iPsychotherapy for the Advanced Practice Psychiatric Nurse

iPsychotherapy for the Advanced Practice Psychiatric Nurse

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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.

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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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ivCopyright © 2014 Springer Publishing Company, LLC

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The author and the publisher of this Work have made every effort to use sources believed to be reliable to provide information that is accurate and compatible with the standards generally accepted at the time of publication. Because medical science is continually advancing, our knowledge base continues to expand. Therefore, as new information becomes available, changes in procedures become necessary. We recommend that the reader always consult current research, specific institutional policies, and current formularies or drug guides before performing any clinical procedure or prescribing or administering any drug(s). The author and publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance on, the information contained in this book. The publisher has no responsibility for the persistence or accuracy of URLs for external or third-party Internet Web sites referred to in this publication and does not guarantee that any content on such Web sites is, or will remain, accurate or appropriate.

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.

p. ; cm. Includes bibliographical references and index. ISBN 978-0-8261-1000-8—ISBN 978-0-8261-1008-4 (e-book)

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

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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

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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,

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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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.

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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

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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

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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.

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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

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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

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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.