Psychotherapy for the Advanced Practice Psychiatric Nurse

iPsychotherapy for the Advanced Practice Psychiatric Nurse



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


iiiPsychotherapy for the Advanced Practice Psychiatric Nurse

A How-To Guide for Evidence-Based Practice

Second Edition



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

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





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

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

Kathleen Wheeler 2. The Neurophysiology of Trauma and Psychotherapy

Kathleen Wheeler 3. Assessment and Diagnosis

Pamela Bjorklund 4. The Initial Contact and Maintaining the Frame

Kathleen Wheeler

Part II. Psychotherapy Approaches 5. Supportive and Psychodynamic Psychotherapy

Kathleen Wheeler 6. Eye Movement Desensitization and Reprocessing Therapy

Kathleen Wheeler 7. Motivational Interviewing

Edna Hamera 8. Cognitive Behavioral Therapy

Sharon M. Freeman Clevenger 9. Interpersonal Psychotherapy

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

Candice Knight 11. Group Therapy

Richard Pessagno 12. Family Therapy

Candice Knight

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

Kathleen Wheeler 14. Dialectical Behavior Therapy for Complex Trauma

Barbara J. Limandri


15. Psychopharmacotherapy and Psychotherapy Lisabeth Johnston

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

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

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

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

Mary Moller 20. Termination and Outcome Evaluation

Kathleen Wheeler

Afterword Index





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

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

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

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

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

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

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

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

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

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

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

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

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


New Jersey

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

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

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

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







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!






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 W

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