additionally, the PMHNP offers to consult with Alicia’s school to develop a school plan for responding to Alicia’s needs and support her return to normal developmental functioning.

CASE EXAMPLE

Jennifer, who is 10 years old, came to the hospital accompanied by her mother and father. They were seeking admission to a partial-hospitalization program for their daughter because of

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increasing aggression at home and school over the past several months. When frustrated, Jennifer lashed out at other children, particularly her brother. The APPN discussed with the family how the intake would proceed and explained that the first step was to hear the family’s story about how they saw both Jennifer’s problems as well as her strengths. Their stories depicted not just a child having problems with aggression but an unhappy child who seemed overwhelmed by her emotions. In addition, Jennifer’s problems had created tremendous tension in the home.

The parents were frustrated with the services they had received in the past. Jennifer had been seen in the mental health system for several years. In reviewing her history, the APPN noted that Jennifer has been assigned a variety of diagnoses, the most prominent being ADHD, Oppositional Defiant Disorder, and possible learning disability. Following a recent extensive diagnostic evaluation at the clinic, Jennifer was thought to be exhibiting behaviors consistent with ADHD but was also displaying increasing aggression and ER issues. Jennifer was medically and neurologically clear. In the initial intake session, the APPN gathered ideas around the family’s goals for treatment and what they considered to be a priority focus while building a relationship with the parents and Jennifer. This was accomplished by forming an empathic bridge with their disappointments with previous treatment and their sense of urgency to stop what they perceived to be a path of deteriorating behavior.

The APPN listened carefully, moving inside the family’s narrative and how they pieced together events and assigned meaning to Jennifer’s behavior and the school’s response. Valuable information was attained in the initial interview about how the family framed the behaviors, what they believed treatment should accomplish and what, in their own terms, improvement would look like. The APPN inquired about the child’s strengths and competencies in order to capture an image of the child Jennifer can be at times, and a future vision of how she might increase those strengths. At the same time, Jennifer’s behaviors during the intake were noted as well as her predominant affect and ability to contain strong emotions. After approximately 30 minutes with the parents and Jennifer, the APPN asked to see Jennifer alone. The APPN used conversation and expressive techniques to observe how she responded to some mild probing questions, the partial hospital setting, and the therapist’s presence. During this phase of the interview, Jennifer said that she was somewhat confused by her outbursts and aggression. She could not describe the events that led to a typical “meltdown” but stated that she would like to get along better at home and at school. Thus Jennifer and her parents exhibited motivation for change.

Following this immersion in the family narrative, clarification of their treatment goals, and the tentative exploration of how Jennifer experienced the world, the APPN worked with the family on selecting one area for change and eliciting their ideas on what might bring about this change. All agreed that they wanted the focus to be the aggressive behavior. The evidence-based CBT with the best support is a family cognitive behavioral psychoeducational intervention, drawing from components of the Coping Power Program (Lochman, & Wells, 2004). One aspect of Coping Power is to work with the child and family to increase emotional awareness and to identify triggers for anger arousal (Lochman, Powell, Boxmeyer, & Jimenez-Camargo, 2011). The first step was teaching Jennifer and her family to recognize the signs of mounting tension/frustration and then catching the escalation early. The severity of her outbursts was “scaled” with a target number for improvement. The parents and Jennifer drew a picture of what the future would look like when they had achieved the family goal. This session was conducted along the lines of solution-focused therapy (Selekman, 2002). It was aimed at a family-centered, solution-oriented method for approaching one aspect of Jennifer’s behavior.

The partial-hospitalization program Jennifer attended, in a sense, mimicked a typical day at school and employed a similar strategy. During the time on the unit, staff carefully watched and patterned Jennifer’s behavior. This close observation gave some clues to how Jennifer became frustrated, especially evident when events did not unfold as expected. As the staff and APPN talked with Jennifer, it was noted that Jennifer could identify basic feelings but did not have a large emotional vocabulary and could not connect her feelings to the events that triggered them. Observing the signs of mounting frustrations, the APPN and staff stepped in early and interrupted the behavior before it escalated. A plan was agreed on that Jennifer might “take space” and avoid any involved conversation during tense times. Calm role playing was initiated to help Jennifer learn how one uses an emotional vocabulary to describe events.

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These simple strategies were effective on the unit, and were discussed with Jennifer’s parents. Each evening, on leaving the partial-hospitalization program, the APPN discussed Jennifer’s day with the parent who picked her up and planned on what they might work on at home. In the morning, the time at home was reviewed with the parents. The family and Jennifer began to regain their confidence that they could dampen down mounting escalation. They scaled her improvement in the positive zone. The family began to see the “old” Jennifer, an energetic, curious child. After 10 days in the partial program, both Jennifer and her family thought they were ready to transition to outpatient care. At that point, the parents were provided several options. They decided to remain with the psychiatrist for medication management and to continue working with the APPN who continued to approach Jennifer’s outbursts working with the components of the Coping Power Program, moving now to perspective taking and anger management.

CONCLUDING COMMENTS

Paradigms are slow to change. For 50 years, the prevailing notion in child psychotherapy has led to an approach ground in a deficit model and, often, interventions based solely on the label assigned to the child (March, 2009). Approximately one in every four to five U.S. children and adolescents meets criteria for a mental disorder with severe impairment across their lifetime (Merikangas et al., 2010), yet serious deficiencies remain in our mental health systems, particularly for children with SEDs (Cooper et al., 2008). It is time to reach toward a new frontier. Neuroscience might help get us there if children are approached with a family- centered approach with a view on building resources to promote resiliency. Of particular importance in the future will be the use of evidence-based approaches to promote mental health and early intervention into childhood mental distress. The primary focus of child psychiatric nurses should be promotion of mental health, prevention, and then at early stages of illness, secondary prevention to help the child return to health (Delaney, 2011; Delaney & Staten, 2010). It is imperative that APPNs call on all their relationship skills, as well as their knowledge of neuroscience and evidence-based therapies to build a public health model of treatment that is strength based and family centered.

DISCUSSION EXERCISES

1. How might the traditional structure of mental health treatment and professional relationships block family participation in treatment decisions?

2. Discuss your experiences with accessing and using evidence-based therapies in child/adolescent treatment.

3. Name the quality and characteristics you would include when listing a child’s strengths. 4. Discuss how you might build an environment around a child that would support competency and

augment vulnerabilities. 5. What developmental issues of adolescence might pose difficulties in relationship building during

psychotherapy? 6. How might you use the neurobiology material in this chapter in your approach to

children/adolescents with serious emotional illness? 7. This chapter contains a case example of how to intervene using a common factors method. How

does this differ from your notion of the process of child psychotherapy?

REFERENCES

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Psychotherapy With Older Adults GEORGIA L. STEVENS MERRIE J. KAAS KRISTIN HJARTARDOTTIR

he demographics of aging and mental health service use as well as the workforce shortage documented by the Institute of Medicine (2008) should encourage nurses to seize the opportunity to create new

models of mental health care for this growing population of older adults. The new population of older adults in this country will become increasingly diverse as minorities become emerging majorities, and we attempt to address the needs of the incoming baby boomers (Canive & Escobar, 2009; Touhy & Jett, 2010). This shift in aging demographics provides us with the opportunity to continue to rethink our concept of aging from inevitable decline to what is possible with optimal aging (Depp & Jeste, 2010). Furthermore, this shift impacts our conceptual models of mental health and highlights new areas for mental health care.

The number of older adults in the United States is expected to nearly double from 40.3 to 72.1 million from 2010 to 2030. Although mental illness is not a normal part of aging, at least 20% of older adults have one or more mental health or substance use conditions (Institute of Medicine, 2012). It is also anticipated that aging baby boomers (born between 1946 and 1964), who number 75 million in the United States, will be at greater risk for mental disorders than the current cohort of elders, thereby increasing the need for behavioral health and substance abuse specialty services in both primary care and psychiatric care settings. The 1999 Surgeon General’s ground breaking report on mental health stressed the growing prevalence of psychiatric disorders among the elderly and the need for evidence-based services (United States Public Health Service, 1999).

There have been significant changes in academic and research interests in aging and the elderly in the past few decades. New scientific findings and hypotheses have addressed illness and the concepts of health promotion and preventive medicine to move studies beyond what aging is to what is possible with aging. Understanding potential in relation to aging is profound, because doing so will enable older people to access latent skills and talents in later life and will challenge younger age groups to think in a different way about what is possible in their later years (Jeste & Depp, 2010). It will also challenge mental health professionals to address factors that impact the mental health and well-being of older adults and as well as to reduce psychiatric symptoms.

The MacArthur Study of Successful Aging demonstrated that positive mental attitude and participation in social activities, including regularly scheduled activities appear to exert a protective factor similar to exercise on mental and cognitive functioning and successful aging. In fact, combining social engagement and exercise seems to give extra protection against cognitive and physical decline. These positive effects were also found among those with chronic conditions, thus encouraging the adoption of a healthy lifestyle (Rowe & Kahn, 1998). Since this study, we have in fact seen the positive impact of life style management, social support, cognitive engagement, self-care enhancement, spiritual support, and community services in mental health promotion among older adults (Stevens, 2012). Nurses are ideally suited to provide such interventions for mental health promotion for older adults with late onset as well as those with chronic mental illness.

This chapter provides the advanced practice psychiatric nurse (APPN) with the foundation for conducting psychotherapy with the older adult to enhance mental health and reduce psychiatric symptoms. The chapter addresses the role of the APPN and education and certification for APPNs who wish to attain further education in the care of this population. We also address the underlying assumptions and principles for psychotherapy with older adults, diagnostic considerations and goals in selecting therapy approaches for late-life psychiatric disorders, general guidelines for psychotherapy with older adults, the evidence base for specific therapy modalities, and implementation strategies for cognitive behavioral therapy (CBT), relaxation training, interpersonal psychotherapy (IPT), reminiscence therapy (RT), and life review therapy (LRT) with older adults. The chapter ends with a case illustrating the use of LRT.

Advanced practice nurses who work with older adults should be proficient at assessing the status of their

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patients’ cognitive, affective, functional, physical, and behavioral function as well as their family dynamics. They must also be knowledgeable about the effects of psychotropic medication on elderly people and the factors that increase older adults’ risk for drug toxicity such as age, polypharmacy, adherence, and comorbidity. Specialized advanced practice geropsychiatric nurses are challenged to integrate multiple psychotherapeutic modalities with knowledge of the normal aging process, physiologic disorders, and sociocultural influences when working with older adults and their families.

EDUCATION, CERTIFICATION, AND ROLE OF THE ADVANCED PRACTICE NURSE IN GEROPSYCHIATRIC NURSING

Due to the demographic imperative of the aging population, there is increasing awareness of the complex needs of older adults and the need for more nurses to help meet those needs. In 2008, the John A. Hartford Foundation funded the American Academy of Nursing to develop core competencies in geropsychiatric nursing at all levels of nursing education and disseminate these core competencies and corresponding geropsychiatric nursing curriculum content for entry level and advanced practice level nurses in gerontologic, psychiatric, and medical specialty and other programs whose graduates work with older adults. The aim of the Geropsychiatric Nursing Collaborative was to suggest enhancements or refocus of current competencies toward older adults with mental health/mental illness concerns, not to develop competencies for a new subspecialty or certification. Complete documents of these geropsychiatric nursing competency enhancements can be accessed at the Portal of Geriatric Online Education (www.pogoe.org). The Geropsychiatric Nursing Collaborative also developed a definition of geropsychiatric nursing to stimulate discussion about the preparation of nurses to work with older adults who have mental health concerns. The following definition can be found at www.pogoe.org.

“Geropsychiatric nursing (GPN) practice includes holistic support for and care of older adults and their families as they anticipate and/or experience developmental and cognitive challenges, mental health concerns and psychiatric/substance misuse disorders across a variety of health and mental health care settings. GPN practice is based on expert knowledge of normal age-related changes and common psychiatric, cognitive, and co-morbid medical disorders in later life. Promotion of mental health and treatment of psychiatric/substance misuse and cognitive disorders emphasize strengths and potentials, integrate biopsychosocial, functional, and spiritual, cultural, economic and environmental factors, and address stressors that affect mental health of older adults and their families” (Beck, Buckwalter, & Evans, 2012).

Advanced practice psychiatric nurses provide specialized psychiatric care to persons of all ages, including complex psychiatric diagnostic assessments and psychotropic medication prescribing and management, and are required to achieve competency in psychotherapy. Advanced practice psychiatric nurses (clinical nurse specialist [CNS] and nurse practitioner [NP]) practice independently and collaboratively to manage the psychiatric care of older adults in settings such as inpatient and emergency psychiatric services, outpatient mental health clinics, psychiatric home care, long-term care facilities, and substance abuse treatment centers. Although APPNs can assess for common medical conditions often comorbid with psychiatric conditions, they do not generally diagnose and manage complex medical conditions of older adults. Generally the medication prescribing practice of an APPN is focused on psychotropic medications and drugs to manage the side effects of these medications.

Some advanced practice nurses have expertise in both gerontologic and psychiatric nursing and although few in number, they practice in settings where the elderly receive medical and psychiatric care and have been shown to be effective catalysts for improved clinical outcomes (Kaas & Beattie, 2006). The subspecialty of gerontologic mental health nursing was developed in the 1970s. Core content for this specialty was identified in the 1980s by Beverly Baldwin, but few specialized geropsychiatric nursing programs have been developed (Morris & Mentes, 2006). Currently, there is no geropsychiatric advanced practice nursing certification available.

UNDERLYING ASSUMPTIONS AND PRINCIPLES

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Effective psychotherapy with older adults relies on an understanding of individual, family, collective, and systemic issues, which together provide basic principles for psychotherapy with older adults. The next section summarizes basic considerations and principles that underlie the conduct of psychotherapy with older adults.

DEVELOPMENTAL CONSIDERATIONS IN LATE ADULTHOOD

Although late adulthood development has not been as well delineated as other stages, Erik Erikson described the developmental task of “integrity versus despair,” which his wife extended to a ninth stage of gerotranscendence. Gerotranscendence emphasizes ongoing growth over decrements (Erikson & Erikson, 1997).

The transition from young-old (ages 65–74 years) to middle-old (ages 75–84 years) to old-old (ages 85 years and older) is more than a series of birthdays; it is a gradual biopsychosocial developmental process that may be viewed as both positive and negative. From a positive perspective, the later years allow time for personal growth and development that were impossible when work and family responsibilities were priorities. Travel, friendships, and engaging in neglected hobbies enhance quality of life and improve well-being. Family relationships change, as once-dependent children grow into adulthood and become parents themselves. Friendships change and losses occur. Retirement requires finding new meaning in life (Stevens, 2012). Psychotherapy interventions that address these developmental transitions can strengthen quality of life and well-being.

Strengths, Resilience, and Wisdom

While there are positive and negative outcomes as we age, our understanding of successful aging has evolved as we have learned more from research. A view of inevitable decline was derived from past cross-sectional studies of a point in time, while more recent longitudinal and qualitative studies have yielded a more optimistic picture of aging with less cognitive and physical decline and more wisdom as major contributors to successful aging (Vaillant, 2007). Older adults have described a balance between self-acceptance and self- contentedness and engagement and continuing self-growth in later life.

Positive mental aging is greater than the absence of impairment; it involves older adults’ resilience in recovery, a sense of personal control and empowerment, and decisional control (Jeste & Depp, 2010). These factors support emotional stability and well-being. Wisdom has been associated with successful aging and conceptualized as social decision making, emotional regulation or balance, and tolerance accrued from life experience. Age may be a source of strength from a lifetime of experience, associated wisdom, flexibility, and more mature coping strategies from which the elder and APPN can share a sense of optimism (Blazer, 2006; Meeks & Jeste, 2009). Psychotherapy interventions to support successful aging might include information to support informed decision making, strengthening coping strategies, and promoting meaningful activities, social engagement, and social support (Blazer, 2006; Reichstadt et al., 2010).

Functional Status

Functional status refers to a person’s capacity to manage activities of daily living independently. Functional dependency generally increases with advancing age with neurocognitive frailty contributing significantly to frailty and functional decline (McGuire, Ford, & Ajani, 2006; Park & Reuter-Lorenz, 2009). Strategies to address these limitations can be part of the psychotherapy with older adults and their caregivers to decrease excess disability.

Chronic health problems can impact psychotherapy with the elderly. Eighty percent of those 65 years or older have at least one chronic illness, although chronic illness need not determine an older adult’s sense of strength and value. Living with chronic illness can be a topic of psychotherapy as the APPN addresses comorbidity, health management strategies, doctor visits, and medication management.

The impact of cognitive issues on psychotherapy with older adults is extremely important because research has revealed that cognitive deficits are an integral component of all late-life psychiatric disorders and

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that they significantly impact functional capacity and disability. Multiple studies have revealed that cognitive impairment does not respond to treatment for other disorders, such as depression, and therefore requires simultaneous treatment (Twamley & Harvey, 2006). Cognitive principles suggest targeting cognitive symptoms and taking functional deficits into account when doing psychotherapy using accommodations such as conducting shorter sessions, using memory aids and mnemonic devices, summarizing previous sessions, and taking notes.

Mobility is critical to a person’s perception of being healthy. Exercise should be encouraged for its beneficial effect on mobility and for its impact on emotions, depression, and sense of well-being (Saxon, Etten, & Perkins, 2010). Personal independence and self-mastery in everyday life are significantly impacted by visual and auditory losses. Given that visual and auditory changes impact functional capacity and lifestyle, one’s capacity for adaptation and compensation is crucial. Such losses can be accommodated in psychotherapy by using large-print materials, ensuring that personal assistive devices are working properly at each session, clearly articulating, and audiotaping sessions for later review and learning at home.

Cohort Issues and Changes

Among the most important considerations for the APPN conducting psychotherapy with older adults is an understanding of cohort effects, or the impact of having been socialized with certain beliefs, attitudes, personality dimensions, and abilities. For example, the stigma of mental illness is different in the current cohort of elders from the future cohort of baby boomers. Because the stigma of mental illness is more pronounced in the current cohort of older adults, often psychiatric symptoms are expressed with physical symptoms, less discussion of emotions, and a preference for primary care rather than specialized mental health. Although the current cohort may prefer primary care, models that involve collaboration of psychiatric- mental health clinical nurse specialists (PMHCNSs) in primary care settings are both well received and yield better outcomes (Saur et al., 2007). The baby boomer cohort may lead the way in the empowerment and education of older adults, their families, providers, and the public to overcome the barriers imposed by stigma. Outreach and peer support groups will likely have a bigger role in treatment.

Social Support and Family Issues

Most older adults value their capacity to live independently at home, although they may be supported and cared for by family and friends. Social support is critical to successful aging. It is important to understand the older adult’s relationship and social engagement histories and preferences in order to promote effective social networks and coping (Reichstadt et al., 2010). This must include an understanding of the changes and losses of significant relationships in order to be able to decrease potential isolation and strengthen a sense of a trusted and safe social network as well as well-being.

Later when the impact of functional decline necessitates a higher level of support, older adults rely primarily on the help of family caregivers. Such family support may be quite rewarding while also being quite stressful with potential negative impacts for the caregivers themselves. When older adults become more dependent on family caregiving, it is imperative that we provide effective family caregiver support to address the mental, emotional, physical, and financial stresses that caregivers face as an older adult’s health deteriorates. Individual, family, and group therapy interventions can be tailored to the individualized caregiver needs. Although existing scientific evidence and clinical experience have largely evolved from a treatment model of therapeutic interventions for caregivers of those with dementia, they also address the treatment needs of those caring for elders with chronic and late-onset mental and somatic disorders. Therapy goals may include caregiver education, specific problem-solving skills, resource acquisition, long-range planning, emotional support, respite, and the reduction of caregiver burden (Cangelosi, 2009; Sörensen & Conwell, 2011).

Societal Issues

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Ageism and bias have contributed to a historically pessimistic perspective on the effectiveness of psychotherapy with the elderly. Stigma is a collective and cohort issue. As more accurate information about aging has evolved and as psychotherapy approaches have developed, clinical psychotherapy practice and research have developed over the past two decades. This research is yielding an evidence base to support specific therapy approaches for psychiatric disorders in late adulthood and specific information about adapting psychotherapy approaches for older adults. There is a great need for more qualified, specially trained APPNs to provide mental health care, including psychotherapy, to older adults.

Existing funding streams and service delivery models need to be adapted to meet the need for long-term, community-based treatment, housing, and support. Organizational barriers such as therapy time, transportation, and available providers may not match the needs of the current cohort of elders. Our fragmented health care system contributes to the vulnerability of older adults with late-life psychiatric disorders that are complicated by significant comorbidity issues. APPNs, certified in psychiatric-mental health or gerontology, can make a significant contribution to the emerging elder mental health crisis.

TREATMENT OPTIONS FOR PSYCHIATRIC DISORDERS IN OLDER ADULTS

The following sections provide an overview of the significant late-life psychiatric disorders, assessment strategies, goals for psychotherapy, and treatment considerations for each of the following geriatric psychiatric disorders: mood disorders, anxiety, schizophrenia, and dementia. Websites for resources and practice guidelines are included in Box 18.1. Challenges in assessing psychiatric symptoms in the elderly include the masking of symptoms by comorbid disorders and medications, difficulty in obtaining an accurate mental health history, age-related variations in symptom presentation, and denial of symptoms. Assessment tools frequently used in geriatric psychiatry are included in Box 18.2.

Depression

BOX 18.1

WEBSITES FOR GERIATRIC MENTAL HEALTH RESOURCES AND PRACTICE GUIDELINES

www.POGOe.org: Portal of Geriatric Online Education (CornellCARES.com): geriatrics psychosocial patient handouts

www.alz.org/AboutAD/WhatisAD.asp

www.geronurseonline.org: Nurse Competence in Aging is a 5-year initiative funded by The Atlantic Philanthropies (United States) and awarded to the American Nurses Association (ANA) through the American Nurses Foundation (ANF). It represents a strategic alliance between ANA, the American Nurses Credentialing Center (ANCC), and the John A. Hartford Foundation Institute for Geriatric Nursing, New York University College of Nursing

http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1679489: Practice guideline for the treatment of patients with Alzheimer’s disease and other dementias of late life

www.aagponline.org: American Association for Geriatric Psychiatry provides information and resources about geriatric mental health practice

http://69.195.124.63/~reminis8/: International Institute for Reminiscence and Life Review

www.thebcat.com

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http://www.POGOe.org

http://CornellCARES.com

http://www.alz.org/AboutAD/WhatisAD.asp

http://www.geronurseonline.org

http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1679489

http://www.aagponline.org

http://69.195.124.63/~reminis8/

http://www.thebcat.com

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Depression, including subsyndromal depression, and other mood disorders are common among the elderly but are not a natural aspect of aging. Although rates of remission are comparable, poorer outcomes may be impacted by chronicity and comorbid psychiatric and somatic illnesses, factors frequently experienced by older adults. The Depression and Bipolar Support Alliance has indicated that mood disorders are under- recognized, inadequately treated, and underserviced in older patients. Under-recognition is a particular problem in primary care, the health care setting most often used by the elderly. Worsening of depression symptoms leads to decrease in cognitive function, functional impairment, poorer well-being, and increased risk of death for older adults. Thus, appropriate diagnosis and timely treatment are critical in the care of older adults (Cairney et al., 2008; Kuchibhatla et al., 2012).

Symptoms of depression in older adults often include an emphasis on physical (e.g., aches, pains, and gastrointestinal problems) and cognitive symptoms (e.g., memory), as well as changes in sleep, appetite, and use of pain medication. Psychologically, older adults are more likely to express an exaggerated sense of helplessness, apathy, and emptiness or loneliness, rather than other emotions and often seem more agitated than younger adults with depression (Hegeman et al., 2012; Husain et al., 2005). Even though older adults talk less about suicide, they have the highest rate of completed suicides, especially older White males, as compared to other age groups worldwide (Adams-Fryatt, 2010).

TREATMENT Psychotherapy is a viable treatment for elders (Brandon et al., 2011). CBT, RT, problem-solving therapy, and a combination of IPT and medication have the most evidentiary support for the treatment of mild to moderate major depression (Cuijpers et al., 2008; Mackin & Areán, 2005; Peng et al., 2009). Problem-solving therapy has also been shown to result in better outcomes of symptom reduction and remission when compared to supportive therapy (Areán et al., 2010). Results of randomized, controlled trials suggest that the combination of pharmacologic and psychotherapy interventions, especially IPT, may be more effective than either intervention alone in treating recurrent major depression (Brandon et al., 2011). More research is needed on maintenance therapy, the treatment of subsyndromal depression, and special populations, including minorities and those with mild cognitive impairment (MCI) (Mackin & Areán, 2005). It has been suggested

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that CBT and RT have the potential to prevent depression in elders who present with risk factors for depression, including bereavement, sleep disturbances, chronic disorders, prior depression, and female gender (Cole, 2005). Additionally, Internet-based CBT has shown promising results for older adults with subthreshold depression (Spek et al., 2007) adding to the multiple possibilities of therapy in the future.

There is much promise in the results of large clinical trials of different models of depression care, including integrated treatment in primary care, enhanced referral, and depression care managers (DCMs). The outcomes of the Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E), Improving Mood: Promoting Access to Collaborative Treatment for Late-Life Depression (IMPACT), and Prevention of Suicide in Primary Care Elders: Collaborative Trial (PROSPECT) trials may lead to more effective models of care (Alexopoulos et al., 2009; Oxman et al., 2005).

Bipolar Disorder

Although 5% to 19% of patients presenting to geriatric psychiatrists have bipolar disorder, there remains a paucity of treatment outcome studies (Dunn & Rabins, 1996). Psychopathology can be severe with a high prevalence of cognitive dysfunction, incomplete responses, further episodes, and high mortality (Young, 2005a). Bipolar mania in late life usually is milder than in younger patients; can present as mixed, dysphoric, or agitated states; and has a higher probability of irritability. Bipolar depression in late life usually manifests with depressed mood; sleep, appetite, and activity level disturbance; and cognitive impairments, such as executive dysfunction that may mimic dementia (Young, 2005a). Primary bipolar disorder may be early onset (i.e., recurring in later years) or late onset (first episode at age greater than 50 years). Older adults with late-onset bipolar disorder may not have a family history of bipolar disorder, but have higher rates of neurological and medical comorbidity, and relapse vulnerability (Trinh & Forester, 2007).

Longitudinal assessment is especially important because depression is more prevalent than mania; depression often precedes mania; mania presents with paranoia, agitation, and delusions; and symptoms overlap with other psychotic and cognitive disorders (Sajatovic et al., 2005). Given the high rates of alcohol abuse and suicide among older adults with bipolar disorder, it is important to screen for both. Diagnostic challenges associated with bipolar disorder in older adults include patient under-reporting, vague or nonclassic symptoms, comorbid health conditions, and the fact that depressive and manic symptoms can be induced by somatic conditions and medications.

TREATMENT Treatment has primarily focused on medications, including mood stabilizers and atypical antipsychotics (Young, 2005b). There have been no controlled psychotherapy trials in geriatric bipolar disorder without medications. There is empirical support for IPT and CBT in conjunction with medications (Gonzalez-Isasi, Echegurua, Liminana, Jose, & Gonzalez-Pinto, 2012). Education of patients and caregivers about bipolar disorder, treatment adherence, health maintenance, and good sleep practices is recommended (Gildengers et al., 2005). Additionally, evidence suggests that psychoeducation can have a long-term positive effect (Colom et al., 2009).

Anxiety Disorders

According to the report of the Surgeon General (U.S. Public Health Service, 1999), anxiety disorders are probably the most commonly occurring psychiatric disorders in the elderly. It is estimated that the prevalence of anxiety disorders among older adults is between 7% and 14.2%. Those estimates include all DSM-IV diagnosis of anxiety disorders (Wolitzky-Taylor et al., 2010). However, the prevalence of anxiety symptoms not meeting the threshold of a disorder is estimated to be even higher. More age appropriate diagnostic measures are needed to understand anxiety syndromal and subsyndromal presentation, prevalence, and appropriate treatment. This is especially important as they not only negatively impact current functioning and life but increase risk for other problems including depression and dementia (Lenze & Wetherell, 2011).

The incidence of posttraumatic stress disorder (PTSD) in elderly persons is between 4.5% and 5.5% (Pietrzak, Goldstein, Southwick, & Grant, 2012). Most research of PTSD in elderly persons has examined

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individuals who are Holocaust survivors or who were prisoners of war during World War II. In these populations, symptoms of PTSD tend to be chronic, persisting into late life in many cases. In one study, spouses of those who had suffered more traumatic experiences and PTSD symptoms in World War II also had more PTSD symptoms (Bramson et al., 2002). This study speaks to the importance of family work and a systems approach for treatment if one partner has suffered significant trauma.

Some anxiety disorders are more likely to occur during late adulthood. These include generalized anxiety disorder (GAD), agoraphobia, anxious depression, and anxiety associated with medical illnesses. Although treatable, it may be difficult because of greater severity and higher suicidality, yielding poorer outcomes (van Hout et al., 2004). Obsessive–compulsive disorder and panic disorder usually have much earlier onset and tend to be more severe and disabling. There are several risk factors for geriatric anxiety, including gender (female), single for any reason versus married, poor physical health, low socioeconomic status, high-stress life events, depression, and physical limitations in daily activities (Wolitzky-Taylor et al., 2010).

Somatic symptoms, such as dyspnea, dizziness, chest pain, irritable bowel, heartburn, tremors, initial insomnia, and hypochondriasis, are predominant in older adults experiencing anxiety disorders. Anxiety disorders may also be expressed as irritability, nervousness, trouble concentrating, worry, and fear. It may be difficult to determine whether the symptoms reflect anxiety or an underlying physical cause, such as endocrine imbalance, pulmonary disease, delirium or dementia, or medication side effects or interactions (Burke et al., 2004; Flint, 2005).

TREATMENT There continues to be a gap in the literature about the effectiveness of therapy for anxiety in older adults. Research suggests that therapies are less effective for geriatric anxiety than for geriatric depression, while pharmacotherapy appears to be equally efficacious for older adults with both disorders (Lenze & Wetherell, 2011). CBT continues to have the most robust evidence. Wetherell and colleagues (2005) conducted a review of evidence-based treatment of geriatric anxiety disorders. Promising practices include CBT enhancements to counteract cognitive changes, attention to quality of life indicators, cognitive limitations as predictors of response, treatment in primary care settings, and CBT based on intolerance of uncertainty. Given elders’ preference for primary care settings, personalized approaches such as modular intervention for anxiety in older primary care patients, may offer guidelines for future treatment (Wetherell et al., 2009). An interesting finding in studies of CBT with older adults with GAD is that an early response after 4 weeks predicted better long-term outcomes, thus supporting the need to personalize treatment early (Lenze & Wetherell, 2011). Relaxation training also has introduced some positive outcomes for late-life anxiety (Ayers, Sorrell, Thorp, & Wetherell, 2007).

Schizophrenia

Elders with early-onset schizophrenia have had a debilitating chronic disorder most of their lives. The course of the disorder is relatively stable, with some changes in symptom intensity: positive symptoms become less prominent, whereas negative symptoms persist. Severity of movement disorders in older patients is greater than in younger patients. Cognitive decline is similar in patients regardless of age, age of onset, or illness duration and much greater when compared with older adults who do not have the illness (Heaton et al., 1994; Lowenstein et al., 2012). Depressive symptoms are common in chronic schizophrenia and are linked to physical, social, and financial distress. Demoralization and relapse are also associated with the clinical symptoms of depression and schizophrenia.

Late-onset schizophrenia occurs after the age of 45 years and accounts for 20% to 25% of elders with schizophrenia. It differs from early-onset disease in that it is more common in women, is mostly a paranoid subtype, and has less severe symptoms, including less severe negative symptoms, less impairment in learning and abstraction or cognitive flexibility, and less affective blunting or personality deterioration, thereby requiring lower doses of antipsychotics (Rabins & Lavrisha, 2003). Up to 20% of elderly patients with schizophrenia may maintain remission, and age does not negatively impact remission rate (Barak & Swartz, 2012; Jeste & Twamley, 2003).

Assessment should address the full range of schizophrenia symptom clusters, including presence and severity of psychosis and psychotic-related symptoms, positive and negative symptoms, depression, cognitive

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changes associated with the negative symptoms, and neurocognitive impairment. Given the widespread use of older antipsychotic medication in this cohort and an increased prevalence of tardive dyskinesia with age, it is important to assess for involuntary movement side effects.

TREATMENT Not many studies have been done with older adults and schizophrenia in terms of therapy outcomes, but many treatment options could be appropriate with adults as well as older adults. Both individual CBT and group CBT have been found effective in reducing positive and negative symptoms of schizophrenia and distress associated with symptoms, and improving social functioning (Penn et al., 2009). CBT seems to be a good option for patients at a stable point in their illness, not at recent onset or during the acute phase of the illness. Variations of CBT to better fit the specific patient population have been developed (Dickerson & Lehman, 2011). One method, metacognitive training, was developed from the basis of CBT and psychoeducation. The focus is not of what thought (delusion) needs to change, but on the thought process, teaching the patient to recognize and investigate erroneous thinking. New pilot studies show feasibility of the treatment and some improvement in symptoms (Moritz et al., 2011). Addressing defeatist attitudes and using manualized therapies offer much promise for older adults with schizophrenia (Twamley, 2013).

Dementia

Dementia symptoms may occur as a result of a number of disorders and underlying causes. Alzheimer’s disease (AD), with 4.5 million victims, accounts for 50% to 60%; vascular or multi-infarct disease for up to 20%; and diffuse Lewy body disease for 10% to 20% of dementia disorders, with more overlap than previously thought. In each case, the classic symptoms of dementia (i.e., cognitive impairments along with a number of functional, behavioral, and psychological deficits) are present. Increasing attention has been paid in recent years to MCI, which may or may not progress to dementia.

Neuropsychiatric symptoms, such as psychosis (e.g., delusional thought content, paranoia, and hallucinations), agitation and anxiety, depression, apathy, and sleep–wake cycle reversal, are common in patients with dementia. These emotional and behavioral disturbances are a significant cause of patient and caregiver stress and require appropriate intervention (Rabins & Pearlson, 2009). It is generally accepted that the course of the disorder is much longer than an average of 9 years (Alzheimer, 1907; Lyketsos et al., 2006; Tariot, 2006). Given the prevalence and significance of concurrent depression and anxiety, the APPN should include early diagnosis and treatment of these conditions (Tampi et al., 2011). Teri and associates (1999) found a 70% prevalence of anxiety symptoms among community-residing elders with AD, which correlated with significant behavioral and activities of daily living impairment. Psychotherapy to cope with the losses associated with dementia and resultant emotional issues is important in reducing excess disability and premature institutionalization.

TREATMENT A comprehensive approach to symptom management involves identifying and treating cognitive, emotional, and functional symptoms and coexisting medical conditions; formulating and implementing evidence-based interventions; and monitoring symptom severity, treatment progress, and safety. The type of treatment depends on the stage of illness, specific symptoms, and safety considerations. Psychotherapy that focuses on effective adaptation to this debilitating chronic illness, as outlined in the goals, has the potential to reduce the impact of symptoms and delay institutionalization.

Psychotherapy aimed at the symptoms of dementia has traditionally focused on including caregivers. There is support for the impact of behavior therapy administered by a trained caregiver for agitation and mild depression in people with AD. Teri and coworkers (1997) found that CBT and behavioral therapy could be useful for patients and families. Cognitive rehabilitation with patients and caregivers has shown promising effect on quality of life, antidepressant effects, especially for female patients, and in lowering anxiety (Kurz et al., 2012; Paukert et al., 2010). Reminiscence and life review therapies have been widely used with dementia patients. Randomized controlled trials have shown effects on mood, behavior, and well-being but are unfortunately often of poor quality and further studies are needed (Cotelli et al., 2012).

Cognitive approaches such as reality orientation and cognitive retraining have shown little more than

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transient effects, with the added burden of potential adverse emotional responses (Bartels et al., 2002). Cohen (1998) has raised the issue that anxiety has been neglected by a focus on agitation in dementia. He further named four types of anxiety associated with challenge, unfamiliarity, isolation, and lack of structure, and he encouraged clinicians to use psychosocial strategies to alter these experiences. Psychotherapy has the potential to be an important part of dementia treatment in assisting patients to deal with losses, structure their lives, and support maximal functioning and quality of life. This depends on the early recognition of symptoms, appropriate assessment, and intervention.

SUICIDE RISKS, ASSESSMENT, AND INTERVENTION

Suicide is a tragic event for the individual and family at any age. Recent statistics show that suicide rates in the United States have been steadily decreasing since 1985 and have dropped by 35% in older adults (Conwell, Van Orden, & Caine, 2011). Although these statistics are encouraging, the National Institute of Mental Health reports that older adults die by suicide proportionately more than younger age groups. Older men, both White and Black over 85 years of age, have the highest suicide rates of all gender, race, and age groups. The baby boomer cohort appears to have a higher rate of suicide at any given age than subsequent cohorts, giving rise to increasing concern about suicide as these adults age (Conwell et al., 2011). Suicide risk factors include depression, loss of a loved one, physical illness and/or uncontrollable pain or fear of a long illness, social isolation and loneliness, perceived poor health, and major role changes (Conwell et al., 2011; National Center for Injury Prevention and Control, 2007). These factors are necessary to routinely assess when working with older adults. Relief of symptoms, working with complex grief, and helping older adults to find meaning in life and to be able to maintain social connections are important goals in therapy with suicidal individuals.

GENERAL GUIDELINES FOR PSYCHOTHERAPY WITH OLDER ADULTS

Before the discussion of specific therapies, it is important to consider general issues related to conducting psychotherapy with older adults as noted in the literature by clinicians and researchers (Areán, 2004; Hinrichsen & Clougherty, 2006; Knight, 2004; Laidlaw et al., 2003). One psychotherapy issue concerns the development of the therapeutic alliance between the clinician and the older adult. The cohort of older adults who are now in their 70s, 80s, 90s, or older, have had few experiences with the process of psychotherapy. More recently, there is an increasing acceptance of mental health services. Although attitudes are changing, older adults still need to be educated about psychotherapy and the therapeutic process. It is likely that a new cohort of aging adults will use both psychotherapy and complementary and alternative therapies to manage their mental health issues.

Knight (2004) describes points to discuss when teaching older patients about psychotherapy. He suggests the following ideas be discussed early in the therapy process with patients: normalizing the therapy process as assistance with problems in living; setting goals and priorities for therapy and teaching older adults how to set realistic goals for themselves; explaining how the therapy process works to improve symptoms; describing the conduct of therapy sessions, including the responsibilities of the patient and APPN and the length, number, and cost of therapy sessions, as well as the projected outcome of the therapy; and talking about the confidentiality of the information that is discussed in therapy. This list is useful to discuss with all patients, but repeated discussions and written materials about these topics may be most helpful when working with older adults.

Comorbidity

Older adults have a number of medical, psychological, and social issues to manage. Where does the APPN begin to sort out these issues and determine which ones are best treated with psychotherapy? An assessment of the presenting problems must also be done to be clear about what psychotherapy issues are and what concerns need to be addressed medically. APPNs who work with older adults must know about the particular issues

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related to the elderly and aging. For example, they need to know about the psychological effects of medications commonly taken by older adults to understand whether the presenting symptoms are psychologically or medicinally driven.

Another important issue related to comorbidity, which is often overlooked or underestimated, is the impact of the current and long-standing early traumatic experiences of the older adult. The ongoing losses inherent in the aging process, such as physical, cognitive, functional, friends, family, and role losses, as well as the increase in medical procedures, may be overwhelming to the person. The experience of cumulative and early childhood trauma for the older adult is unfortunately all too common. Many survivors of physical, sexual, and emotional abuse in early life might never have been diagnosed or treated. Even if the person has been high functioning throughout life, current and ongoing losses may trigger implicit memory and previous abuse that has been dormant for decades. This is sometimes overlooked in the older adult because it may be difficult for the APPN to imagine the older person as a vulnerable little girl who was raped by her father 70 years ago. The person’s life might have been spent in an effort to deal with the anxiety and the long-term sequelae of the abuse. Identification and recognition of the impact of current and past trauma on the person is an essential first step toward helping the person stabilize and then process such experiences.

Another overlooked comorbidity is complicated grief. Grief is a process that is impacted by the individual’s feelings about the loss and the ability to use new coping skills to find meaningful ways of managing the realities of the loss. Complicated grief is a syndrome that occurs in about 10% of older bereaved adults (Zisook & Shear, 2009). As a result of the inability of the older adult to accept the loss and move beyond the acute grief response, some older adults experience prolonged grief, which becomes a major focus of their lives. Risk factors for complicated grief include difficult early relationships marked by separation anxiety, history of mood disorders, experience with multiple and/or concurrent important losses including relationships, health, home, income, pets, and the lack of social support. Complicated grief may be an early signal of depression or complicate an existing mood disorder. Recognition of complicated grief as a serious response to multiple significant losses can be the first step in appropriate targeted grief psychotherapy treatment.

APPNs must also understand the psychological impact of coexisting physical and emotional disorders and begin to distinguish between memory problems resulting from depression and those caused by dementia or medications. Because many older adults have multiple chronic illnesses, APPNs must be able to recognize common red flags that may signal a medical problem and have available medical resources for referral and collaboration. The APPN must recognize the limits of his or her expertise in assessment and seek referrals to a specialist when needed. An example of guidelines for psychological practice with older adults is one published by the American Psychological Association (APA, 2004). Similar guidelines, if they were to be developed by nurses, would assist APPNs in psychiatric or mental health nursing and geriatric nursing to target more efficiently their therapy interventions with older adults.

Collaboration

In some instances, the presenting problem is an older adult with a physical or memory problem that needs referral to a medical practitioner. In other cases, the problem is a social one, such as isolation, and requires a referral to social services. Too often, psychological problems coexist with medical and social problems, which make coordination of care a very important component of the APPN’s role. When a decision is made to initiate psychotherapy, a choice of therapy is based on the scientific evidence, patient and clinician values and abilities, projected treatment outcomes, and financial concerns. Some study authors have suggested an integration of therapeutic modalities and professionals to achieve more successful and long-lasting therapy outcomes with older adults (Hillman & Stricker, 2002).

Working with older adults means collaborating with a multimember team, which includes the patient, the family, and the institution. Many older adults live with chronic illnesses that are being treated by a variety of health care providers who may have a stake in the outcome of psychotherapy. Families request that their parent, grandparent, or sibling be seen by an APPN and consequently are interested in the process and outcome of the therapy. Institutions such as nursing homes and assisted-living facilities also request psychotherapy for an older resident and expect communication about the problem, treatment, and follow-up. In the process of providing psychotherapy services, collaboration with families, institutions, and other health care providers is essential to obtain the information needed to conduct a thorough assessment, validate patient information provided in therapy, teach families and staff to work with a particular older adult, and document

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outcomes of treatment over time. This is especially true when the older adult has impaired cognitive or physical abilities. One of the reasons expressed by health care providers for not working with older adults is the added time (i.e., higher cost) it takes to collaborate with all the members of the team, including the families. As Knight (2004) exhorts, it is important to understand who the APPN is working for and to be sure, when interventions are done for a third party, that the ethical implications are considered.

Transference and Countertransference

After therapy begins, issues of transference and countertransference may occur between any clinician and patient, but there are likely to be different issues when the patient is older. Because of the variety of lived experiences of the older adult, the origin of transference can come from many stages of life and from any family setting. There are many life experiences from which relationship distortions can occur. Knight (2004) and others describe situations in which the patient may respond to the APPN as a child, grandchild, parent, spouse, sibling, erotic object, or social authority figure. Unfortunately, there is little guidance from the literature for the clinician to understand, explicate, and use this transference process effectively with older patients to resolve problems in living.

Countertransference issues can also affect the APPN’s perception of the older patient. Most psychotherapy programs do not offer substantial training to students about how to work with the elderly (APA, 2004). However, when faced with a therapy situation with an older adult, projections of past relationships with older adults can significantly impact the APPN’s ability to establish and maintain a therapeutic alliance. Unresolved issues with parents, personal fears about aging and death, and experiences with caretaking responsibilities of parents or grandparents may distort images of the older patients APPNs serve. Learning about these types of transference and countertransference issues with older adults is extremely important to work effectively with older adults. Ongoing clinical supervision is essential for working through these challenges during the psychotherapy process.

Termination

Another psychotherapy issue that may be different with older adults is that of termination. Termination of psychotherapy should occur by a mutual decision between the APPN and the patient based on the therapy goals attained. However, terminating psychotherapy can be very difficult for the APPN and an older adult patient because of fears that the older person will have no one else with whom to share personal thoughts and feelings. Granted, these feelings can originate because of transference and countertransference issues or the APPN’s personal sense of importance, but it is exactly for these reasons that it may be easier to cross the professional boundary from APPN to friend with older adults. To mitigate the potential for inappropriate boundary crossing, it is essential to discuss the criteria for termination from therapy and the importance of endings early in the therapy process; to identify potential options for replacing the social and emotional intimacy of therapy as therapy draws to an end; and to examine at the end of therapy what was learned by both the patient and the APPN as a result of the psychotherapy process to foster a sense of reciprocity, sharing, and completion.

Practical Issues

Practical issues such as physical arrangement of the therapy office to accommodate diminished sight and hearing are issues to be addressed when working with older adults. Environmental noise should be kept to a minimum, and the APPN and patient need to be seated facing each other to facilitate communication. Accommodations may also have to be made for assistive devices such as walkers and wheelchairs when entering the building and office. Chairs may need to be situated so that older adults have access to something firm and stable to help them rise after sitting through a long therapy session. Bathrooms need to be available and easily accessible, even with ambulatory assistive devices. Patient information materials should be written in at least a 14-point font and easily available. It is also useful to call and remind the patient about the therapy

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session 1 or 2 days in advance until the sessions become routine.

Complementary and Alternative Medicine Therapies and Older Adults

Increasingly middle-aged and older adults are using complementary and alternative medicine (CAM) therapies for the management of health and mental health concerns. In a 2007 study by the American Association of Retired Persons (AARP) and the National Center for Complementary and Alternative Medicine (NCCAM), 63% of survey respondents who were 50 to 65 years of age and older reported having used one or more CAM therapies. The two most common types of CAM therapies were bodywork (e.g., massage and chiropractic manipulation) and herbal products or dietary supplements for the use of treating specific conditions and for overall wellness (AARP & NCCAM, 2007). Results of an earlier study found similar results from older adult survey respondents aged 66 to 100 years who reported using CAM therapies such as chiropractic, herbal medicines, massage, and acupuncture for pain relief, improved quality of life, and maintenance of health and fitness (Williamson, Fletcher, & Dawson, 2003).

Complementary medicine refers to use of CAM together with conventional medicine, such as using meditation practices in addition to medications to help reduce anxiety. Most use of CAM by Americans is complementary. Alternative medicine refers to use of CAM in place of conventional medicine, such as using dietary supplements or traditional Chinese medicine for the depressive effects of seasonal affective disorder or depression. Integrative medicine combines treatments from conventional medicine and CAM for which there is some high-quality evidence of safety and effectiveness (AARP & NCCAM, 2007).

So why should information about CAM therapies be part of this chapter? This is because CAM therapies can be used in conjunction with psychotherapy to provide effective, evidence-based treatments to older adults with psychiatric disorders who request them. Advanced practice psychiatric nurses need to understand that many of their patients may already be using CAM therapies and will continue using them as part of the treatment for psychiatric disorders; therefore we need to ask patients about any CAM therapy use. APPNs can develop their own competencies and licensure to provide various CAM therapies directly to their patients in conjunction with psychotherapy, such as energy or bodywork therapies. APPNs should develop a network of relationships with professional CAM providers to whom patients can be referred. Future graduate programs in psychiatric and geriatric nursing will need to teach students to assess patients for CAM use and teach about the use of effective CAM therapies for maximizing the health and well-being of older adults and for the treatment of mood and cognitive symptoms of various psychiatric disorders.

Although some of the issues about the use of psychotherapy with older adults are similar to those of any age, there are differences that need to be considered before commencing therapy. Arguably, the conduct of specific types of psychotherapies also requires some modifications for an older adult population. The following sections describe the evidence base for various psychotherapies and the modifications needed when working with older adults.

EVIDENCE-BASED RESEARCH AND PSYCHOTHERAPY

At one time, psychotherapy for the treatment of psychiatric disorders in late life was not enthusiastically endorsed by the mental health community. This perspective has changed in the past 20 years, largely because of clinical trials that demonstrated that mood disorders, especially depression, can be treated successfully in older adults when psychotherapies are adapted to meet the physical and cognitive requirements of older adults (Pinquart, Duberstein, & Lyness, 2006).

A number of psychotherapies have been reported in the literature to be used successfully with older adults. Most often, these approaches have been used for individual therapy with older adults, although the literature does report the effectiveness of group and family (Payne & Marcus, 2008). Scientific evidence supports the use of psychotherapy with older adults alone, with medications, and with complementary and alternative therapies (Table 18.1). This section reviews the evidence for using three of these psychotherapies with older adults and discusses the modifications needed to assist elders to be successful in using these psychotherapies.

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Cognitive Behavioral Therapy

The most extensively studied of the psychotherapies with older adults is CBT. More than 15 clinical trials have compared CBT with other therapies, medications, or usual care (Areán, 2004). Results of systematic reviews and meta-analyses of psychosocial treatments for depression and anxiety in the elderly, including CBT, indicate that CBT can be effective in the treatment of depression and anxiety, albeit with some age- specific modifications, that are described in Table 18.2 (Ayers et al., 2007; Cuijpers et al., 2006; Gatz et al., 1998; Laidlaw et al., 2003; Pinquart & Sorenson, 2001; Serfaty et al., 2009; Shah, Scogin, & Floyd, 2012).

CBT has been used in older adults as a treatment for illnesses such as tinnitus (Andersson et al., 2005), chronic insomnia (Dillon, Wetzlet, & Lichstein, 2012; Sivertsen et al., 2006), and chronic pain (Reid et al., 2003) and to promote exercise in older adults (Schneider et al., 2004). CBT has been combined with other therapies, such as social skills training, to manage the symptoms of schizophrenia in older persons (Granholm et al., 2013). Because CBT has been explained in Chapter 8, this discussion focuses on the use of CBT with older adults and the modifications that may be needed for this population. Although many older adults do not require significant modifications of CBT to be successful in learning and applying the CBT tools in their lives, some common CBT issues and suggested modifications are summarized in Table 18.2. Other resources can provide explicit descriptions of using CBT techniques with older adults (Gallagher & Thompson, 1981; Granholm et al., 2006; Laidlaw et al., 2003). Although, CBT has been provided to older adults in individual and group modalities, this review focuses on individual CBT.

CBT generally consists of 16 to 20 sessions, divided into three phases: introductory or early phase, working or middle phase, and termination or late phase (Areán, 2004; Laidlaw et al., 2003). These phases usually do not change when working with older adults, although each phase may be extended. The focus of the initial phase (i.e., approximately sessions 1 through 3) of CBT is to socialize the patient to psychotherapy and CBT and build the therapeutic alliance. This is also the time to begin to identify goals of therapy and any barriers that may impact working toward or achieving these goals (e.g., family support, transportation, and physical limitations). After the older patient is comfortable with the CBT model and begins to ask questions about how the therapy works, it is time to move into the middle phase of CBT.

During the middle phase of CBT (i.e., approximately sessions 4 through 16), the focus is on building behavioral skills to increase pleasant activities, cognitive skills to challenge negative thinking, and social skills to improve problem-solving communication. The weekly activity schedule and the automatic thought diary may need to be modified so that the older person is able to use these tools easily. Because most older persons are not used to identifying their feelings and thoughts and writing them down and then challenging their way of thinking, learning to use the CBT tools during this phase may take longer than in younger adults. Completing homework can be a problem because of vision and writing barriers. Reading and homework assignments may seem too much like school to be acceptable to some older adults, and other older patients seem to appreciate the structured, educational approach of CBT. Using motivational interviewing techniques may be helpful in overcoming reluctance to doing the homework. Sometimes it may be more efficient to do the homework during the therapy session.

TABLE 18.1 Treatment Options for Common Psychiatric Disorders in Older Adults

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**Lake (2007).

TABLE 18.2 Modification of CBT for Older Adults CBT Issue CBT Modifications Difficulty in increasing pleasant events due to social isolation and physical limitations Adapt the pleasant event list to activities that are realistic.

Ask patient to identify only 5 to 10 pleasant events. Consider appropriate nonphysical pleasant events. Remind patient of events to engage in.

Multiple physical, social, and cognitive problems identified each week Set agenda each week. Set priorities for work and skill building each week. Refocus on abilities as well as disabilities. Use “faces” chart to identify feelings.

Confuses thoughts and feelings Worries about writing things down because of hand tremors or embarrassment about ability to express thoughts and feelings

Adapt worksheets to provide adequate space; consider lined paper for guide to writing. Ask patient to use audiotape or voice mail as option to writing or use keyboard and computer. Reassure patient that writing is a memory and learning tool; penmanship is not evaluated. Encourage patient to use a writing prosthesis.

Forgets to complete weekly activity schedules and dysfunctional thought records Ask patient to use audiotape recorder or voice mail. Develop reminders (calendar, voice mail, friend, or family) for patient.

The later phase (i.e., approximately sessions 16 through 20) addresses termination and relapse prevention. Movement into this phase is dictated by goal attainment and the resolution of major complaints and symptoms. Skill building during these last sessions aims to consolidate learning by reinforcing the behavioral and cognitive skills learned, identifying expected “rough spots” when maintaining treatment outcomes, and developing a guide for surviving those difficult times. During this last phase of CBT, the APPN may find it helpful, with the patient’s consent, to teach family members and health care staff ways to support the patient in maintaining therapeutic gains and prevent relapse.

In summary, CBT has been shown to be an effective intervention for a variety of conditions affecting older adults, but the most common use of CBT has been to treat depression and anxiety disorders. A number of manuals have been developed to assist the clinician to adapt and conduct CBT with older adults. Many older adults do not require extensive modifications to the structured CBT approach, but when modifications are required, they usually focus on improving physical and memory capabilities to engage successfully in CBT. A thorough description of the use of CBT in the elderly is provided in Cognitive Behavioral Therapy with Older People (Laidlaw et al., 2003), in Treating Late Life Depression: A Cognitive-Behavioral Therapy Approach (Gallagher-Thompson & Thompson, 2009), and by Mark Floyd in Making Evidence-Based Psychological Treatments Work with Older Adults (Shah, Scogin, & Floyd, 2012).

Relaxation Therapy

Older depressed adults often do not get treatment or delay getting treatment for their depression because they do not want to take medications or options for getting psychotherapy are limited by access and/or cost. Recent systematic reviews about the use of relaxation therapy to treat adult depression and anxiety found that it was better than no treatment but not as effective as CBT for significant depressive symptoms (Ayers et al., 2007; Jorm, Morgan, & Hetrick, 2009; Thorp et al., 2009). Relaxation therapy can be easily administered with brief training and has the potential for first-line psychological treatment for depression in older adults for whom other types of therapy may not be an option.

In the studies above, relaxation therapy usually involved breathing, mediation or visualization, and some form of muscle relaxation. Deep breathing exercises involve consciously slowing the breath and focusing on taking regular, deep breaths. Guided imagery or visualization focuses on pleasant images and sensations, imagining a place where one feels at peace and free to let go of all the tension and anxiety. The purpose of meditation is to consciously relax the body and focus the thoughts on one thing to distract the person’s stressful thoughts. Muscle relaxation exercises involve relaxing muscle groups in the body. A common muscle relaxation is Jacobson’s relaxation technique, or progressive muscle relaxation, in which the person systematically tenses and relaxes different muscle groups, usually starting with the feet and moving upward toward the face. Becoming more common with older adults, mindfulness-based stress reduction (MBSR) programs combining meditation, guided imagery, and relaxation aim to reduce loneliness (Creswell et al., 2012) and emotional distress (Young & Baime, 2010).

Interpersonal Psychotherapy

IPT, like CBT, has been studied for its effectiveness in reducing depression and anxiety in older adults. IPT

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gained attention as a therapeutic intervention in the 1970s work by Gerald Klerman and Myrna Weissman and has been shown in clinical trials to be an effective intervention for depression compared with antidepressants. Unfortunately, the early clinical trials (DiMascio et al., 1979; Elkin et al., 1989) did not include a significant elderly population and did not identify age-specific outcomes. For the last 20 years, IPT has been used in a number of populations, with and without modifications to the original IPT manual (Weissman et al., 2000).

Sholomskas and colleagues (1983) published an article that argued IPT could be used with older adults. Since then, there have been a few randomized clinical trials of IPT for the treatment of acute depression and for maintenance therapy for prolonging relapse and preventing recurrence of major depression in older adults (Miller et al., 2001, 2003; van Schaik et al., 2007). Most of the available research studies have evaluated IPT in combination with psychopharmacology for the treatment of depression in adults, including some older adults in the study population (Mackin & Areán, 2005). Generalization of IPT research findings and their application to older adults has been limited. Significant addition to the literature about IPT for older adults is Interpersonal Psychotherapy for Depressed Older Adults, written by Hinrichsen and Clougherty (2006) and Clinician’s Guide to Interpersonal Psychotherapy in Late Life by Miller (2009). These author clinicians review the information available on IPT and discuss the specific strategies for using IPT in older adults and the modifications needed for older adults with mood disorders and with cognitive impairments. The most recent IPT manual (Weissman et al., 2000) includes a review of the research, a user-friendly description for conducting IPT, clinical case summaries, and fidelity scales.

IPT can be an important vehicle for reflection and resolution of roles and relationships. Gerontologists have long discussed the changing roles and relationships of older adults as they traverse the landscape of old age (Rosow, 1967). Many publications have focused on the loss of social roles, the transition from one role to another (e.g., in retirement and widowhood), and the resulting sense of isolation and grief experienced by some older adults. Well-known theorists such as Erikson (1982) and Levinson (1986) have identified the importance of interpersonal relationships in maintaining stable physical and emotional health across life’s stages. During transition from one life stage to another, adults often reflect on what is important and what needs to be changed. In adult development and aging, social relationships are often the focal point of these reflections. With older adults, IPT can be the vehicle for this reflection and resolution.

Clinician authors who have used IPT with depressed older adults suggest that there are few modifications needed when translating IPT for use with an older population (Areán, 2004; Hinrichsen & Clougherty, 2006; Miller, 2009). Their perspective is that the structure of IPT provides a workable therapy framework to focus on bereavement, role transitions, and role conflict. Table 18.3 describes the modifications of IPT for older adults. The modifications commonly identified are those needed to support the physical and cognitive capabilities of older adults:

Increasing the time to review new material during the therapy session so that the APPN can explain a new behavior, demonstrate the skills needed to achieve that new behavior, and then have the patient practice the new skill during the IPT sessions

Repeating new material or skills over a number of sessions Adding more time for the older patient to process and verbally respond to questions Adjusting the physical barriers to make communication easier

Reasons for choosing IPT over CBT include the comfort of the APPN with the type of therapy and whether the older patient is able and willing to address a specific here-and-now problem within a brief period. If the older adult presents with concerns focused on loss, grief, interpersonal conflicts, or role transitions; is cognitively intact; and is mildly to moderately depressed without a clear personality disorder, IPT appears to be a good choice for therapy. If the older adult presents with moderate or chronic or partially remitted depression or with MCI and expresses concerns about a negative life event and perceives himself or herself as helpless, CBT may be the better choice for therapy.

Hinrichsen and Clougherty (2006) suggest that the modifications needed when applying IPT to older adults are those that clinicians need to make. They suggest that novice APPNs with little experience working with older adults may have less success with IPT than with other therapies because of conflicting attitudes and values about the responsiveness of older adults to therapy. Clinicians may have difficulty maintaining the structure of IPT when older adults lose focus and become reflective and tangential during sessions. They may become overwhelmed with the multitude of problems and have difficulty prioritizing problems appropriate for IPT. When this occurs, APPNs may not present a clear plan for treatment and then have difficulty moving through the phases of IPT in a timely fashion. Sometimes, APPNs may choose to extend the contract for IPT

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past the 16 weeks of treatment, which may reinforce dependency in the clinician/patient interpersonal relationship.

Reminiscence and Life Review

RT and LRT are approaches that focus on reflecting on life, on the aging process, and on constructing a sense of self-continuity. Both approaches can be less challenging for the patient to use because they use remote memory processes to integrate a lifetime of successes and challenges rather than working memory, which might be less available to some older adults. Because these therapies have not previously been described in this textbook, we offer a brief theoretical overview, differentiate these two concepts, and summarize the evidence using them with older adults.

TABLE 18.3 Modificationn of Interpersonal Psychotherapy for Older Adults IPT Issues IPT Modifications Initial Sessions Many problems are presented by patient, and there is too much life history to cover. Patient does not understand he or she has depression. Patient wants the therapist to “cure” depression.

Link presenting problems to one or two focus areas, and have patient prioritize these. Quantify depression with standardized scales; use these scales to educate the patient and family or support system about depression. Take an active role to structure therapy sessions using the IPT manual. Give the patient permission to temporarily take on the sick role so that energy can be focused on getting healthier rather than external demands.

Intermediate Sessions Patient is reluctant to talk about conflictual, negative feelings. Patient does not understand he or she has depression. Patient has difficulty staying focused on problem areas. Patient is reluctant to identify changes needed in his or her behavior. Patient wants to include family and other support in sessions.

Educate the patient about basic communication principles and identification of feelings. Quantify depression with standardized scales; use these scales to educate the patient and family or support system about depression. Address the patient’s difficulty staying focused on the topic; look for patterns of distraction, and correlate feelings with distraction. Take an active role in therapy, but do not provide advice about therapy dilemmas presented by the patient; encourage the patient to state what can be done about the problem. Include joint meetings if appropriate, and IPT issues can be addressed.

Termination Sessions Patient experiences ongoing physical problems or stressors and wants to continue IPT. Every few sessions, remind the patient of the number of sessions left.Remind the patient about the contract, and address sadness due to loss or change in the interpersonal

relationship.

The common roots of reminiscence and life review are found in the seminal article by Robert Butler (1963), a geropsychiatrist, who described the “looking back” process he observed in his patients and observed the therapeutic value of reflecting on the there and then, rather than as an escape from the here and now. Butler distinguished life review from reminiscence by saying that life review is a type of reminiscence. In 1974, Lewis and Butler described LRT as an effective method with older adults to assist them during developmental transitions. About the same time, Erikson (1982) described more fully the last developmental stage in late adulthood: ego integrity versus despair. Applying the concepts of RT and LRT in clinical practice was emphasized during the 1970s and 1980s because these concepts provided positive outcomes to what had been assumed to be old-age forgetfulness and escape from the realities of old age. New roles and goals were described for older adults.

Since that time, many study authors have struggled with distinguishing reminiscence and life review from each other and from other types of autobiographical reflections. Table 18.4 differentiates reminiscence from life review. This ambiguity has limited empirical study of their effectiveness in research and clinical practice. Burnside and Haight (1992) provide a conceptual analysis of reminiscence and life review therapies. In their analysis, reminiscence is defined as “a process of recalling long-forgotten experiences, events which are memorable to the person” (p. 856). Life review is defined as “a retrospective survey or existence, a critical study of a life, or a second look at one’s life” (p. 856). Both processes depend on memory recall but reminiscence is thought to reconstruct life events from memory (Staudinger, 2001) and life review as deconstructing life events into a more positive life narrative (Molinari, 1999).

TABLE 18.4 Distinguishing Reminiscence and Life Review

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At the risk of oversimplifying the distinctions between reminiscence and life review, Table 18.4 is provided so that the therapist can begin to understand the difference and choose the most appropriate intervention for the situation. These distinctions are drawn from a number of resources, including Molinari (1999), Burnside and Haight (1992), Haight and Burnside (1993), Staudinger (2001), and Knight (2004). A recent article characterized RT interactions into three types: simple and unstructured, life review or structured reminiscence, and life review therapy the most structured (Webster, Bohlmeijer, & Westerhof, 2010). Differentiating these types of reminiscence interventions could be useful in developing protocols for different mental health problems for older adult populations.

The focus on practical, clinical application of reminiscence and life review rather on empirical study of its efficacy has led to conclusions by some geropsychiatric clinicians that these therapies are not useful for treating psychiatric illnesses but are reserved as more global psychosocial interventions for healthier older adults. Authors’ recent systematic reviews of research related to life review and reminiscence suggest that LRT and RT can be effective in early treatment of depression with older adults who experience loss of meaning in life (Bohlmeijer et al., 2003, 2007; Hsieh & Wang, 2003; Lin et al., 2003; Shah, Scoggin, & Floyd, 2012) but also report a lack of consistent findings about the efficacy of both therapies due to different outcomes and outcome measurements, small and varied samples, ambiguous and diverse intervention protocols, and methodological flaws. Results from recent randomized controlled trials (Korte et al., 2012; Pot et al., 2010) provide some evidence for the positive effects of reminiscence and life review for the treatment of depressive symptoms in older adults. Further study will help to clarify for whom these therapies are appropriate, when to provide these therapies, and how to use these therapies to alleviate psychiatric symptoms (Shah, Scoggin, & Floyd, 2012; Webster, Bohlmeijer, & Westerhoff, 2010).

There is no standard structure or method of life review and reminiscence. Knight (2004) suggests using a timeline to guide the life review, such as reviewing life events over each decade. Another approach is to review various domains of life such as family of origin, educational experiences, military experiences, sexual development, and religious or spiritual history. Dutch researchers (Pot et al., 2010) developed a structured life review course, “Looking for Meaning,” that improved coping skill and decreased depressive symptoms and anxiety. Each of the twelve 2-hour sessions centered on a topic and included sensory recall exercises, creative activities, and discussions. Approaching life review with an overall structure in mind facilitates discovering gaps in recall of significant events, which can open the door to discussions of positive and negative emotional issues that can be evaluated in light of the person’s self-concept.

Haight and Olson (1989) offer sample questions that can be asked to direct life review following Haight’s Life Review and Experiencing Form (Haight et al., 1995). They also suggest structuring the life review around developmental stages of life, such as childhood (What was your childhood like? What were your parents like?), adolescence (Who were important people for you? Do you remember feeling alone?), adulthood (Do/did you enjoy your work? How were you appreciated for your work?), and older age (What have been some of the disappointments in your life? What are the happiest moments in your life? What would

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you do differently?). Burnside and Haight (1992) suggest using pictures, books, autobiographical writing or journaling, audiotaping or videotaping, and letter writing to elicit memories. They also suggest asking questions to encourage a self-examination and exploration of how patients might have changed things if they had the opportunity.

In summary, reminiscence and life review therapies are useful techniques for helping older adults recall life events and in the process of talking about their lives, come to an understanding of who they are as whole persons. The empirical evidence for the effectiveness of reminiscence and life review therapies is growing and these therapies have been reported to improve self-esteem, increase socialization, and decrease depressive symptoms. Authors agree that the less structured approaches may prove to be a vital option for older adults in normal developmental transitions or experiencing dramatic life events, and the more structured LRT more appropriate for the treatment of significant depressive symptoms. A clinical example is provided subsequently in the case study of reminiscence and life review.

Reminiscence and life review are not manualized therapies consistently used by therapists. Although some personal historians and autobiographers in the private sector have developed their own products and processes for assisting persons to write their personal memoirs, these contracted personal memoirs are not done for the primary purpose of developing a coherent sense of self or reducing depressive symptoms. Biennial conferences of the International Institute of Reminiscence and Life Review demonstrate the variety of applications of reminiscence and life review therapies for different populations. Box 18.1 provides relevant websites.

CASE EXAMPLE

This case study reflects the life review process familiar to the author (Kaas, 2006), the timeline approach rather than the event approach, and was agreeable to the patient.

Violet wheeled herself into the APPN’s office and told her that she was 98 years old, soon to be 99, and wanted to get ready for her 100th birthday in just over a year. When the APPN asked Violet what she meant by “getting ready” she replied she wanted to clear up some things in her life to feel good about what she had accomplished. The APPN asked her where they should begin, and she replied, “At the beginning, as far back as I can remember.” That was the start of a long but interesting journey with Violet as she sorted through her life on her way to being a centenarian.

Violet was living in a nursing home on a senior housing campus that included a primary geriatric clinic. Violet was referred by one of the geriatricians because she requested “someone to talk to about things.” Little did he know how much talking she had to do! Violet was in a wheelchair because she was no longer able to walk independently because of peripheral vascular disease, which caused her leg tremors and pain.

At the first meeting, the APPN discussed with Violet her timeframe for sorting things out. She planned to come for about 6 months and was able to come to therapy about every 2 weeks. A timeline was developed from her birth to current age, and then 100 was added at the end of the timeline, which was drawn on large paper sheets taped together and put on the office wall. The timeline was marked off in decades, much like a ruler, and notes on the paper were written during the therapy sessions. Because Violet could not remember much of her life before 3 years of age, the beginning of the timeline was information she remembered from family stories. The focus of each session was on a particular time in Violet’s life. Structured questions centered on her family, work, decisions she had made, challenges she experienced, and what she had learned from the experiences during that time. She reminisced about the happy times and the sad times. Sometimes, Violet brought family pictures or letters to talk about. When there were gaps in her memory, another decade became the focus, with a return later to fill in the gaps.

When the APPN asked Violet how she had decided to do this life review, she replied that she wanted to know who she was and wanted to tell people about her life at the 100th birthday party she was planning. Her life was charted through her 98th year, and she noted this life review on her life chart. When the review of her 90s was completed, Violet thanked the APPN and invited her to the upcoming 100th birthday party. The value of the relationship for both Violet and the APPN was discussed. The APPN did attend her 100th birthday party, and the life review chart was on the wall for all to see.

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The patient’s goal of “clearing things up” was met during LRT as Violet became clearer about what the significant events were in her life, when these events happened, and how her emotional response impacted her self-identity and later relationships with her husband and children. The collaborative goal was met because Violet was able to emotionally disengage from past mistakes and negative experiences and to find some comfort in her sense of self at 100 years.

CONCLUDING COMMENTS

Some psychotherapies have been shown to be effective with older adults with few modifications from the original theoretical or practice frameworks. When modifications are necessary, they are individualized for the physical and cognitive impairments of an older adult. The scientific evidence shows us that longer sessions or extended treatment of individual therapy may positively impact the outcomes of therapy, yet increased age and the severity of psychiatric and medical illnesses may limit the type of therapies used with older adults. There is less information about how to use psychotherapies with older adults with coexisting substance use and medical illness, and how to use any particular psychotherapy with specific ethnic/cultural populations of older adults.

The literature regarding specific psychotherapy interventions for psychiatric disorders in late life is growing with nurses making significant contributions to the body of knowledge. This is encouraging because it is important for APPNs to look to the future and develop the evidence for the use of psychotherapies that promote mental health and effective coping. Our understanding of how to adapt these therapies to older adults may provide the basis of targeted health promotion psychotherapy, which can address the needs of the next cohort of older adults for whom psychiatric disorders and psychotherapy carry less stigma and for whom health promotion is more frequently perceived to be a personal responsibility.

DISCUSSION EXERCISES

1. Discuss education and certification issues for APPNs working with geropsychiatric patients. 2. Describe how individual, collective, and system issues influence psychotherapy with older adults. 3. Describe general characteristics, assessment tools, treatment goals, and psychotherapy

considerations for the following late-life psychiatric disorders: mood disorders, anxiety, schizophrenia, and dementia.

4. Discuss general modifications for the effective conduct of psychotherapy with older adults. 5. Discuss the evidence base and implementation strategies with older adults for each of the

following psychotherapies: CBT, IPT, psychodynamic psychotherapy, and LRT. 6. Discuss the evidence and significance of family caregiver therapy. 7. Describe innovative diagnostic and strategic uses of psychotherapy with older adults. 8. Describe factors contributing to the impending geriatric mental health crisis. 9. Discuss contributions that APPNs can make to geriatric mental health promotion and treatment.

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Reimbursement and Documentation MARY MOLLER

he ability to be sufficiently reimbursed for all types of clinical services is critical for the psychiatric mental health advanced practice registered nurse (PMH-APRN). For those reading this book who are

seasoned clinicians, January 2013 was a watershed date because the way reimbursement had occurred for psychiatric services over 40 years came to an abrupt halt. Prior to 2013, psychiatric services were primarily billed using psychiatric specialty billing codes. Starting in January 2013, evaluation and management (E/M) codes (99xxx) were identified as the base codes for psychiatric services and psychotherapy codes (908xx) were identified as procedure codes to be used as add-on codes.

Documentation requirements were also revised. For those accustomed to the narrative or SOAP format, the progress notes were changed to reflect a more “medical format.” For those who are new to the field, the documentation required to pass an insurance or Medicare audit of chart notes using evaluation and management terminology may seem foreign from what was learned in graduate programs. The purpose of this chapter is to clarify the who, what, why, when, and where of how to use the current psychiatry billing codes and required documentation changes.

DEVELOPMENT OF 2013 PSYCHIATRIC CPT CODES

Clinical procedural terminology (CPT) codes are devised, maintained, owned, copyrighted, revised, retired, and published annually by the American Medical Association (AMA, 2013a). These codes are used to identify accepted medical procedures and services provided by licensed medical providers including advanced practice registered nurses (APRNs). The manual (AMA, 2012a) is available from the AMA website at https://commerce.ama-assn.org/store/catalog/productDetail.jsp?product_id=prod1180004&navAction=push and other retail vendors. All advanced practice psychiatric nurses (APPNs) are encouraged to purchase this book. The first CPT manual was developed in 1966 to provide uniform language to describe medical, surgical, and diagnostic services in order to standardize language used by various medical professionals and Medicare providers and to communicate with insurance companies. CPT codes are continually changing as medical and surgical advances occur.

Codes are grouped by medical, surgical, and diagnostic services. The psychiatry codes were previously listed in the specialty code section and used by all psychiatric providers including psychiatrists, APPNs, psychologists, social workers, counselors, and various licensed therapists. Evaluation and management CPT codes are nontimed 5-digit numerical references that begin with 99xxx. The other three digits differentiate whether the patient is new or an existing patient, the location of service, and the level of complexity. The time-based psychotherapy codes that all psychiatric providers were accustomed to using started with a 908xx. The other two digits differentiated the time spent with the patient and type of service delivered. Selected 908xx codes included evaluation and management services, but these codes were not as descriptive as the E/M codes and therefore did not accurately reflect the complexity of the care that was given. The change to E/M results in more precision in documenting the complexity of our work.

Every 5 years, the Centers for Medicare and Medicaid (CMS) require that all codes are reviewed, revised, and/or eliminated. A two-part process, each involving a separate committee, occurs for each new/revised code. First the CPT editorial panel evaluates and votes on the rationale and language of the code. Each code is then assigned a reimbursement value based on a very complex process that takes into account the variables of practice expense, provider work, and malpractice costs. This process is overseen by a committee referred to as the resource-based relative value scale update committee (RUC). The RUC was specifically formed in 1992 to offer recommendations on the valuation of CPT codes to the CMS. After an evolving process, all aspects of payment were resource based by 2002 (AMA, 2013b). A CMS representative sits on both committees. Please see how rates are calculated at www.cms.gov/apps/physician-fee-schedule/search/search-

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criteria.aspx. This information is published annually in the Federal Register. Private insurance companies may reimburse higher than the CMS minimums. There are also regional differences around the country that are available on the CMS website.

Timeline and Process of the 2012 Review of Psychiatry Codes

The RUC, composed of 21 members from medical specialty associations, had not formally revalued the 24 existing major CMS code categories for Psychotherapy Services since 1998 (CMS, 2013). In 2008, the professional societies began the mandatory review process of requesting a revaluation when it was recognized that the existing psychotherapy codes used by psychiatrists and APRNS were valued lower than the E/M codes used by all other physicians and APRNS. An additional concern was that the psychotherapy codes did not adequately differentiate the difference in the work performed by a psychiatrist or APPN from that provided by a psychologist, social worker, or licensed counselor.

The extremely detailed process of code review and revaluation is one in which there is strict scrutiny and numerous checks and balances. The group recommending code changes must present “compelling evidence” to increase the value of a code. The evidence is based on changes in technology or the typical patient, flawed methodology of the current values, relativity analysis between the values, and actual time spent with patients related to various codes. Finally there must be budget neutrality, which means that an increased relative value unit (RVU) for one service will lead to decrease in final payment for all other services (AMA, 2013). Ultimately it was determined that psychiatrists, psychiatric APRNs, and prescribing clinical psychologists would use the standard E/M codes and selected codes from the psychiatry section of the 2013 CPT Codebook (AMA, 2012).

The New Way of Coding

The use of the nontimed 99xxx E/M codes has distinct advantages over the use of the previous timed 908xx psychotherapy codes in which evaluation and management work was bundled into the code to differentiate level of service. The E/M base codes allow the provider to create an itemized bill of the services delivered. The bundled codes did not allow accurate description of the intensity of the service provided. This resulted in a lack of understanding and ability to communicate the complexity involved in delivering a given service. Evaluation and management codes refer to just that—the work that goes into both the evaluation of the patient and management of the diagnoses. These codes also have the added benefit of being able to be billed based on the time spent in counseling and coordination of care (CCC) if greater than 50% of the encounter is spent in these kinds of discussions. The selection of the nontimed-based code is determined by the level of medical decision making (MDM) which takes into account the complexity of treatment risk, number of problems, and amount of collateral information required to provide care. An invaluable guide is published by the Department of Health and Human Services (2010).

Most outpatient medical encounters are coded with a basic E/M code plus an add-on code or two. For example, if you go to your provider for a primary care visit and any kind of lab work, x-ray, or a procedure is done, those services are billed with add-on codes to document the procedures and tests that are done. With the 2013 revision, psychotherapy codes are now add-on codes to the base E/M code as psychotherapy is one of psychiatry’s major procedures. An additional add-on code is interactive complexity, which refers to any kind of communication difficulty such as working with irate family members or patients who have lost control, hearing impairments, cognitive and intellectual disabilities, the need for language translation, as well as work with children. In the past, interactive complexity was typically used only by child/adolescent providers. A complex visit can now be fully documented and reimbursed for all the work that is required in a given patient encounter/session including therapy and management of complex family and/or patient interactions.

Nurse Psychotherapists

Nurse psychotherapists can still bill for stand-alone psychotherapy using the psychiatry specialty codes, but if

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the encounter involves discussing medications and/or diagnosis, and requires coordination of care with the prescriber, the APRN should bill using an E/M base code with a psychotherapy add-on procedure code. All APRNs need to remember that complex physiological and psychopharmacological content is part of our education and training and is reflected in our assessment, diagnosis, and treatment. Reimbursement is typically greater for an E/M code with a psychotherapy add-on than a stand-alone psychotherapy code. The documentation needs to reflect both of these billing codes. An example of this type of progress note is provided later in this chapter. As a reminder, psychotherapy process notes represent a unique Health Insurance Portability and Accountability Act (HIPAA) protected form of chart note. In circumstances where psychodynamic psychotherapy is being conducted, separate process notes can be maintained and are uniquely protected (Clemens, 2013; Gutheil, 1980).

Codes That Did Not Change

The psychotherapy codes that did not change include: psychoanalysis (90845); family psychotherapy without the patient present (90846) and conjoint with the patient present (90847); multifamily group psychotherapy (90849); and group psychotherapy (90853). In addition, the psychotherapy procedural codes that did not change include narcosynthesis (90865); therapeutic repetitive transcranial magnetic stimulation (TMS) (90867), subsequent (90868), subsequent w/motor threshold redetermination (90869); and electroconvulsive therapy (90870). These codes did not change because the complexity of the work that is involved with those codes had been adequately captured in the original valuation process.

Codes That Were Eliminated

The two codes that were eliminated include interactive group psychotherapy (90857) and pharmacologic management (90862). This caused a ripple effect throughout the profession as 90862 was the most commonly billed code used throughout psychiatry. This code had been very problematic as it was a nontimed code that frequently had high reimbursement. However, sometimes it had low reimbursement and providers were finding themselves trying to see more patients in order to receive adequate compensation for the work that was being done. A vestige of this code remains as an add-on code (+90863) and is to be used by prescribing psychologists with stand-alone psychotherapy services.

Codes That Were Added

The previous code for a new patient without interactive complexity was 90801 and with interactive complexity was 90802. These codes have been eliminated. A new patient evaluation without any medical evaluation and management is now coded as a 90791 and is most commonly used by nonprescribing psychologists, therapists, and social workers. There is a code for a new patient evaluation that includes medical services (90792). Psychiatrists and APPNs should use the new patient E/M codes; however, it is appropriate to use 90792 (even though it may be reimbursed at a lower rate than an E/M code) when there is medical evaluation beyond the mental status exam and there is prescribing of medications and ordering or discussion of laboratory or other diagnostic tests. However, this code cannot be used on the same day with an E/M or psychotherapy code.

New timed stand-alone codes for the provision of psychotherapy only were developed and include 30 minutes (90832), 45 minutes (90834), and 60 minutes (90837). They were simplified and include time spent with the family. These codes can be used by the APRN when there are no E/M services provided; however, these codes were primarily meant for use by psychologists, social workers, and licensed counselors. When a psychiatrist or APPN provides therapy within a standard E/M encounter, the new add-on psychotherapy codes should be used. Psychotherapy with E/M services is based on time: +90833 is to be used when the psychotherapy delivered is from 23 to 37 minutes; +90836 is used when the range is between 37 and 52 minutes; and +90838 is used if the encounter extends beyond 52 minutes.

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Documentation Requirements for Psychotherapy Only and Psychotherapy Add-On Codes

Recent Medicare audits of psychotherapy notes request the inclusion of specific content to successfully pass the audit. It will be important to include narrative comments related to target symptoms; goals of therapy; method of monitoring outcomes; frequency of treatment; clinical records to support relevant medical history; results of diagnostic tests or procedures; prognosis or progress to date; and estimated duration of treatment. The types of psychotherapy recognized by CMS include psychodynamic, behavioral, and ego supportive. It is suggested to create a template that you can modify with changes that have occurred since the last session. Medicare requirements for psychotherapy session documentation are included in Box 19.1.

BOX 19.1

MEDICARE REQUIREMENTS FOR PSYCHOTHERAPY SESSIONS

Target symptoms Goals of therapy Method of monitoring outcomes Frequency of treatment Clinical records to support relevant medical history Results of diagnostic tests or procedures Prognosis or progress to date Estimated duration of treatment

New codes were added for crisis intervention (90839) to be used for initial contact and +90840 used as an add-on to capture subsequent crisis intervention and can be added on in 30-minute increments. The caveat with these codes is that CMS has not yet sanctioned a value and determined they are for reimbursement. Currently the crisis intervention codes are reimbursed depending on the protocol set forth by individual insurance carriers (carrier priced). CMS will be asking for these carrier-priced codes to be surveyed at a later date as well as several of the new codes after they have been used for a sufficient time period. See Table 19.1 for old and new CPT codes.

THE BASICS OF AN E/M CODE

The ins and outs of using E/M codes are thoroughly outlined in the Medicare Learning Network publication entitled Evaluation and Management Services Guide (DHHS, 2010). This guide is freely available to the public and all APPNs are encouraged to download this publication that is referenced at the end of this chapter. The evaluation component of E/M refers to the collection and assessment of relevant information related to the patient, and the management component refers to the planning of treatment or further assessment and includes prescribing medication. All procedures associated with an E/M are billed using add-on codes.

Understanding the Five Digits of an E/M Code

The specific 5-digit E/M code is selected based on the type of patient, location of service, and level of service. The first two digits, 99 indicate that it is an E/M code. The third and fourth digits identify the type of patient and location of service. The fifth digit indicates the level of service, which is determined by the complexity of history, physical exam, and MDM. The level of service is different in the outpatient and inpatient settings. In the outpatient setting, the fifth digit is on a range of 1 to 5, while the inpatient range is 1 to 3. In an office or

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other outpatient settings, a fifth digit of 1 or 2 is a problem-focused encounter involving straightforward MDM of minimal complexity. It should be noted that a level 1 does not require a licensed provider and is typically reserved for encounters where a patient is coming to an office to receive medical assistant type services. A fifth digit identified with a 3 indicates an expanded problem-focused encounter involving MDM of low complexity. A fifth digit identified with a 4 indicates a detailed encounter involving MDM of moderate complexity. Lastly, a fifth digit identified with a 5 indicates a comprehensive encounter involving MDM of high complexity. Whereas, in an initial hospital or subsequent hospitalization of the same problem, a 1 is straightforward, a 2 is moderate, and a 3 indicates high complexity. Table 19.2 depicts the standard CPT outpatient new patient and established patient, and facility codes and RVU designation for 2013.

TABLE 19.1 Revised Psychotherapy Codes All CPT Codes are Registered Exclusively to the American Medical Association Before 2013 After 2013 90801—Diagnostic interview 90791 (no medical)

90792 (with medical)

(report with interactive complexity add-on [+90785] when appropriate)

90802—Interactive diagnostic interview Work now captured by interactive complexity add-on

90804, 90816—Individual psychotherapy, 20 to 30 minutes 90832—Psychotherapy, 30 (16–37) minutes

(report with interactive complexity add-on [+90785] when appropriate)

90810, 90823—Interactive individual psychotherapy, 20 to 30 minutes Work now captured by interactive complexity add-on

90806, 90818—Individual psychotherapy, 45 to 50 minutes 90834—Psychotherapy, 45 (38–52) minutes

(report with interactive complexity add-on [+90785] when appropriate)

90812, 90826—Interactive individual psychotherapy, 45 to 50 minutes Work now captured by interactive complexity add-on

90808, 90821—Individual psychotherapy, 75 to 80 minutes 90837—Psychotherapy, 60 (53+) minutes

(report with interactive complexity add-on [+90785] when appropriate)

90814, 90828—Interactive psychotherapy, 75 to 80 minutes Work now captured by interactive complexity add-on

90805, 90817—Individual psychotherapy with E/M, 20 to 30 minutes +90833—Psychotherapy, 30 (16–37) minutes, use only add-on code to selected E/M code

(report with interactive complexity add-on [+90785] when appropriate)

90811, 90824—Interactive individual psychotherapy with E/M, 20 to 30 minutes Work now captured by interactive complexity add-on

90807, 90819—Individual psychotherapy with E/M, 45 to 50 minutes Eliminated, use only as add-on code to selected E/M code

+90836—Psychotherapy, 45 (38–52) minutes

(report with interactive complexity add-on [+90785] when appropriate)

90813, 90827—Interactive individual psychotherapy with E/M, 45 to 50 minutes Work now captured by interactive complexity add-on

90809, 90822—Individual psychotherapy with E/M, 75 to 80 minutes Eliminated, use only as add-on code to selected E/M code +90838—Psychotherapy, 60 (53+) minutes

(report with interactive complexity add-on [+90785] when appropriate)

90815, 90829—Interactive individual psychotherapy with E/M, 75 to 80 minutes Eliminated

90857—Interactive group psychotherapy Eliminated, now use 90853, group psychotherapy

(reported with interactive complexity add-on [+90785] when appropriate) 90862—Pharmacologic management Eliminated

Adapted from American Psychiatric Association materials available at www.psych.org/practice/managing-a-practice/cpt-changes-2013.

TABLE 19.2 Commonly Used CPT Codes

Assigning the Five Digits

A new patient is one who has not received services from the provider or a provider in the same specialty or subspecialty in a medical group in the past 3 years. An established patient is one who has been seen by the provider or a provider in the same specialty or subspecialty in the medical group within the past 3 years. Even if the APRN is on call for the practice and has not personally seen the patient, the patient is considered an established patient for E/M purposes. If the psychiatric APRN is in a primary care setting and is referred an existing clinic patient who is new to the psychiatry/behavioral health service, the documentation would be for a new patient. The location of service is designated as hospital inpatient, office, or other outpatient, nursing

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facility, or emergency department. A new patient seen in an office or other outpatient setting that is highly complex would be identified by the E/M code of 99205. When this patient returns as an established patient who remains complex, the E/M code changes to 99215. A new patient who is highly complex and seen in a hospital-type setting would be identified by the E/M code of 99223. If this patient is seen in a subsequent hospitalization setting, the code would change to 99233. The add-on codes of psychotherapy (+90833) and/or interactive complexity (+90785) can be added to any encounter but must be properly documented.

The complexity level designated by the fifth digit of an E/M code for an outpatient is determined by three specific components: history, physical examination, and MDM. Each component has a specific label that indicates the amount and type of information required (Table 19.3). A new vocabulary has been created with specific guidelines as to how to determine the MDM, and ultimately the level of service for a given encounter. These terms will be described in detail for each of the major levels of service used to code and bill an outpatient encounter.

TABLE 19.3 Language Associated With E/M Codes

Source: DHHS (2010). *History of present illness. **Past, family, and social history. ***Review of systems.

UNDERSTANDING THE MAJOR ELEMENTS OF AN E/M CODE (DHHS, 2010)

There are three broad elements in an E/M visit: history, physical exam, and MDM. Of these elements, the history is the most familiar to psychiatric providers. The physical exam and MDM are less well known and PMH-APRNs may feel uncomfortable with the terminology. One reason why psychiatry has been reluctant to embrace E/M codes is because of the concept of a physical exam. However, in 1997, CMS changed the documentation requirements and created 11 single-system specialty exams of which psychiatry was included: cardiovascular; ears, nose, mouth, and throat; eyes; genitourinary (female); genitourinary (male); hematologic, lymphatic, and immunologic; musculoskeletal; neurological; psychiatric; respiratory; and skin. In a level 5 complex patient the psychiatric specialty exam (physical exam) only requires that the constitutional, psychiatric, and musculoskeletal systems be included. Each of these systems has specific bullet points that must be included and is described in a later section. As mentioned earlier, the MDM component comprises three sections: the number of diagnoses or management options; the amount and/or complexity of data to be reviewed; and the risk of significant complications, morbidity, and/or mortality. In order to objectify each of these MDM components for audit purposes, specific criteria in the form of points were developed and approved by CMS in the early 1990s by the Marshfield Clinic (over 600 multispecialty providers in 32 clinics throughout Wisconsin). It is to be noted that CPT itself does not require the Marshfield criteria, but CMS does. In order to be at the top of the documentation bar, it is suggested to include them in every encounter. Each of these three broad elements will now be reviewed.

History

Obtaining the history is no different in psychiatry than in any other branch of medicine. However, the

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verbiage that is used for medical symptoms has been adapted. Elements of the history include the chief complaint (CC) or better stated, reason for encounter, history of present illness (HPI), review of systems (ROS), and the past, family, and social history (PFSH). The specified elements for each level of service are summarized in Table 19.4.

TABLE 19.4 CPT Requirements: History

Source: DHHS (2010). *No PFSH required for subsequent hospital visits. **Only two elements required for established patient.

CHIEF COMPLAINT (REASON FOR ENCOUNTER) The CC should be documented in the patient’s exact words with quotation marks. An example is “I feel like life isn’t worth living at all anymore. This has been going on for about a month,” and encompass the problem and the duration.

HISTORY OF PRESENT ILLNESS The HPI is a very familiar element to APPNs as it encompasses a portion of what used to go into the subjective section of a traditional narrative progress note documenting subjective and objective patient data, assignment and dignosis, and plan (SOAP). What is different are the names of the elements that comprise the HPI. There are eight elements used to qualify and quantify the HPI. These include location (emotion and behavior are types of location in psychiatry), quality (description of symptom, i.e., sadness), severity, duration, timing, context, modifying factors, and associated signs/symptoms. The following is an example of all eight elements in a typical patient description of HPI:

The patient reports ongoing (timing) emotional (location) problems of moderate (severity) anger (symptom) starting with the discovery of spousal marital affair (context) 2 weeks ago (duration), and now does not want to live in the same house (modifying factors) and associated with disrupted sleep and loss of appetite (associated signs/symptoms).

There are two major levels of HPI. The first is referred to as brief and consists of one to three elements or the status of one to two chronic or inactive conditions. Brief HPI is required for problem-focused (99212) and expanded problem-focused encounters (99213). The second level of HPI is referred to as extended and consists of four or more elements or the status of three or more chronic or inactive conditions. Extended HPI is required for detailed (99214) and comprehensive (99215) encounters (see Table 19.4).

REVIEW OF SYSTEMS The ROS is exactly what it says. There are 14 systems that could potentially be reviewed and include: constitutional (vital signs and general appearance including nutritional status and fever); eyes; cardiovascular; neurological; genitourinary; ears, nose, throat, and mouth; gastrointestinal; integumentary (skin and/or breast); musculoskeletal; psychiatric; respiratory; hematologic/lymphatic; endocrine; and allergic/immune. The ROS is only a very brief comment related to the system being reviewed. There is no requirement for ROS for a problem-focused (99202, 99212) encounter.

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TABLE 19.5 CPT Physical Exam Requirements for Psychiatry Elements of Examination Level

One to five bulleted elements from psychiatric exam Problem focused 99202, 99212

At least six bulleted elements from psychiatric exam Expanded problem focused 99203, 99213

At least nine bulleted elements from psychiatric exam Detailed 99204, 99214

– All bulleted elements from psychiatric exam – Three of seven components of vital signs and general appearance (two bullets) from constitutional – One bullet element from unshaded border from musculoskeletal

Comprehensive 99205, 99215

Source: DHHS (2010).

There are three levels of ROS: problem pertinent (1 system), extended (2–9 systems), and complete (10– 14). An expanded problem-focused encounter (99203, 99213) requires only the problem-pertinent system to be reviewed. A detailed encounter (99204, 99214) requires two to nine systems and typically comprises psychiatric and constitutional, although the system to be reviewed could be related to a reported side effect. A comprehensive encounter (99205, 99215) requires all 10 to 14 systems to be reviewed. The documentation of complete ROS must include individual systems and may include positive or pertinent negative responses and the following statement in addition is permissible: “All other systems reviewed and are negative.” In the absence of such a notation, at least 10 systems must be individually documented (see Table 19.5).

PAST, FAMILY, AND SOCIAL HISTORY The elements of PFSH are also very familiar to psychiatric providers as this component also includes information that was contained in the objective section of a traditional SOAP note. Past history for a new patient includes current medications, illnesses and injuries, operations and hospitalizations, allergies, treatments, dietary status, and age appropriate immunizations. Past history for an established patient would include any update since the last encounter/session.

Family history for a new patient includes medical events in the patient’s family related to CC, HPI, PFSH, and ROS. Other elements of family history include hereditary or high-risk diseases, and health status or cause of death of parents, siblings, and children. Family history for an established patient would include any updates since the last encounter/session.

The final element of PFSH is the social history. Social history for a new patient includes: marital status; living arrangements; occupational history; use of drugs, alcohol, and tobacco; extent of education, sexual history, and current employment. Social history for an established patient would include any updates since the last encounter/session.

There are also two levels of PFSH: pertinent and complete. Pertinent is one item from one of the three areas and is required only for a detailed (99214) encounter. Complete is three out of three areas for a new patient and two out of three areas for an established patient and is required only for comprehensive (99215) encounters. PFSH is not required for problem-focused or expanded problem-focused encounters or in subsequent inpatient visits (see Table 19.4).

BOX 19.2

DESCRIPTIVE STATEMENTS

Description of speech including: rate; volume; articulation; coherence; and spontaneity with notation of abnormalities (e.g., perseveration, paucity of language)

Description of thought processes including: rate of thoughts; content of thoughts (e.g., logical vs. illogical, tangential); abstract reasoning; and computation

Description of associations (e.g., loose, tangential, circumstantial, intact) Description of abnormal or psychotic thoughts including: hallucinations; delusions; preoccupation with violence; homicidal or suicidal ideation; and obsessions

Description of the patient’s judgment (e.g., concerning everyday activities and social situations) and insight (e.g., concerning psychiatric condition)

Source: DHHS (2010).

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Physical Exam

As mentioned earlier, the physical exam was an intimidating requirement for psychiatric providers, but with the 1997 CMS changes to include a single-system specialty there are now 11 possible systems: cardiovascular; ears, nose, mouth, and throat; eyes; genitourinary (female); genitourinary (male); hematologic, lymphatic, and immunologic; musculoskeletal; neurological; psychiatric; respiratory and skin. There are some differences from the traditional mental status exam in how CMS defines the elements of the psychiatric single system.

Psychiatric Single-System/Specialty Exam

The psychiatric single-system exam consists of 11 bullets that are divided into two sections: descriptive statements and a complete mental status including cognitive exam. The groupings of symptoms include general, neurologic, psychiatric, and mental status/cognitive (see Boxes 19.2 and 19.3).

A problem-focused exam (99202, 99212) requires one to five bulleted areas. An expanded problem- focused exam (99203, 99213) requires at least six bulleted areas. A detailed exam (99204, 99214) requires at least nine bulleted areas.

The comprehensive exam (99205, 99215) requires all 11 bullets from the psychiatric single system plus a different set of bullets and elements from the constitutional (shaded border) and musculoskeletal (unshaded border). This is the first time we see the phrase shaded and unshaded border. The 1997 CMS guidelines include detailed instructions for completion and documentation of the comprehensive physical exam. Each of the 11 major single systems has individual guidelines regarding which elements from each of the 11 major single systems are required for a comprehensive single-system exam. The requirements are identified by shaded and unshaded sections. The reader is referred to pages 76 and 77 of the 2010 DHHS publication at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf to visualize the shaded versus unshaded portion of a required exam. The psychiatric exam requires all elements in the shaded border from the constitutional exam and all elements in the shaded border from the psychiatric exam as well as one element from the two in the unshaded border of the musculoskeletal exam. Nothing from the other single- system exams is required for a comprehensive psychiatric single-system exam.

BOX 19.3

COMPLETE MENTAL STATUS EXAM INCLUDING COGNITIVE FUNCTION

Orientation to time, place, and person Recent and remote memory Attention span and concentration Language (e.g., naming objects, repeating phrases) Fund of knowledge (e.g., awareness of current events, past history, vocabulary) Mood and affect (e.g., depression, anxiety, agitation, hypomania, lability)

Source: DHHS (2010).

The constitutional system (shaded border) consists of two bullets that cover eight major areas:

Measurement of any three of the seven vital signs: B/P__ sitting or standing, B/P__ supine, P__, R__, T__, Ht__, Wt__

General appearance which includes grooming, deformities, nutrition, and development

The musculoskeletal system (unshaded border) consists of two bullets that cover a broad area:

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Assessment of muscle strength and tone (e.g., flaccid, cog wheel, and spastic), with notation of any atrophy and abnormal movements (e.g., motor tics, tremors, and vermiform tongue movements), or

Examination of gait and stations

Table 19.5 summarizes the required elements of the physical exam for psychiatry.

Medical Decision Making

The MDM in psychiatry is based on the nature of the presenting problem and comprises three components: the number of diagnoses, the amount of data to be reviewed, and risk of mortality/morbidity. This is what drives everything else in the encounter including the history, psychiatric specialty exam, and intensity of the service delivered. Providers have always done this intuitively but now are being asked to make explicit what has been implicit in how an encounter is conducted. Medical decision making is a sort of “thinking out loud” for the record and often “transposes into the key of psychiatry” (Burd, 2013). The three components have distinct guidelines and are summarized in Tables 19.6 and 19.7. Appendix 19.1 includes an example of an Evaluation and Management Established Patient Office Progress Note created as a worksheet that incorporates the major elements of MDM.

THE NUMBER OF DIAGNOSES OR MANAGEMENT OPTIONS The MDM component of establishing the number of diagnoses and management options can be determined by using the Marshfield problem point chart developed for CMS audit purposes because the basic language was very ambiguous (DHHS, 2010). This component is based on the number and types of problems, the complexity of establishing a diagnosis, and the potential clinical management decisions. These are influenced by undiagnosed problems, the number and type of tests that need to be ordered, the need to seek advice from others, and problems worsening or failing to respond to the existing treatment plan.

The Marshfield scoring of this component is as follows. A self-limiting problem with minimal management options is scored with 1 point. An established problem that is stable or improved and also has minimal management options is also scored with 1 point. An established problem that is worsening is scored with 2 points. This level typically requires prescription medications, which elevate the level of complexity. A new problem that requires no additional workup or diagnostic procedures ordered is scored with 3 points. There is a maximum of two new problems that can be scored in one encounter. Lastly, a new problem that requires additional workup is scored with 4 points. These last two options typically require complex pharmacological management and/or procedures such as TMS or ECT. The management options are scored according to the following algorithm: minimal = less than 1; limited = 2; multiple = 3; and extensive = 4.

TABLE 19.6 Tabulation of MDM Elements (Marshfield Criteria) Score Based on Highest 2 out of 3 in the Office or Other Outpatient Settings

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Source: DHHS (2010).

TABLE 19.7 Determination of Level of MDM

Source: DHHS (2010).

THE AMOUNT AND COMPLEXITY OF DATA The amount and complexity of data are also based on a data point chart for audit purposes because the basic language is ambiguous. This component is based on the types of diagnostic tests, the need to obtain records, and the need to obtain history from other sources. This information is influenced by unexpected findings, independent interpretation of images and specimens and diagnostic tests, and the need to discuss test results with the provider performing the test.

The scoring of this section is as follows. The need to review and/or order lab data, review and/or order radiology tests, review and/or order tests in the medical section of the CPT manual, discussion of test results with the performing provider, and a review and summarization of old records and/or obtaining history from someone other than the patient are each scored with 1 point. The review and summarization of old records and/or obtaining history from someone other than the patient and/or discussion of case with another provider and the need for independent visualization of image tracing, or specimen itself and not simply reviewing the report are each scored with a 2. This component is scored according to the following algorithm: minimal or none = 0 to 1; limited = 2; multiple = 3; and extensive = 4.

RISK FACTORS OF PRESENTING PROBLEMS This MDM component is based on the risk involved in the presenting problem, diagnostic procedures, and management options. This information is influenced by several factors including: comorbidities, underlying conditions, and risk factors; uncertain prognosis, exacerbations, and/or complications; decision to order prescription drugs and/or the need for intravenous (IV) medications; and a decision to perform invasive tests, procedures, or major surgery. The scoring for this section is different from the first two MDM elements. One self-limited or minor problem, such as mild anxiety, that does not require medication and minimal therapy is rated as minimal risk. Two or more self-limited or minor problems, one stable chronic illness, or an acute uncomplicated illness that can be treated with brief therapy and/or over-the-counter medications are rated as low risk. Two or more chronic illnesses with mild exacerbation, progression, or side effects; two or more stable chronic illnesses; undiagnosed new problem with uncertain prognosis; or an acute illness with systemic symptoms are rated as moderate risk. Lastly, one or more chronic illnesses with severe exacerbation, progression, or side effects; or acute or chronic illnesses that pose a threat to life or bodily function and require medications involving intensive management and monitoring are rated as high risk.

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SELECTING THE LEVEL OF MEDICAL DECISION MAKING The selection of the appropriate level of MDM in the office or other outpatient settings is determined by the highest 2 out of 3 ratings in the three overall elements (presenting problem, diagnostic procedures, and management options). For example, let us calculate the MDM for a patient who has dysthymia and is responding to standard dose selective serotonin reuptake inhibitor (SSRI) treatment with a side effect of sexual dysfunction and brief, solution-focused therapy provided by another therapist who has mailed you a copy of rating scales and asked you to review progress to determine whether therapy needs to be continued. You have taken the history and conducted the psychiatric exam based on the nature of the presenting problem and you have also been asked to provide a report to the insurance company. Under the diagnoses or management options, there is one established problem that is stable or improving (1 point) for a score of 1. Under the amount and complexity of data, you will review the rating scale scores (1 point) and obtain history from the therapist (1 point), and you will summarize the records and provide documentation to the insurance company (2 points) for a score of 4. Under the risk section, there is the need for prescription psychotropic medications that require monitoring of side effects elevating the risk to moderate. The highest 2 out of 3 yield a score of extensive for the amount and complexity of data and moderate risk for an MDM score of moderate complexity. This would result in a level 4 service, or a 99214.

Documentation of MDM should include: assessment; impression; diagnosis, status of established diagnosis, differential diagnosis, probable diagnoses, and rule-outs for potential diagnoses; initiation/changes in treatment; and referrals, request, and advice from other providers. Additional MDM documentation includes type of tests, review and findings of tests, relevant findings from records, discussion of test results, direct visualization of images, comorbidities/underlying conditions, and the type of surgical or invasive procedure. See Table 19.6 for tabulation of MDM elements.

COUNSELING AND COORDINATION OF CARE

The purpose of the CPT coding process is to capture the work required to deliver a level of service and is not time dependent. Depending on the complexity of the patient, a level 5 service could occur in less than 30 minutes. However, in some situations the bulk of the work may occur in delivering what is referred to as counseling and coordination of care (CCC). If this type of care comprises over 50% of the encounter, then time becomes the controlling factor in designating the level of service. See Box 19.4 for examples of CCC discussions.

In the outpatient setting, care is required to be delivered face to face and must be documented as such. Additional documentation requirements include the length of time of the encounter and of the time spent in CCC. Many payors require documentation of encounter start and end times. The presence of family members present for the encounter must also be documented. The time designations for counseling/coordination of care are: 99212 = 10 minutes; 99213 =15 minutes; 99214 = 25 minutes; and 99215 = 40 minutes.

BOX 19.4

EXAMPLES OF CCC DISCUSSIONS

Diagnostic results Impressions related to the diagnosis Recommended diagnostic studies Prognosis Risks and benefits of management options Instructions for management and/or follow-up Importance of compliance with chosen management options Risk factor reduction Patient and family education

Source: DHHS (2010).

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Table 19.8 summarizes all that has been presented related to documenting E/M codes for a new or established patient in an office or other outpatient settings.

TABLE 19.8 All Required E/M Elements

Source: DHHS (2010).

CASE EXAMPLES

Following are case examples of patient scenarios depicting typical outpatient psychiatric encounters and how they should be documented using E/M codes. The goal of the chart note is to demonstrate how ill the patient is, how to document the care given, and to provide documentation for the itemized bill submitted for reimbursement.

99212—Established Patient

CASE Thirty-year-old female with a history of depression who is stable on an SSRI for the past 4 months and reports no depressive symptoms. She comes for a prescription renewal. There are no treatment changes, no side effects, and her medication is prescribed at the same dose.

PRESENTING PROBLEM Patient is stable and requesting a 3-month medication refill.

HISTORY For a 99212, there is no ROS or PFSH required. The HPI requires one to three elements or one to two chronic conditions.

PHYSICAL EXAM Only one to five bulleted points from the psychiatric single-system exam are required.

MEDICAL DECISION MAKING This patient has 1 problem point under diagnoses and management options for her stable diagnosis. Reviewing her record from 4 months ago results in 1 data point. Her risk is low due to being stabilized on an SSRI with no side effects. This averages to a straightforward level of

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MDM which translates to a problem-focused 99212.

99212—PROGRESS NOTE CC/Reason for encounter “I’m here to get my citalopram renewed, everything is going well.”

HPI Forty-year-old married, African American female, comes to office for follow-up visit for treatment of depression that is stable with no exacerbations, no side effects.

PE Speech: normal rate and tone. Mood: “I’m feeling good.” Affect: broad, congruent, animated. Presentation: good hygiene and grooming. No S/I. Sleeping well.

Impression Patient is stable and responding to SSRI. Diagnosis: 311 Depression not otherwise specified— improved on citalopram.

Plan Continue same medication dose, wrote script for citalopram 20 mg #30 2 refills. Return

visit in 3 months.

99213—Established Patient

CASE Office visit for a 32-year-old single Hispanic female with major depression, moderate, without psychotic features who is stable 6 months on an SSRI and who wants to decrease her current dosage due to sexual dysfunction.

HISTORY An expanded problem-focused encounter requires a brief HPI consisting of one to three elements or one to two chronic conditions, PFSH is not required, and the ROS is problem pertinent for one system.

PHYSICAL EXAM At least six bulleted points from the psychiatric single-system exam are required.

MEDICAL DECISION MAKING This patient has 1 problem point under diagnoses and management options for an established problem that is stable. She has 3 problem points for a new problem that may require additional workup. Reviewing her record from 6 months ago results in 1 data point. Her risk is moderate due to being on an SSRI and having a side effect. This averages to a low level of MDM which translates to an expanded problem-focused 99213.

99213—PROGRESS NOTE CC/Reason for Encounter Thirty-two-year-old married Hispanic female reports “My depression is okay, but my sex drive is zero. I think it’s from my medication.”

HPI The patient reports ongoing (timing) decreased libido (location) creating moderate (severity) frustration (quality) that has been going on for the last 6 weeks (duration). Now that her depression is better, she wants an active sex life (context). Her husband is supportive and not pressuring her (modifying factors). (Although only one to three elements are required, seven are captured as she describes the HPI which often happens with psychiatric E/M documentation.)

ROS Psychiatric—no symptoms of depression or anxiety. Genitourinary—reports decreased libido.

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PE Psychiatric: Appearance: appropriately dressed, verbal, and cooperative; speech: normal rate and tone; mood: euthymic; affect: full and appropriate; thought process: logical, associations intact, no suicidal or homicidal ideation.

Problem Depression responding to treatment but patient presents with a new problem of sexual side effects.

Diagnostic Impression 296.32 Major depression, moderate without psychotic features responding to SSRI.

Plan Decrease fluoxetine from 40 to 20 mg. Called pharmacy with change. Return visit in 1 month.

99214—Established Patient

CASE Office visit for a 52-year-old married man, with a 16-year history of bipolar disorder responding to lithium carbonate and brief insight-oriented psychotherapy. Patient reports tremors and some diarrhea. Psychoeducation and prescription provided. Ordered laboratory tests.

HISTORY A detailed encounter requires an extended HPI that includes 4/8 elements or greater than three chronic conditions. This level of encounter requires a pertinent level of PFSH which is one element. An extended ROS of two to nine systems is required.

PHYSICAL EXAM A 99214 detailed encounter requires nine bulleted items from the psychiatric single-system exam.

MEDICAL DECISION MAKING This patient has 4 points under diagnoses and management options for a new problem that requires additional workup. There are 2 points under amount and complexity of data for the need to order lab data and review of old records and labs. He is on lithium which has a moderate risk for side effects and requires monitoring. The highest 2 out of 3 rates the MDM at the moderate complexity level. The appropriate level of service is 99214.

PROGRESS NOTE CC/Reason for Encounter Fifty-two-year-old single White male. Scheduled visit for treatment of bipolar disorder, stable on lithium for 16 months. Complains of tremors and diarrhea.

HPI The patient reports increased tremors and diarrhea (location) creating moderate difficulty (severity) with fine motor tasks and fear of not being around a bathroom (associated signs and symptoms) that has been going on for the last 3 weeks (duration). This has happened since having the “bad GI flu” (context). He has decreased his salt and fluid intake but continued his lithium (modifying factors). He is also feeling dizzy.

PFSH He is concerned he won’t be able to work.

ROS (Required only 2 systems) Psychiatric: reports no change in mood, thinking, speech, continued taking lithium while he had the flu. Constitutional: reports changes in diet after experiencing fever, nausea, vomiting, and diarrhea for 4 days. No blood in vomitus or diarrhea.

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GI: reports ongoing diarrhea and cramping after getting over the flu. Musculoskeletal: complains of tremors and weakness on getting up too fast.

PE (Nine elements) Psychiatric: Appearance: appropriately dressed, verbal, and cooperative; speech: clear with no slurring or increased rate; thought process: normal; associations: normal; thought content: normal with no grandiosity; judgment: adequate; mood: euthymic; affect: broad, congruent, and animated; orientation: fully oriented; memory: intact. Constitutional: B/P = 168/110, P = 92, R = 18, T = 99, weight = 224 (increase of 10#), well groomed with good hygiene. Musculoskeletal: normal strength, fine tremors observable in both extremities that have never occurred before, gait normal, balance normal.

Impression Bipolar disorder, stable. Mild lithium toxicity related to continuing lithium while experiencing vomiting and diarrhea, possible dehydration. Plan Continue lithium and therapy. Called lab and ordered stat lithium level, comprehensive metabolic panel, renal function, thyroid function. Reviewed diet and instructed to return to normal diet and increase water intake back to normal 2 liters/day. Reviewed effects of lithium during dehydration. Call patient with lab results. Return visit in 2 weeks to recheck vitals.

99215—Established Patient

CASE Office visit for a 25-year-old male with a 7-year history of schizophrenia and polysubstance abuse who has been seen bimonthly and is partially compliant with oral antipsychotic medication, statin, antihypertensive, and antidiabetic medications. He lives in a group home and has a case manager. He is brought in by his parents. Patient reports auditory hallucinations which is a new symptom and is unkempt.

History A comprehensive encounter requires an extended HPI that includes 4/8 elements or greater than three chronic conditions. This level of encounter requires a complete level of PFSH which is two elements. A complete ROS of 10 to 14 systems is required.

Physical Exam A 99215 comprehensive encounter requires all bullets in constitutional and psychiatric shaded boxes and one bullet from the musculoskeletal unshaded box.

Medical Decision Making This patient has 4 points under diagnoses and management options for a new problem that requires additional workup. There are 3 points under amount and complexity of data for the need to order lab data (1), review of old records and labs and obtain history from someone other than the patient and discussion with a case manager (2). He is on medications that require monitoring and has one or more chronic illnesses with severe exacerbation (high risk). The highest 2 out of 3 rates the MDM at the high complexity level. The appropriate level of service is 99215.

PROGRESS NOTE CC/Reason for Encounter Twenty-five-year-old SWM. Scheduled visit for treatment of schizophrenia. “I’m hearing these really weird and scary voices. I’ve never heard voices before, I feel like I need to blow my ears off my head because they are telling me I would be better off dead. I’m afraid to answer the telephone because I hear them from the phone wires and can’t tell who I’m talking to.”

HPI The patient reports a new symptom, increased auditory hallucinations (location) creating severe

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difficulty (severity) because of persecutory nature (quality) that has been going on for the last 3 weeks (duration). He has never heard these kinds of voices before (context). This has happened since increasing marijuana intake to three times daily (timing and modifying factors). Dealing with the voices is causing him to feel lethargic (associated signs and symptoms).

PFSH He has moved into a new group home that is known to have drug dealers in the vicinity. He has increased marijuana use. He may be using other drugs as well. His family insisted he come in for an appointment and brought him to the appointment.

ROS (Required 10 systems) Psychiatric: anxious, paranoid; appearance: disheveled and unkempt, strong body odor, fingers stained yellow from smoking; constitutional: hasn’t eaten in 2 days; sleep: disrupted; nutrition: gaining weight; respiratory: he is developing a smoker’s cough. All other systems reviewed and are negative.

PE (All bullets in constitutional and psychiatric and 1 bullet in musculoskeletal) Constitutional: BP = 140/98, P = 90 RSR, R = 20; weight = 235—gain of 10 pounds. Appearance: unkempt, bizarre, unable to maintain eye contact, reluctant to engage in conversation, frequently turns head and mumbles to unseen voices. Psychiatric: Attitude: guarded; speech: soft, slowed, mumbles, incoherent; mood: agitated; affect: restricted, incongruent; thought process: illogical, paranoid, loose associations; thought content: persecutory auditory hallucination, ideas of reference, paranoid ideation, delusions; orientation: self, place; memory: impaired for both recent and remote; judgment and insight: poor; attention and concentration: impaired; language: named 1/3 items after 3 minutes; fund of knowledge: poor, doesn’t know president. Musculoskeletal: Gait—shuffles; station: slightly off balance.

Problem/Diagnostic Impression 295.9 Schizophrenia in exacerbation related to substance use and medication nonadherence. In addition to delusions and negative symptoms, now has auditory hallucinations and is unable to care for self (corroborated by family). Smoking increasing.

Plan Switch oral olanzapine to long-acting aripiprazole following standard titration and switch methodology to hopefully reverse metabolic syndrome that may be related to olanzapine; order drug screen and CMP, lipid profile, hemoglobin A1C, methylfolate, vitamin D. Consult with internist regarding metabolic status and other medications. Temporarily move home with family to monitor substance use and assist with medication administration and activities of daily living (ADL). Contact ACT team, refer family to NAMI, discuss group home situation with case manager prior to going back to this group home. Return visit in 1 week, may need hospitalization if unable to stabilize.

99215—Established Patient Seen for Counseling and Coordination of Care

Counseling and coordination of care is based on time, individuals present during the encounter, and the fact that over 50% of the encounter is spent discussing one or more of the following: diagnostic results; impressions related to the diagnosis; recommended diagnostic studies; prognosis; risks and benefits of management options; instructions for management and/or follow-up; importance of compliance with chosen management options; risk factor reduction; and patient and family education. There are no specific documentation requirements for history, physical exam, and MDM in a CCC encounter (E/M University, 2013). Using the patient with schizophrenia described in the previous case, his follow-up appointment the next week is now described using language specific to CCC.

PROGRESS NOTE: COUNSELING AND COORDINATION OF CARE

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Session Started 2:00 p.m.

Session Ended 2:45 p.m.

Persons Present Patient, mother, father, case manager

Narrative Note The entire appointment was spent in counseling and coordination of care. The first 10 minutes was spent discussing the diagnosis of schizophrenia and the differences between positive and negative symptoms. Misconceptions were clarified. The next 15 minutes was spent discussing the risks/benefits of switching to a long-acting injectable medication and the rationale for doing so. The patient was in agreement by the end of this section of the encounter, and an informed consent was signed. Ten minutes was spent coordinating the medical care with the case manager who would be present with the patient in the visit to the internist. The case manager was instructed in helping the patient check his blood sugars and to assuring that reliable test strips were used. Instructions about diet, smoking, and metabolic syndrome were provided. The last 10 minutes of the session was spent in explaining how to switch from oral olanzapine to long-acting injectable aripiprazole and the need to first take oral aripiprazole. We will have weekly CCC sessions during the medication switch.

CONCLUDING COMMENTS

The goal of this chapter is to inform the APPN on the ins and outs of using evaluation and management clinical procedural terminology. Added suggestions and clinical pearls include the following. For new patient intakes, you will probably be reimbursed more for a 99205 than a 90792 as the latter code does not take MDM into consideration. However, this is dependent on the carrier. Always remember to use the code that best describes the care given. Medication follow-up encounters should never be coded less than a 99214 unless it is a very simple patient. Do not hesitate to use the CCC option for standard encounters that you know ahead of time will be spent discussing the components of CCC. However, be cognizant that CCC and psychotherapy are not the same. Avoid billing a 99212 and definitely not a 99202 because these codes are for 10 minutes of low complexity, which is probably not something the APPN would regularly do such as giving samples or taking vital signs. Remember to use the interactive complexity add-on code when encounters become heated or the family gets involved, but you probably will not be reimbursed very much. Remember to use the psychotherapy add-on codes, even though they do not reimburse that much when you are engaging in specific psychotherapy modalities. If the content is more CCC, use that to your advantage as a 99215 will likely reimburse more than a 99213 with a 90833 add-on. Seriously think how much education is done in a typical encounter particularly when considering explaining labs and drug interactions and neurobiology to the patient and family. Do not be afraid to use 99215, even though it will likely trigger an audit. A helpful documentation guide is available through one of the Medicare carriers (CGS, 2012). Once the auditors see your excellent documentation you will probably be spared future audits. Lastly, the more you use the codes and adjust your documentation, the easier it will become. Please view the helpful web pages listed on the reference pages and download the materials. It will take some study, but you may actually find you like the new way of doing business as it definitely does a better job of capturing the outstanding and comprehensive work of the APPN.

DISCUSSION EXERCISES

1. After viewing the AMA document titled “CPT® and RBRVS 2013 Annual Symposium,” what are your thoughts about the process that led to the conclusion of changing the major focus of psychiatric billing, coding, and documentation to that of the E/M codes? Do you agree? Why or

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why not? 2. Think of one of your past patient and family encounters in which members were shouting and not

listening to you or each other and it took you 2 hours to de-escalate and salvage the situation. Were you reimbursed adequately for that amount of work? Or did you just “write it off” to one of those days when you knew you were not going to get reimbursed nearly enough to compensate for the time?

3. Even though you are primarily a psychotherapist, you are still an APRN and as such you are aware of the interrelatedness of the body and mind. Have you had psychotherapy sessions derail into discussion of medications in which you spent the majority of the session clarifying perceptions? Were you able to be reimbursed for that psychoeducation using a psychotherapy code? How did you document that as a psychotherapy session?

4. In your discussions with colleagues about the new codes, what have been some of the common themes? Are you better able to understand the rationale for the coding changes after reading this chapter?

5. What has been your major personal objection to switching from psychiatric specialty codes to the medical E/M codes used by all other medical providers? Is it a reluctance to think of psychiatric care in the language of medical terminology?

6. What could be some of the advantages to using E/M language in communicating with medical colleagues?

7. Can you identify the similarities between SOAP language and the language of HPI, PFSH, and ROS?

8. In thinking about an insurance audit of a 99215 chart note, what is your greatest fear related to your current method of documentation?

ACKNOWLEDGMENT

A special thank you to Ronald Burd, MD, for his thoughtful review and editorial comments to this chapter.

REFERENCES

American Medical Association (AMA). (2012a). CPT (current procedural terminology) 2013 professional edition. Chicago, IL: AMA Publishing. Retrieved from: https://commerce.ama-assn.org/store/catalog/productDetail.jsp?product_id=prod1180004&navAction=push

AMA. (2012b). CPT® and RBRVS 2013 annual symposium. Retrieved from http://www.ama-assn.org/resources/doc/cpt/15-psychotherapy- puente-musher.pdf

American Medical Association. (2013a). Current procedural terminology. Retrieved from http://www.ama-assn.org/ama/pub/physician- resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page

American Medical Association. (2013b). The RVS update committee. Retrieved from http://www.ama-assn.org/ama/pub/physician- resources/solutions-managing-your-practice/coding-billing-insurance/medicare/the-resource-based-relative-value-scale/the-rvs-update- committee.page

American Psychiatric Association. (2013). Crosswalk for CPT changes. Retrieved from http://www.psych.org/practice/managing-a-practice/cpt- changes-2013

Burd, R. (2013). Personal communication. Celerian Group Systems (CGS). (2012). Documentation checklist: Evaluation and management 99215. Retrieved from

http://www.cgsmedicare.com/ohb/coverage/mr/PDF/99215.pdf Centers for Medicare and Medicaid Services. (2013). Physician fee schedule search. Retrieved from http://www.cms.gov/apps/physician-fee-

schedule/search/search-criteria.aspx Clemens, N. (2013). New medical psychotherapy CPT coding: The tail wagging the dog? Journal of Psychiatric Practice, 19, 150–151. Department of Health and Human Services. (2010). Evaluation and management services guide. Retrieved from the Medicare learning network:

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide- ICN006764.pdf

E/M University Online. (2013). Coding based on time. Retrieved from http://emuniversity.com/Coding BasedonTime.xhtml Gutheil, T. (1980). Paranoia and progress notes: A guide to forensically informed psychiatric recordkeeping. Hospital and Community Psychiatry,

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https://commerce.ama-assn.org/store/catalog/productDetail.jsp?product_id=prod1180004&navAction=push

http://www.ama-assn.org/resources/doc/cpt/15-psychotherapy-puente-musher.pdf

http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page

http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/the-resource-based-relative-value-scale/the-rvs-update-committee.page

http://www.psych.org/practice/managing-a-practice/cpt-changes-2013

http://www.cgsmedicare.com/ohb/coverage/mr/PDF/99215.pdf

http://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf

http://emuniversity.com/CodingBasedonTime.xhtml

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Evaluation and Management Established Patient Office Progress Note

Client Name:________________________________________

Date of Service:______________________________________

Provider Name:______________________________________

Time In:__________________am/pm Time Out:__________________am/pm

Total Time Spent (minutes):_______________

Level of Service: 99212________99213________99214________99215________

Counseling/Coordination > 50% of time (explain)________________________________

_____________________________________________________________ _____________________________________________________________ _____________________________________________________________

Tabulation of Medical Decision-Making Elements—Highest 2 Out of 3 for Overall MDM

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Termination and Outcome Evaluation KATHLEEN WHEELER

his last chapter presents a general overview of termination: when to terminate, how to handle the patient who terminates prematurely, under what circumstances the therapist initiates termination, and ethical

issues related to termination. The termination issues discussed in this chapter are germane to all psychotherapy approaches. In addition, practice guidelines and outcome evaluation in psychotherapy are discussed. Evidence-based practice guidelines are essential in order to make conscientious clinical decisions about patients so that appropriate goals can be set, which when met will then determine when to terminate psychotherapy. Outcome measurement helps to ensure that goals are met for an effective and ethical practice. These outcomes may reflect various levels of measurement. The chapter ends with a case example illustrating termination and the use of practice guidelines and outcome measures in time-limited psychodynamic psychotherapy.

WHEN TO TERMINATE

In contrast to the literature on the therapeutic alliance and other phases of the psychotherapeutic relationship, there is little literature and almost no empirical evidence about the best way for therapists to deal with termination. Competency in the last phase of psychotherapy reflects the therapist’s ability to assess the patient’s readiness for termination and to manage termination issues within the context of the approach utilized in the treatment. Termination is an essential phase of the therapeutic relationship and there should be a plan in place by the therapist in order to process relevant issues that arise as the end to the relationship nears.

Binder (2004) reviews the few studies that have been conducted on termination and the duration of therapy, and arrives at these tentative conclusions: (a) limiting the duration of therapy may influence the rate of change; (b) acute symptoms exhibit more rapid change than characterological problems; and (c) more time in therapy leads to more change. However, Siegel disagrees with the last point and says there are no longitudinal studies proving that longer-term psychotherapy results in better outcomes than shorter-term psychotherapies.

Hopefully, the goals that have been set at the outset of therapy have been successfully met. Research suggests that at least 11 to 13 sessions of evidence-based therapy are needed for 50% to 60% of patients to have good outcomes (Lambert, 2007). Unfortunately, this often is not the case. Patients frequently drop out of treatment without a plan for termination, especially in community mental health centers. Approximately 50% of patients drop out of therapy by session 3, while 35% end therapy after the first session (Barrett, Chua, Crits-Christoph, Gibbons, Casiano & Thompson, 2008). There are many reasons for termination, including:

1. Mutually agreed on based on achievement of goals 2. Preplanned based on number of sessions 3. Forced termination because therapist graduates or changes clinical assignment 4. Forced termination because the patient moves 5. Forced termination because patient cannot afford fee or insurance will not pay 6. Patient terminates because he or she feels not helped 7. Therapist refers patient elsewhere because therapist feels there is no value in continuing 8. Setting ends the treatment for any reason (Gabbard, 2010)

An extensive review of the literature on termination revealed six strategies that reduce premature termination (Swift et al., 2012). These include: (a) providing education about the duration and pattern of change because studies have shown that most patients expect to attend five sessions or less; (b) providing role induction such as instructing the patient that he or she will be doing most of the talking; (c) incorporating

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client preferences such as type of therapy, directive or manualized, versus less directive, homework or no homework; (d) strengthening early hope, which can be done by expressing confidence in the patient and his or her ability to have a successful therapy outcome and commending the person for seeking therapy; (e) fostering the therapeutic alliance; and (f) assessing and discussing treatment progress, which can be done through outcome measurement and sharing the results with the patient.

Termination optimally occurs when coping and functioning have improved, symptoms are reduced, and the goals of treatment are met. The achievement of goals depends on the collaborative goals set with the patient at the outset of treatment as well as the type of approach or model utilized. For example, supportive psychodynamic psychotherapy criteria for termination would include the strengthening of the ego, reversal of regression, and symptom improvement. In contrast, historically, more expressive psychoanalytic psychotherapy criteria for termination would involve the resolution of the transference neurosis, an acceptance of the futility of perfectionist strivings and childhood fantasies, a reduction in the intensity of core conflicts, and the development of a self-analytic capacity (Wolitzky, 2003). Self-analytic capacity means that the person has learned to be reflective and become their own therapist. This would occur after patterns of defenses emerge again and again and are observed and interpreted until the patient accepts the therapist’s interpretations in the working through process (Gabbard, 2010). A more contemporary view is that relationships change for the better. This illustrates that new neural networks involving a different kind of relationship are developed.

The advanced practice psychiatric nurse (APPN) can usually detect that this has been achieved by what the patient says and does. Often, for example, the person may say: “I thought about what you would say when I was in that situation” or “I had a whole conversation in my head with you before I talked to him.” These kinds of statements reflect the patient’s internalization of the therapist’s reflective function. Sometimes nothing is said but the person’s functioning has greatly improved and it is obvious to the therapist from what the person says about how he or she has handled various situations that a newfound ability to self-reflect and/or self-soothe is operating.

For cognitive behavioral therapy (CBT), termination begins in the first session and the expected duration is usually discussed at that time when issues and goals for treatment are clarified. The therapist usually sets a specific number of sessions, a predetermined date to end, or informs the patient that the treatment will not go longer than a few weeks or months without specifying an exact date (Binder, 2004). The idea is for the therapist and patient to keep a problem focus and momentum moving forward. Reinecke and Freeman (2003) recommend setting parameters for treatment at the outset because studies have found no correlation between duration of therapy and effectiveness. Improvement after 12 to 15 sessions has been found to be minimal so it is the first 3 to 4 months in which most of the positive changes occur. It is a generally accepted practice in CBT to remind the person, from time to time throughout the treatment, of when termination will occur so that the person has an opportunity to discuss how he or she feels about ending and can prepare for it.

The goals of treatment in CBT involve changes in maladaptive thinking and behaviors toward more positive adaptive thinking and behavior and more effective coping skills. The last session reviews the goals and skills the person has developed as well as discussing how to prevent a relapse. Cognitive and behavioral factors that are unique for the person that brought them into treatment and that were ameliorated such as perfectionism, negative thinking, lack of assertiveness, and so on are highlighted with new strategies that were learned and consolidated. Usually termination for CBT is gradual with the person coming to sessions every other week, then every month, every 3 months, and then every 6 months so that modifications or changes can be addressed in order to ensure success.

In interpersonal psychotherapy (IPT), major goals of treatment relate to the resolution of interpersonal problems in the here and now. To that end, alternative strategies for interpersonal relationships are identified, new relational patterns are practiced, and old ways of relating are grieved. Once the patient is successfully implementing the new ways of being, goals of therapy are met. Termination begins as early as the middle phase of treatment and is embedded in the work of that phase, working with the sadness about the loss of the relationship with the therapist as well as issues of relapse prevention. As with CBT, there are a finite number of sessions delineated, 16, and this provides incentive for the person to do the work within circumscribed parameters of the treatment. The therapy does not really end at the last session in that the work continues with the person working independently. See Chapter 6 for termination strategies suggested for successful outcome.

In eye movement desensitization and reprocessing (EMDR) therapy, therapy is ended when the collaboratively identified targets representing the adverse life experience or trauma are reprocessed and the subjective units of disturbance (SUD) scale is 0 and the validity of cognition (VOC) is 7. The EMDR

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therapist reevaluates the target of the previous reprocessing by asking the patient to bring the incident to mind after each reprocessing session. When a past event has been completely processed and there is no disturbance in the body, the person is guided to present triggers and then develops a future template. A future template is a mental imagery or video of how the person wants to be with respect to the trauma or adverse life experience going forward. At the final session, all the issues that have been addressed will be discussed and if any outcome/assessment measures were given at the beginning of therapy, the patient will be asked to take these again and these results are shared with the person (Dodgson, 2009).

HOW TO TERMINATE

Historically, psychodynamic psychotherapists thought that termination represented a crisis that needed to be worked through as earlier losses or separations are revived and inevitable. For example, if a patient suffered abandonment issues, then this would get enacted and exacerbated in the transference just prior to termination. Termination has been likened to the rapprochement crisis as delineated by Mahler, Pine, and Bergman (1975). That is, the patient’s core conflict centers on the need to be autonomous and self-reliant while at the same time to be dependent. These opposing forces are always in the background of the therapeutic process and as such must be understood in order for a successful termination to occur (Quintar, 2001).

The idea that separation anxiety about termination occurs has largely changed as psychotherapy is briefer and therapy is viewed now more from a primary care perspective, that is, that patients feel they can come in and out of psychotherapy and use it as a resource much as one would any health care provider (Gabbard, 2010). In fact, an intermittent psychotherapy model has evolved that treats termination as an interruption of services rather than an end point. Proponents of this model posit that complications inherent in termination, such as exacerbation of symptoms and transference issues, are avoided if termination is reframed as an interruption of services (Cummings, 2001).

In intermittent psychotherapy, the word termination is not used but rather therapy is only interrupted. It may be resumed in several months or several decades depending on the patient. The person is encouraged to write to the therapist about how he or she is doing after interrupting treatment and the therapist responds to all communications warmly. If the person is doing well, the therapist responds by offering positive comments on the person’s problem-solving skills. On the other hand, if the person is having difficulties, the therapist asks the patient whether it is time to come in for a session. Foundational to this process is the therapeutic contract, homework, and resiliency. In this model, the patient is required to complete assigned homework as part of the therapeutic contract and failure to do so results in sending the person home or even termination of treatment. Although seemingly a severe punishment for such a transgression, the author points out that if enforced, there is rarely the forfeiture of a second session.

From a psychodynamic viewpoint, all requests from the patient to terminate should be explored. Often the patient’s desire to end treatment is thought to reflect resistance. Gabbard (2010) states that underlying motives should always be explored with these questions in mind: Is the patient anxious and afraid and running from something? Is the patient angry at the therapist? Is the patient enacting a flight into health? Is the patient discouraged about the therapy, and feeling judged by the therapist? If the goals of treatment have not been met, it is likely that anxiety is underlying the wish to terminate. The person may not be aware of any underlying reason other than the stated: “I am fine now.” For example, one patient who had been in treatment for depression and had difficulty in sustaining long-term relationships came only for several sessions and then unexpectedly announced that this would be her last session because she was feeling much better. The therapist was quite surprised and taken aback as in the previous session the patient had talked about how sad she had felt as a little girl about her mother’s absence in her life due to her alcoholism. This issue of loss seemed to permeate all relationships and situations, and the therapist had been moved by the previous session. The therapist gently explored whether the patient felt that her goal of being able to sustain a long-term relationship and trust someone was already met. As the session unfolded, the therapist wondered aloud whether her desire to leave now was based on some of the sad feelings she had expressed during the last session. Tearfully, the patient realized that she was fleeing as she was beginning to feel vulnerable in therapy. Once expressed, she was able to stay and continue to work in ongoing psychotherapy. The inability to tolerate intense emotions speaks to the importance of the therapist assisting the person in affect management strategies and titrating the amount of arousal during treatment. Patients may be well-served to flee treatment if their defenses are fragile and they are not assisted with controlling overwhelming states of anxiety, rage, depression, and guilt. See Chapter 13 for stabilization and affect management strategies.

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For those patients who are unable to tolerate success, treatment may be terminated by the patient as soon as the person begins to improve, leaving a perplexed therapist wondering what happened. These individuals may mistake early gains in well-being as recovery and see little benefit from continuing. This issue may also be triaged through their history of self-defeating behavior in times of happiness and success. The therapist can point out to the patient that this may happen in therapy too and stress the importance of discussing ending treatment when the patient wants to leave treatment. Underlying this may be a great deal of guilt and masochism as the person may unconsciously feel that they do not deserve to be happy or successful. Dynamic interpretations about this issue can be helpful throughout the treatment and the vigilant therapist keeps this in mind as the person improves.

Perhaps the devaluing patient is the most difficult to work with as the person insists that the therapy was not worth the time and did not help and the therapist most likely feels demoralized. Often these individuals do not keep their last appointment. Of course, they may be accurate in their assessment, but it is important for the therapist to keep in mind that these feelings may be anxiety-driven and unconsciously the person may need to minimize the loss by not acknowledging the importance of the relationship. Underlying the devaluation may be deep feelings of inadequacy and worthlessness with the person perceiving the therapist as critical and uncaring. Maintaining an empathic, exploring stance without defensiveness in the face of a barrage of devaluation is extremely difficult. Sometimes the best that can be hoped for in such situations is providing the patient a new type of relationship experience through the therapist’s benign presence. The overall goal then is that the person will be more likely to seek help at some point in the future.

If the APPN knows that the person has a history of anger, it may be helpful to include the family in treatment, especially initially (Stevenson, 2000). The therapist can then prepare the patient and family member for the likelihood of anger at the therapist and premature treatment at the beginning of treatment. In this way, Stevenson posits that the anger will seem like a “normal” part of the therapy and a healthy triangulation with the family, therapist, and patient will be established at the outset. In addition, these patients are often not self-referred and may be less than willing participants in therapy. Stevenson also suggests reframing anger as a problem for the patient’s physical health in order to normalize anger and motivate the person for treatment.

For patients who are aggressive, termination can be seen as the ultimate rupture in the therapeutic alliance. Relational psychodynamic theorists posit that these patients are counterdependent and that termination provides a rich opportunity to rework conflicts of dependency versus autonomy. Safran and Muran (2000) say that when patients are aggressive and counterdependent in therapy, the therapist’s work involves ultimately working toward an exploration of the dependency that is being defended against. In contrast, when patients are more dependent and deferential, the therapist’s job is to help the person access the angry feelings that are being defended against. This gives the person the opportunity to learn that the therapist can survive their aggression. The therapist empathizes with and validates feelings of anger that emerge during termination, such as feelings of disappointment and resentment at not getting what the person wanted from therapy.

Gabbard (2010) points out that termination involves mourning by both the therapist and the patient. This is thought to be especially true for those who have been significantly traumatized in that the loss of termination relates to the loss components of the traumatic event (Horowitz, 2003). The person has emerged from the trauma having lost a sense of personal invulnerability. The loss of the therapeutic relationship and acceptance of the idea provide a context for mourning other past major losses. The patient realizes that ultimately no one can take care of them and love them unconditionally. The therapist also mourns the loss of the relationship with the patient. In addition, the therapist must reconcile with the limitations of what the therapy has accomplished. Novice APPNs sometimes have unrealistic expectations about what therapy can accomplish. Both parties may harbor unconscious fantasies about being healed and healing and must come to terms about the limitations of what one person can do for another.

However, if the goals of therapy have been met, typically the patient does not have much to say about termination when asked other than expressing appreciation and some sadness about terminating. No matter which psychotherapy approach the therapist is using, once a termination date has been set, whether a month, 6 weeks, or several months hence, the patient’s feelings about termination should be explored intermittently in the time left. Even if the patient initiates termination, the therapist’s agreement to terminate may be experienced as a rejection and abandonment.

Toward the end of treatment, the patient may have an exacerbation of symptoms that brought the person into therapy in the first place or a decrease in functioning. For this reason, it may be important for the therapist to inform the patient that this commonly occurs beforehand. The APPN should be aware and watchful for recidivism so that the person can be encouraged to express his or her feelings of sadness,

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abandonment, and loss rather than acting them out. Important work can be accomplished during termination, particularly for those patients with significant issues revolving around loss and dependency. These painful feelings are associated with earlier memories of loss and/or abandonment and related neural networks are often triggered by the present loss of relationship. This is important to point out to the patient; however, the therapist needs to explore this issue with sensitivity so that the treatment does not end on a bad note with the person feeling battered by repeated interpretations that only serve to further entrench the patient’s position that there is no connection. Leaving therapy feeling misunderstood can feel better to the patient than the pain of separation and loss but this is not the ideal way to terminate. A useful analogy to keep in mind is the nearly universal experience of most adolescents in senior year of high school who turn their parents into ogres and become so obnoxious that all parties concerned are glad when they finally leave home. This helps to assuage sadness about leaving but is a less than ideal way to terminate a therapeutic relationship.

In addition to understanding the patient’s unconscious issues related to termination, the therapist needs to be aware of his or her own issues. It is a good time for the therapist to reflect on whether his or her goals are congruent with what the patient wants. The therapist’s goals may be too ambitious for the person and wanting the person to function at a higher level may not be appropriate at this time for this person. The APPN may be busy rescuing the person who does not share the same values or aspirations. In addition, the therapist may have his or her own abandonment issues and feel comfortable and rewarded from working with the patient and find termination difficult. These issues affect both the therapist and the patient. For the therapist, unresolved personal conflicts may predispose the therapist to use the therapeutic relationship to satisfy his or her own social and emotional needs. On the other hand, patients who have been difficult to work with may engender a sense of relief when they terminate. In that case, the therapist may neglect to adequately explore their wish to stop. Thus, it is important for the APPN to self-reflect and examine his or her own feelings about the patient’s termination to ensure that the patient’s best interests are in the foreground of the therapeutic process.

As noted previously, there are various models for whether to taper sessions or schedule follow-up sessions depending on the therapist’s orientation, the goals, and the needs of the patient. Most psychoanalytic psychotherapies do not taper off sessions but some contemporary relational psychodynamic-oriented therapists do feel that it is useful in order for patients to see how they manage on their own (Gabbard, 2010). Other therapists schedule an appointment for a month or two after the last session as a follow-up session. A review of the treatment and how the person has changed may be conducted in the last session. Scheduled periodic phone calls may also be helpful for the therapist to monitor how the person is able to handle stresses outside of therapy. Some patients find regular ongoing support after therapy crucial in keeping on an even keel, and checking in periodically helps the person to maintain functioning at a high level. This may be especially important for the patient who has suffered severe and/or complex trauma.

Kluft (1999) suggests that for these patients, follow-up sessions may need to be held every few months indefinitely. It is prudent to ask the patient what would be good for him or her if you suspect that ongoing support is needed. However, it is important not to convey to the person that you expect that he or she will have problems in the future. One patient who had been severely depressed and came intensively over a period of 2 years achieved much higher functioning than he ever dreamed possible and continued to schedule appointments over the next several years every few months to “touch base.” The focus of these sessions reflected his eagerness to share with the therapist his successes, and the therapist shared his pleasure but she also further explored how he did not believe that these changes belonged to him and were long-lasting. As his confidence grew in his newfound ability to deal with his life, he was able to lengthen the time between sessions further and further. Some patients may never wean themselves completely from therapy. Gabbard (2010) calls these individuals “therapeutic lifers” and suggests that consultation be sought to be sure about whether this arrangement is beneficial for the patient.

An important point about termination is that the door should always be left open for the patient to return and hopefully if the experience was a positive one, the person will be able to use therapy as a resource and feel comfortable about seeking help in the future. However, if the patient is being transferred to another therapist, it may not be appropriate to “leave the door open” for the person to return to you as this can cultivate splitting. In these situations, when the person is being transferred to another colleague, particularly if it is in a clinic setting, it may be helpful to introduce the patient to the new therapist and/or have the new therapist come to a few sessions pre-termination to ensure a smooth transition (Gabbard, 2010).

Reviewing the patient’s file prior to termination in order to identify issues and important themes highlighted during treatment is helpful so that the APPN can organize his or her own thinking about the progress that has been made during the therapy process. In addition to the APPN’s reflections, it is important to ask the patient what was and was not helpful in the treatment. Reflecting and reminiscing with the patient

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and outlining the ways that the person is functioning better are important in the sessions leading up to the last session or at the very least in the last session. This discussion should emphasize that these accomplishments are a consequence of changing maladaptive thinking patterns and/or insight gained and/or better ways of handling situations and/or increased ability to manage emotions, and so on. In examining the changes that have occurred, the therapist can reinforce education about how to maintain the gains made during times of stress and explore patient expectations about accessing resources in the future. Hopefully, educating the person has been part of the therapy all along but reinforcing again is essential during termination.

WHEN THE THERAPIST INITIATES TERMINATION

Occasionally, the therapist initiates termination because the patient is noncompliant, refuses to pay, is not benefiting from therapy, or needs other treatment not in the therapist’s expertise. All these situations would probably benefit from consulting with a colleague prior to ending the treatment in order to clarify countertransference and ethical issues and plan how best to proceed. Chapter 4 discusses how to handle missed sessions and how and when to terminate when the person does not come to scheduled appointments. A termination letter that states one’s concerns, the reasons for recommending continued treatment, and the referral should be sent to the patient with a copy of the letter kept in the patient’s file. See Appendix 4.6 for a sample termination letter. However, if in the opinion of the APPN, the person needs further care, it is incumbent on the therapist to make sure that the patient is not in crisis and then refer the person to a specific therapist as well as follow up on the appointment. This is important not only to protect the patient’s well- being but also the APPN’s legal liability.

Ethical issues may arise, particularly when managed care has denied authorization. For example, one patient with a panic anxiety disorder began to have fewer panic attacks so that he could drive to work, which he previously was unable to do. After the six authorized sessions, the APPN submitted the required outpatient treatment report (OTR) for further sessions and was denied. The therapist was alarmed and felt strongly that the progress that had been made would be jeopardized without further solidification and support for the gains made. If the therapist believes that the person’s safety will be compromised by termination, it is incumbent on the therapist to ensure that treatment continues either at a lower cost by offering a sliding scale fee or payment plan, or referring the patient to a lower cost clinic and assist in treatment transition. It is important to not terminate abruptly because of an unpaid bill without first attempting to work things out and giving the person suitable warning.

Although the American Nurses Association (ANA) Code of Ethics (2001) does not specifically address abandonment of the patient, it clearly states: “The nurse’s primary commitment is to the patient.” However, the American Psychological Association Ethics Code (2010) does specifically address abandonment, and this should be followed by APPNs who are working with patients in psychotherapy. The American Psychological Association Code of Ethics requires that arrangements must be made for the patient’s ongoing treatment, if needed, despite employment and/or contractual agreements. Courts have ruled that if health professionals terminate treatment because of managed care’s failure to authorize sessions, the health professional is liable for harm as a result of abandonment (Wickline v. State of California, 1986). The standard of care must be followed even if the managed care company denies payment or authorization to the provider. Managed care companies protect themselves from liability because of loopholes in the Employees Retirement Insurance Security Act (ERISA). The licensed health professional is responsible for the patient’s care until treatment is ended by the patient or until treatment is no longer necessary. The APPN must refer the patient to a specific therapist and ensure that an appointment is set up, and must be especially careful if the person is in crisis. These efforts need to be carefully documented including consultations with colleagues, decisions made and rationale, and patient follow-through. Along the same lines, a therapist must neither propose nor agree to see a seriously ill patient infrequently. An important point to consider is if emotional or physical harm occurs to the patient as a result of failure of the therapist to meet a standard of care, the therapist is legally liable.

On the other hand, a mental health professional can also be sued for continuing to work with a patient when the treatment is not working. Again, the key here is, was the standard of care followed? And was there damage to the patient? One such case involved a patient, who was a physician himself, was in psychodynamic psychotherapy and was hospitalized for major depressive disorder (Osheroff v. Chestnut Lodge, 1985). Eventually he was given antidepressants by another psychiatrist and he rapidly improved. The patient sued the hospital and psychiatrists who did not treat him with antidepressants. The case was settled out of court. However, APPNs who practice psychotherapy must follow practice guidelines and standards of care

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developed by other mental health professionals for psychotherapy and psychopharmacotherapy. APPNs are beginning to be more visible on some consensus panels that develop these guidelines.

PRACTICE GUIDELINES

Practice guidelines are official statements that summarize research findings and present the appropriate management for specific problems. It is important for the APPN to be familiar with those that are relevant for practice and incorporate the suggestions as appropriate. The guidelines are recommendations only and the APPN should tailor the guidelines to each individual patient’s needs. Practice guidelines are intended to be flexible while standards of care should be followed for all cases. Although practice guidelines are foundational to improving health care but are not in themselves legally binding, they do not replace clinical judgment, and are not in and of themselves standards of care. Standards of care are determined based on all clinical data available for an individual case and subject to change as knowledge advances. The ultimate judgment regarding care for a specific patient should always be based on the patient and family’s circumstances as well as available resources. The APPN should be knowledgeable about the practice guideline for the specific diagnosis treated and document if there is a deviation in care from the suggested guideline and why.

Relevant practice guidelines have been identified in this book for the specific topics discussed as appropriate. In addition to those developed by professional associations, academic centers, and government agencies, managed care organizations have also developed their own. Many practice guidelines are available on the web. Currently, there are over 30 groups that have developed practice guidelines for mental health and substance abuse problems (Stuart & Laraia, 2005). These evidence-based guidelines are based on systematic reviews of randomized controlled studies. Reviews are based on electronic searches of databases such as Medline, PsychLit, the Cochrane Library, meta-analysis, as well as hand-searching journals. Once the literature is reviewed, consensus opinion of an expert panel is sought regarding the appropriateness, safety, and efficacy of treatment options (Parry, 2000). The quality of the evidence is usually stated for each recommendation. The American Psychiatric Association (2010) and the American Academy of Child & Adolescent Psychiatry (AACAP) have developed a number of practice guidelines for psychiatric disorders, and these are available at www.psychiatry.org/practice/clinical-practice-guidelines and www.aacap.org/cs/root/member_information/practice_information/practice_parameters/practice_parameters, respectively. Both the American Psychiatric Association and the AACAP Guidelines are based on the DSM- IV and are being updated with the publication of the DSM-5. The National Guideline Clearing House provides the ability to access and compare practice guidelines at the following website: www.guideline.gov/help/ConstructComparison.aspx

Because controlled clinical trials require strict inclusion criteria and few confounding variables, rarely does clinical practice reflect these stringent requirements. Most subjects with more than one diagnosis are excluded from the study and those who qualify and are asked to participate are not representative of the majority of patients (NIMH, 2013). In addition, clinicians rarely adhere to one specific method but tailor the therapy to meet the individual’s needs and integrate various methods and models to achieve efficacy. Psychotherapy approaches that utilize structured techniques and protocols lend themselves better to experimental design criteria. Therefore, approaches such as CBT and EMDR therapy have been studied more than less structured approaches such as psychodynamic psychotherapy. Psychodynamic interventions such as free association and dynamic interpretations are harder to quantify. However, this does not mean that less structured psychotherapy approaches are not effective, only that efficacy has not been established. See Chapter 5 for discussion of some of the inherent validity problems of evidence-based research in clinical practice.

Practice guidelines are based on the person’s diagnosis and as Chapter 3 noted, DSM diagnoses are highly variable and reflect only a snapshot in time. Many voice concern about diagnostic inflation with the new DSM-5 diagnoses of binge eating disorder, bereavement, disruptive mood dysregulation for children with temper tantrums, somatic symptom disorder for those worried about a medical illness, mild neurocognitive disorder for those who are forgetful in old age, and an expanded attention-deficit disorder for adults (Frances, 2013). The danger is overtreatment of patients with medication. Despite a petition from an independent scientific review that more than 50 mental health associations endorsed, the American Psychiatric Association refused to discuss or be transparent in the process of developing the DSM-5.

The NIMH (2013) also recently recognized the limitations of the DSM-5 and research based on these diagnostic categories and symptom amelioration. A new system for decisions about research funding will incorporate genetics, imaging, cognitive science, and other levels of information instead of relying on DSM

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diagnostic categories. Although the DSM is reliable, that is, consistent with clinicians agreeing that certain symptoms constitute a specific label for a patient, it does not have validity in that the clusters of symptoms are not based on any objective measure. Without validity, reliability is insufficient on which to base treatment decisions. With such a dramatic change in funding criteria, there may be important implications for future practice guidelines because practice guidelines are based largely on large federally funded randomized clinical trials, which in the past were based on a specific diagnostic category.

In addition to a DSM diagnosis, many other factors should be considered when deciding which psychotherapy treatment approach and interventions to use with the patient. These include clinical presentation, severity of symptoms, progression, coexisting conditions, genetic or biologic variations, susceptibility to complications, and allergies to medications (Latov, 2005). In addition, the developmental history, defenses, pattern of relating, behavioral analysis, placebo response, coping skills, patient preference, compliance, intelligence, personality, and support system vary from person to person. It is not possible for practice guidelines to address all the nuances of clinical practice and it is important that guidelines do not override clinical judgment and common sense. Of course, the therapist’s personality and training, therapeutic relationship with the patient, and the treatment setting are also important considerations in deciding what approach and interventions to use. In fact, given the research on therapist effectiveness, patient outcome, and the therapeutic alliance, Binder (2004) suggests that psychotherapy outcome studies should focus on empirically supported psychotherapists, not empirically supported treatments.

Yet, despite the complexity of clinical problems and inherent difficulties with evidence-based research in clinical practice, psychotherapy practice guidelines remain important in that empirical data for effective practice promotes accountability and positive outcomes. What is curious is that although studies have found that guidelines increase a research-based practice and improve patient outcomes, often clinical practice does not reflect that the person will receive the intervention(s) that are evidence based. For example, Sanderson (2002) points out that only a small percentage (15%–38%) of patients who have panic and phobic disorders receive the evidence-based psychotherapy interventions of exposure and cognitive restructuring, which are recommended by numerous practice guidelines. This gap between evidence-based treatments and real-world practice may be due to clinicians’ inadequate training in these modalities or ignorance about practice guidelines.

OUTCOME EVALUATION

Outcome evaluation has become a critical issue in health care for everyone. The Institute of Medicine’s (IOM) (2001) Crossing the Quality Chasm Report emphasizes that health care should be “… safe, accessible, timely, equitable, efficient, cost effective, patient-centered, and evidence-based, based on latest scientific evidence coupled with the provider’s clinical judgment, and informed by the patient’s preferences …”. The $787 billion economic stimulus bill provided substantial amounts of money for the federal government to compare the effectiveness of different treatments for the same illness: “… researchers are receiving $1.1 billion to compare interventions for treating specific conditions” (New York Times, Feb 16, 2009).

The move toward evidence-based care began in earnest in 2010 with the initiation of health reform policy in order to lower costs and improve outcomes (National Research Council, 2011). Inpatient medical settings have already adopted quality indicators that include such markers as 30-day readmission, discharge planning, and follow-up in the community for specific diagnoses. For example, if a patient has been discharged from an inpatient setting with a diagnosis of congestive heart failure (CHF) and is readmitted within the next 30 days, the hospital will not get paid for the readmission inpatient hospitalization costs because research shows that if proper discharge instructions are given regarding diet, medication, and follow- up, the person would not suffer CHF again so soon after discharge. Linking outcomes of treatment and quality indicators to reimbursement for outpatient behavioral health care seems inevitable.

Behavioral health quality indicators have been slower to develop but there are already 300 process measures for assessment and improvement of mental health and substance abuse. See www.cqaimh.org/quality.xhtml for examples of screening and assessment quality measures for behavioral health. As of 2013, quality measures are mandated by Medicare and financial penalties are slated for 2015 for therapists who are noncompliant with the Physician Quality Reporting System (PQRS). PQRS is a reporting program that mandates that clinicians report at least three screening measures and these are tied to the new CPT codes. So far the only psychiatric diagnosis that is slated for quality reporting is major depressive disorder in addition to screening measures for clinical depression and unhealthy alcohol use. This is a

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beginning step toward linking reimbursement to the “best” mental health treatments. The best treatments are those that are evidence-based, and in the future, those that are not considered

evidence-based may not be reimbursed. Outcome effectiveness is predicted to be part of an organized care delivery system (Bobbitt et al., 2012). APPNs must document outcomes of psychiatric care to satisfy employers, consumers, insurers, policymakers, the general public, and themselves. Accountability and quality are hallmarks of professional nursing practice and are based on measurement of outcomes. Clinical rating scales and outcome measures should be essential to APPN practice. Outcomes can include clinical, functional, satisfaction, and financial indicators.

An outcome measure should have demonstrated validity and reliability as well as sensitivity to clinically important changes over time. Appropriate symptom scales such as the clinical rating scales included in Table 3.6 in Chapter 3 have good normative data as do the measures in Tables 13.2 and 13.3 in Chapter 13. Medication targets discrete symptoms such as anxiety and so on; thus symptom outcome measures reflect specific decreases in these parameters and are most appropriate when measuring outcome indicators of psychopharmacology. Appendix 20.1 includes a table of common outcome measures used in psychotherapy research and practice.

Psychotherapy, on the other hand, facilitates more holistic outcomes and affects all dimensions of the person: emotional, intellectual, physical, relational, spiritual, vocational, and psychological. The holistic model presented in Chapter 1 is embedded in relationships with others with a change in one dimension of the person affecting all other dimensions. Healing is “… 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 …” (Mariano, 2013, p. 60). Thus, although symptom measures are one parameter of change for psychotherapy treatment, global holistic outcomes reflecting relationships and overall health may be more accurate indicators of healing. Examples of measures reflecting holistic outcomes might include hope, resilience, connection to others, relationships with others, quality of life, overall health status, and spiritual well-being. Many of these instruments have been developed by nurse researchers. Selected holistic outcome measures are included in Table 20.1.

Another way to think about meeting the goals of psychotherapy and outcome measurement is according to how immediate to the patient’s experience the outcome measure is (see Figure 20.1). The level of measurement reflects the degree of abstraction of the construct. The collaborative goal(s) of psychotherapy are reflected in outcome measures that are concrete, patient-centered, and quantifiable. Hopefully if these are met, all levels of measurement reflect positive outcomes as significant change would reverberate toward the larger global measurement of holistic outcomes that are more abstract. For example, a patient came to treatment with dissociative identity disorder and was disturbed by the intensity and frequency of the dissociative episodes she was experiencing each day. The immediate collaborative goal set with the patient was to decrease the number of dissociative episodes per day, so the first step was to establish a baseline measure of how many times she was currently experiencing dissociation throughout the day. The APPN set an appropriate goal collaboratively with the patient to decrease that number by a certain date and initiated interventions to decrease the baseline number. Accomplishing this then decreased the patient’s overall anxiety and depression that were measured with appropriate instruments measuring these respective clinical indicators. The psychotherapy approach employed to accomplish this was supportive psychodynamic, so a measure reflecting outcomes for this model was an instrument measuring improved ego functioning. These measures then were validated and reflected in the holistic outcome measurement of the construct of resilience. It is up to the clinician to decide which level of measurement to assess. Obviously, the more levels assessed, the more certain the APPN can be that significant change and healing have occurred. This type of outcome measurement strategy is called multimodal measurement.

TABLE 20.1 Selected Holistic Outcome Measures

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Another consideration in choosing a measure for treatment effectiveness is who is reporting on the improvement. There is a growing focus on the value of patient-reported outcomes, that is, patient self-report measures (Bobbitt et al., 2012). A baseline outcome measure should be obtained on assessment and measurement should again be done at termination and also at several points during the treatment in order to monitor progress. Although very few clinicians routinely monitor outcomes during the course of treatment, the data can be quite useful not only for research purposes but also when therapy is stagnating. This can alert the APPN so that interventions and treatment can be reevaluated and modified. In addition, measuring outcomes intermittently comparing the patient’s own scores with each other at different points in time is considered a rigorous time-series research design and sidesteps the validity issues inherent when comparing patients who have the same diagnosis with each other. Documenting patient outcomes using a time-series design would make an excellent empirically valid case study for publication. The following case example illustrates termination and the use of practice guidelines and outcome measures.

FIGURE 20.1 Level of outcome measurement in psychotherapy.

CASE EXAMPLE

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Ms. K, a 60-year-old divorced, home health aide presented for outpatient psychotherapy a week after discharge from a 5-day inpatient stay at the local psychiatric hospital after her ex-husband moved in with another woman. Ms. K had subsequently recurrent suicidal thoughts and voluntarily admitted herself. She was started on fluoxetine 30 mg and participated in group therapy but remained depressed after discharge.

In her initial session with the therapist, Ms. K scored 40 on the Beck Depression Inventory (BDI), indicating severe depression and described sadness, loss of interest in pleasurable activities, guilt, loss of energy, tearfulness, hopelessness, fatigue, loss of appetite, middle of the night insomnia, a 10-pound weight loss, and concentration problems over the past month. The patient’s identified complaint at the time of intake was “I am helpless, hopeless and will never have a good life.” She denied memory problems, substance abuse, delusions, or present suicidal ideation. Her depression, lack of social supports, hopelessness, and no spouse were risk factors for suicide. However, she did not have an organized plan to hurt herself and her voluntary hospitalization for previous suicidal ideation as well as current denial of suicidal thoughts indicated that the risk for self-harm was present but not high. The APPN knew that risk might increase as she began to feel better and that Ms. K should continue to be closely monitored. There was no history of mania, hypomania, or illicit drug use. Two prior episodes of depression were reported. The first episode was 10 years previously when she suffered an automobile accident that fractured her left arm and lacerated her face after she was thrown face first through the passenger side of a non-safety-plate windshield. She was diagnosed with major depressive disorder after this event and treated with fluoxetine for a year. Eight years after this accident, she was diagnosed with breast cancer and underwent a mastectomy followed by a course of chemotherapy and radiation. She was treated at that time with CBT for 16 sessions and venlafaxine for 2 years with a partial response.

Ms. K had a history of early traumatic relationships. She reported that her early childhood was marked by emotional and physical abuse from her rageful, alcoholic father and emotional neglect by her mother. Although she had amnesia for much of her childhood, one of her few early memories was of her father demeaning her and calling her “stupid” when she made a mistake. Her mother too was berated by her father and Ms. K felt her mother was afraid to intercede on her daughter’s behalf. Her father insisted that she adhere to a strict regimen throughout her childhood and when she did not comply, he was angry and punishing. For example, she recalled that when she was learning to tie her shoes around the age of 4, her father slapped her across the face each time she did not correctly remember the proper sequence of steps to accomplish this task. She was expected to take care of her two younger sisters at an early age and was not allowed to play with other children. At the age of 10, her parents divorced, leaving her with her depressed, emotionally unavailable mother and her two sisters. Her mother remarried a year later and her stepfather frequently beat her while her mother did nothing about it. The continuing emotional and physical abuse interfered with her ability in school. She finally left home at age 17 and lived at a convent where she took classes to become a home health aide. At age 20, she met her ex-husband whom she married several months later.

She reported that her marriage of 30 years was not happy and that she was physically and emotionally abused by her husband who was an alcoholic with frequent angry outbursts. On several occasions, he had punched and slapped her. Her husband had divorced her 10 years previously leaving her without alimony or financial security. In fact, he financially exploited her by coming to her for money whenever he ran out. She had no children and expressed great regret at never being able to conceive but believed that she did not deserve children anyway. Her parents were both deceased at the time of intake and her relationship with her two sisters was distant and passive. Ms. K had been able to work full-time as a home health aide until her recent hospitalization and lived alone. She stated that she was hardworking and conscientious and liked helping others. Her work was a significant area of gratification for her.

Ms. K had recently had a physical exam at her nurse practitioner’s office with complete blood count (CBC) with differential and chemistry profile all within normal limits. After a comprehensive psychiatric assessment and history, a diagnosis of major depressive disorder, recurrent, severe without psychotic features was made. In addition, her chronic dysphoria and poor self-esteem warranted an additional diagnosis of persistent depressive disorder (dysthymia). Medical diagnoses included obesity, type 2 diabetes, and hypertension. Medications included IC

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lisinopril–HCTZ 10/12.5, Toprol XL 100 mg, and Actoplus Met 15/500 mg. A Global Assessment of Functioning (GAF) score was 45/60 at intake. A treatment plan was developed using the practice treatment guidelines from the American Psychiatric Association (2010).

Practice guidelines suggest that frequent monitoring to assess suicidality and response to psychopharmacology is important in the acute phase of treatment. CBT and IPT are identified as the psychotherapeutic approaches that have the best documented efficacy. In addition, the guidelines state: however, since CBT was used before with some success yet did not result in longer-term change, a combination of psychodynamic and CBT approaches was chosen. Ms. K’s stated goal for therapy was first and foremost “to sleep better” and second to “be less lonely.” Collaborative goals were set to sleep 6 hours a night within a month and to develop two new friends within 3 months. Sessions were scheduled for once a week for the next 40 weeks.

The acute phase of treatment aims to eliminate the symptoms and restore psychosocial functioning. Although Ms. K acknowledged that her depression was significant, she was passive and subdued in sessions and resisted attempts to discuss her feelings focusing instead on her physical symptoms of fatigue, insomnia, and anorexia. She was not enthusiastic about the antidepressant medication saying that she had tried it in the past and it was not particularly helpful. Trazodone 50 mg was prescribed at night for sleep. Given her tumultuous early relationship history, it was felt that stabilization was needed with supportive psychodynamic psychotherapy and cognitive behavioral education strategies designed to increase resources. Therapeutic communication techniques for stabilization as outlined in Table 4.1 based on the treatment hierarchy for this book were used. Patient outcome measures chosen to monitor progress were the Beck Depression Inventory (BDI) and the Sense of Belonging Instrument (SBI) because of their ease of administration, adequate normative data, appropriateness to goals of treatment, and the ability to provide both symptom-specific as well as a more holistic outcome measure. The SBI addressed the latter and would reflect the patient’s stated outcome “to be less lonely.” At the beginning of her second session, she scored 58 on the SBI indicating a low sense of belonging. This was explained to Ms. K as important so that the APPN could monitor her functioning and improvement as therapy progressed.

Integrated treatment with the APPN both prescribing and conducting the psychotherapy was thought to be the most effective model to ensure coordination of care. Also given her proclivity to focus on her physical symptoms and difficulty with emotional expression, it was felt that integrated rather than split treatment might help to provide a model for uniting her emotions with her physical symptoms. In this way, splitting and resistance to emotional exploration might be ameliorated. In light of her negative comments about her medication and her difficulty with identifying and expressing her feelings, the APPN did not increase her fluoxetine and joined with her initially in discussing her physical symptoms as the focus of treatment. Further testing with the Toronto Alexithymia Scale (TAS) indicated significant difficulties in identifying and describing feelings with an overall score of 62 with 51 or more significant for alexithymia. This is common for those who have suffered early trauma. It is therefore important that the APPN provide an emotional vocabulary through empathically linking the patient’s feelings to events and her somatic symptoms.

As treatment evolved, the APPN felt that by Ms. K giving voice to her life narrative, she might be able to remember childhood events and integrate her dysfunctional memories into more adaptive memory networks. In doing so, the implicit beliefs that claimed responsibility for her own neglect and abuse could change by deepening her understanding of her family of origin and her ex-husband’s psychopathology. One of the most powerful experiences in therapy, particularly for someone who has been disempowered and disrespected, is to be carefully listened to and taken seriously by another person. Ms. K’s fear of dependency and abandonment issues were great and as such the APPN attended to the relationship and used countertransferential feelings as a source of data and a barometer for how the work was progressing. At times, there was significant deadness in the sessions with Ms. K filling the hour with her litany of somatic complaints and the APPN struggled to maintain a sense of emotional engagement, wishing that the sessions would end. The APPN noted these times gently to Ms. K and explored her underlying feelings contributing to this way of communicating. Ms. K was able to articulate that she protected herself from caring too much about coming to therapy.

After 16 sessions, outcome indicators showed a significant decrease in symptoms on the

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BDI with a score of 26, indicating moderate depression as the patient entered the continuation phase of treatment. As her depression abated, her self-esteem increased and she was able to go back to work. She began to take increasing responsibility for her role in creating her loneliness and the unhealthy ways of getting her dependency needs met though passivity and withdrawing. Given the recurrent and chronic nature of Ms. K’s depression and the improvement noted with combined psychotherapy and medication, ongoing psychodynamic psychotherapy was continued on a one time a week basis. At the 30th session, the APPN reviewed with Ms. K the number of sessions that were left and explored her feelings about the upcoming termination.

APPN: We have 10 more sessions left. Ms. K: Okay, well how can we speed this up? I don’t think that this has helped that much.

APPN: How frustrating to feel the lack of progress here and so little time left. Can you tell me more how you are feeling?

Ms. K: Well, I am not blaming you but I need more direction and more from you. APPN: Tell me more about what you need from me. Ms. K: I don’t know. I know you tried to do your best.

APPN: How does that feel for you to tell me that? Ms. K: Scary, like you won’t like me now and won’t want to see me anymore.

APPN: That I will abandon you by not caring if you say what you need? Ms. K: Well I guess. It seems that this has brought out so much sadness that instead of feeling better, I

just want to avoid the loneliness and pain. I guess I just shut down and am scared when I think about therapy ending.

In this session, Ms. K linked her withdrawing (defense) to her pain (anxiety) and this is an important step in understanding how she creates her own loneliness (response). Her ability to self-reflect had markedly improved. Over the next several months, she continued to deepen her emotional awareness about how the termination of therapy revived earlier pain of significant abandonment experiences relating to her childhood. At the 40th session, the BDI and the SBI were administered with scores 20 and 40, respectively, indicating significant improvement on both indicators. Her GAF was 70/60. Ms. K continued to come every 4 to 6 weeks for medication management and psychotherapy over the next 6 months. Given the severity of her initial depression and the long-term nature of her chronic dysthymia, she remained on 30 mg of fluoxetine and returned every 3 months for ongoing support in the maintenance phase of treatment. This is consistent with the American Psychiatric Association’s practice guideline recommendations for the maintenance phase of treatment.

Ms. K’s therapy was unremarkable in the sense that there are many stories like hers in mental health clinics for those who have been ravaged by trauma. Yet what is remarkable is that it is the Ms. Ks who most need and benefit from the APPN’s expertise, time, and caring. When a patient is psychologically savvy and engaging to work with, it is interesting and easy to invest the psychic energy needed to affect positive changes. Ms. K found relief in knowing that someone was willing to listen to her about her physical complaints and this led to discussing and linking her somatic symptoms to her emotional issues in a safe, supportive environment. Understanding the connection between conditioned somatic and emotional responses to internal and external sources allowed Ms. K to enhance self-regulatory skills. This understanding coupled with her experiencing emotions in an empathic relationship with the APPN facilitated integration of neural connections and healing. Careful attention was paid to pacing each session to what Ms. K could handle so that she would not be overwhelmed. She initially believed that her problems were all her own fault and that she did not deserve to get any better. Although demoralized and “resistant,” she gradually began to look forward to her sessions and never missed once after the first month of treatment.

CONCLUDING COMMENTS

In addition to using measuring instruments and framing the goals of therapy according to the overall model of therapy used, it is incumbent on the therapist to check throughout therapy and at termination whether the specific collaborative goal(s) the patient and therapist identified are being met. For example, the problem of

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social isolation for Ms. K was addressed by the collaborative goal, “to feel less lonely.” Thus, the specific outcome identified was to develop two new friends within 3 months. Her other problem of insomnia was addressed by the goal “to sleep better” and was measured by setting a specific date one month hence by which she would be able to sleep 6 hours a night. Both goals were met and were clearly measurable, patient-centered, and easily quantified. Because APPNs are used to developing nursing care plans, identification of collaborative specific outcomes for psychotherapy is usually easily accomplished. An excellent adjunct to assist in developing specific goals, objectives, and interventions for psychotherapy treatment is The Complete Psychotherapy Treatment Planner (Jongsma, Peterson, & Bruce, 2006).

Integrating outcome measures into your clinical practice is prudent not only to determine whether collaborative goals are being met but also to meet the growing mandate for linking reimbursement to quality indicators. In addition, administering selected instruments at intake and throughout treatment allows the APPN to monitor the treatment process. Tracking the process of therapy can provide valuable information related to dynamics and determinants that help us to understand the process of therapeutic change. Which intervention is most effective for what problem for which population at which time in treatment? Not only does this assist with practice decisions for individual patients, but these data can also be disseminated to colleagues through reporting a single case or through a case series (a collection of cases with a similar problem or presentation). The case study has traditionally been the primary means of inquiry, teaching, and learning in psychotherapy.

DISCUSSION EXERCISES

1. What tools do you believe would be appropriate outcome measures for psychodynamic, cognitive behavior, and interpersonal psychotherapy approaches? Review the instruments included in this book and identify specific tools reflecting indicators theoretically consistent for each model.

2. A patient says that he or she will be stopping psychotherapy after the current session. You do not believe this is in the person’s best interests. Discuss how you would handle this.

3. Compare and contrast several practice guidelines available for a specific diagnosis. Identify any discrepancies. How would you go about choosing the best one for use for a patient you are seeing for outpatient psychotherapy?

4. You have a patient who has not paid you in several months but says that he or she will. Discuss how you would deal with this situation and how you would decide whether to terminate.

5. Review the ANA Code of Ethics. Do you believe that it adequately addresses issues related to the APPN conducting psychotherapy? If yes, state how it does so; if not, discuss how it does not and whether you feel it should.

6. Discuss the importance of outcome measurement for APPNs conducting psychotherapy. 7. Review the literature and identify three or four other specific outcome measures not listed in this

chapter that you think would be good holistic indicators of improvement in psychotherapy. Provide the instrument’s name, the concept measured, type of tool, why it would be an appropriate holistic measure, normative data (reliability and validity), and how to obtain it.

8. What psychotherapy approaches “fit” the best with how you like to work? How do you plan to continue to expand the ways you work with patients?

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http://www.who.int/mental_health/media/en/622.pdf

713APPENDIX 20.1

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Selected Instruments for Psychotherapy Outcome Measurement

The table below is a selected list of instruments that may be used in psychotherapy research. This is not a comprehensive list but does include many instruments that have been used in EMDR research. Sources of other instruments include journals, publishing houses, as well as the following publications:

American Psychiatric Association. (2000). Handbook of psychiatric measures. Washington DC: APA. Antony, M., Orsillo, S., & Roemer, L. (2001). Practitioner’s guide to empirically based measures of anxiety. New York, NY: Kluwer

Academic/Plenum Pub. Conoley, J. D., & Kramer, J. J. (1995). The twelfth mental measurements yearbook. Lincoln, NB: Buros Institute of Mental Measurement. Fischer, J., & Corcoran, K. (2007). Measures for clinical practice & research (Vol. 1 & 2) New York, NY: Oxford University Press. Stanford School of Medicine, Research Instruments Developed, Adapted or Used by the Stanford Patient Education Research Center accessed

July 21, 2009, http://patient education.stanford.edu/research

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http://patienteducation.stanford.edu/research

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717

718

Afterword

This book is a how-to compendium of evidence-based approaches. The novice advanced practice psychiatric nurse (APPN) may feel a bit overwhelmed after reading this book and wonder where and how to begin to integrate these approaches into practice. Keep in mind that all the authors of the chapters in this book were also all beginners at one time. The contributing authors have generously shared their considerable clinical knowledge and expertise to provide a how-to for each respective approach and/or population that will benefit both the novice and experienced APPN. Expert clinicians seek individual and group supervision, ongoing education, and further certification throughout their professional career. An ethical, compassionate practice requires no less.

The work of psychotherapy requires lifelong learning, and ongoing education and supervision in order to practice competently, effectively, and ethically. To ensure lifelong education, mandating a minimum of 25 contact hours of psychotherapy CEUs for psychiatric mental health nurse practitioner (PMHNP) recertification in addition to the current requirement of 25 contact hours of pharmacotherapeutics is one possible cogent solution. This would highlight how essential psychotherapy is for APPN practice as well as encourage PMHNP graduate curricula to place greater emphasis on psychotherapy skills and content. In order for this to occur, our professional associations must endorse and propose such a mandate to the American Nurses Credentialing Center (ANCC). This speaks to the importance of joining our professional organizations that support psychiatric nursing, the American Psychiatric Nurses Association, the International Society of Psychiatric Nursing, and the National Organization of Nurse Practitioner Faculty. It is imperative and crucial for the growth, credibility, and viability of the psychotherapy role to our profession to raise a collective voice endorsing ongoing education.

It is curious that there seems to be concern by some nursing editors and authors that nurses do not have their own body of research demonstrating the effectiveness of psychotherapy. There is abundant research demonstrating the efficacy and cost-effectiveness of the psychotherapy approaches included in this book. The research is not discipline specific, that is, the focus is not on who is delivering the intervention but the particular intervention(s) and the specific problem/diagnosis that is treated. Nurse-delivered psychotherapy research is not essential to support the practice of nurses as psychotherapists any more than nurse-delivered pharmacotherapy research is necessary in order to prescribe. If a particular intervention or medication is effective, it will be effective if properly delivered no matter which discipline is delivering the treatment. Building our own evidence base for psychotherapeutic approaches that already have solid outcome data is redundant and reflects our own anxiety and insecurity about the APPN psychotherapy role. There are many other important nuanced questions to be asked about clinical issues, and interprofessional research needs to be conducted in collaboration with other mental health disciplines, which advances and furthers existing psychotherapy outcome data.

Students are often relieved to learn that the therapeutic alliance accounts for a significant percentage of the therapeutic outcome of psychotherapy. However, the therapeutic alliance is a prerequisite, not a substitute for empirically supported interventions. Being a good listener, well-intended, and compassionate is not enough to disregard the scientific evidence when making practice decisions nor is adherence to an evidence-based approach in a rigid, mechanistic manner without a strong therapeutic alliance. The power of the alliance in tandem with research-supported interventions for the particular patient problem illustrates Florence Nightingale’s reflection on nursing, that is, this puts patients in the best possible condition or environment for healing to occur. Embedding evidence-based interventions in the healing relationship requires clinical expertise, knowledge of the approach and interventions, as well as knowledge of your patient’s culture, preferences, and characteristics. Practicing without consideration of all these components will result in less potent outcomes.

It is likely that you will gravitate toward one type of approach and feel less comfortable with others, and consequently what you decide to focus on will relegate other dimensions or interventions to the background. If

631

you know only one approach well, that is good news for those who are responsive and receptive to that type of therapy; however, it limits your ability to treat the variety of problems and patients who you will likely encounter in clinical practice. If you do not have the expertise in the approach that has the best evidence, it may be necessary to refer the patient to a colleague who can skillfully provide the evidence-based intervention. Commitment and hard work are necessary to learn new interventions and to integrate various approaches into practice. The ambiguity of psychotherapy can generate a great deal of anxiety and challenge even experienced APPNs. The available research, the relationship-based framework for practice, and the resources presented in this book serve as a compass to guide APPNs toward an ethical, compassionate, empirically based practice. Hopefully, this book is only the beginning of your journey toward expert psychotherapy practice.

Kate Wheeler

632

719Index

acetylcholine, messenger molecule, 56 actualizing tendency, 375 acute stress disorder (ASD), 477 adaptive information processing (AIP) model

EMDR therapy processing, 271 psychotherapy hierarchy framework, 25–27 trauma, 54–55

addicted to crisis, 487 addictions

case study, 589–590 co-occurring disorders, 577–578 DSM-5 criteria, 569–570 etiology, 571–572 evidence-based psychotherapeutic interventions

cognitive behavioral coping skills, 586 complementary and alternative therapies, 587 contingency management, 585–586 critical goals, 584–585 integrated family therapy, 586–587 motivational interviewing, 586 relapse prevention, 586 therapeutic frame, 587–589

integrative theoretical framework, 583–584 neurobiology of reward system, 573–574 person-centered care, 574–577 prevalence, 566–569 recovery and principles, 571–572 relapse, 570–571 screening and assessment, 580–583 training and certification requirements, 590–591 trauma-informed care, 578–579 treatment principles, 575 12-step peer support groups, 579–580

adolescent depression, interpersonal psychotherapy, 357 adult attachment, 116–118 advanced practice psychiatric nurses (APPNs)

addictions, 566–591 assessment, 95–126 child psychotherapy, 597–616 cognitive behavioral therapy, 313–339 diagnosis, 126–129 dialectical behavior therapy, 509–526 EMDR therapy, 261–283 family therapy, 429–462 group therapy, 407–425 humanistic–existential therapy, 369–392, 396–401 interpersonal psychotherapy, 347–365 motivational interviewing, 299–310 neurophysiology, 53–73 nurse psychotherapist, 3–25 older adults, 625–650 outcome evaluation, 702–705 psychodynamic psychotherapy, 225–258 psychopharmacotherapy and, 529–558 solution-focused therapy, 392–396 therapeutic alliance, 170–195 therapeutic frame, 195–207 treatment hierarchy framework, 25–31

Adverse Childhood Experiences (ACE) Scale, 166–167 adverse life experiences, 22–25 affect development, 83

assessment, 111–113

633

720

AGPA. See American Group Psychotherapy Association alexithymia, 86–87 allostasis, 75 allostatic load, 75 altruism, 412 American Group Psychotherapy Association (AGPA), 408 American Psychiatric Association (APA), 242 American Psychoanalytic Association, 257 amygdala, 69–70 anterior cingulate, 71 anxiety

cognitive model, 329–330 systemic family therapy, 438

anxiety disorder, in older adults, 633–634 anxiety management, 15–18 APA. See American Psychiatric Association APPNs. See advanced practice psychiatric nurses arborization, 58 ASD. See acute stress disorder assertiveness training, behavioral technique, 322 assessment. See also clinical assessment

affective development, 111–113 belief systems, 118–121 child psychotherapy, 605–606 continuum of openness, 101 for dissociation, 479 ego functioning, 106–111 emotionally focused family therapy, 449 emotion-focused therapy, 390 existential psychotherapy, 386–387 functional status, 121 genogram, 123–124 Gestalt psychotherapy, 380 humanistic–existential psychotherapy, 398 identity diffusion, 110 interpersonal relationships, 113–118 mental status examination, 102–105 person-centered psychotherapy, 376 present illness history, 100–103 safety, 172–175 screening tools, 125–126 solution-focused therapy, 394 special populations, 124–125 strategic family therapy, 445 structural family therapy, 441 systemic family therapy, 437 timeframes, 104–106 timeline, 482 for trauma, 480

assessment forms Adverse Childhood Experiences Scale, 166–167 CAGE Questionnaire, 162 case formulation, 145 Child Attachment Interview Protocol, 164–165 clinical assessment, 143–144 Dissociative Experiences Scale, 146–149 Generalized Anxiety Disorder Questionnaire, 157 Geriatric Depression Scale 152 Hamilton Anxiety Rating Scale, 156 Impact of Event Scale, 150 Michigan Alcohol Screening Test–Revised, 163 Patient Health Questionnaire-9, 153 Quality-of-Life Scale, 160–161 SPRINT, 505 Yale-Brown Obsessive–Compulsive Scale, 158–159 Young Mania Rating Scale, 154–155 Zung Self-Rating Depression Scale, 151

attachment patterns/schemas, 63–64, 84 autobiographical memory, 60 autognosis, 196 automatic thought record, 321, 345

behavioral chain analysis worksheet, 515 behavioral rehearsal, 322 belief systems, assessment, 118–121 bibliotherapy, 324 biomedical/allopathic model, 11–12

634

721

biopsychosocial addiction assessment, 582 bipolar disorder

interpersonal psychotherapy, 358–359 in older adults, 632–633

body and energy work, 484–485 borderline personality disorder (BPD), 242–243, 359 boundaries

split treatment, 553–554 structural family therapy, 440 therapeutic frame, 195, 198

BPD. See borderline personality disorder brain development, 55–59 brain structures

amygdala, 69–70 anterior cingulate, 71 cerebellum, 68 cerebral cortex, 70–71 corpus callosum and hemisphere, 72–73 hippocampus, 68–69 hypothalamus, 70 insula, 72 locus ceruleus, 68 orbital medial prefrontal cortex, 71 thalamus, 67–68

brief psychodynamic psychotherapy, 254–257 burnout, 10

CAGE Questionnaire, 162 caring, psychotherapy, 13–14 case formulation

assessment, 129–131 assessment forms, 145 cognitive behavioral therapy, 334–335 psychodynamic psychotherapy, 236, 246–248

case management case presentation, 38–39 client case management needs, 48 container exercise, 52 goal sheet, 47 processing checklist, 50 safe-place exercise, 51 stabilization checklist, 49 and treatment, 43–46 weekly plan, 40–42

catastrophic thinking, 319 catharsis, 413 CBT. See cognitive behavioral therapy CCC. See counseling and coordination of care cerebellar vermis, 68 cerebellum, 68 cerebral cortex, 70–71 certifications

addiction nurse, 590–591 child psychotherapy, 598–599 cognitive behavioral therapy, 338–339 EMDR, 282 family therapy, 461–462 group psychotherapy, 424 humanistic–existential psychotherapy, 401–402 interpersonal psychotherapy, 364 psychodynamic psychotherapy, 257 trauma, 500

Certified Group Psychotherapist (CGP), 424 CGP. See Certified Group Psychotherapist (CGP) “change talk,” 586 Child Attachment Interview (CAI) Protocol, 164–165 child psychotherapy

assessment, 605–606 assumptions and principles, 599–603 case study, 614–616 evidence-based practice, 603–604 family-centered care approach, 601 general principles

combined approach, 612–613 common elements approach, 611–612 common factors model, 610–611 manualized approach, 609

635

historical background, 597–598 self-regulation, 600 training and certification, 598–599 treatment planning, 608

circle of strength, 298 circular causality, 444 classic stress response, 74 client-centered psychotherapy. See person-centered psychotherapy clinical assessment

beginning of, 98 ending of, 106 goals of, 95 sample form, 143–144

clinical procedural terminology (CPT) codes, 661–662 clinical rating scales, 122 clonazepam, 495 coalition, 440–441, 456 cognitive behavioral coping skills, 586 cognitive behavioral therapy (CBT)

applications to psychiatric disorders anxiety, 329–330 depression, 328–329 personality disorders, 330 substance misuse, 331 termination, 694–695

behavioral techniques assertiveness training, 322 behavioral rehearsal, 322 bibliotherapy, 324 contingency management, 322–323 guided relaxation and meditation, 324 homework assignments, 324–325 psychoeducation, 325 shame-attacking exercises, 324 social skills training, 324

case study case formulation and treatment plan, 334–335 course of therapy, 335–336 description, 331, 334 monitoring and feedback, 336–338 process and outcome, 338

cognitive techniques processing, 327–328 stabilization, 314–321

description, 313–314 evidence-based research, 314–315 modifications

dialectical behavior therapy, 326–327 schema therapy, 325–326

in older adults, 641, 643 Socratic dialogue, 314–317 stabilization strategies

body and energy work, 484–485 debriefing, 485 group therapy, 484 psychodynamic psychotherapy, 485

therapist website resources, 332–333 training and certification requirements, 338–339

cognitive dissonance theory, 299–300 cognitive distortions, 318 cognitive rehearsal, 320–321 cognitive restructuring, 321 cognitive techniques

processing, 327–328 stabilization, 483–485

advantages and disadvantages, 320 automatic thought record, 321 cognitive rehearsal, 320–321 cognitive restructuring, 321 decatastrophizing, 319–320 downward arrow, 316–317 examining options and alternatives, 319 idiosyncratic meaning, 317 labeling of distortions, 318 paradox/exaggeration, 320 questioning the evidence, 318–319 reattribution, 319

636

722

thought stopping, 321 turning adversity to advantage, 320

collaborative agreement, 560–561 collaborative split treatment, 548–549 collaborative treatment contract, 551–552 community reinforcement approach (CRA), 331 comorbidity, older adults, 637–638 complementary and alternative therapies, 587 complementary countertransference, 245 complementary identification, 196–197 complex posttraumatic syndrome, 475 complex reflection, 302 compliments, solution-focused therapy, 396 concordant identification, 196 conflict split, 391 container exercise, 52 contingency contract, 323 contingency management, 322–323 contract, 214–215 co-occurring disorders, 577–578 coping questions, 396 core negative beliefs, 85 corpus callosum and hemisphere, 72–73 corrective recapitulation, 412 cortisol, messenger molecule, 56 counseling and coordination of care (CCC), 676–677 counteradaptation, 573 countertransference, 195–198

chronic, 197 complementary, 245 concordant, 196 older adults, 639 psychopharmacotherapy, 535–536

CRA. See community reinforcement approach cross-cutting assessments, 127 cross-generational coalition, 440 cultural competency, 20 cultural relativity, 19 cybernetics, 444 cyclical psychodynamics, 16, 227

DBT. See dialectical behavior therapy debriefing, 485 decatastrophizing, 319–320 declarative memory, 60 defectiveness, negative beliefs of, 85 defense mechanisms, 61–62, 85 dementia, older adults, 635 depression

cognitive model, 328–329 interpersonal psychotherapy, 354–355 in older adults, 630, 632

depressive symptomatology, 334 DES. See Dissociative Experiences Scale devaluing patient, 697 diagnosis, 126–129 Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), 12, 19, 469, 569–570 dialectical behavior therapy (DBT)

assumptions, clients and treatment, 510–512 behavioral chain analysis worksheet, 515 borderline personality disorder, 87 case study, 522–526 characteristics of DBT therapists, 512 cognitive behavioral treatment, 326–327 functions of treatment, 510 individual therapy, 517 principles of practice, 512–513 skills modules, 516 skills training, 515–517 stages of treatment, 514–515 training, 526 trauma-focused therapy, 518–521

DID. See dissociative identity disorder differentiation of self, 435 dimensional assessments, 127 diseases and disorders of trauma, 477 disengaged family, 440, 456

637

723

disorders of extreme stress, 475–476 displacement, 252 dissociation, 76–77

assessment/outcome instruments, 479 client-reported signs, 471 observable signs, 472 practice guidelines, 483

dissociative disorders, 473–475 Dissociative Experiences Scale (DES), 146–149 dissociative identity disorder (DID), 474 dopamine, messenger molecule, 56 dreams, 252–254

condensation, 254 displacement, 254 secondary revision, 254 symbolic representation, 254

drug misuse, interpersonal psychotherapy, 358 DSM-5. See Diagnostic and Statistical Manual of Mental Disorders, fifth edition dual awareness, 492 dyadic states of consciousness, 63 dysfunctional multigenerational patterns, 438

eating disorders, interpersonal psychotherapy, 356–357 EFT. See emotion-focused therapy ego aliens, 245 ego dystonic, 245 ego functioning, 106–111 ego syntonic, 245 e-mails, therapeutic frame, 201–202 EMDR. See eye movement desensitization reprocessing (EMDR) therapy emotional connection, psychotherapy, 14 emotional cutoff, 436 emotional regulation, 82–83 emotionally focused family therapy

attachment, 448 description, 446–447 emotions, 83, 447–448 goals of, 448–449 psychotherapeutic interventions

assessment, 449 empathic attunement, 449 encouraging acceptance, 450 evocative questions, 450 images and metaphors, 450 intimate attachments, 450 reflective statements, 449–450

emotional-state-dependent memories, 60 emotion-focused therapy (EFT)

definition, 388 emotion schemes, 388–389 goals of, 390 memory, 389 psychotherapeutic interventions

assessment, 390 markers, 391–392

emotions, 82–86 definition, 388 instrumental, 389 primary, 389 primary adaptive, 389 primary maladaptive, 389 secondary, 389

empathic attunement, 449 empathic resonance, 189 empathy, 189–191 enactments, 442 endocrine, messenger molecule, 56 endorphin, messenger molecule, 56 engagement, motivational interviewing skills, 303 enmeshed family, 440, 456 Erikson’s psychosocial stages, 229–230 evaluation and management (E/M) codes

99212—established patient, 678–679 99213—established patient, 679–680 99214—established patient, 680–681 99215—established patient, 681–684 counseling and coordination of care, 676–677

638

5-digit, 665, 667 history, 668–670 language associated with, 667 medical decision making, 672, 675–676 psychiatric single-system exam, 671

evenly hovering attention, 246 evidence-based research

addictions cognitive behavioral coping skills, 586 complementary and alternative therapies, 587 contingency management, 585–586 critical goals, 584–585 integrated family therapy, 586–587 motivational interviewing, 586 relapse prevention, 586 therapeutic frame, 587–589

child psychotherapy, 603–604 cognitive behavioral therapy, 314–315 EMDR therapy, 262 group therapy, 416–417 humanistic–existential psychotherapy, 396–397 interpersonal psychotherapy

adolescent depression, 357 bipolar disorder, 358–359 borderline personality disorder, 359 depression, 354–355 drug misuse, 358 eating disorders, 356–357 perinatal depression, 355–356

motivational interviewing, 300–302 in older adults

cognitive behavioral therapy, 641, 643 interpersonal psychotherapy, 644–646 relaxation therapy, 643–644 reminiscence and life review, 645–648

psychodynamic psychotherapy, 231–233 stabilization, 483

evocation, 299 questions, 450

evoking, motivational interviewing skills, 303, 305 existential factors, group therapy, 414 existential psychotherapy

description, 384 existential themes, 385–386 goals of, 386 psychotherapeutic interventions, 386–387

existentialism, 370 experiential reflection, 387–388 explicit memory, 60 expressive psychotherapy, 242–245 extreme stress disorders, 475–476 eye movement desensitization and reprocessing (EMDR) therapy

circle of strength, 298 clinical applications, 267–268 description, 261–262 evidence-based research, 262 lightstream exercise, 297 mechanism of action, 262, 269 meta-analysis, 263–266 process trauma, 278–282 processing

AIP model, 271 general guidelines, 273–275 therapeutic window, 272–273 traumatic memories, 272

protocols for, 275–278 randomized clinical trials, 263–266 stabilization, 269–271 termination, 695 training and certification requirements, 282

false memories, 85 family therapy

assumptions, 432–433 case study, 431–432, 458–461 emotionally focused approach

attachment injuries, 448

639

724

attachment styles, 448 description, 446–447 emotions, 447–448 goals of, 448–449 psychotherapeutic interventions, 449–450

evidence-based research, 457–458 evolution of, 433–434 knowledge importance, 429–431 practical guidelines

beginning session, 451–453 conceptualizing problem, 455 conducting assessment, 453–455 diagnosing problem, 455 facilitating change, 455–457 forming relationship, 450–451

strategic approach circular causality, 444 cybernetics, 444 description, 443–444 feedback loops, 444 first-order changes, 444 goals of, 444–445 homeostasis, 444 psychotherapeutic interventions, 445–446 second-order changes, 444

structural approach boundaries, 440 coalition, 440–441 disengaged family, 440 enmeshed family, 440 family structure, 439–440 goals of, 441 parentification, 441 psychotherapeutic interventions, 441–443 subsystems, 440

systemic approach differentiation of self, 435 emotional cutoff, 436 family projection process, 436 goals of, 437 multigenerational transmission process, 436 nuclear family emotional system, 436 psychotherapeutic interventions, 437–439 sibling position, 436 triangles, 435–436

training and certification requirements, 461–462 family-centered care approach, 601 feedback loops, 444 feeling-state addiction therapy (FSAT), 583–584 feeling-state addiction protocol (FSAP), 585 feeling-state therapy (FST), 583 fees, 179–182, 200–201 flashbacks, 472, 494 focusing, motivational interviewing skills, 303 Fraser table technique, 31, 496–497 Freud’s psychosexual stages, 228 frontal lobe, 70 FSAP. See FSAT. See feeling-state addiction protocol FSAT. See feeling-state addiction therapy functional status, assessment, 121 future-oriented questions, 395

GABA. See gamma-aminobutyric acid GAD-7. See Generalized Anxiety Disorder Questionnaire GAF. See Global Assessment of Functioning gamma-aminobutyric acid (GABA), 56 GDS. See Geriatric Depression Scale Generalized Anxiety Disorder Questionnaire (GAD-7), 157 genogram, 123–124, 438 Geriatric Depression Scale (GDS) (Short Form), 152 geropsychiatric nursing (GPN), 626–627 Gestalt psychotherapy

boundary disturbances (interruptions), 379 description, 377–378 figure and ground, 379 goals of, 380 layers of personality, 379–380

640

725

organismic self-regulation, 378–379 psychotherapeutic interventions

assessment, 380 creative experimentation, 381–384 I–Thou relationship, 381

Global Assessment of Functioning (GAF), 121 glutamate, messenger molecule, 56 GPN. See geropsychiatric nursing group cohesiveness, 413 group psychotherapy

benefits of, 414–416 case study, 422–424 evidence-based research, 416–417 formation/development of, 417–420 history, 407–409 stabilization, 484 theoretical approaches and focus, 410–411 therapeutic factors, 409, 412–414 training and certification requirements, 424 treatment and practice, 420–422 types of groups, 414

Hamilton Anxiety Rating Scale (HAM-A), 156 healing, 11 hippocampus, 68–69 holding environment, 229 holistic model, 11–12, 703–705 holistic outcomes, 703–705 homeostasis, 444 homework assignments

behavioral technique, 324–325 solution-focused therapy, 396

5HT. See serotonin humanistic–existential psychotherapy

beliefs about clients, 373–374 case study, 398–400 characteristics

belief in holism, 372 emphasis on themes, 372–373 experiential techniques, 373 focus, 372 phenomenological perspective, 371 prominence of process, 373 therapist–client relationship, 371–372

evidence-based research, 396–397 historical roots, 370 nursing and, 369–370 training and certification requirements, 401–402

hypothalamus, 70

IBCGP. See International Board for Certification of Group Psychotherapists identity diffusion, 110 IES. See Impact of Event Scale imitative behavior, 413 immature defenses, 61–62 immediacy, 194, 251 immune messenger molecules, 56 Impact of Event Scale (IES), 150 implicit memory, 60 insomnia, 495 instillation of hope, group psychotherapy, 412 instrumental emotions, 389 insula, 72 integrated family therapy, addictions, 586–587 integrated psychopharmacologic and psychotherapy treatment

medication treatment, 537 orientation phase, 538–541 pitfalls of, 546 practice guidelines, 545–546 termination phase, 543–545 working phase, 542–543

interactive dialogue, 353 International Board for Certification of Group Psychotherapists (IBCGP), 424 International Society of Study for Dissociative Disorders (ISSD), 173 interpersonal counseling (IPC), 359 interpersonal learning, 413 interpersonal psychotherapy (IPT)

641

case study, 361–364 evidence-based applications

adolescent depression, 357 bipolar disorder, 358–359 borderline personality disorder, 359 depression, 354–355 drug misuse, 358 eating disorders, 356–357 interpersonal counseling, 359 perinatal depression, 355–356

foundational concepts, 347–348 goals, 360–361 nursing theory, 348–349 in older adults, 644–646 principles and guidelines, 351–354 vs. psychodynamic psychotherapy, 350–351 role of therapist, 352–353 strategies, 360–361 termination, 695 therapeutic alliance, 353–354 training and certification requirements, 364 underlying assumptions, 350

interpersonal relationships, 113–118 interpersonal styles, 115 interruptions, 379 intersubjectivity, 230 invariant prescription, strategic family therapy, 446 Inventory of Psychosocial Functioning (IPF), 121 IPC. See interpersonal counseling IPF. See Inventory of Psychosocial Functioning IPT. See interpersonal psychotherapy ISSD. See International Society of Study for Dissociative Disorders I–Thou relationship, 381

joining questions, 393–394

kindling, 76 Kohut, Heinz, 230–231

life review, in older adults, 645–648 lightstream exercise, 297 limbic resonance, 82 listening, therapeutic communication, 184–189 locus ceruleus, 68 long-term potentiation, 58

Mahler’s stages of separation–individuation, 229 maladaptive schemas, 326 manualized therapy, 232 Maslow’s hierarchy of needs, 18–19 mature defenses, 62 MDM. See medical decision making medical decision making (MDM), 672, 675–676 memory

attachment, 63–66 consolidation, 389, 573 defense mechanisms, 60–63 motor, 60 reconsolidation, 389, 573

mental health, and culture, 18–21 mental illness, 21–25 mental status examination (MSE), 102–105 messenger molecules, 56 meta-analysis

EMDR therapy, 263–266 motivational interviewing, 301 psychodynamic psychotherapy, 234

Michigan Alcohol Screening Test (MAST)–Revised, 163 mindfulness

definition, 248 psychotherapy, 9 in stabilization, 489–492

miracle questions, 395 mirror neurons, 65, 189 motivational interviewing

addictions, 586 case studies, 306–309

642

726

complex reflection, 302 evidence-based research, 300–302 guiding principles, 299–300 history, 300 meta-analysis, 301 modifications, 305 phases of change process

engagement, 303 evoking, 303, 305 focusing, 303 planning, 305

simple reflection, 302 training, 309–310

motor memories, 60 MSE. See mental status examination multigenerational transmission process, 436 multiple selves, 231

narcissistic defenses, 61 narcissistic transference, 230 narrative, 237–238 narrative elements, psychotherapy, 14–15 NE. See norepinephrine negative reinforcers, 322–323 negative therapeutic reaction, 251 neural networks, restructuring, 77–82

alexithymia, 86–87 emotions, 82–86

neuropeptides, 83 neurophysiology

responses to trauma, 73–77 trauma and psychotherapy

AIP model, 54–55 brain development, 55–59 brain structures, 67–73 memory, 59–66 restructuring neural networks, 77–82

neuroplasticity, 57 neuropsychosocial and psychopharmacotherapy assessment, 532 neurotic defenses, 62 nondirective–facilitative counseling, 376–377 norepinephrine (NE), 56 Notice of Privacy Practices, 211–213 nuclear family emotional system, 436, 438 nurse psychotherapists

cultural competency, 20 history, 7 holistic paradigm of healing, 11–13 learning stages, 6 psychiatry codes, 663 psychotherapy elements

and anxiety management, 15–18 caring, 13–14 connection, 14 narrative, 14–15

qualities of, 6–8 requisites for, 8–11

nurse–patient relationship, 9 nursing

geropsychiatric, 626–627 humanistic–existential psychotherapy, 369–370 pediatric bipolar disorder, 606–607 psychopharmacotherapy, 534–535 theory in interpersonal psychotherapy, 348–349

object constancy, 245 observer-rated ego function assessment tool, 108–109 observing ego, 14 occipital lobe, 70 older adults

assumptions and principles, 627 case study, 649 evidence-based research

cognitive behavioral therapy, 641, 643 interpersonal psychotherapy, 644–646 relaxation therapy, 643–644 reminiscence and life review, 645–648

643

727

general guidelines collaboration, 638 comorbidity, 637–638 complementary and alternative medicine therapies, 640 countertransference, 639 practical issues, 639 termination, 639 transference, 638–639

in geropsychiatric nursing, 626–627 late adulthood development

cohort effects, 629 functional status, 628 social support and family issues, 629 societal issues, 629–630 strengths, resilience, and wisdom, 628

person-centered care, 574–577 psychiatric disorders

anxiety disorder, 633–634 bipolar disorder, 632–633 dementia, 635–636 depression, 630, 632 schizophrenia, 634–635 treatment options, 642

suicide risks, assessment, and intervention, 636 OMPFC. See orbital medial prefrontal cortex orbital medial prefrontal cortex (OMPFC), 71 ordeals, strategic family therapy, 446 organismic self-regulation, 378–379 outcome evaluation, 702–705 overconsolidation of traumatic memories, 76 overdeterminism, 9 oxytocin, messenger molecule, 56

paradoxical interventions, 205–207 paradoxical technique, strategic family therapy, 445 parallel split treatment, 548–549 parentification, 441 Patient Health Questionnaire-9 (PHQ-9), 153 patient-identified problem, 98–99 pediatric bipolar disorder, 606–607 perinatal depression, interpersonal psychotherapy, 355–356 personality disorders, cognitive model, 330 person-centered care, addictions, 575–577 person-centered psychotherapy

actualizing tendency, 375 belief of human nature, 375 description, 374–375 fully functioning person, 375 goals of, 375–376 psychotherapeutic interventions

assessment, 376 nondirective–facilitative counseling, 376–377 personality growth, 377

self-concept, 375 PHQ-9. See Patient Health Questionnaire-9 physiologic arousal, 492–494 planning, motivational interviewing skills, 305 postmodernism, 392 posttraumatic stress disorder (PTSD), 477–478 practice guidelines, 484, 700–702 prefrontal cortex, 70 presence, existential psychotherapy, 387 pre-session change questions, 393 pretend techniques, strategic family therapy, 445–446 primary adaptive emotions, 389 primary emotions, 389 primary maladaptive emotions, 389 primary maternal preoccupation, 229 primitive defenses, 61 problematic reactions, emotion-focused therapy marker, 391 process note, 183 process recording

criteria for evaluation, 219–220 directions, 218–219 purpose, 218

processing technique case management, 50

644

cognitive techniques, 327–328 EMDR therapy

AIP model, 271 general guidelines, 273–275 therapeutic window, 272–273 traumatic memories, 272

treatment hierarchy framework, 29–30 progress note, 217 progressive muscle relaxation, 506–507 projective identification, 244–245 psychiatric database, comprehensive outlines, 137–142 psychiatric disorders

CBT applications anxiety, 329–330 depression, 328–329 personality disorders, 330 substance misuse, 331

older adults anxiety disorder, 633–634 bipolar disorder, 632–633 dementia, 635 depression, 630, 632 schizophrenia, 634–635 treatment options, 642

practice guidelines, 235 psychiatry codes

add-on codes, 664–665 CPT codes, 661–662 eliminated, added, and did not change codes, 663–664 new way of coding, 662–663 timelines and process, 662

psychic determinism, 249 psychoanalytic psychotherapy, 245–246 psychodynamic continuum, 233, 236–238 psychodynamic psychotherapy

alliance ruptures repairing, 250–251 assumptions, 226–227 brief, 254–257 and case formulation, 246–248 Erikson’s psychosocial stages, 229–231 evidence-based research, 231–233 expressive psychotherapy, 242–245 Freud’s psychosexual stages, 227–228 vs. interpersonal psychotherapy, 350–351 Mahler’s stages of separation–individuation, 229 meta-analytic studies of, 234 psychoanalytic psychotherapy, 245–246 vs. relational psychodynamic therapy, 232 stabilization, 485–486 supportive psychotherapy, 238–242 termination, 696 training and certification requirements, 257 working with dreams, 251–254 working-through process, 248–250

psychoeducation behavioral technique, 325 group therapy, 414 stabilization, 497–498

psychopharmacotherapy case study, 555–556 competencies and prescribing principles, 532–534 consultation and collaboration request form, 551, 562–563 history and scope of practice, 529–532 neurosychosocial assessment, 532 principles of, 533 single-provider integrated treatment

medication treatment, 537 orientation phase, 538–541 pitfalls of, 546 practice guidelines, 545–546 termination phase, 543–545 working phase, 542–543

split treatment APPN practice status, 550 boundaries of, 553–554 characteristics of, 549–550 collaborative vs. parallel, 548–549

645

728

history of, 547–548 integrated model for, 555 pharmacotherapist, skills of, 550–551 psychological and relational aspects, 554 shared communication of, 552–553 tools of, 551–552

therapeutic relationship, 534–536 psychosomatic disorders, 476–477 psychotherapy

adverse life experiences, 22–25 child, 597–616 cognitive behavioral therapy, 313–339 elements of, 13–14, 15–18 EMDR therapy, 261–283 family therapy, 429–462 group therapy, 407–425 humanistic–existential therapy, 369–392, 396–401 interpersonal, 347–365 mental health and culture, 18–21 mental illness and, 21–25 mindfulness, 9 motivational interviewing, 299–310 with older adults, 625–650 outcome evaluation, 702–705 paradoxical interventions, 205–207 process note, 216 process recording, 218–220 progress note, 217 psychodynamic, 225–258 psychopharmacotherapy and, 529–557 solution-focused therapy, 392–396 treatment hierarchy framework

AIP model, 25–27 case study, 30–31 processing strategies, 29–30 stabilization strategies, 27–29

working with resistance, 202–205 PTSD. See posttraumatic stress disorder

QOL. See Quality-of-Life Scale Quality-of-Life Scale (QOL), 160–161

rational emotive therapy (RET), 324 reactance theory, 300 reattribution, 319 records, 183 reflection, empathic validation, 190 reflective statements, 449–450 relapse prevention, addictions, 586 relational psychodynamic therapy, 232 relaxation therapy, in older adults, 643–644 reminiscence, 645–648 repairing alliance ruptures, 250–251 resilience, 12–13 resistance, psychotherapeutic process, 202–205 resources, 494–495 restructuring neural networks, 77–87 RET. See rational emotive therapy (RET) rituals, strategic family therapy, 446

safe-place exercise, 51 safety

assessment, in therapeutic alliance, 172–175 therapeutic relationship, 488–489

sample case formulation, 129–130 sample termination letter, 221 scaling questions, 395 schema therapy, 325–326 schism coalition, 440 schizophrenia, in older adults, 634–635 screening tools, assessment, 125–126 SD. See Socratic dialogue secondary emotions, 389 secondary gain, 207 secondary revision, 252 self-actualization, qualities of, 19 self-awareness, 9–10

646

729

self-care, 10 self-concept, 375 self-disclosure, 199–200 self-help groups, 414 self-interruptive split, 391 self-regulation, child psychotherapy, 600 semantic memory, 60 sensitization, 573 sequential acquisition, 55, 57 serotonin (5HT), messenger molecule, 56 SFT. See solution-focused therapy shame-attacking exercises, 324 shared attunement, 63 Short PTSD Rating Interview (SPRINT), 505 simple reflection, 302 single-provider integrated treatment

medication treatment, 537 orientation phase, 538–541 pitfalls of, 546 practice guidelines, 545–546 termination phase, 543–545 working phase, 542–543

skewed coalition, 441 sleep hygiene, 494–496 social constructionism, 392–393 social skills training, 324 socializing techniques, group psychotherapy, 413 Socratic dialogue (SD), 314–317 solution-focused therapy (SFT)

goals of, 394 postmodernism, 392 psychotherapeutic interventions

assessment, 394 compliments, 396 coping questions, 396 exception questions, 395 future-oriented questions, 395 homework assignments, 396 joining questions, 394–395 miracle questions, 395 pre-session change questions, 394 scaling questions, 395 subsequent sessions, 396

social constructionism, 392–393 solution talk, 393–394

somatic symptoms and related disorders, 476 split treatment

APPN practice status, 550 boundaries of, 553–554 characteristics of, 549–550 collaborative vs. parallel, 548–549 hierarchy/mutuality among therapist, 554–555 history of, 547–548 integrated model for, 555 pharmacotherapist, skills of, 550–551 psychological and relational aspects, 554 selection of, 549 shared communication of, 552–553 timing of, 552 tools of, 551–552

SPRINT. See Short PTSD Rating Interview stabilization

case management, 49 case study, 499–500 cognitive behavioral strategies

body and energy work, 484–485 debriefing, 485 group therapy, 484 psychodynamic psychotherapy, 485

cognitive techniques advantages and disadvantages, 320 automatic thought record, 321 cognitive rehearsal, 320–321 cognitive restructuring, 321 decatastrophizing, 319–320 downward arrow, 316–317 examining options and alternatives, 319

647

idiosyncratic meaning, 317 labeling of distortions, 318 paradox/exaggeration, 320 questioning the evidence, 318–319 reattribution, 319 strategies, 27 thought stopping, 321 turning adversity to advantage, 320

EMDR therapy, 269–271 evidence-based interventions, 483 flashbacks, 494 framework for treatment, 485–486 Fraser table technique, 496–497 goals of treatment

assessment, 479–482 timeline construction, 482

mindfulness, 489–492 physiologic arousal, 492–494 psychoeducation, 497–498 safety issues, 486–489 sleep hygiene and medication, 494–496 stages of learning, 7 traumatic stress responses

acute stress disorder, 477 dissociative disorders, 473–475 extreme stress disorders, 475–476 posttraumatic stress disorder, 477–478 practice guidelines, 483 psychosomatic disorders, 476–477 somatic symptoms and related disorders, 476 spectrum of, 470–471 structural dissociation theory, 473

treatment hierarchy framework, 27–29 state-dependent learning, 59, 247 strategic family therapy

circular causality, 444 cybernetics, 444 description, 443–444 feedback loops, 444 first-order changes, 444 goals of, 444–445 homeostasis, 444 psychotherapeutic interventions

assessment, 445 invariant prescription, 446 ordeals, 446 paradoxical technique, 445 pretend techniques, 445–446 rituals, 446

second-order changes, 444 stress diathesis model, 21 stress response components, 75 structural dissociation theory, 473 structural family therapy

boundaries, 440 coalition, 440–441 disengaged family, 440 enmeshed family, 440 family structure, 439–440 goals of, 441 parentification, 441 psychotherapeutic interventions

assessment, 441 enactments, 442 problematic interactions, 442–443 structural mapping, 442

subsystems, 440 structural mapping, 442 substance misuse, cognitive model, 331 support groups, group therapy, 414 supportive psychotherapy, 238–242 symbolic representation, 252 systemic family therapy

differentiation of self, 435 emotional cutoff, 436 family projection process, 436 goals of, 437

648

730

multigenerational transmission process, 436 nuclear family emotional system, 436 psychotherapeutic interventions

anxiety and interrupt conflict, 438 assessment, 437 detriangulate, 438–439 dysfunctional multigenerational patterns, 438 nuclear family emotional process, 439 repair cutoffs, 439 self-statements, 438

sibling position, 436 triangles, 435–436

telephone calls, therapeutic frame, 201–202 telepsychiatry, 180 temporal lobe, 70 termination

case study, 705–709 cognitive behavioral therapy, 694–695 EMDR therapy, 695 intermittent psychotherapy, 696 interpersonal psychotherapy, 695 older adults, 639 practice guidelines, 700–702 psychodynamic, 694, 696 reasons for, 694 sample letter, 221 therapist initiation, 699–700

thalamus, 67–68 therapeutic alliance, 82, 84

elements of, 170 first contact, 175–178

ending session, 182 fees, 179, 181–182 goal establishment, 182 practical arrangements, 178–179 records management, 182–183

interpersonal psychotherapy, 353–354 ongoing process, 170–171 relationship-building skills, 172 safety assessment, 172–175 strategies, 171

therapeutic communication attending, 184–189 description, 183–184 empathy, 189–191 exploration, 191–195 listening, 184–189 techniques, 185 treatment hierarchy and continuum, 185

focusing, 193 immediacy, 194 interpretation, 194–195 observation, 193 reflection, 190

therapeutic frame addictions, 587–589 boundaries, 195 cancellations, 200–201 countertransference, 195–198 e-mails, 201–202 fees, 200–201 lateness, 200–201 self-disclosure, 199–200 telephone calls, 201–202

therapeutic relationship existential psychotherapy, 387 psychopharmacotherapy

countertransference, 535–536 nursing, 534–535 prescribing medications, 536 transference, 535

safety issues, 488–489 therapeutic strategies, alliance repair, 205 therapeutic use of self, 196 thought stopping, 321 training

addictions, 590–591

649

731

child psychotherapy, 598–599 cognitive behavioral therapy, 338–339 dialectical behavior therapy, 526 EMDR, 282 family therapy, 461–462 group psychotherapy, 424 humanistic–existential psychotherapy, 401–402 interpersonal psychotherapy, 364 motivational interviewing, 309–310 psychodynamic psychotherapy, 257 trauma, 500

transference definition, 186 narcissistic, 230 neurosis, 246 older adults, 638–639 psychopharmacotherapy, 535

transference cure, 250 trauma

AIP model, 54–55 brain development, 55–59 brain structures

dialectical behavior therapy assumptions, clients and treatment, 510–512 behavioral chain analysis worksheet, 515 case study, 522–526 characteristics of therapists, 512 elements, 510 focused therapy, 518–521 functions of treatment, 510 individual therapy, 517 principles of practice, 512–513 skills modules, 516 skills training, 515–517 stages of treatment, 514–515 training, 526

memory attachment, 63–66 defense mechanisms, 60–63

and mental illness, 24–25 neural networks, restructuring, 81–82

alexithymia, 86–87 emotions, 82–86

neurophysiological responses, 73–77 stress responses

acute stress disorder, 477 dissociative disorder, 473–475 extreme stress disorder, 475–476 posttraumatic stress disorder, 477–478 practice guidelines, 483 psychosomatic disorder, 476–477 somatic symptoms and related disorders, 476 spectrum of, 470–471 structural dissociation theory, 473

training and certification requirements, 500 trauma narrative, 392 trauma response, 470 trauma-informed care, 578–579 traumatic memories, 72 traumatic transference, 488 two-person psychology, 230

undifferentiated ego mass, 435 unfinished business, emotion-focused therapy marker, 391–392 universality, 412

650

vasopressin, messenger molecule, 56 vicarious or secondary traumatization, 10 vulnerability, 392

window of arousal, 17, 65, 233, 493 working-through process, 248–250

Yale-Brown Obsessive–Compulsive Scale (Y-BOCS), 158–159 Y-BOCS. See Yale-Brown Obsessive–Compulsive Scale YMRS. See Young Mania Rating Scale Young Mania Rating Scale (YMRS), 154–155

ZSRDS. See Zung Self-Rating Depression Scale Zung Self-Rating Depression Scale (ZSRDS), 151

651

Contributors
Foreword
Foreword
Preface
Acknowledgments
Part I. Getting Started

1. The Nurse Psychotherapist and a Framework for Practice
2. The Neurophysiology of Trauma and Psychotherapy
3. Assessment and Diagnosis
4. The Initial Contact and Maintaining the Frame

Part II. Psychotherapy Approaches

5. Supportive and Psychodynamic Psychotherapy
6. Eye Movement Desensitization and Reprocessing Therapy
7. Motivational Interviewing
8. Cognitive Behavioral Therapy
9. Interpersonal Psychotherapy
10. Humanistic–Existential and Solution-Focused Approaches to Psychotherapy
11. Group Therapy
12. Family Therapy

Part III. Psychotherapy With Special Populations

13. Stabilization for Trauma and Dissociation
14. Dialectical Behavior Therapy for Complex Trauma
15. Psychopharmacotherapy and Psychotherapy
16. Psychotherapeutic Approaches for Addictions and Related Disorders
17. Psychotherapy With Children
18. Psychotherapy With Older Adults

Part IV. Documentation, Evaluation, and Termination

19. Reimbursement and Documentation
20. Termination and Outcome Evaluation

Afterword
Index