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,
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
