Midterm Exam: NR605/ NR 605 (Latest Update 2024/ 2025) Diagnosis & Management in Psychiatric-Mental Health across the Lifespan I Practicum Review |Weeks 1-4 Covered| Questions and Verified Answers| 100% Correct- Chamberlain

Midterm Exam: NR605/ NR 605 (Latest
Update 2024/ 2025) Diagnosis &
Management in Psychiatric-Mental Health
across the Lifespan I Practicum Review
|Weeks 1-4 Covered| Questions and Verified
Answers| 100% Correct- Chamberlain
Q: Treatment Hierarchy Framework
Answer:
therapeutic aims at the base of the model must be addressed before the client can move up the
triangle
Top: Stabilization
Internal resources
External resources
Bottom: Foundational needs
Q: strategies to support resource development and stabilization:
Answer:
-case management
-provision of safety
-stress management
-management of physiological arousal
-exercise
-cognitive or dialectical behavioral therapy
-role play
Q: Processing
Answer:

involves helping clients explore the meaning of adverse life events
-adapting memory, cognition, behavior, affect, and beliefs surrounding traumatic events

achieve positive change
Q: Cultural Considerations
Answer:
Culture shapes one’s perceptions, attributions, emotions, and judgments in ways that are both
conscious and unconscious
-PMHNP must consider ethnicity, religion, race, class, cultural identity, and the cultural
explanations of illness to effectively diagnose and treat mental health conditions
-Outline for Cultural Formulation includes an assessment of the following categories:
cultural identity of the individual
cultural conceptualizations of distress
psychosocial stressors and cultural features of vulnerability and resilience
cultural features of the relationship between the individual and clinician
overall cultural assessment
Q: Illness Perception
Answer:
psychodynamic approach
-attributes mental illness to environmental and psychosocial problems
biophysiological model
-attributes mental illnesses to chemical imbalances of neurotransmitters
Q: epigenetics
Answer:
the study of how the environment and other factors change the way genes are expressed
Q: Documentation requirements

Answer:
-standard format of chief complaint, history of present illness, review of systems, past psychiatric
history, mental status exam, diagnostic formulation, and treatment plan
-Psychotherapy sessions must include the following:

target symptoms
goals of therapy
method of monitoring outcomes
frequency of treatment
clinical records to support relevant medical history
results of diagnostic tests or
procedures
prognosis or progress to date
estimated duration of treatment
Q: Reimbursement
Answer:
Clinical procedural terminology (CPT) codes
-standardized codes used to communicate services completed to Medicare and other insurance
companies for reimbursement
-PMHNPs can bill for stand-alone psychotherapy using psychiatry specialty codes
if the encounter includes diagnosing and/or prescribing medications, a medical evaluation and
management (E/M) base code should be used with an add-on psychotherapy procedure code
Q: Medical Evaluation and Management Codes
Answer:
specific five-digit E/M code
-based on the type of client, location of service, and level of service
XX=20 new client office/inpatient visit
XX=21 established client office/outpatient visit
XX=24 consultation for office/outpatient
XX=22 inpatient care
Q: Medical Decision Making

Answer:
level of medical-decision-making (MDM) is rated as straightforward, low, moderate, or high
-based on three components:

number of diagnoses
amount of data being reviewed
risk of mortality/morbidity
-The level of MDM is selected based on complexity
Q: Psychotherapy Codes
Answer:
90832- psychotherapy duration 16-37 minutes
90833- psychotherapy duration 16-37 minutes used as an add on code to a E/M code
90834- psychotherapy 38-52 minutes
90836- psychotherapy duration 38 or more minutes used as an add on code to a E/M code
90837- psychotherapy 53 or more minutes
90846- family psychotherapy client not present
90847- family psychotherapy with client present
90853- group psychotherapy
Q: Lori, a 42-year-old female, presents to the office for an initial consultation. She has just
experienced a breakup after a 5-year relationship and is feeling “depressed.” A comprehensive
initial evaluation which includes chief complaint, history or present illness, medical history,
previous psychiatric history, family history and a comprehensive review of systems was
completed. Psychotherapy was included in the session – 18 minutes time.
provide the appropriate CPT code
Answer:
99205+90833
Rationale: The client is new to the practice (20) and presents with one problem which addressed
4 or more elements, had a comprehensive history and interview. No additional testing was
needed, treatment was initiated (05). Psychotherapy was included in the session- 18 minutes
time. Therapy goals were established and reviewed with the client.
Powered by https://learnexams.com/search/study?query=

Psychotherapy
-nonpharmacological intervention
-used to tx mental health diagnoses or distress
-help clients improve functioning and well-being
-talk therapy
-provided by psychiatrists, psychologists, social workers, marriage and family therapists, counselors, and PMHNPs
-may include individual, couple, family, or group sessions
-Goals: symptom reduction, improvement in functioning, relapse prevention, empowerment, achievement of collaborative goals set by the client & therapist.

Methods of Collaboration
Intraprofessional Collaboration
-the interaction and efforts between two disciplines with the same profession

Potential barriers: tension, large team size, high turnover, lack of familiarity and common goals, role ambiguity, generational differences, and lack of undergraduate nursing education on intraprofessional practice.

Transprofessional Collaboration
-includes communication with various disciplines: physicians, physical/occupational therapy, and social services, along with others to ensure care is delivered safely

Potential barrier: lack of training

Role of PMHNPs in Psychotherapy
-unique, full-spectrum approach
-may provide psychotherapy in addition to prescribing medications
-providing client and family education
-coordinating care and referrals as a part of the treatment plan
-provide psychotherapy in a variety of ambulatory, emergency department, inpatient, and outpatient settings

Holistic Paradigm of Healing
-holistic model of care with a focus on healing
-Holistic therapy respects the complexity of each unique individual

appreciating the relationship between the client’s mind, body, and spirit
recognizing the interdependence of all parts of the human system
-Foundational to healing is the relationship between the client and therapist
Emotional connection in the relationship is critical to the success of psychotherapy
PMHNP approaches the nurse-client relationship with acceptance, empathy, patience, and kindness to create a space for healing
-psychotherapy can help the individual accept dysregulation and disharmony in the present moment
achieves acceptance of the present, they may be able to let go of resistance, relax, and release fears

Theoretical Models in Psychotherapy
Maslow’s Hierarchy of Needs
Health Belief Model
Transtheoretical Model of Change

Maslow’s Hierarchy of Needs
framework for understanding client motivation
-first four levels of need in the hierarchy (physiological needs, safety, love and belonging, and esteem) are sometimes referred to as deficiency needs (D-needs)

Motivation decreases once D-needs are met
-highest level of need, self-actualization, is considered a growth or being need (B-need)
Once D-needs are met, clients can focus on self-actualization and personal growth
As the B-need is met, motivation for further growth increases

self-actualized person
is self-fulfilled
-Qualities exhibited by the self-actualized person include independence, autonomy, creativity, and maturity

Maslow’s Hierarchy of Needs Pyramid
TOP: Self-actualization
-Morality, creativity, spontaneity, lack of prejudice, acceptance of facts

Esteem
-Self-esteem, respect, achievement, confidence

Love/Belonging
-Friendship, family, intimacy, sense of connection with others

Safety
-Security of body, of employment, of resources, of morality, of the family, and of health, of property

Bottom: Physiological
-Air, food, water, shelter, clothing, sleep

Health Belief Model
-used to explain and predict health behaviors
-a person’s belief about a perceived threat of illness combined with belief in the effectiveness of the recommended action predict the person’s willingness to change
-constructs:

perceived seriousness
perceived susceptibility
perceived benefits of treatment
perceived barriers to treatment
cues to action
self-efficacy

Transtheoretical Model of Change
assumes that behavior changes take place over time and that people move through stages of decision-making to make changes to behavior
-stages:

precontemplation
contemplation
preparation
action
maintenance

Nancy is a 64-year-old who is wondering if losing weight might benefit her self-esteem and self-confidence. Based on the transtheoretical model of change, which of the following actions by the PMHNP would be appropriate for Nancy if she is in the contemplation stage of change?

Ask Nancy to create a list of reasons that she wants to lose weight.

Refer Nancy to her primary provider to obtain medical clearance for an exercise program.

Explore Nancy’s anxiety and emotional responses related to be
Ask Nancy to create a list of reasons that she wants to lose weight.

Rationale: Creating a list of reasons to lose weight would be appropriate for the contemplation phase. Obtaining medical clearance for exercise is a part of the preparation phase of the Transtheoretical Model of Change. Exploring emotional responses to being overweight would be appropriate for the precontemplation phase. Addressing rewards for reinforcement of behaviors would occur in the action phase.

Treatment Hierarchy Framework
therapeutic aims at the base of the model must be addressed before the client can move up the triangle

Top: Stabilization
Internal resources
External resources
Bottom: Foundational needs

strategies to support resource development and stabilization:
-case management
-provision of safety
-stress management
-management of physiological arousal
-exercise
-cognitive or dialectical behavioral therapy
-role play

Processing
involves helping clients explore the meaning of adverse life events
-adapting memory, cognition, behavior, affect, and beliefs surrounding traumatic events

achieve positive change

Cultural Considerations
Culture shapes one’s perceptions, attributions, emotions, and judgments in ways that are both conscious and unconscious
-PMHNP must consider ethnicity, religion, race, class, cultural identity, and the cultural explanations of illness to effectively diagnose and treat mental health conditions
-Outline for Cultural Formulation includes an assessment of the following categories:

cultural identity of the individual
cultural conceptualizations of distress
psychosocial stressors and cultural features of vulnerability and resilience
cultural features of the relationship between the individual and clinician
overall cultural assessment

Illness Perception
psychodynamic approach
-attributes mental illness to environmental and psychosocial problems

biophysiological model
-attributes mental illnesses to chemical imbalances of neurotransmitters

epigenetics
the study of how the environment and other factors change the way genes are expressed

Documentation requirements
-standard format of chief complaint, history of present illness, review of systems, past psychiatric history, mental status exam, diagnostic formulation, and treatment plan
-Psychotherapy sessions must include the following:

target symptoms
goals of therapy
method of monitoring outcomes
frequency of treatment
clinical records to support relevant medical history
results of diagnostic tests or
procedures
prognosis or progress to date
estimated duration of treatment

Reimbursement
Clinical procedural terminology (CPT) codes
-standardized codes used to communicate services completed to Medicare and other insurance companies for reimbursement
-PMHNPs can bill for stand-alone psychotherapy using psychiatry specialty codes

if the encounter includes diagnosing and/or prescribing medications, a medical evaluation and management (E/M) base code should be used with an add-on psychotherapy procedure code

Medical Evaluation and Management Codes
specific five-digit E/M code
-based on the type of client, location of service, and level of service

XX=20 new client office/inpatient visit
XX=21 established client office/outpatient visit
XX=24 consultation for office/outpatient
XX=22 inpatient care

Medical Decision Making
level of medical-decision-making (MDM) is rated as straightforward, low, moderate, or high
-based on three components:

number of diagnoses
amount of data being reviewed
risk of mortality/morbidity
-The level of MDM is selected based on complexity

Psychotherapy Codes

90832- psychotherapy duration 16-37 minutes
90833- psychotherapy duration 16-37 minutes used as an add on code to a E/M code
90834- psychotherapy 38-52 minutes
90836- psychotherapy duration 38 or more minutes used as an add on code to a E/M code
90837- psychotherapy 53 or more minutes
90846- family psychotherapy client not present
90847- family psychotherapy with client present
90853- group psychotherapy

Lori, a 42-year-old female, presents to the office for an initial consultation. She has just experienced a breakup after a 5-year relationship and is feeling “depressed.” A comprehensive initial evaluation which includes chief complaint, history or present illness, medical history, previous psychiatric history, family history and a comprehensive review of systems was completed. Psychotherapy was included in the session – 18 minutes time.

provide the appropriate CPT code
99205+90833

Rationale: The client is new to the practice (20) and presents with one problem which addressed 4 or more elements, had a comprehensive history and interview. No additional testing was needed, treatment was initiated (05). Psychotherapy was included in the session- 18 minutes time. Therapy goals were established and reviewed with the client.

Hannibal, a 23-year-old male, is admitted to an inpatient psychiatric facility with symptoms of auditory hallucinations, paranoia, and suicidal ideations. A comprehensive initial evaluation which includes chief complaint, history or present illness, medical history, previous psychiatric history, family history and a comprehensive review of systems was completed.

provide the appropriate CPT code
99223

Rationale: The client presents for initial hospital care (22) and has a high level of medical decision-making due to an acute illness that poses a threat to life (3).

Shakina, a 19-year-old transgender female, has been referred to the PMHNP from primary care. The PMHNP reviews the primary provider’s note and identifies symptoms of bipolar I disorder. The PMHNP completes a comprehensive assessment and prescribes medications for the client.

provide the appropriate CPT code
99245

Rationale: The client has been referred (24), has complex medical decision-making needs (5) based on one undiagnosed new problem with an uncertain prognosis, required review of referral notes, and requires prescription drug management. No psychotherapy provided.

Steve, a 30-year-old married client returns for a follow up appointment. He was initially seen 3 months ago due to increased anxiety over his marriage. His diagnoses include generalized anxiety disorder (F41.1) and major depressive disorder (F32.1) The PMHNP has provided both medication management and cognitive behavioral therapy (CBT). Today the PMHNP obtains a chief complaint, history of present illness, reviews medical history, and a focused review of three systems was completed. Medications
99214 + 90833

Rationale: This is a returning client with two documented diagnoses. A focused encounter was conducted that included psychotherapy.

The PMHNP has initiated a grief support group at her practice. The support group is one hour in length and can include the client and family members.

provide the appropriate CPT code
90853

Rationale: This is group psychotherapy with no medication management. Only a psychotherapy code is necessary.

Interprofessional Collaboration and Referrals
-PMHNPs may receive client referrals from primary care providers to address mental health problems
-refer clients to primary care providers for medical care
-PMHNPs may collaborate with social workers to address clients’ needs for social support
-vocational counselors to assist with employment needs
-refer clients to other therapists

geriatrics, psychiatric emergencies, eating disorders, family therapy, or pediatrics
-telehealth services or a support group

Disparities in Mental Health Services
Racial, ethnic, gender, and sexual minorities
-often experience poor mental health outcomes due to inaccessibility of quality mental health services, discrimination, a cultural stigma surrounding mental health care, and lack of knowledge about mental health

To address disparities, the American Psychological Association (2022) advocates for the expansion and use of culturally and linguistically competent psychological and behavioral research and services

Legal & Ethical Considerations
Provider initiated termination for cause
Termination letters
Court mandated treatment
Process and progress notes

Code of Ethics for Nurses
Respect for the Individual
Commitment to the Healthcare Consumer
Advocacy for the Healthcare Consumer
Responsibility and Accountability for Practice
Duties to Self and Others
Contributions to Healthcare Environments
Advancement of the Nursing Profession
Collaboration to Meet Health Needs
Promotion of the Nursing Profession

A client who is alert and oriented declines the PMHNP’s treatment recommendation for an antipsychotic in a non-emergent situation.

Informed consent required
Exception to informed consent
Informed consent required

Rationale: The client has the capacity to consent and the situation is not emergent. The ethic of autonomy provides for the client to refuse treatment options.

An agitated, hallucinating client with a diagnosis of schizophrenia and no designated decision-maker threatens to shoot his neighbors. The client acts out violently towards the security guard in the emergency department. The PMHNP orders haloperidol and lorazepam for the client.

Exception to informed consent
Informed consent required
Exception to informed consent

Rationale: The client does not have the capacity to provide consent.

A very anxious client is seeking treatment for anxiety symptoms. When the PMHNP begins to explain the treatment options, the client says she is too anxious to hear them and asks that the PMHNP select the best option.

Exception to informed consent
Informed consent required
Exception to informed consent

Rationale: Clients may choose to waive their right to informed consent.

A client with depression is unhappy about the performance of the anti-depressant that has been prescribed and would like to discuss alternate treatment options with the PMHNP.

Informed consent required
Exception to informed consent
Informed consent required

Rationale: Clients have a right to information about treatment options with associated risks and benefits.

Circumstances that increase suicide risk: Individual Risk Factors
Previous suicide attempt
History of depression and other mental illnesses
Serious illness such as chronic pain
Criminal/legal problems
Job/financial problems or loss
Impulsive or aggressive tendencies
Substance use
Current or prior history of adverse childhood experiences
Sense of hopelessness
Violence victimization and/or perpetration

Circumstances that increase suicide risk: Relationship Risk Factors
Bullying
Family/loved one’s history of suicide
Loss of relationships
High conflict or violent relationships
Social isolation

Circumstances that increase suicide risk: Community Risk Factors
Lack of access to healthcare
Suicide cluster in the community
Stress of acculturation
Community violence
Historical trauma
Discrimination

Circumstances that increase suicide risk: Societal Risk Factors
Stigma associated with help-seeking and mental illness
Easy access to lethal means of suicide among people at risk
Unsafe media portrayals of suicide

Circumstances that protect against suicide risk: Individual Protective Factors
Effective coping and problem-solving skills
Reasons for living (for example, family, friends, pets, etc.)
Strong sense of cultural identity

Circumstances that protect against suicide risk: Relationship Protective Factors
Support from partners, friends, and family
Feeling connected to others

Circumstances that protect against suicide risk: Community Protective Factors
Feeling connected to school, community, and other social institutions
Availability of consistent and high quality physical and behavioral healthcare

Circumstances that protect against suicide risk: Societal Protective Factors
Reduced access to lethal means of suicide among people at risk
Cultural, religious, or moral objections to suicide

warning signs for suicide:
Talking about being a burden
Being isolated
Increased anxiety
Talking about feeling trapped or in unbearable pain
Increased substance use
Looking for a way to access lethal means
Increased anger or rage
Extreme mood swings
Expressing hopelessness
Sleeping too little or too much
Talking or posting about wanting to die
Making plans for suicide

Phases of Therapy
Initiation
Working
Termination

Initiation of Therapy
-one of the most important goals of the first session is establishing a therapeutic alliance

fundamental component of successful therapy
-comprehensive history & mental status examination
collect info to establish a psychiatric history and dx
guide the development of a tx plan
-location, frequency of sessions, and payment
-safety, primary consideration in psychotherapy
safety assessment should be conducted in the initial session, questions regarding suicidal and homicidal thoughts and thoughts of self-harm
collaboratively written safety plan should be created for any client identified to be at risk for self-harm

suicide
-a leading cause of death in the U.S.
-In 2020, suicide was the:

12th leading cause of death overall
2nd leading cause of death among individuals between the ages of 10 and 34
3rd leading cause of death among individuals between the ages of 35 and 44
-clients with mental health diagnoses such as mood disorders, psychotic disorders, and substance use disorder are at particularly high risk
50% of those who die by suicide do not have a previous psychiatric history

safety plan includes:
a prioritized list of coping strategies and resources the client can use when thinking about suicide or self-harm

Implementing the Safety Plan: 6 Step Process
Step 1: Warning Signs
Step 2: Internal Coping Strategies
Step 3: Social Contacts Who May Distract from the Crisis
Step 4: Family Members or Friends Who May Offer Help
Step 5: Professionals and Agencies to Contact for Help
Step 6: Making the Environment Safe

A no-suicide or no-harm contract:
-not a legal document but rather an agreement between the client and therapist about what the client should do if they become suicidal
-involves a commitment by the client to not commit suicide.
-may not be effective in a crisis and is not a substitute for clinical judgment.
-only as beneficial as the therapeutic alliance

frame of the relationship
rules and boundaries
-psychotherapist is responsible for setting and keeping the frame during therapy sessions
-Common elements:

process for contacting the provider
what to do in case of an emergency
adherence to a schedule
fees
confidentiality
boundaries of the therapeutic relationship
whether eating & drinking during the session are appropriate
whether session interruptions are allowed
whether phone calls between sessions are acceptable
starting and stopping on time

establishing a psychotherapeutic environment
-Safe and therapeutic
-Boundaries
-Rules
-Environment
-Contact Processes
-Emergency Plan
-Miscellaneous
-Adherence

Setting Goals and Duration of Therapy
-overall goal of psychotherapy is to help clients gain self-awareness and decision-making
-psychotherapy is goal-directed

Goal-setting should be a collaborative process between the therapist and the client
-duration of therapy varies
common for therapy to last for at least 3-4 months
client’s financial situation & insurance coverage may also impact the duration of therapy

Practical considerations for psychotherapy
scheduling
-outpatient therapy, sessions are typically scheduled in 45 to 50-minute blocks
-permits time between sessions to document and prepare for the next
-initial intake session may be up to 90 minutes
-inpatient psychotherapy will vary based on unit scheduling & ind client needs.

Fees
-Fees & payment options should be discussed during the initial visit
-private practice typically collect insurance co-pays or fees directly
-PMHNPs who work within a larger health system may not be responsible for discussing or collecting fees from clients
-discuss charges for missed sessions as well as the required notification to prevent charges

confidentiality
-paramount to establishing a therapeutic alliance
-Providers must abide by the standards set by HIPAA as well as any applicable state laws

must provide clients with information regarding HIPAA and explain what information will be shared and with whom
-mandated to report concerns of threat of harm to self or others and child abuse.

Psychotherapy Contracts
not required to begin therapy
-best practice is to provide a written therapy contract detailing:

terms of the therapeutic relationship
scheduling
missed appointments
fees
confidentiality
termination

setting for psychotherapy
-Create a warm, welcoming, and safe environment
-tissues available
-clock where it is visible by both therapist and client
-ensure client and provider safety
-Therapist should avoid sitting behind a desk

instead sit 3-4 ft. away but not directly across from client.
-Office uses neutral décor

working phase of therapy
-when therapeutic interventions typically take place.
-content of the working phase is driven by:

client’s diagnosis
identified goals
selected treatment modality

Termination
number of therapy sessions is often dependent on the type of therapy
-CBT typically engage in 5-20 sessions
-Discussion of therapy termination should begin at the initiation of therapy
-Ideally, when goals have been met, the client and therapist mutually decide to terminate the therapy relationship
-client can choose to terminate non-court-ordered therapy at any time
-Reasons for premature termination include:

inability to afford therapy
feelings that therapy is no longer beneficial
relocation out of the therapist’s service area

The PMHNP can take steps to prevent client-initiated premature termination. Which strategies can be used to help promote the completion of therapy? Select all that apply.

express confidence in the client for seeking therapy
assign homework for each session
describe the planned duration of therapy during the initial session
strengthen the therapeutic alliance
educate the client on their role in the therapy sessions
discuss progress at the end of the last session
-express confidence in the client for seeking therapy
-describe the planned duration of therapy during the initial session
-strengthen the therapeutic alliance
-educate the client on their role in the therapy sessions

Rationale: Providing education to clients about their role in the therapeutic process and the expected duration of therapy, strengthening the therapeutic alliance, and strengthening client hope by expressing confidence can help reduce premature termination by the client. Although assigning homework for each session is an acceptable strategy for therapy, client preferences should be considered. Therapy progress should not be limited to the last session but should be incorporated regularly throughout therapy.

Termination for Cause
provider must ensure that legal and ethical obligations towards the client are met
-client’s needs are beyond the scope of the provider’s competence or license, the provider may refer the client and terminate therapy
-PMHNP changes employment or moves, they have a responsibility to provide a referral to another provider
-Providers may consider termination for noncompliance or missed sessions
-client presents a safety risk to the provider and the provider is unwilling to meet with the client in person, termination may be appropriate
-Failure to pay or insurance authorization denial is not acceptable grounds for termination during a crisis

-PMHNP should prepare a termination letter that delineates the reasons for termination and provides recommendations regarding further treatment if applicable.copy of the letter should be retained in the client’s records.

Court-Mandated Treatment
-require treatment for individuals or families.
-Mandated therapy may be ordered as an alternative to jail for clients with mental health or substance use disorders
-Parents may be compelled to attend therapy during a divorce trial or as a stipulation to regain custody after allegations of abuse or neglect
-Sex offenders may also be obligated to attend mandated therapy
-Clients who fail to meet the requirements of court-mandated therapy may be found in contempt of court or be required to serve jail time
-Confidentiality

provider may be required to share information with the court
must frankly discuss the limits of confidentiality with the client

psychotherapy documentation: Provider Responsibilities
Clinical Management
-Informs the provision of care and provides a review of past proceedings
-Supports the continuity of care when referrals or interdisciplinary care occurs

Legal Implications
-Records may be shared during civil proceedings, such as for divorce or custody cases
-Courts may subpoena records for criminal proceedings
-Court-ordered counseling records may be shared with the court

Risk Management
-Documentation of high-risk situations can be protective in litigation and should include:

situation
severity of threat
all possible interventions considered
colleague consultations
intervention implemented
follow-up

Process Notes versus Progress Notes
Process notes
-personal tool for the therapist to record thoughts, feelings, observations, or hypotheses during or immediately following the session
-private; Clients, other providers, and insurance companies may request access to process notes; however, the provider is not obligated to share them except in limited situations

Progress notes
-contain treatment plan: history, diagnosis, medication details, and progress summaries
-considered a part of the medical record and may be shared, as appropriate, with other providers, insurance companies, and the client.

Ruben is a 36-year-old who has been in therapy for 5 months. He is in the process of divorcing his wife of 12 years and is seeking custody of his daughter. His attorney has requested copies of his psychotherapy notes to use in support of the custody hearing. Can the therapist choose to share the psychotherapy notes?

Yes, no client authorization necessary
Yes with written authorization from the client
No
Yes with written authorization from the client

Rationale: the client must provide written authorization for his notes to be shared with his attorney.

Kathy is a 32-year-old who has been in court-mandated therapy for two months after her children were removed from the home by Child Protective Services for suspected physical abuse and neglect. The social worker has requested copies of her progress notes as a part of the investigation. Is the therapist obligated to provide the progress notes?

Yes, no client authorization necessary
Yes with written authorization from the client
No
Yes, no client authorization necessary

Rationale: Because the notes were requested for a health and human services investigation, the therapist may release the notes without client authorization.

Juanita is a 17-year-old who has been in therapy for 3 months for major depressive disorder. Her mother is requesting a copy of her psychotherapy notes so she can better understand the progress her daughter is making. Juanita has indicated that she is “ok” with her mom accessing the notes. Is the therapist obligated to provide the psychotherapy notes?

Yes, no client authorization necessary
Yes with written authorization from the client
No
No

Rationale: Even though the client may authorize the release of notes to her parent, the therapist is not obligated to release the process notes to the client or her mother if they feel it is not in the best interest of the client.

Raghu is a 22-year-old who has been in therapy for two years. Recently, he was arrested on charges of assault with a deadly weapon. The therapist receives a subpoena from the court with requests for his progress notes. Is the therapist obligated to provide the progress notes?

Yes, no client authorization necessary
Yes with written authorization from the client
No
Yes, no client authorization necessary

Rationale: The therapist must obey the court subpoena and provide the progress notes. Psychotherapy notes may still fall under therapist-client privilege and may be withheld from the court; in this case, the therapist should seek legal counsel to ensure proper compliance with the subpoena.

therapeutic communication
-Translating emotions

Sharing observations
Sharing empathy
Sharing hope
Sharing humor
Sharing feelings

-Non-verbal communication

Active Listening
Using touch
Using silence

-Information verification/dissemination

Providing information
Clarifying
Focusing
Paraphrasing
Validation
Asking relevant questions

nontherapeutic techniques
Asking for Explanations
-Why are you so anxious?

Asking Personal Questions
-Why don’t you and John get married?

Giving Advice
-If I was you, I’d take a break from school.

Disapproval
-You shouldn’t even think about assisted suicide; it’s not right.

Defensive Responses
-No one here would intentionally lie to you.

False Reassurance
-Don’t worry, everything will be all right.

Therapeutic techniques
Broad Openings
-What would you like to talk about today?

Reflecting
-What do you think you should do about it?

Presenting Reality
-I don’t see anyone else in the room.

Sympathy
-I’m so sorry about your mastectomy; it must be terrible to lose a breast.

Summarizing
-Today we have talked about a plan for you to manage feelings of anger.

Making an Observation
-You seem upset about something.

Which theory would the psychiatric mental health nurse practitioner (PMHNP) most need to consider when conducting a psychiatric interview in the following situations?
A 35-year-old homeless client is in the emergency department with suicidal ideations.

Hierarchy of Needs Theory
Psychosocial Development Theory
Cognitive Development Theory
Hierarchy of Needs Theory

Rationale: To attend to higher-level needs, a client must first meet foundational needs. A homeless client may be struggling to meet physiological and safety needs.

Which theory would the PMHNP most need to consider when conducting a psychiatric interview in the following situations?
A 14-year-old foster child struggling to develop trusting relationships with his foster parents.

Hierarchy of Needs Theory
Psychosocial Development Theory
Cognitive Development Theory
Psychosocial Development Theory

Rationale: According to Erickson’s theory, a developmental crisis in infancy trust vs. mistrust. When basic trust in caregivers is not developed in early life, it can impact the creation of trusting relationships later.

Which theory would the PMHNP most need to consider when conducting a psychiatric interview in the following situations?
A 4-year-old is struggling to understand what she has seen on television about civil protests.

Hierarchy of Needs Theory
Psychosocial Development Theory
Cognitive Development Theory
Cognitive Development Theory

Rationale: According to Piaget, children in early childhood do not have the cognitive ability to understand abstract concepts, such as justice.

Erikson’s psychosocial stages:
-Infancy: Trust vs. Mistrust (birth-18 months)

-Early Childhood: Autonomy vs. Shame and Doubt (ages 18 months-2 to 3 years)

-Preschool: Initiative vs. Guilt (ages 3-5)

-School Age: Industry vs. Inferiority (ages 6-11)

-Adolescence: Identity vs. Role Confusion (ages 12-18)

-Young Adulthood: Intimacy vs. Isolation (ages 19-40)

-Middle Adulthood: Generativity vs. Stagnation (ages 40-65)

-Maturity: Integrity vs. Despair (ages 65-death)

Psychoanalytic theory
Freuds theory of personality
-childhood experiences & unconscious desires influence behavior
-libido, fixation stuck at psychosexual development stages

predicts adult personality

The Therapeutic Alliance
the cooperative, purposive working relationship that exists between the psychotherapist and the client
-essential factors:

agreement on the goals, tasks, & strategies of tx
bond between the provider & the client
-strong therapeutic alliance is crucial to the success of therapy
-foundations of a therapeutic alliance:
trust, connection, and rapport

Provider characteristics that help build the therapeutic alliance:
-empathy
-genuineness
-warmth
-acceptance
-a collaborative approach to goal-setting
-strong communication skills
-Unconditional positive regard

Hildegard Peplau Theory of Interpersonal Relations in Nursing
defined nursing as an interpersonal therapeutic process in which nurses engage in therapeutic relationships with individuals in need of health services
-Peplau is considered to be the “mother of psychiatric nursing”

her work is foundational to the development of the PMHNP role in psychotherapy
-emphasized the need for self-awareness in the nurse-client relationship
critical to ensure that the therapist will act in the client’s interests
-nurse-client relationship has four sequential phases:
orientation
identification
exploitation
resolution

Hildegard Peplau therapeutic relationship six nurse roles

Stranger: Nurse creates an environment to build trust
Teacher: Nurse imparts relevant knowledge and provides instructions and training
Resource person: Nurse provides specific information needed by the client, answers questions, and interprets clinical data
Counselor: Nurse helps the client understand and integrate meaning into life’s circumstances, provides guidance and encouragement for change
Surrogate: Nurse helps clarify domains of dependence, interdependence, and independence and acts as an advocate for the client
Leader: Helps client take maximum responsibility for meeting treatment goals

therapeutic alliance Boundaries
create a formal structure and set of rules or limits that help provide a safe relationship between the provider and client
-may include the psychotherapist’s self-disclosure, the therapeutic use of touch, exchange of gifts, fees, timing, and location of therapy sessions, and contact outside of the office

Self-Disclosure
when the psychotherapist shares personal rather than professional information with the client
-used sparingly with care for the benefit of the client

can contribute to the building of trust & empathy & can strengthen the therapeutic alliance
-overuse can remove the focus from the client
-Inappropriate self-disclosure can lead to a role reversal between the psychotherapist and the client
client feels the need to take care of the provider
boundary violation

Transference
when a client directs their feelings towards a significant person in their lives
-such as a parent, or a psychotherapist
-typically unconscious
-may be positive or negative
-may provide perspective into client’s relationships & offer an opportunity to help the client gain insight

Countertransference
psychotherapist’s conscious or unconscious reactions to a client based on their own psychological needs or conflicts
-can have a negative impact on the therapeutic alliance

if boundaries between the psychotherapist and the client are blurred and the psychotherapist loses perspective
-can undermine trust in the therapeutic alliance

A client and her husband approach the psychotherapist at a mutual friend’s party. The client introduces her husband to the provider who returns the greeting.

May or may not be a boundary violation
Boundary violation
Not a boundary violation
Not a boundary violation

Rationale: This is not a boundary violation because the client approached the psychotherapist. If the psychotherapist approached the client, it would be a boundary violation

A psychotherapist holds the client’s hand during the client’s retelling of a traumatic event after the client reaches out.

May or may not be a boundary violation
Boundary violation
Not a boundary violation
Not a boundary violation

Rationale: This is not a boundary violation. Touch may be therapeutic in certain situations.

A psychotherapist agrees to a blind date with a client’s sister.

May or may not be a boundary violation
Boundary violation
Not a boundary violation
May or may not be a boundary violation

Rationale: This may or may not be a boundary violation depending on whether the client is a current client. Refer to state-specific guidelines for information about boundaries with former clients.

A psychotherapist was in a car accident and needs auto body work completed. When the psychotherapist arrives at the auto body shop suggested by the insurance company, she realizes that the shop is managed by one of her clients. The psychotherapist schedules the needed repairs.

May or may not be a boundary violation
Boundary violation
Not a boundary violation
May or may not be a boundary violation

Rationale: This may or may not be a boundary violation. Dual relationships may be problematic; however, if the psychotherapist resides in a small town and the body shop is the only shop approved by insurance, it may not be a boundary violation.

A client has a florist shop in town. The psychotherapist needs to send an arrangement to a friend and typically orders from another shop when he remembers that his client owns a shop. He orders the flowers from the client’s shop.

May or may not be a boundary violation
Boundary violation
Not a boundary violation
Boundary violation

Rationale: This is probably a boundary violation. It’s helpful to avoid dual relationships when possible.

A psychotherapist shares her history of sexual assault with a client who has had a similar experience.

May or may not be a boundary violation
Boundary violation
Not a boundary violation
May or may not be a boundary violation

Rationale: This may or may not be a boundary violation. Some forms of psychotherapy may include self-disclosure as part of the therapeutic alliance.

Psychodynamic Therapy
a form of talk therapy that helps clients to better understand the thoughts, feelings, and conflicts that contribute to behavior
-grew out of the 19th-century work and theories of Sigmund Freud
-client’s past relationships may be reenacted in the present

Sigmund Freud
considered to be the father of psychoanalytic psychotherapy
-ID’d three levels of awareness:

preconscious
conscious
unconscious
-theory postulates that all actions are based on unconscious sexual or aggressive drives
-Psychological symptoms result from conflicts between three parts of the mind:
id
ego
superego

Id:
Primitive
instinctive
unconscious
basic urges
seeks pleasure
demands immediate satisfaction

Ego:
Rational
logical
mostly conscious
allows the mind to satisfy id’s urges appropriately and safely
moderates between id and superego

Superego:
A sense of right and wrong
both conscious and unconscious
internalized morals

psychosexual stages of development
Oral stage: 0-1 yr

Anal stage: 2-3 yr

Phallic stage: 3-6 yr

Latency stage: 6 yr to puberty

Genital Stage: Beyond puberty

Erik Erikson psychosocial stages of development
expanded the developmental theory to encompass the full lifespan rather than just childhood and adolescence
-conceptualized development in terms of psychosocial rather than psychosexual crises/conflicts
-successful resolution of each conflict is necessary to move successfully from stage to stage
-8 stages

key principles of psychodynamic therapy
-unconscious motivations affect behavior
-past experiences shape personality
-past experiences affect the present
-developing insight into patterns of behavior, feelings, relationships can help with psychological issues
-transference can help the individual work through past issues
-freedom from the past can help improve life in the future

Defense Mechanisms
tactics to protect the ego from anxiety
-Displacement
-Denial
-Sublimation
-Projection
-Regression
-Repression
-Rationalization
-Intellectualization

Aleksander received an inferior performance evaluation at work. When he arrived home after a long day, he shouted at his 3-year-old daughter for leaving her toys out in the playroom.

-Displacement
-Denial
-Sublimation
-Projection
-Regression
-Repression
-Rationalization
-Intellectualization
Displacement

Displacement occurs when a person expresses an emotion, such as anger or frustration, towards a “safe” person rather than towards the cause of the emotion.

Frieda drinks 5-6 alcoholic beverages each night when she comes home from work. She typically drinks until she passes out; however, she never drinks during the day and never misses work due to her drinking, though her drinking has impacted her relationship with her spouse. She does not believe that her drinking is a problem because she goes to work and pays bills on time.

-Displacement
-Denial
-Sublimation
-Projection
-Regression
-Repression
-Rationalization
-Intellectualization
Denial

Denial occurs when a person refuses to admit to reality or an obvious fact.

Gabriella presents to therapy with concerns about anxiety and difficulty forming relationships. She suffered childhood abuse; however, she has little memory of the incidents.

-Displacement
-Denial
-Sublimation
-Projection
-Regression
-Repression
-Rationalization
-Intellectualization
Repression

Repression occurs when painful memories are “forgotten.” The memories become subconscious and continue to impact behavior.

Ahmad recently experienced a nasty breakup with his girlfriend after she cheated on him. While he would like to call her to vent his anger and frustration, instead, he channels his energy into training for a marathon.

-Displacement
-Denial
-Sublimation
-Projection
-Regression
-Repression
-Rationalization
-Intellectualization
Sublimation

Sublimation occurs when a person transfers unacceptable impulses into socially acceptable forms.

Anderson has been having an affair with his secretary at work. He has become highly suspicious of his wife and frequently accuses her of being attracted to her boss.

-Displacement
-Denial
-Sublimation
-Projection
-Regression
-Repression
-Rationalization
-Intellectualization
Projection

Projection involves ascribing one’s feelings to another person.

Cieran’s boss is routinely rude and abrupt with him. Today she accused him of arriving late to work though he was on time. Rather than confront his boss, Cieran wonders whether his boss has difficulties at home that make her irritable.

-Displacement
-Denial
-Sublimation
-Projection
-Regression
-Repression
-Rationalization
-Intellectualization
Intellectualization

Intellectualization occurs when a person uses intellectual thought or learning to suppress an emotional aspect of a situation.

Levi asked his coworker Marilyn out on a date. She declined the invitations. When telling his friend about the incident, he states he wasn’t all that attracted to her anyway.

-Displacement
-Denial
-Sublimation
-Projection
-Regression
-Repression
-Rationalization
-Intellectualization
Rationalization

Rationalization involves creating rational explanations to avoid the emotional consequences of a situation.

Ramona is sexually assaulted when walking home from work late at night. Following the assault, she begins sucking her thumb for comfort.

-Displacement
-Denial
-Sublimation
-Projection
-Regression
-Repression
-Rationalization
-Intellectualization
Regression

Regression occurs when a person reverts to early developmental coping mechanisms based on Freud’s stages of psychosexual development.

Training and Certification Requirements for psychodynamic psychotherapy
must complete additional post-master’s level training
-rograms vary in length from two to four years

Psychodynamic Continuum
continuum from supportive and stabilization therapy to expressive and psychoanalytic therapy
-supportive end of the continuum, therapy is focused on stabilization through anxiety reduction, defense stabilization, and improved problem-solving
-the psychoanalytic end, therapy is directed at interpreting unconscious conflict and gaining insight
-Expressive therapies are focused on emotional processing

Types of Psychodynamic Psychotherapy
Psychoanalysis
Supportive Psychotherapy
Expressive Psychotherapy
Brief Psychodynamic Therapy

Psychoanalysis
-Indications: commonly used for anxiety disorders, OCD, depressive disorders, personality disorders, & sexual dysfunction
-goals: development of a deeper understanding of self and a desire to create change
-Contraindications: not motivated, poor impulse control, concrete thinkers, those amid a major physical or emotional crisis
-tends to be more intense than other forms of psychotherapy in terms of the frequency of sessions and the intense nature of the transference that occurs

several sessions per week over several years
-variety of techniques
recollection
repetition
working through
free association
transference
interpretation

Supportive Psychotherapy
-an approach used to help clients who are experiencing emotional distress or problems in living
-appropriate for clients experiencing specific stressful situations:

psychotic personality organization
preoccupied or overly emotional attachment style
those with immature defenses
-goals of therapy: problem-solving, management of feelings and life stressors, and symptom relief
-used for:
stabilization
resource building
anxiety reduction
problem-solving
-Therapeutic Techniques: providing comfort, encouragement and reassurance, and empathic listening

Expressive Psychotherapy
-appropriate for clients with unresolved, disorganized attachment styles and clients with a neurotic defense schema
-along with dialectical behavioral therapy, is the preferred form of psychotherapy for clients with a borderline personality disorder or borderline character structure
-goals: processing of relational trauma and learning emotional self-regulation
-sessions typically several times per week
-Therapeutic Techniques:

transference
counterconditioning
desensitization to past traumatic relationships

Brief Psychodynamic Therapy
-used when the client has a specific issue or conflict such as difficulty in relationships, school or work, or communication.
-time-limited form of psychotherapy

occurs fewer days per week over a shorter length of time
typically 20-30 sessions with a termination date set at the beginning of therapy
-Goals: enhancement of self-awareness and understanding the impact of the past on present behavior
-Therapeutic Techniques: pressure, or encouragement, to examine feelings and situations; challenge to defenses, and head-on collision to overcome defenses.

Sofia is a 32-year-old new mom who presents for therapy. She states that her relationship with her mother has always been “terrible,” and she wants to identify patterns and behaviors in that relationship so that she does not “repeat history” with her child. She is not exactly sure why she and her mother do not get along well, and she is willing to commit to long-term therapy.
Which of the psychodynamic psychotherapies below is best suited for Sofia?

expressive psychotherapy
brief psychodynamic
psychoanalytic psychotherapy

Rationale: Sofia presents with a desire to create lasting change and is willing to commit to long-term therapy. Her deep-rooted relationship issues with her mother may best be addressed in psychoanalytic psychotherapy.

Tiffany is a 24-year-old who presents for therapy after encouragement from her sister. She endorses difficulty forming close relationships and admits to sexually promiscuous behavior regularly. During the intake interview, she discloses a history of physical abuse by both parents; she has never admitted the abuse to anyone but her sister. She also admits to cutting as a coping strategy.
Which of the psychodynamic psychotherapies below is best suited for Sofia?

expressive psychotherapy
brief psy
expressive psychotherapy

Rationale: Tiffany presents with behaviors consistent with borderline personality structure, including difficulty forming relationships, acting out via sexually promiscuous behavior, and self-harm. Expressive psychotherapy can assist Tiffany with reliving her past trauma and activating emotions to begin the healing process.

Terrell is a 40-year-old who presents for therapy. He is recently separated from his partner of 10 years, and he tearfully states that thinking about returning to dating is “horrifying,” but he expresses anxiety about “being alone for the rest of my life.”
Which of the psychodynamic psychotherapies below is best suited for Sofia?

expressive psychotherapy
brief psychodynamic therapy
psychoanalytic psychotherapy
supportive psychotherapy
supportive psychotherapy

Rationale: Terrell presents with an emotional communication style, life stressors related to a recent breakup, and anxiety related to change. Supportive psychotherapy will help Terrell problem solve, reduce anxiety, and build appropriate resources.

Olathe is a 26-year-old who presents for therapy related to relationship issues with her spouse. She states that their communication has been “nonexistent” for several months and that she is “at the point where divorce seems like the only option.” While she verbalizes understanding that therapy is not a “quick fix,” she indicates that she would like to learn communication tools that she can use immediately.
Which of the psychodynamic psychotherapies below is best suited for Sofia?

expressive ps
brief psychodynamic therapy

Rationale: Olathe presents with a specific conflict that is related to communication with her spouse. Because she is interested in pursuing therapy to address this specific conflict and learn new communication tools, brief psychodynamic therapy to challenge and overcome her defenses is a good option.

humanistic-existential approach
-foundational to psychiatric mental health nursing

central tenets of holism, self-actualization, and the therapeutic alliance
-places emphasis on understanding human experience
focusing on the client rather than the symptom
-Interventions seek to increase client self-awareness and self-understanding
-Holistic
assumes an interrelationship between the client’s psychological, biological, social, and spiritual dimensions

Humanism is often referred to as the _ in psychology
“third force” in psychology
-after psychoanalysis and behaviorism

Humanism eventually gave way to a later force: _______
transpersonal psychotherapy

early forces of psychotherapy
Behaviorism
-focuses on observable behavior

Psychoanalysis
-studies the unconscious mind

Humanistic-existential
-focuses on individual free will

Types of Humanistic—Existential Therapy
Person-Centered Therapy

Gestalt Therapy

Person- or Client-centered therapy
-Carl Rogers founded this psychotherapy in the 1940s
role of the psychotherapist is to establish a therapeutic relationship
-using genuine understanding and acceptance

client can discover and explore their reality.
-belief people are essentially trustworthy, have potential for self-understanding & self-directed growth with support of a therapeutic relationship
-congruence (genuineness and realness)
-unconditional positive regard (acceptance and caring)
-accurate empathic understanding through skilled, active listening (perceiving the client’s subjective experience)
Positive belief in human nature
Self-concept (Self-worth, self-image, ideal self)
Actualizing tendency
Fully functioning person

goal of person-centered therapy
assist the client to become a fully functioning person
-role of the person-centered psychotherapist

provide client with unconditional positive regard to help facilitate change
Using congruence, acceptance, and empathy

Person- or Client-centered therapy indications
-useful modality for individuals, groups, and families
-effective in addressing a range of client problems

anxiety disorders, substance abuse disorders, psychosomatic problems, agoraphobia, interpersonal difficulties, personality disorders
often used in crisis interventions such as illness or the death of a loved one
recently demonstrated (+) outcomes with autism, transgender & gender diverse clients

Techniques used in person-centered psychotherapy
-nondirective-facilitative counseling
-congruence, unconditional positive regard
-accurate empathic understanding

Gestalt psychotherapy
-founded by Fritz and Laura Perls
-holistic, person-centered therapy
-assumption that while an individual may come close to understanding the experience of another, one can never fully comprehend another’s experience

therapist observes how the client relates to the environment and moves from one experience to the next
-three key philosophies
Field theory: context of the situation or field
Phenomenology: what is obvious rather than on the therapist’s interpretation
Dialogue: showing the true self and experiencing the other person as they truly are

Gestalt psychotherapy: role and function of the therapist
-inviting the client into an active partnership

learn about themselves
experience how they are in the present moment
explore new behaviors
focusing on the here and now rather than past experiences
-addresses the clients’ nonverbal body language
gestures as cues to rich info that the client may not be aware of
-emphasize language patterns and personality

Key concepts of Gestalt psychotherapy:
-figure and ground

how ind organizes their environment moment to moment

-organismic self-regulation

when equilibrium is disturbed, the organism regulates themselves to restore order

-layers of the personality

disowned parts of the self that create inauthentic layers of the personality

-interruptions

protective resistances or defenses used to safeguard against fully experiencing a present moment experience

Gestalt psychotherapy Indications
-used in individual or group settings
-effective in addressing a range of client problems

medical disorders such as traumatic brain injury
helping adolescents overcome divorce trauma
helping individuals work through difficult dreams

goal of Gestalt therapy
help restore clients to a natural state of self-regulation
-through the reintegration of disowned parts of the self

completion of unfinished gestalts

Techniques used in Gestalt psychotherapy
-I-Thou relationship
-creative experimentation

dreamwork
body awareness
focusing
empty-chair dialogues

Introjection
occurs when a person uncritically accepts another’s beliefs.

Ex: Anders believes he should decline a leadership promotion at work because he was told by his father that he would never be a good manager.

Projection
occurs when a person disowns aspects of themselves by assigning them to the environment.

Ex: Greta did not meet an important project deadline at work and angrily ridiculed her husband for arriving home late.

Retroflection
occurs when a person turns back on themselves what they would like to do to another.

Ex: Mia’s sister often yells at her about sharing clothes and doing household chores. Mia bites her lip intensely to avoid yelling back.

Confluence
occurs when a person blurs the differentiation between the self and the environment.

Ex: Tishon bullies a new kid at school to gain acceptance from a gang he wants to join.

Deflection
occurs when a person uses distraction to avoid sustained contact.

Ex: Farida constantly changes the subject when talking with her husband to avoid talking about their financial difficulties.

Humanistic theory
-view personality with a focus on the potential for healthy personal growth towards self-actualization

Abraham Maslow’s hierarchy of needs
-Who am I
-free will
-people are inherently good
-conscious
-self motivated to improve
-Carl Rogers
self-actualization nurtured in a growth-promoting climate
genuine
acceptance
-Fritz Perls
Gestalt therapy, wholeness of ind’s experience

Hierarchy of Needs Theory
Psychosocial Development Theory
Cognitive Development Theory
Hierarchy of Needs Theory

Rationale: To attend to higher-level needs, a client must first meet foundational needs. A homeless client may be struggling to meet physiological and safety needs.

Hierarchy of Needs Theory
Psychosocial Development Theory
Cognitive Development Theory
Psychosocial Development Theory

humanistic approach to nursing
-Joyce Travelbee’s humanistic approach to nursing

places emphasis on free will and the search for meaning in pain and illness

-Josephine Paterson and Loretta Zderad

view nursing as a lived dialogue between the nurse and client

-Jean Watson’s Theory of Human Caring

nursing as caring action that regards clients with unconditional acceptance and positive regard

Hierarchy of Needs Theory
Psychosocial Development Theory
Cognitive Development Theory
Cognitive Development Theory

Rationale: According to Piaget, children in early childhood do not have the cognitive ability to understand abstract concepts, such as justice.

Essential characteristics of the humanistic-existential approach:
-focus on the phenomenological perspective
-primacy of the therapeutic relationship
-belief in holism
-emphasis on the here and now
-emphasis on humanistic-existential themes
-centrality of process
-use of experiential techniques

Mateo is a 19-year-old transgender male who presents for therapy. He states that his gender identity is incongruent with his sex assigned at birth. He has transitioned to dressing as a man, goes by Mateo, his chosen name, and uses he/him pronouns at school and home. He states that he becomes very angry when people use his “dead” name or wrong pronoun. He states that he tries to correct the person, but he gets very frustrated when he must correct the same person repeatedly. The psychiatric mental
“It’s ok if you are angry when people use your dead name.”

“I accept your gender identity and I understand that it is difficult when you interact with people who don’t accept who you are.”

“It sounds like when people repeatedly use your dead name, you feel like they do not respect you.”

Rationale: Accurate empathic understanding helps the client to value their experiencing and increase their confidence in pursuing a course of action. The therapist can express genuineness, or congruence, towards the client. As the psychotherapist openly expresses feelings, thoughts, and reactions with the client, trust will be generated, and therapy will occur. During client-centered therapy, the therapist should refrain from offering extensive advice and allow the client to drive the therapy session but may paraphrase the client’s statements and repeat them to help the client clarify feelings and actions.

Josefina is a 24-year-old who presents for therapy. She reports she had been working as an exotic dancer to earn money. She endorses a long history of sexual promiscuity that started around age 13 when she experimented with sex with neighborhood boys. Since then, she has had serial relationships that leave her feeling abandoned. She recently got a job as a waitress and wants a “clean” start on her life. The psychiatric mental health nurse practitioner (PMHNP) selects a Gestalt approach to help J
“As you tell me your story, what are you experiencing?”

“I noticed when you told me the story of your childhood sexual activity, your eyes began blinking. Can you give a voice to your blinking eyes?”

“Would you agree to an experiment where you imagine each part of yourself in an empty chair?”

“Would you be willing to say, ‘I am finding it so difficult to find a partner?'”

Rationale: Gestalt psychotherapy promotes understanding of the present experience rather than discussing situations in the abstract or focusing on the content of what the client reveals. Gestalt techniques are used to increase client awareness of what they are doing and how they are doing it. The statements: “What needs to happen today so that when you leave, you’ll think this was a good session?” and “Was there ever a time when you felt happy in a relationship?” focus on content and finding solutions rather than the present experience.

Interpersonal psychotherapy (IPT)
-shifts the emphasis of treatment to improving the quality of a client’s interpersonal relationships and social functioning to help reduce psychological distress
-form of time-limited, evidence-based, structured psychotherapy
-social and interpersonal factors can impact symptoms of psychiatric disorders
-focuses on the interactions between the self and others
-purpose

relieve problems in interpersonal relationships and social adjustment to prevent the formation of additional psychiatric symptoms

Interpersonal psychotherapy (IPT) was developed by:
Myrna Weissman and Gerald Klerman
-in a research setting to study whether antidepressants in combination with psychotherapy provided better outcomes for clients with depression than antidepressant therapy alone

Interpersonal psychotherapy (IPT) has shown efficacy in the treatment of:
-Depression, perinatal depression, anxiety, and eating disorders
-also been used in conjunction with social rhythm therapy in the treatment of bipolar disorder

__ developed the concept of attachment theory
Bowlby
-his studies of the maternal-infant bond
-individuals form attachments to others and that separation or the threat of separation can lead to distress and depression

primary focus of IPT
treatment of the social or interpersonal roots of depression
-four interpersonal problem areas:

interpersonal disputes
role transitions
grief and complicated bereavement
interpersonal deficits

Characteristics of IPT
-Time-limited: usually 12-16 weekly sessions
-Focused
-Based on current relationships
-Interpersonal, not intrapsychic, cognitive, or behavioral
-Aware of personality, but not focused on it

Role of the Therapist in IPT
-help the client identify and address interpersonal issues

may be contributing to an exacerbation of psychiatric symptoms
-communicate unconditional positive regard
-provide an analysis of the client’s communication skills
-use techniques such as coaching or role-play
help the client improve communication skills

IPT Phases
The initial phase
-First three to four sessions
-psychiatric hx & interpersonal inventory
-1 of 4 interpersonal problem areas as focus of tx

The middle phase
-Active tx phase
-uses the IPT model for selected problem to ID goals & address concerns
-Allows client to explore experiences & create new relational patterns

Termination
-role transformation from acute therapy
-Often overlaps with middle phase
-Focus on concluding tx & addressing grief about loss of therapy & relationship with therapist
-Therapist & client work together, review gains made in tx, assess future tx needs

IPT Therapeutic Techniques
clarification, communication analysis, interpersonal incidents, role-playing, and problem-solving.

Daniela is a 35-year-old who presents with symptoms of apathy, sadness, and irritation. She states that she and her husband have been arguing for months about the division of labor associated with household tasks. Both Daniela and her husband work full time, but she states she “takes on the lion’s share” of the work. She feels fed up and misunderstood.
Which interpersonal problem area best fits this situation?

Grief
Role dispute
Interpersonal deficit
Role transition
Role dispute

Rationale: Role disputes occur in marital, family, social, and work settings when individuals have different expectations of a situation. The conflict leads to significant distress in at least one of the individuals.

Peg is a 46-year-old teacher and mother of one. She presents with symptoms of sadness and anger after learning that her husband of 15 years is gay and is planning to move across the country to live with a partner, leaving her to raise their daughter alone.
Which interpersonal problem area best fits this situation?

Grief
Role dispute
Interpersonal deficit
Role transition
Role transition

Rationale: Role transitions require an adaptation in life circumstances, often from adjustments in work, social settings, or after major life events such as parenthood, marriage, or divorce. The transitions are experienced as a form of loss for those who develop depression.

Tomas is a 27-year-old computer programmer who presents with symptoms of major depressive disorder. He states that he feels lonely and has never been able to form close friendships. He occasionally goes to happy hour after work with colleagues but has not been able to establish connections with any of them. He has had a robust sex life, but he struggles to maintain relationships with women longer than a few months.
Which interpersonal problem area best fits this situation?

Grief
Role dispute
In
Interpersonal deficit

Rationale: Interpersonal deficits are noted when clients lack lasting relationships, have difficulty making friends, or have poor quality relationships.

Claire is a 30-year-old nurse who presents with symptoms of distress and sadness. Several years ago, she became involved in a relationship with a colleague. One night as she was watching the news, she saw that he and his family had been killed in a car accident. Until that point, she had not been aware that he was married with children. She is struggling to move on to a new relationship.
Which interpersonal problem area best fits this situation?

Grief
Role dispute
Interpersonal deficit
Role tra
Grief

Rationale: Grief involves a loss through death. Clients may present for therapy due to normal, complicated, or delayed grieving.

Related Posts