The Nurse Psychotherapist and a Framework for Practice KATHLEEN WHEELER

The Nurse Psychotherapist and a Framework for Practice KATHLEEN WHEELER This chapter begins with the historical context of the nurse’s role as psychotherapist and the resources and challenges inherent in nursing for the development of requisite psychotherapy skills. Using a holistic paradigm, 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,