Final Exam: NR605/ NR 605 (Latest Update 2024/ 2025) Diagnosis & Management in Psychiatric-Mental Health across the Lifespan I Practicum Review |Weeks 5-8 Covered| Questions and Verified Answers| 100% Correct- Chamberlain

Final Exam: NR605/ NR 605 (Latest Update
2024/ 2025) Diagnosis & Management in
Psychiatric-Mental Health across the
Lifespan I Practicum Review |Weeks 5-8
Covered| Questions and Verified Answers|
100% Correct- Chamberlain
Q: Behavioral theory
Answer:
-Personality is a result of the interaction between an ind. and their environment.
-focus on observable and measurable behavior
-Skinner

associated with the concept of operant conditioning, using rewards and punishments to increase
or decrease a behavior
-Pavlov
Russian Physiologist, father of behaviorism, associated with classical conditioning, Pavlov dog,
Q: Cognitive theory
Answer:
-Study of mental processes and complex behaviors
-Albert Bandura combines concepts of observing, thinking, and behaving.
-Tying external behaviors in with internal mental processes that facilitate them
learning, memory, language development, mental problem solving.
Q: Cognitive Distortions
Answer:
-faulty, exaggerated, or irrational thinking patterns
cause ind’s to inaccurately perceive reality
lead to (-) emotions & psychopathological states, including depression & anxiety

Q: common cognitive distortions
Answer:
-Should statement

“I shouldn’t yell at my kids. I should always be able to keep my temper. I’m the adult here.”
-All-or-nothing thinking
“I got an A- on the biology exam! I never get below an A. I am such a complete failure!”
-Catastrophizing
“I know my relationship is in trouble. If my girlfriend leaves, I know I’ll never find someone
else and will be alone forever.”
-Filtering
“I just read my student evaluations for the term. While they’re almost all positive, one student
felt that I was insensitive and never responded promptly even though I answered every email
within 24 hours. I’m a terrible teacher.”
-Overgeneralization
“Every single time I work the night shift at the hospital, they always give me the worst
assignments! It’s always a nightmare!”
-Mind reading
“I was at lunch with my friend today. She kept looking at her phone the whole time. I just know
she didn’t want to be there and is bored with our friendship.”
-Emotional reasoning
“I started a diet on Monday and was doing well until they brought in pizza for lunch on
Thursday. I feel like I’ll never be able to succeed at this, so I’m giving up.”
Q: Cognitive Techniques for Stabilization
Answer:
-Socratic dialogue (SD)
-Decatastrophizing

Q: Socratic dialogue (SD)
Answer:
-hallmark of CBT
-helps facilitate guided discovery
-therapist guides the client through a series of questions & answers to draw out the client’s
automatic thoughts & assumptions

collaboratively examine the logic underlying the assumptions
ID thought processes that may be creating problems
-can be used to:
facilitate cognitive reappraisal
information processing
emotional regulation
support tx processes
Q: Socratic questions
Answer:
-Socratic questions
What is the evidence your belief is true?
What is the evidence your belief is not true?
-Alternative Explanation Socratic Questions
Is there another point of view?
Are you paying attention to only one aspect of the situation?
Are you misinterpreting the evidence?
Are you making assumptions?
-Impact of the automatic thought Socratic Question
What is the effect of believing “If I’m not perfect then I’m a failure?”
-Distancing Socratic Question
What would you advise a friend who told you something similar?
-Problem solving Socratic Question
What would be good to do now?
What would you like to do about this situation?
Q: Decatastrophizing

Answer:
-Catastrophic thinking

common for clients with anxiety
focusing on most (-) outcome of a situation
-Decatastrophizing
cognitive restructuring technique
used to explore fears
help challenge catastrophic thinking
-examining the outcome the client considers to be the “worst possible”
developing a plan of action to address that outcome to decrease anxiety
Q: Valerie is a 34-year-old who presents for therapy with symptoms of anxiety and depressive
disorder. She has been in a relationship with her partner for the past 12 years. She feels like her
partner makes all the decisions in the relationship, and when Valerie’s opinions differ, she does
not feel comfortable sharing her thoughts. She states, “If my partner can’t figure out what my
needs are after so many years, I don’t know how we can save this relationship.”
What can you use to assist the client?
Assertiveness training
Bibliotherapy
Contingency management
Behavioral rehearsal
Answer:
Assertiveness training
Rationale: Assertiveness training can assist clients who are experiencing symptoms of
depression, anxiety, and low self-worth. It may help clients learn how to express their point of
view in a respectful manner. The client and therapist may use role-play to practice verbal and
nonverbal behaviors and improve assertiveness.
Q: Dustin is a 24-year-old who presents for therapy with symptoms of anxiety. He has a remote
position with a large company and rarely meets with colleagues or clients in person. When he
does have an in-person meeting, he states “I feel like an idiot whenever I open my mouth. I’m
always tripping over my words, and I feel so awkward.”
What can you use to assist the client?
Assertiveness training
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cognitive-behavioral therapy
-focus on how well individuals can adapt cognitively and functionally to their environments
-short-term, structured, goal-oriented form of psychotherapy
-stresses necessity of challenging maladaptive thoughts that lead to behavioral problems
-first emerged in 1955
-most widely practiced psychotherapy
-help clients recognize and address cognitive distortions

by Albert Ellis, widely known as the grandfather of cognitive behavior therapy
-Beck
originally trained in psychoanalysis, pioneered cognitive therapy in the 1960s, through his research on depression
also developed the popular Depression Inventory instrument

CBT Relationship to Nursing Theory
-Orem’s self-care deficit nursing theory

provides a framework to view CBT as a supportive intervention
fosters effective self-care behaviors

-Roy’s Adaptation Theory

premise that individuals use coping mechanisms to adapt to stimuli, both internal and external
share underpinnings with CBT.

Indications for CBT
-treatment of a wide range of diagnoses

depression
anxiety disorders
substance use disorders
eating disorders
severe mental illness
PTSD

Principles of CBT include:
-way an ind cognitively structures thoughts about self & the world determines how the ind feels & behaves
-Dysfunctional thoughts are rooted in irrational assumptions
-Dysfunctional thinking and learned patterns of maladaptive behavior contribute to psychological problems
-Ind’s can learn more adaptive behaviors which can relieve symptoms & improve quality of life
-CBT is (+) & stresses collaboration & active participation
-CBT includes action plans in the form of therapy homework

Role of the Psychotherapist in CBT
-using a structured, collaborative approach to help clients recognize and reevaluate cognitive distortions
-help clients:

better understand the behaviors of others
develop improved coping skills
-Psychoeducation
-Homework
to help clients reinforce & build on what was learned during the therapy session

motivational interviewing (MI)
-helps individuals prepare for change
-person-centered, evidence-based approach to behavior change
-using a collaborative, goal-oriented communication style
-empowers clients to draw on their meanings & capacities to facilitate change

addressing issues with ambivalence and resistance
-grew out of William R. Miller’s clinical practice working with clients with substance use disorders in the 1980s
collaborated with Stephen Rollnick to write book: Motivational interviewing

Indications for MI
-reduction of substance use and health promotion
-improving medication adherence in clients with schizophrenia

MI Guiding Principles
-acceptance
-empathy
-compassion
-respect of client autonomy
-acknowledgment of the client’s strengths & efforts
-Spirit of MI

Partnership, compassion, acceptance, evocation

MI Role of the Psychotherapist
represented by the mnemonic RULE:

Resist the righting reflex
Understand the patient’s motivation
Listen to the patient
Empower the patient

OARS
Communication skills for MI:
-Open questions

cannot be answered with a yes or no, require elaboration

-Affirming

provide encouragement, are (+) comments on a client’s strengths or efforts

-Reflecting

mirror the content or feelings explicitly or implicitly stated by the client
convey empathy, demonstrate listening, highlight emotions & beliefs, • provide opportunities for the client to elaborate on their concerns
empower clients to take control of the conversation
recommended to use at least two reflections for every question

-Summarizing

links together what has been stated to help the client organize their experiences

MI Phases of the Change Process
-engagement

establishment of trust & a helping relationship between the therapist & client
uses reflections that communicate understanding

-focusing

identification of the direction or target of the change
uses open-ended questions

-evoking

identifying the client’s motivation for change and evoking hope
uses reflections and summaries

-planning

creating a plan for change

acceptance and commitment therapy (ACT)
-helps individuals accept life’s challenges while focusing on their values and goals

learning how to relate to thoughts & feelings which impact life rather than changing those thoughts & feelings
-referred to as a “third wave” CBT therapy
-Accepting reactions and being present
-Choosing a valued direction
-Taking action
-Used for:
depression, anxiety, substance use, chronic pain, transdiagnostic combinations of conditions

solution-focused therapy (SFT)
-future-oriented approach
-helps client ID problems & construct solutions that will result in change
-postmodern thinking

reality is shaped by multiple and conflicting “truths” & constructed through human interaction
there are as many stories of meaning as there are people involved
-fourth force of psychotherapy
transpersonal, going beyond the ideas of humanness, identity, and self-actualization
-client is considered to be the expert of their lives
-focus from the problem to the solution
-grew out of the work at the Brief Family Therapy Center in Milwaukee in the 1970s
influenced by many psychotherapists, work at the Mental Research Institute in California, and the philosophies of Buddhism and Taoism

solution-focused therapy Key Concepts and the Role of the Psychotherapist
-Solutions talk

Shift talk from problems to solutions

-Positive orientation

Shift focus from problems to new possibilities

-Looking for what is working

Focus on the exceptions within problem patterns

Indications for SFT
-used for individual or group therapy across settings

marriage, family, and child therapies
trauma
postpartum depression
depression
eating disorders
severe mental illness

how SFT is used to alleviate anxiety
4-Step Approach for Overcoming Anxiety

-Identify the meaningful parts of life that the anxiety is blocking.

-Shift the focus away from the anxiety itself toward the meaningful goal.

-Create a list of positive messages that would motivate you toward that goal.

-Be gentle with yourself – you’re not alone. Many of the people you meet may be working through something similar.

Behavioral theory
-Personality is a result of the interaction between an ind. and their environment.
-focus on observable and measurable behavior
-Skinner

associated with the concept of operant conditioning, using rewards and punishments to increase or decrease a behavior
-Pavlov
Russian Physiologist, father of behaviorism, associated with classical conditioning, Pavlov dog,

Cognitive theory
-Study of mental processes and complex behaviors
-Albert Bandura combines concepts of observing, thinking, and behaving.
-Tying external behaviors in with internal mental processes that facilitate them

learning, memory, language development, mental problem solving.

Cognitive Distortions
-faulty, exaggerated, or irrational thinking patterns

cause ind’s to inaccurately perceive reality
lead to (-) emotions & psychopathological states, including depression & anxiety

common cognitive distortions
-Should statement

“I shouldn’t yell at my kids. I should always be able to keep my temper. I’m the adult here.”

-All-or-nothing thinking

“I got an A- on the biology exam! I never get below an A. I am such a complete failure!”

-Catastrophizing

“I know my relationship is in trouble. If my girlfriend leaves, I know I’ll never find someone else and will be alone forever.”

-Filtering

“I just read my student evaluations for the term. While they’re almost all positive, one student felt that I was insensitive and never responded promptly even though I answered every email within 24 hours. I’m a terrible teacher.”

-Overgeneralization

“Every single time I work the night shift at the hospital, they always give me the worst assignments! It’s always a nightmare!”

-Mind reading

“I was at lunch with my friend today. She kept looking at her phone the whole time. I just know she didn’t want to be there and is bored with our friendship.”

-Emotional reasoning

“I started a diet on Monday and was doing well until they brought in pizza for lunch on Thursday. I feel like I’ll never be able to succeed at this, so I’m giving up.”

Cognitive Techniques for Stabilization
-Socratic dialogue (SD)
-Decatastrophizing

Socratic dialogue (SD)
-hallmark of CBT
-helps facilitate guided discovery
-therapist guides the client through a series of questions & answers to draw out the client’s automatic thoughts & assumptions

collaboratively examine the logic underlying the assumptions
ID thought processes that may be creating problems
-can be used to:
facilitate cognitive reappraisal
information processing
emotional regulation
support tx processes

Socratic questions
-Socratic questions

What is the evidence your belief is true?
What is the evidence your belief is not true?

-Alternative Explanation Socratic Questions

Is there another point of view?
Are you paying attention to only one aspect of the situation?
Are you misinterpreting the evidence?
Are you making assumptions?

-Impact of the automatic thought Socratic Question

What is the effect of believing “If I’m not perfect then I’m a failure?”

-Distancing Socratic Question

What would you advise a friend who told you something similar?

-Problem solving Socratic Question

What would be good to do now?
What would you like to do about this situation?

Decatastrophizing
-Catastrophic thinking

common for clients with anxiety
focusing on most (-) outcome of a situation
-Decatastrophizing
cognitive restructuring technique
used to explore fears
help challenge catastrophic thinking

-examining the outcome the client considers to be the “worst possible”

developing a plan of action to address that outcome to decrease anxiety

Valerie is a 34-year-old who presents for therapy with symptoms of anxiety and depressive disorder. She has been in a relationship with her partner for the past 12 years. She feels like her partner makes all the decisions in the relationship, and when Valerie’s opinions differ, she does not feel comfortable sharing her thoughts. She states, “If my partner can’t figure out what my needs are after so many years, I don’t know how we can save this relationship.”
What can you use to assist the client?

Assertiveness training
Bibliotherapy
Contingency management
Behavioral rehearsal
Assertiveness training

Rationale: Assertiveness training can assist clients who are experiencing symptoms of depression, anxiety, and low self-worth. It may help clients learn how to express their point of view in a respectful manner. The client and therapist may use role-play to practice verbal and nonverbal behaviors and improve assertiveness.

Dustin is a 24-year-old who presents for therapy with symptoms of anxiety. He has a remote position with a large company and rarely meets with colleagues or clients in person. When he does have an in-person meeting, he states “I feel like an idiot whenever I open my mouth. I’m always tripping over my words, and I feel so awkward.”
What can you use to assist the client?

Assertiveness training
Bibliotherapy
Contingency management
Behavioral rehearsal
Behavioral rehearsal

Rationale: Behavioral rehearsal can assist clients who experience anxiety with social skills or interactions with others. Rehearsal may be conducted using guided imagery where the client pictures themselves responding appropriately, or the client and therapist may choose to explore a behavioral rehearsal using role-play.

Corinne is a 46-year-old who presents for therapy with symptoms of depression. The therapist recommends that Corinne read Cognitive Behavioral Therapy in 7 Weeks by Dr. Seth J. Gillihan between sessions.
What can you use to assist the client?

Assertiveness training
Bibliotherapy
Contingency management
Behavioral rehearsal
Bibliotherapy

Rationale: CBT therapists may prescribe specific readings or self-help books related to the client’s condition as an adjunct to in-session work.

Tina is a 52-year-old who presents with depression and obesity. She has struggled with her weight for the last several years. The therapist implements a series of rewards when Tina adheres to treatment goals.
What can you use to assist the client?

Assertiveness training
Bibliotherapy
Contingency management
Behavioral rehearsal
Contingency management

Rationale: Contingency management reinforces or rewards positive behavioral changes. The client and therapist can work together to identify appropriate rewards; for instance, Tina may choose to reward herself for maintaining an exercise regimen by scheduling a relaxation massage.

Amina is a 40-year-old who presents for therapy. She reports that she has felt “depressed” most of her life but never sought mental health services. She discloses that she was a victim of childhood incest and neither reported the abuse nor discussed it with anyone before this time. She feels that the time is right to do therapy. The psychiatric mental health nurse practitioner (PMHNP) selects solution-focused therapy (SFT) to create a warm and supportive climate in which the client can identify her resources to create a shift from the past to the present, integrate her memories, and empower herself beyond her victimization.
Which of the following provider statements or question prompts are congruent with SFT? Select all that apply.

“What needs to happen today so that when you leave, you’ll think this was a good session?”

“I can see that things have been difficult for you. How have you managed to carry on and prevent things from becoming worse?”

“How bad is the problem? What would it take to move one point higher?”

“Between now and the next time we meet, observe what happens in your life that you want to continue.”
“What needs to happen today so that when you leave, you’ll think this was a good session?”

“I can see that things have been difficult for you. How have you managed to carry on and prevent things from becoming worse?”

“How bad is the problem? What would it take to move one point higher?”

“Between now and the next time we meet, observe what happens in your life that you want to continue.”

Rationale: Joining questions helps the therapist to connect with and accommodate the client’s world. Coping questions help the client to identify resources that may have gone unnoticed. Scaling questions helps the client to pay attention to what they are doing and how they can take steps that lead to the changes they desire. Future-oriented questions help the client to shift their focus from problems to envisioning a better life.

group therapy first appeared in the _
1940s
-grew out of the need to efficiently treat large groups of psychiatrically disturbed soldiers following World War II

figures in group therapy
-Joseph Moreno

psychodrama to enable veterans to participate in group dramatizations, reenact or role-play scenarios in their past and present
learn to better manage fears and anxieties

-Wilfred Bion

identified fundamental patterns that could disrupt group work

-Samuel Slavson

used psychoanalytic approaches in working with groups of disturbed children and adolescents

psychodrama
Therapy in which clients act out personal conflicts and feelings in the presence of others who play supporting roles

Stages
-the warm up

getting to know each other
-the drama
the enactment
-sharing

Group therapy
-form of psychotherapy
-group of clients meets to discuss problems or concerns under the guidance of a therapist
-one to two hours per week either online or in-person
-may be designed to address a specific problem or diagnosis or may be more general
-benefit, provides opportunity to expand access to care & efficiency

therapists can provide tx to several clients at once
more cost-effective than individual therapy

Mindfulness- and cognitive-based group therapy has shown efficacy for ________________
schizophrenia spectrum disorders

Group therapy has also shown efficacy in helping clients with physical diagnoses such as ________________________
neurological conditions, chronic pain, and cancer

Principles of Group Therapy
Existential psychoanalyst Irvin Yalom identified eleven principles that underpin group therapy:

Instillation of hope
Universality
Imparting information
Altruism
Corrective recapitulation of the primary family group
Development of socializing techniques
Imitative behavior
Interpersonal learning
Group cohesiveness
Catharsis
Existential factors

catharsis
the process of releasing, and thereby providing relief from, strong or repressed emotions.

Altruism
unselfish regard for the welfare of others

Nikki typically pouted through group meetings. When asked about her silence, she said she felt other members were favored and that she wanted to quit the group and do therapy on her own. Over time, she saw that her feelings stemmed from her jealousy of her sister and was able to address her feelings.
Which principle of group therapy is this an example of?
Corrective recapitulation of the primary family group

Rationale: Corrective recapitulation of the primary family group helps group members work through unresolved family issues, such as sibling rivalry. Group therapy helps members process unresolved family conflicts.

Kesha told the group that the most important aspect of therapy was just having a group of people she could talk to, that wouldn’t walk out on her.
Which principle of group therapy is this an example of?
Group cohesiveness

Rationale: Group cohesiveness occurs when members feel they belong and are unconditionally accepted by the other members. Group cohesion correlates with positive outcomes.

At home, Tuan used communication strategies he observed in group therapy to try to improve his relationship with his daughter.
Which principle of group therapy is this an example of?
Imitative behavior

Rationale: Learning from the therapy of others helps members experiment or try on new behaviors.

Van recently joined group therapy for sexual abuse survivors and listened to others talk about their feelings of shame, guilt, rage, and uncleanliness which mirror his feelings.
Which principle of group therapy is this an example of?
Universality

Rationale: Being part of a group of people who have the same experiences helps members feel that they are not alone and what they are going through is universal. A feeling of universality is a fundamental step in healing for clients burdened by shame, stigma, and self-blame.

Stasia joined group therapy following the recent death of her child. Group members helped her to anticipate feelings associated with significant days in her first year of bereavement, such as birthdays, anniversaries, and holidays.
Which principle of group therapy is this an example of?
Imparting information

Rationale: Group members help one another by sharing information. Information about the natural cycle of bereavement can help Stasia realize there is a sequence of pain and a lessening of distress as the stages are experienced.

Madison told the group how she shoplifts clothes, makeup, and other items when life feels out of control. She noticed that she felt better after sharing.
Which principle of group therapy is this an example of?
Catharsis

Rationale: Sharing feelings and experiences with group members can help relieve pain, guilt, or stress. Group members may benefit from witnessing a peer in emotional catharsis.

Sindhu is typically withdrawn in group therapy. She developed a large axillary lymph node and underwent a biopsy. She arrived at the next meeting animated and wanted to plunge into her feelings of fear about the implications of her diagnosis.
Which principle of group therapy is this an example of?
Existential factors

Rationale: Existential factors include the ultimate concerns of the human condition—death, isolation, freedom, and meaninglessness—and may be the basis of psychiatric problems. Experiencing an existential event such as possible illness may mobilize awareness that each individual is responsible for their lives, actions, and choices.

Inmates in group therapy were asked to share one thing they valued about each of the other group members.
Which principle of group therapy is this an example of?
Interpersonal learning

Rationale: Group members gain a deeper understanding of themselves through interacting with others and receiving feedback.

Jamilla just began group therapy for an eating disorder and shared that she has overwhelming shame. Another group member, Jessamine, has been in the group for a while and talked openly about how she has overcome her body shame and shame around eating, which was encouraging to Jamilla.
Which principle of group therapy is this an example of?
Instillation of hope

Rationale: Sharing insight and resources among group members are important sources of realistic, therapeutic hope. Seeing others who are coping or recovering gives hope to those at the beginning of the process.

Aroon joined therapy because of his isolation and loneliness. After joining, he monopolized the conversation talking about the weather and other details. One of the group members told him, “If you talk about feelings, I want to listen to you, but if you just talk about things like the weather, I just want to walk away.”
Which principle of group therapy is this an example of?
Development of socializing techniques

Rationale: Group members learn from each other about basic social skills and how to overcome maladaptive social tendencies.

When Raub, initially started in group therapy, he felt anxious and isolated. Over time, he became more comfortable. Recently, a new member, Anita joined the group. She appeared anxious and rarely spoke. Raub reached out to her and shared his experience with joining the group, which helped Anita feel better and gain confidence.
Which principle of group therapy is this an example of?
Altruism

Rationale: Altruism plays an important part in the healing process. People need to feel they are needed and useful. They also need to transcend themselves to consider something greater than their self-absorption.

Group Leadership
-starting a group

first step, ID the purpose & types of clients likely to benefit from the group
-Groups may be led by single leaders or co-leaders
-Leaders responsible for:
articulating ground rules and expectations
ask that clients not socialize outside of group sessions to avoid alliances that could disrupt group dynamics

Types of Groups
-Psychoeducational Groups
-Support Groups
-Self-Help Groups
-Acute Inpatient Therapy Group

Psychoeducational Groups
-most common types of therapeutic groups
-provide education to clients & families about a variety of psychiatric & mental health topics
-may provide info about a pt dx as well as encouragement to remain committed to a tx plan
-may include info about addiction, medication, self-care, and recovery
-may teach pts how to avoid maladaptive behaviors

how to engage in (+) behavioral change
-less focused on developing relationships between group members
-role of the therapist
educator
support client engagement, incorporating diff learning styles

Support Groups
-focus on providing members with an opportunity to interact and share personal experiences, feelings, or coping strategies with others who may be going through similar circumstances

serious illness, grief, or loss
-formal or informal
-may be led by professional or nonprofessional leaders

Self-Help Groups
-typically comprised of participants experiencing a common issue or concern

provide a venue for members to share struggles and successes and to help members feel less alone
-not considered a form of psychotherapy though they often help support members’ efforts to change
-substance-centered Twelve Step groups
Alcoholics Anonymous
Narcotics Anonymous
Al-Anon
-Other focuses
bipolar disorder, substance use disorder, or cancer
Grief
-members may participate for months to years
-do not have a professional formal leader

Acute Inpatient Therapy Group
-not an independent, freestanding entity

group has a complex relationship with the inpatient ward
-challenges:
client turnover
variety of psychiatric diagnoses and concerns
therapist’s time with clients is limited
Boundaries blurred, clients spending much time outside group together
-Opportunities:
engaging pts in therapeutic process
helping pts see that engagement can be helpful
assisting pts in problem identification
decreasing isolation
allowing pts to help others
reducing ward-based anxiety or tension

who identified the five phases of group development?
Tuckman (1965)
-Phases of group formation are useful in documentation and in assessing the group’s productivity.

Phases of Group Formation
-Forming
-Storming
-Norming
-Performing
-Adjourning

Forming
-getting acquainted and orientation to the group process.
-Most interactions are social as members get to know each other.

Storming
-phase is one of transition and is often marked by conflict, anxiety, and ambiguity as members define themselves by testing or acting out behaviors and define group norms.

Norming
-marked by group cohesion and the formation of the therapeutic alliance.
-The group develops standards of behavior.

Performing
-Encompasses individual and group growth.
-Members experiment with new ideas or behaviors.
-Conflict may emerge but is dealt with constructively.

Adjourning
-Involves closure for the group or an individual that left.
-Achievements are reviewed and feelings are explored about what worked (and what didn’t), and any feelings of loss.

Selena feels apprehension and asks herself: “What does the group offer me?” “What is expected of me?” “Will I fit in?”
What phase of group development?

Forming
Adjourning
Performing
Storming
Norming
Forming

Rationale: The forming phase involves getting acquainted and orientation to the group process. Most interactions are social as members get to know each other.

Garrick expresses frustration that Simone fidgets in her seat and appears disinterested while he’s talking. He shouts: “Can’t you sit still for just a minute? What’s wrong with you?”
What phase of group development?

Forming
Adjourning
Performing
Storming
Norming
Storming

Rationale: The storming phase is one of transition and is often marked by conflict, anxiety, and ambiguity as members define themselves by testing or acting out behaviors and define group norms.

Kara is excited about the topic the group is discussing but respectfully waits for David to finish speaking before expressing her enthusiasm.
What phase of group development?

Forming
Adjourning
Performing
Storming
Norming
Norming

Rationale: The norming phase is marked by group cohesion and the formation of the therapeutic alliance. The group develops standards of behavior.

Chimene emulates the therapist’s communication techniques when responding to another member of the group.
What phase of group development?

Forming
Adjourning
Performing
Storming
Norming
Performing

Rationale: The performing stage encompasses individual and group growth. Members experiment with new ideas or behaviors. Conflict may emerge but is dealt with constructively.

Leonard expresses how much he appreciates the other members of the group and how much he will miss meeting with them.
What phase of group development?

Forming
Adjourning
Performing
Storming
Norming
Adjourning

Rationale: The adjourning phase involves closure for the group or an individual that left. In this phase, achievements are reviewed and feelings are explored about what worked (and what didn’t), and any feelings of loss.

Contraindications for Group Therapy
-paranoid
-significant brain injury
-acutely psychotic
-Delusional clients

may incorporate the group into their delusions
-aggressive clients
may pose a threat to others

indications for couples, and family therapies
presence of relational difficulty is the primary indication

Family Therapy
-type of therapy that seeks to improve the functioning of a family as a unit
-Types of families:

traditional nuclear family
single-parent
blended
extended
alternative
institutional family
family by choice or chosen family (provides love and support but may not be recognized by the legal system)

Family Therapy: Underlying Assumptions
-Individuals are best understood within the context of the family system.
-The whole family is viewed as the client.
-The behavior of one family member influences all family members and the behavior of the family influences each member.
-Symptoms are viewed as an expression of family dysfunction.
-Problematic behaviors may serve a purpose for the family and may be unintentionally maintained.
-Attempts at change are best accomplished by working with the family as a whole.

Approaches to Family Therapy
-Systemic
-Structural
-Strategic
-Emotionally Focused

Systemic Approach to Family Therapy
-multigenerational framework

family is a complex, self-regulating unit that seeks to maintain homeostasis
-change in functioning of one member affects functioning of other members
-Family systems therapy seeks to change systemic factors that produce dysfunction in the family using a psychodynamic approach
goal, help members increase their self-differentiation, reduce emotional turmoil

applications for systemic family therapy
-attachment problems
-child abuse
-childhood disruptive behavior disorders
-psychosexual problems
-intimate partner violence
-substance use disorders
-mood and anxiety disorders
-adjustment to illness or disability

systemic family therapy Therapeutic techniques
-promoting self-statements
-transforming dysfunctional generational patterns
-decreasing anxiety and interrupting conflict
-detriangulating family members
-reestablishing connections between family members

Couples Therapy
-designed to improve the interactions between two individuals who are in conflict with one another

conflicts: emotional, sexual, economic, or social elements
-therapist helps the couple:
ID & address maladaptive behavior or communication patterns
finds shared resources for problem-solving
encourages personality growth & development
-goal of therapy: alleviate emotional distress & promote well-being of the partners both together and individually

Four principles of couple counseling

Build a balanced connection
Identify patterns of connection
Identify patterns of disconnection
Create new experiences of intimacy

Commonly used evidence-based psychotherapies for the tx of trauma:
-Trauma Resiliency Model (TRM)
-eye movement desensitization and reprocessing (EMDR)
-dialectical behavior therapy (DBT)

Trauma Resiliency Model (TRM)
-biologically based or bottom-up psychotherapy
-helps support clients in processing acute or cumulative trauma once preliminary stabilization skills have been learned

eye movement desensitization and reprocessing (EMDR)
-bottom-up psychotherapy
-helps clients in accessing & processing traumatic memories

dialectical behavior therapy (DBT)
-cognitive or top-down approach
-support self-regulation after trauma

Primate/Human Brain (Cortex)
-Responsible for: Higher mental functions
-Core functions: Regulating attention, feelings, and desires, complex reasoning, abstract thoughts, imagination, language, empathy
-Basic “need”: Connection and attachment to others
-When need is met: We feel LOVE
-When need is not met: We experience HEARTACHE

Mammalian Brain (Subcortical region)
might think of it as the little mouse part of the brain.
-Responsible for: Feelings and memory formation
-Core functions: Emotions, learning and memory, reward/motivation
-Basic “need”: Satisfaction and approaching rewards
-When need is met: We feel CONTENTMENT
-When need is not met: We experience FRUSTRATION

Reptilian Brain (Brain stem and cerebellum)
-Responsible for: Survival and maintenance
-Core functions: Regulating heartbeat, breathing, and other vital organs
-Basic “need”: Safety and avoiding harm
-When need is met: We feel PEACE
-When need is not met: We experience FEAR

Trauma
-any incident or series of events that overwhelm an individual’s ability to cope
-What happens inside us as a result of what happens to us
-may be emotionally disturbing or life-threatening
-may have enduring effects on emotional, psychological, physical, and spiritual well-being
-70% of adults in U.S. report having had a traumatic experience

that at increased risk of experiencing a traumatic event
gay, lesbian, bisexual, transgender, people of color, low education & socioeconomic status

experiences that may be traumatic include:
-physical, sexual, and emotional abuse
-childhood neglect
-living with someone with mental health or substance use disorders
-a sudden separation from a loved one (death, divorce, separation)
-poverty
-racism, discrimination, and oppression
-violence in the community, war, or terrorism
-disasters, natural and man-made
-serious, invasive, distressing medical illness and procedures

Neurobiology of a Traumatic Event:
disrupts the limbic system, amygdala, orbitofrontal cortex, and anterior cingulate gyrus
-amygdala or “fear center” of the brain stores the physical impact of negative emotions.

interferes with the hippocampus, which is involved with the recall of memory
causes the prefrontal cortex to function less effectively, and the brain goes into survival mode

What happens in the brain during a potentially traumatic event
-brain stem directly connected with the retina

retina sends visual info to the brain stem before higher levels of brain are aware of threat.
-predator moves closer, periaqueductal gray initiates a fight or flight response
activates the sympathetic nervous system
Heart rate goes up. Blood flow to muscles increases. Blood pressure increases. Pupils dilate
-person may enter the freeze response, or feigned death
periaqueductal gray activates the parasympathetic nervous system as well
Muscles get tight and freeze. Both gaze and breath may freeze, not a cognitive choice
-predator doesn’t move away, the person may shutdown completely
Heart rate drops. Respiratory rate drops. Some people stop breathing. Muscles become limp. Metabolism shuts down. Endorphins released.
state of “no pain”. They are no longer aware of their surroundings
During inescapable trauma

differences between the freeze and shutdown trauma responses
-Freeze

The client is HYPERaroused.
The muscles are tense and full of energy, but can’t release it.
In this stage, there are similar levels of sympathetic and parasympathetic activation.
Increased heart rate/blood pressure.
The client might say, “I feel stuck,” “I can’t move,” or “I feel like I am encased in cement.”
Eyes widen.
The body is ready to return to fight/ flight as soon as the threat passes.

-Shutdown/Collapse

The client is HYPOaroused.
The muscles are flaccid and loose.
The parasympathic nervous system is dominant.
Decreased heart rate/blood pressure/temperature.
The client may not be able to speak at all.
Blank stare.
Sensory info stops at the thalamus. It doesn’t reach the cortex (so it’s not integrated). The client is less aware of their internal and external world.
Endorphins release to numb pain. Dynorphins release, which can make the client feel detached from their body.
Can result in fainting.

impact of trauma on Semantic Memory
-What it is: The memory of general knowledge and facts.
-Example: You remember what a bicycle is.
-How trauma can affect it: Trauma can prevent information (like words, images, sounds, etc.) from different parts of the brain from combining to make a semantic memory.
-Related brain area: The temporal lobe and inferior parietal cortex collect information from different brain areas to create semantic memory.

impact of trauma on memory
-Explicit Memory

Semantic Memory
Episodic Memory

-Implicit Memory

Emotional Memory
Procedural Memory

impact of trauma on Episodic Memory
-What it is: The autobiographical memory of an event of experience – including the who, what, and where.
-Example: You remember who was there and what street you were on when you fell off your bicycle in front of a crowd.
-How trauma can affect it: Trauma can shutdown episodic memory and fragment the sequence of events.
-Related brain area: The hippocampus is responsible for creating and recalling episodic memory.

impact of trauma on Emotional Memory
-What it is: The memory of the emotion you felt during an experience.
-Example: When a wave of shame or anxiety grabs you the next time you see your bicycle after the big fall.
-How trauma can affect it: After trauma, a person may get triggered and experience painful emotions, often without context.
-Related brain area: The amygdala plays a key role in supporting memory for emotionally charged experiences.

impact of trauma on Procedural Memory
-What it is: The memory of how to perform a common task without actively thinking about it.
-Example: You can ride a bicycle automatically without having to stop and recall how it’s done.
-How trauma can affect it: Trauma can change patterns of procedural memory. For example, a person might tense up and unconsciously alter their posture, which could lead to pain or even numbness.
-Related brain area: The striatum is associated with producing procedural memory and creating new habits.

Exposure to repeated stress leads to dysregulation of the _
nervous system

Adverse Childhood Experiences (ACEs)
-Neglect

Physical
Emotional

-Abuse

Physical
Emotional
Sexual

-Household Dysfunction

Mental illness
Substance abuse
Divorce
Parent treated violently
Incarcerated relative

4 or more ACEs
-heart disease 240%
-cancer 190%
-drug abuse 1030%
-stroke 240%
-suicide attempt 1120%
-obesity 160%
-depression 460%

6 or more ACEs
-life expectancy decreases by almost 20 years

Help regulate ANS
-Therapies
-breathing exercises
-yoga, dance, play
-helping others
-creating art
-singing, humming
-spending time in nature
-awe and gratitude

Effects of Trauma on Health and Relationships
For many capacity to respond to common stressors, experience pleasure, & maintain emotional stability are compromised
-emotional distress, dissociation, or disconnection with the present

lead to unhealthy behaviors, substance use, self-harm, risky conduct
develop stress-related medical problems

Four Key Ways Collapse/Submit Can Present in a Client

Compliance / Obedience
Treatment-Resistant Depression
Interpersonal Conflict
Social Avoidance / Desire to Isolate

Compliance / Obedience:
-might be simply going through the motions of life on autopilot.
-may feel detached from bodily experiences

feelings no longer guide their actions
-Ex: domestic violence pt may no longer be aware of fear, which keeps the person in the situation

Treatment-Resistant Depression:
-Experiencing ongoing, inescapable traumatic stress can lead to treatment-resistant depression
-defining feature of this kind of depression is learned helplessness.
-important to consider the client’s history (for example, did they experience chronic, inescapable stress?).

Interpersonal Conflict:
A patient in collapse/submit might have difficulty engaging with others and/or setting boundaries.

Social Avoidance / Desire to Isolate:
-Collapse/submit can make it difficult for a patient to engage in basic daily activities

making meals or personal hygiene.
may withdraw socially

activated responses: or _
fight or flight

avoiding responses: /
shutdown/collapse

Kahara cannot sit still in class and constantly fidgets in her seat.

activated responses (fight or flight)
or
avoiding responses (shutdown/collapse).
Activated response (fight or flight)

Connie loudly over shares personal information in public settings.

activated responses (fight or flight)
or
avoiding responses (shutdown/collapse).
Activated response (fight or flight)

Genevieve is chronically late or misses meetings.

activated responses (fight or flight)
or
avoiding responses (shutdown/collapse).
Avoiding response (shutdown/collapse)

Eunjee is very directive and controlling of how things should be done.

activated responses (fight or flight)
or
avoiding responses (shutdown/collapse).
Activated response (fight or flight)

Marshawn hides his belongings and tends to sneak things.

activated responses (fight or flight)
or
avoiding responses (shutdown/collapse).
Avoiding response (shutdown/collapse)

Norland often sleeps through class or appears zoned out.

activated responses (fight or flight)
or
avoiding responses (shutdown/collapse).
Avoiding response (shutdown/collapse)

Rhye talks about violence or intense events without emotions.

activated responses (fight or flight)
or
avoiding responses (shutdown/collapse).
Avoiding response (shutdown/collapse)

Leon is easily defensive or reactive at meetings.

activated responses (fight or flight)
or
avoiding responses (shutdown/collapse).
Activated response (fight or flight)

Circuits in the lower brain, responsible for:
emotional reactions and the defense system

With trauma-informed therapy, the client can:
“unlearn” their body’s response to trauma, manage symptoms, process feelings, heal and recover

Brain-based approaches to help clients after trauma
Top-down approaches
Bottom-up approaches

Top-down approaches
-Encourage different ways of thinking, focus on cognitive interventions
-Cognitive-Behavioral Therapy (CBT)
-Dialectical-Behavior Therapy (DBT)
-Mindfulness-based Cognitive Therapy (MBCT)

Bottom-up approaches
-Ways to cope with emotions and defenses
-Eye Movement Desensitization and Reprocessing (EMDR)
-Yoga
-Trauma Resiliency Model (TRM)

memory reconsolidation techniques are good for the _
hippocampus

The Trauma Resiliency Model (TRM)
-bottom-up approach to psychotherapy
-help pt process acute or cumulative trauma once they have learned preliminary stabilization skills
-developed by Elaine Miller-Karas, Geneie Everett, and Laurie Leitch

based on Peter Levine’s work in Somatic Experiencing

Trauma Resiliency Model (TRM) Concepts
-psychoeducation

therapist help pt understand nature of trauma & normal responses
how parts of the brain & autonomic nervous system function

-key concept is the resilient zone (RZ)

represents the optimal zone of arousal for a person in which there is a natural flow of energy and vitality
greatest capacity for balanced thinking, feeling & handling the ups & downs of life in the RZ

-goal: help clients recognize sensations associated with the RZ so they can return to the RZ when hyper- or hypo-aroused.

Trauma Resiliency Model (TRM) Skills
TRM uses a set of nine skills
-first six are stabilization skills, standalone self-care model called the Community Resiliency Model (CRM)

used throughout TRM therapy for self-care & emotional regulation
-three additional TRM components
titration, pendulation, and completion of survival response
potential for destabilizing the client

-CRM Skills

Tracking
Gesturing
Titration
Resourcing & Resource Intensification
Help Now!
Pendulation
Grounding
Shift and StaY

“What are you aware of now? Is this sensation pleasant, unpleasant, or neutral?”

What CRM skill?

Tracking
Gesturing
Titration
Resourcing & Resource Intensification
Help Now!
Pendulation
Grounding
Shift and Stay
Tracking

Rationale: Tracking skills help the client to pay attention to sensations, name them, and distinguish sensations of distress from those of well-being.

“What is it about you that helped you get through that?”

What CRM skill?

Tracking
Gesturing
Titration
Resourcing & Resource Intensification
Help Now!
Pendulation
Grounding
Shift and Stay
Resourcing and Resource Intensification

Rationale: Resource questions can be used to shift from thoughts or feelings of stress or trauma to resilience.

“Place this weighted pillow in your lap and bring your attention to your body sitting in the chair.”

What CRM skill?

Tracking
Gesturing
Titration
Resourcing & Resource Intensification
Help Now!
Pendulation
Grounding
Shift and Stay
Grounding

Rationale: Grounding provides a felt sense of contact in the present moment to provide a sense of safety, security, and control.

“Let’s perform this movement together.”

What CRM skill?

Tracking
Gesturing
Titration
Resourcing & Resource Intensification
Help Now!
Pendulation
Grounding
Shift and Stay
Gesturing

Rationale: Soothing gestures can be used as a form of self-regulation.

“Count backward as you walk around the room.”

What CRM skill?

Tracking
Gesturing
Titration
Resourcing & Resource Intensification
Help Now!
Pendulation
Grounding
Shift and Stay
Help Now!

Rationale: Help Now! strategies decrease or increase activation within the nervous system when a person is hyper- or hypoaroused.

“Shift your awareness by imagining your dog for at least 15 seconds.”

What CRM skill?

Tracking
Gesturing
Titration
Resourcing & Resource Intensification
Help Now!
Pendulation
Grounding
Shift and Stay
Shift and Stay

Rationale: Shift and Stay strategies relieve distress by shifting awareness from distressing sensations to more pleasant or neutral sensations.

“Describe the sensation you’re having, then think about it as an object and focus on a single, small part of that object.”

What CRM skill?

Tracking
Gesturing
Titration
Resourcing & Resource Intensification
Help Now!
Pendulation
Grounding
Shift and Stay
Titration

Rationale: Titration strategies help the client to slow the processing of trauma into small, manageable sensations to build tolerance and avoid overwhelming sensations and retraumatization.

“You’re feeling the tension in your chest. Focus now on feeling the parts of your body that are not tense and notice any sensations that arise when you make this shift.”

What CRM skill?

Tracking
Gesturing
Titration
Resourcing & Resource Intensification
Help Now!
Pendulation
Grounding
Shift and Stay
Pendulation

Rationale: Pendulation is used along with titration and is often referred to as looping, switching between resourcing and titration, to help the client move between a state of arousal triggered by a traumatic event and a state of calm.

Eye Movement Desensitization and Reprocessing therapy (EMDR)
-used for neural network integration for processing traumatic and adverse life events
-Most efficient trauma tx
-Used for:

PTSD, depression, SUDs, anxiety, panic disorder & phobias
-developed by Dr. Francine Shapiro in the late 1980s
-eight-phase psychotherapy
focuses on earlier life experiences
present stressors or triggers
desired thoughts & actions for the future

phases of Eye Movement Desensitization and Reprocessing therapy (EMDR)

Client Hx & Tx Planning
-Assess readiness for EMDR using Dissociative Experiences Scale
Preparation
-Establish therapeutic alliance, provide psychoeducation about EMDR & relaxation strategies
Assessment
-ID aspects of the target or an image to process that best represents the traumatic injury.
Desensitization
-Create bilateral stimulation with eye movements, sound, and/or tapping.
Installing & Strengthening (+) Cognition
-Use (+) cognition with repeated eye movements when the distress has been reduced.
Body Scan
-ensure all aspects of the traumatic injury have been processed.
Closure
-self-calming strategies to end session with the pt feeling safe, psychoeducation about journaling feelings that come up after session is over.
Re-evaluation
-Determine if (+) results maintained
& ID new targets that need processing.

“window of tolerance”
resilient zone (RZ) or therapeutic window
-When you are in your Window of Tolerance, you feel like you can deal with whatever’s happening in your life
-You might feel stress or pressure, but it doesn’t bother you too much
-ideal place to be
-Working with a practitioner can help expand window of tolerance

more able to cope with challenges

How Trauma can Affect Your Window of Tolerance
When stress & trauma shrink your window of tolerance, it doesn’t take much to throw you off balance.

Hyperarousal
-Anxious, Angry, Out of Control, Overwhelmed

body wants to fight or run away

Hypoarousal
-Spacy, Zoned Out, Numb, Frozen

body wants to shut down

Areas of brain r/t traumatic experiences
Amygdala
-alarm system for stressful events

Hippocampus
-assists with learning

including memories about safety & danger

Prefrontal Cortex
-controls behavior & emotion

Elisabeth is a 30-year-old who presents for psychotherapy. Elisabeth’s eight-month-old daughter died suddenly in the night two years ago. The coroner determined the death was sudden infant death syndrome (SIDS). Elisabeth is a critical care nurse and is having difficulty understanding how her baby died so suddenly and without warning. She feels like she should have detected some symptoms of distress and feels guilty that her attempts at cardiopulmonary resuscitation (CPR) did not revive her baby. She also has disturbing memories of finding her baby dead in the crib. The psychiatric mental health nurse practitioner (PMHNP) selects EMDR as a psychotherapeutic approach.
Which of the following responses are congruent with EMDR? Select all that apply.

“Identify the 10 most disturbing experiences in your life?”

“Imagine yourself in a safe train that is speeding by upsetting scenery.”

“Choose a preferred statement, such as I did the best I could to counter your statement that the death is your fault.”

“As you think about the death, how do the words I did my best feel now?”

“Can a mother be guilty of her child’s death when there are no symptoms of distress?”

“Think about the session an
“Identify the 10 most disturbing experiences in your life?”

“Imagine yourself in a safe train that is speeding by upsetting scenery.”

“Choose a preferred statement, such as I did the best I could to counter your statement that the death is your fault.”

“As you think about the death, how do the words I did my best feel now?”

“Can a mother be guilty of her child’s death when there are no symptoms of distress?”

Rationale: A client’s history of disturbing events that might be related to the trauma might also be targeted for processing (client history and treatment planning). Clients are taught ways to relax and calm themselves to cope with distressing arousal. A safe train speeding by distressing scenery may help the client feel safe during EMDR (preparation). Having the client identify a negative belief associated with the event and a preferred statement helps support positive cognition (assessment). Repeating positive cognition after distress strengthens positive cognition (installing and strengthening positive cognition). When processing is stuck, the therapist may pose a question to simulate the connection to a positive cognition (installing and strengthening positive cognition). Trying one thing different between sessions is congruent with Gestalt therapy, not EMDR.

Dialectic Behavior Therapy (DBT) for Trauma
form of cognitive-behavioral therapy

incorporates elements of Zen Buddhism
-developed by Marsha Linehan
approach to treat individuals with chronic suicidal thoughts & BPD
-may also be used with PTSD
shares similar elements with BPD: hyperarousal, hx of invalidation, dissociation, affective instability
often comorbid with personality disorder, depression, substance use
-DBT shows efficacy as a component of:
tx for complex trauma
changing behavioral patterns r/t self-harm
-dialectics is the balance between acceptance and change

The functions of dialectical treatment include:
-enhancing client capabilities
-motivating clients to use and expand capabilities
-helping clients generalize capabilities beyond the therapeutic relationship
-improving the therapist’s skills
-structuring the environment to enhance the therapeutic process

Four Treatment Modes of Dialectic Behavior Therapy (DBT)
typically delivered as a 1-year outpatient treatment modality.

-Mode 1: Individual therapy (1 hour per week)

-Mode 2: Group skills training (2.5 hours per week)

-Mode 3: Therapist consultation team (1 – 1.5 hours per week)

-Mode 4: Phone coaching (as needed)

Four skills of DBT
-Mindfulness

Being aware of the present moment without judgment
Observing, describing, participating

-Emotion regulation

Understanding and reducing vulnerability to emotions
changing unwanted emotions

-Distress tolerance

Getting through crisis situations without making things worse
accepting reality

-Interpersonal effectiveness

Getting interpersonal objectives met
maintaining relationships
increasing self-respect in relationships

core skill of DBT which underpins the other three skills
Mindfulness

Sasha is a 22-year-old, single female who presents for psychotherapy. Sasha has a history of major depression and substance abuse disorder. She was previously prescribed various psychotropics medications that only increased her depression. She began self-medicating with her boyfriend’s pain medications to tolerate her depressive symptoms. The psychiatric mental health nurse practitioner (PMHNP) selects DBT as an adjunct to pharmacological interventions. DBT is selected to address Sasha’s problematic behavioral patterns and enhance her functioning.
In the early phase of DBT, the PMHNP helps Sasha build skills in mindfulness to enhance her awareness and self-observation. Which of the following are the most appropriate exercises to enhance mindfulness skills? Select all that apply.

abdominal breathing
wise mind
judgment diffusion
assertive listening
negotiating
relaxation
abdominal breathing
wise mind
judgment diffusion

Rationale: Mindful abdominal breathing, wise mind, and judgment diffusion are common mindfulness exercises. Assertive listening and negotiating are exercises to build interpersonal effectiveness and relaxation exercises are used to build distress tolerance skills.

Sasha also has low distress tolerance. The PMHNP helps her build distress tolerance skills as a healthier alternative than self-medicating with her boyfriend’s pain medications.
Which of the following are the most appropriate exercises to enhance distress tolerance? Select all that apply.

reducing vulnerabilities
relaxation
recognizing emotions
making a request
self-soothing
radical acceptance
relaxation
self-soothing
radical acceptance

Rationale: Radical acceptance, relaxation, and self-soothing exercises build skills in distress tolerance. Recognizing emotions and reducing vulnerabilities exercises build skills in emotional regulation. Making a request is an exercise to build interpersonal effectiveness.

In the next phase of DBT, Sasha reports that she wants to be able to feel again since her emotions have been “numbed out” due to her substance abuse. The PMHNP uses skills in emotional regulation to help Sasha learn to control her feelings rather than being controlled by them.
Which of the following are the most appropriate exercises to enhance emotional regulation? Select all that apply.

problem-solving
realistic goal setting
passive versus aggressive behavior
radical acceptance
opposite action to emotion
opposite action to emotion
problem-solving

Rationale: Opposite action to emotion and problem-solving exercises build skills in emotional regulation. Realistic goal setting is an exercise to enhance self-management. Radical acceptance builds skills in distress tolerance, whereas exercises in passive versus aggressive behavior build skills in interpersonal effectiveness.

Psychotherapy with older adults considerations
-higher prevalence of dementia
•raises need for neuropsychological screening

-higher prevalence of medical disorders

req careful consideration of physical causes of symptoms & effects of meds

Child Development:
-Physical Development

by three months, infants can lift their heads and clasp their hands
by six months, they may roll over, sit with support, and reach for objects and transfer them from hand to hand
by one year, infants can stand and start to take steps
by one year, birth weight triples and height increases by 50%
-Cognitive and Language Development
by two months, infants start to coo
by six months, infants begin to babble
by nine months, infants imitate sounds and know their name
by one year, infants begin to say words and can follow one-step commands
-Psychosocial Development
by four months, infants socially smile
by six months, infants enjoy their reflection in a mirror.
by nine months, infants enjoy peekaboo and often develop stranger anxiety
-Health History
obtain information from the parent or caregiver observation and report of infant behavior and activity
-Physical Exam
perform as much of the exam with the infant in parent or caregiver’s lap as possible
keep familiar toys or blankets with infant
feed hungry infants before examining them
use a toy or object or play for distraction
-Health Promotion
administer immunizations per the recommended schedule
newborn screens: genetic and metabolic screening; hearing screen, screen for congenital heart disease; bilirubin screening
anticipatory guidance: illness prevention; anticipated growth and development; and when to call for advice

Child Development: Toddler (1 to 4 years)
-Physical Development

after age 2, growth is about 5 centimeters (cm) and gain about 2-3 kilograms (kg) per year
gross motor skills develop from walking to running, jumping, climbing, and riding a tricycle
fine motor skills develop from beginning to feed self, to scribbling, to drawing a person and writing letters
-Cognitive and Language Development
by two years, toddlers can speak in two to three-word sentences and have a vocabulary of up to 300 words
by four years, preschoolers form complex sentences
-Psychosocial Development
toddlers develop from pretend play, to parallel play, to actual play
toddlers have a desire for independence
toddlers are impulsive with poor self-regulation and may have temper tantrums
-Health History
obtain information from the parent or caregiver observation and report of toddler behavior and activity
during the health history assessment, the nurse practitioner (NP) can establish rapport with the child and parent or caregiver
-Physical Exam
toddlers may be alarmed at the examiner and may be uncooperative
engage children in age-appropriate conversation to gain trust
complete most of the exam with the child in the parent or caregiver’s lap
when examining siblings during the same appointment, approach the oldest child first because they may be more cooperative
conduct the exam with the least distressing procedures (i.e., eyes and neck) to the most distressing procedures (i.e., throat and ears)
utilize patience, distraction, and play
-Health Promotion
administer immunizations per the recommended schedule
injury and illness prevention: use of car seats, tobacco exposure, supervision
nutrition and exercise: obesity assessment, healthy meals, and snacks
oral health: teeth brushing and dental visits
screening tests: vision starting at age 3; hearing starting at age 4; hematocrit and lead (if high risk)

Child Development: Children (5 to 10 years)
-Physical Development

develops enhanced strength and coordination
growth is steady but slower
-Cognitive Development
become more “concrete operational” and are capable of limited logic and more complex learning
focus on the present and achievement of knowledge and skills
-Psychosocial Development
desire to “fit in” evolving self-identity and self-esteem
development of belief in their ability to thrive in different situations
-Health History
obtain information from both the child and the parent or caregiver
during the health history assessment, the NP can establish rapport with the child and parent or caregiver
engage in conversation by discussing what interests them, such as favorite toys, books, or television shows
-Physical Exam
parents or caregivers of children younger than 11 should stay in the room
-Health Promotion
administer immunizations per the recommended schedule
discuss experience at school, with peers, and social activities
healthy habits: nutrition, exercise, reading, sleep, screen time5

Child Development: Adolescents (11 years to adult)
-Physical Development

age of onset and duration of puberty vary widely; however, the stages follow the same sequence
puberty typically occurs for girls around age 10 through 14 years
puberty typically occurs for boys around age 11 through 16 years
-Cognitive Development
progress from concrete to formal operational thinking
can reason logically and abstractly to consider the future implications of actions
-Psychosocial Development
the transition from primarily family influences to more autonomy and influence by friends
challenges related to identity, independence, and intimacy
establishing a supportive and nonjudgmental relationship may all lesbian, gay, bisexual, transgender, or queer youths to openly discuss sexual identity and/or concerns
-Health History
utilize a comfortable and confidential environment
informally discuss friends, school, and activities using specific questions to build trust and rapport, then transition to more open-ended questions
a valuable technique to elicit questions about important or sensitive topics is to say, “other kids your age often have questions about…”
use the mnemonic HEADSSS to recall parts of a psychosocial assessment:
‣ Home environment
‣ Education, employment, eating
‣ Activities
‣ Drugs
‣ Sexuality, Suicide/depression, Safety
-Physical Exam
unique to adolescents is puberty and growth
maintain modesty
ask adolescents about their preferences for exams to be alone or with a parent or caregiver in the room
-Health Promotion
administer immunizations per the recommended schedule
healthy habits and behaviors: seat belts, drunk driving, obesity prevention, physical activity, screen time
sexuality: confidentiality, safer sex, contraception if needed
high-risk behaviors: prevention, peer interactions
social achievement: activities, school, peers, future planning

Freud’s Stages of Psychosexual Development
-Oral stage (Stage I): Birth to 1 year

Mouth

-Anal stage (Stage II): 1 to 3 years

Bowel and bladder control

-Phallic stage (Stage III): 3 to 6 years

Genitals

-Latent stage (Stage IV): 6 years to puberty

Libido inactive

-Genital stage (Stage V): Puberty to death

Maturing sexual interests

Freud’s early developmental theory on psychosexual development
-personality is shaped in childhood

maturation into a well-functioning adult requires sequential progression through each psychosexual stage
-instinct or libidinal drives repressed or unmet
fixation occurs & the personality is affected

Anquiette smokes, drinks, and bites her nails nonstop.

match the psychosexual stage with the corresponding fixated behaviors:
-Stage I: 0-1 year, oral, mouth
-Stage II: 1-3 years old, anal, bowel, and bladder
-Stage III: 3-6 years old, phallic, genitalia
-Stage IV: 6-12 years old, latency, dormant sexual feelings
-Stage V: Puberty to death, genital, mature sexual feelings
-Stage I: 0-1 year, oral, mouth

Rationale: Oral desire is the pleasure center for the infant. When oral needs are unmet, libidinal energy fixates, resulting in latent aggressive or passive tendencies, such as smoking, nail-biting, thumb-sucking, excessive drinking.

Quinn is very possessive of his mother and stomped out of the room when his father hugged and kissed her.

Rationale: The pleasure center for the phallic stage is the genitalia. Young children become aware of their genitalia and distinguish the differences between boys and girls. When conflict arises in this stage, fixation with the opposite sex parent occurs, called the Oedipus complex for boys and the Electra complex for girls. Failure to resolve the complex may result in adulthood vanity and ambition.

Nikita is only interested in playing basketball and University activities and has difficulty creating relationships.

Rationale: During the latent stage, the libido is repressed or sublimated; there is no corresponding erogenous zone. The child begins to act on impulses indirectly by focusing on school, sports, and building relationships. Fixation at this stage results in the child’s inability to form healthy relationships as an adult.

Saed has a compulsive need for order and neatness and is a self-proclaimed perfectionist.

Rationale: During the anal stage of psychosexual development, the libido is focused on the anus. When toileting becomes stressful or is punished, fixation can manifest in anal retentiveness (orderliness and tidiness) or anal expulsiveness (messiness and prone to outbursts).

Vonnia has serial relationships with men. No relationship lasts more than a few months before she feels the need to leave the relationship.

Rationale: During this stage, the ego becomes fully developed and independence is sought. Fixation during this period leads to the inability to develop meaningful healthy relationships.

Erikson’s Stages of Psychosocial Development
-Stage 1: Infancy period – Trust vs mistrust
-Stage 2: Early childhood period – Autonomy vs shame, doubt
-Stage 3: Play age period – Initiative vs guilt
-Stage 4: School age period – Industry vs inferiority
-Stage 5: Adolescence period – Identity vs identity confusion
-Stage 6: Young adulthood period – Intimacy vs isolation
-Stage 7: Adulthood period – Generativity vs stagnation/self-absorption
-Stage 8: Old age period – Integrity vs despair

*each stage, ind must resolve two conflicting ideas to become a well-functioning adult

Piaget’s Stages of Cognitive Development
-Sensorimotor stage: Birth to 2 years

-Preoperational stage: 2 to 7 years

-Concrete operational stage: 7 to 11 years

-Formal operational stage: 12 years & up

Margarita scolded her brother who ran down the hallway at the hotel where they were staying. She told him that even though they were allowed to run at home, they can’t run in a hotel.

match the cognitive stage with the corresponding developmental behaviors:
-Sensorimotor
-Preoperational
-Concrete operational
-Formal operational
Formal operational

Rationale: In the formal operational stage, adolescents learn to apply logical rules to abstract concepts, moving beyond facts (what is) to problem-solving (what is possible). Essential skills developed in this stage include hypothetical-deductive thought, propositional thought, isolating variables, and examining combinations.

Nile pulls down the pillow to look for a hidden toy.

match the cognitive stage with the corresponding developmental behaviors:
-Sensorimotor
-Preoperational
-Concrete operational
-Formal operational
Sensorimotor

Rationale: During the sensorimotor stage, a child experiences the world through sensation and movement. This stage is marked by the child’s understanding of object permanence: the ability to understand that objects exist independent of their interaction with them.

Ibrahim understands that 10 cookies are constant in number whether stacked into a tower or spread out on the table.

match the cognitive stage with the corresponding developmental behaviors:
-Sensorimotor
-Preoperational
-Concrete operational
-Formal operational
Concrete operational

Rationale: During the concrete operational stage, a child learns to apply logical rules to concrete or tangible objects and mentally transform what is seen or heard. The concept of conservation is an essential skill during this stage, where values remain unchanged during visual transformation.

Nithin uses a box as a boat to “sail out to sea.”

match the cognitive stage with the corresponding developmental behaviors:
-Sensorimotor
-Preoperational
-Concrete operational
-Formal operational
Preoperational

Rationale: In the preoperational stage, representational thought through signs and symbols occurs. Children mimic behaviors and use their imagination to project an idea onto an object, symbolically. Mastery of this stage indicates that a child can think and assimilate knowledge rather than simply act on present objects.

Psychotherapy with Children and Adolescents may involve:
an individual child or adolescent, a group, a family, or multiple families

Psychotherapy with Children and Adolescents: Development considerations
-developmental level will impact how they:

reason
approach relationships
regulate emotion and behavior
communicate

-Developmental considerations

inform the diagnostic process
guide tx planning

Psychotherapy with Children and Adolescents: Family involvement
-Family involvement in tx & decision-making

a norm in child and adolescent psychotherapy
-invite parents to share the hx of the child or adolescent’s chief complaint & prior tx, medical & developmental hx, & behavioral info privately with the therapist ahead of the session
avoid feelings of criticism or discouragement
-collaborate with parent or caregiver as a tx partner

Psychotherapy with Children and Adolescents: Resiliency
-therapists work to promote resiliency in children and adolescents

using a strength-based orientation that supports functioning, self-regulation, and helps them deal with the challenges they face

Psychotherapy with Children and Adolescents: Systems involvement
-Therapists must consider the systems that surround children & adolescents & promote their development

family
school
peers
the community
-Therapy can help promote the child/adolescent’s socioemotional competence
-help develop a community support system

Special Considerations in Psychotherapy with Children and Adolescents
-Setting
-Establishing a Therapeutic Relationship
-Common Approaches to Tx

Therapy Setting
-appropriate for client level of development
-Toys provide a vehicle for young clients to explore/act out their concerns through play

Observing/interacting through play with children may provide valuable assessment info
-Adolescents may prefer:
to draw
play with a fidget while talking

Children and Adolescents: Establishing a Therapeutic Relationship
-Play therapy may be the therapist’s primary communication modality and may help build a trusting relationship

helps process emotions and feelings
use toys to express themselves
dolls, animals, art supplies
-safe play

Play therapy can address:
-Depression
-ADHD
-Impulsiveness
-Conduct disorder, like bullying
-Aggression
-Anxiety/fearfulness
-Low self-esteem
-Social withdrawal
-Reading difficulties & other school problems

Children and Adolescents: Common Approaches to Tx
-Psychodynamic
-Motivational Interviewing
-Parent Training
-Problem-Solving Skills Training
-Cognitive Behavioral Therapy (CBT)
-Eye Movement Desensitization and Reprocessing (EMDR)
-Group Therapy

Children and Adolescents: Psychodynamic
-primary modality in the treatment of younger children & complex cases
-Psychodynamic techniques

allow pt to express emotions and experiences nonverbally through activities such as:
‣ free play
‣ dolls
‣ expressive art supplies
‣ sand trays
‣ movement

Children and Adolescents: Motivational Interviewing
-often used as a brief intervention for adolescents at risk for SUD
-Substance Abuse and Mental Health Services Administration (SAMHSA, 2021) endorses the use of the SBIRT

Screening
Brief Intervention
Referral
Treatment
‣ model to ensure that adolescents are screened for risk of substance use
‣ 1-4 session intervention used to increase the adolescent’s motivation to decrease substance use

Children and Adolescents: Parent Training
-The Oregon Model (PMTO)

training program for parents and other primary caregivers with children between the ages of 2-18 years who have disruptive behaviors:
‣ conduct disorder
‣ oppositional defiant disorder
‣ anti-social behaviors
uses a behavioral family systems approach
Parents taught:
‣ positive reinforcement methods
‣ limit setting
‣ how to model socially appropriate behaviors
‣ problem-solving skills

Children and Adolescents: Problem-Solving Skills Training
-focuses on cognitive processes
-effective for doing individual work with children
-Solutions-focused therapy can be used to develop new skills while building confidence and strengthening relationships

Children and Adolescents: Cognitive Behavioral Therapy (CBT)
-most commonly recommended therapy with children over the age of 8 & adolescents
-helps clients with:

cognitive restructuring
changing behavior
problem-solving
-techniques adjusted to level of cognitive development

Children and Adolescents: Eye Movement Desensitization and Reprocessing (EMDR)
-used successfully in the tx of children & adolescents with:

PTSD & other trauma
depression
anxiety
phobias
-Parents /caregivers often included in sessions to promote nurturing & sense of safety
-PMHNP adapt the eight phases of EMDR to accommodate the pt’s developmental state

Children and Adolescents: Group Therapy
-may be used to help children learn strategies to improve:

emotional function and self-regulation
stress tolerance
social skills

Children and Adolescents Ethical & Legal Consideration: Confidentiality
-ind’s in psychotherapy under age 18 do not have a blanket right to confidentiality from parents
-Minors’ rights to confidentiality

governed by a complex network of federal and state laws, professional ethics, & court interpretations of law
-parents:
can req medical record, including symptoms, dx, tx plan
do not have the right to view psychotherapy notes without a court order
may not have the right to information in special situations
‣ signed a confidentiality agreement
‣ lost or given up parental rights
‣ court order prohibits access
‣ youth is emancipated

Psychotherapy with Older Adults
-Although mental illness is not a normal part of aging

14.5% over the age of 50 have some type of mental health concern
‣ 3.4% have a serious mental illness
-PMHNP must assess cognitive, affective, & physical function as well as social & family dynamics

Psychotherapy with Older Adults: Developmental Considerations
-transitions

retire
downsize living spaces
lose close friends & family
-physical changes
affect ability to participate in preferred activities or engage in self-care
-changes can impact feelings of satisfaction with life

Erikson’s Stages of Psychosocial Development (late adulthood)
-ego integrity versus despair

individuals reflect on their lives
-Successful resolution of this stage
sense of satisfaction & fulfillment with the life lived
-unsuccessful resolution
sense of regret
result in depression, loneliness, or withdrawal

Bandura’s Self-Efficacy Theory
-relates to a person’s sense of control over their functioning, motivation, behavior, and environment
-Individuals cultivate efficacy by taking on and mastering new challenges
-individuals develop confidence as they realize that they can acquire new skills and achieve goals
-individual’s sense of self-efficacy is influenced by their emotional and psychological state

PMHNP can foster self-efficacy in older adults by:
-advocating for participation in care planning
-providing opportunities to make choices
-promoting physical activity
-providing health self-management education
-encouraging social interaction
-providing positive feedback

Psychosocial Considerations in Older Adults
-Common life events experienced by older adults:

Retirement
Raising grandchildren
Caregiving for significant other
Widowhood

Older Adults Functional Considerations
-race, gender, ethnicity & social determinants of health (SDOH)

economic stability, social & community context, & healthcare access & quality
‣ contribute to wide variability in health status
-physical changes
lead to frailty, functional decline, dependency
-higher prevalence of dementia
raises need for neuropsychological screening
-often seek tx for depression r/t challenges caused by medical comorbidities & cognitive changes
-may also need support navigating healthcare, housing, & finances

psychotherapy for older adults: Transference/Countertransference
-Clients may view therapists as they would a child or grandchild
-therapist may inadvertently project their feelings, biases, or fears about aging onto the client
-Therapists may have own experiences providing care for an older adult family member, which could influence the therapist’s perspective

older adults: Common Approaches to Treatment
-cognitive-behavioral therapy (CBT)
-interpersonal psychotherapy (ITP)
-problem-solving therapy for executive dysfunction (PST-ED)
-cognitive behavioral therapy for mild dementia (CBT-MD)

for pts with cognitive impairment
-ecosystem-focused therapy (EFT)
for pts with post-stroke depression

older adults: Mindfulness-Based Interventions
-Mindfulness-based stress reduction (MBSR)

typically provided over eight weeks
shown some efficacy for novice and regular meditating adults
reduce stress and mood disturbances

older adults: Reminiscence Therapy and Life Review
-Reminiscence therapy (RT) and life review therapy (LRT)

approaches used to help older adults recall life events
promote reflection
help clients understand who they are as individuals
help clients achieve ego integrity
-RT can help improve psychosocial outcomes, cognition, communication, and quality of life for clients with dementia

Legal and Ethical Considerations: Elder Abuse
-PMHNPs must be alert for signs of elder abuse in their clients
-Worldwide

15% over age 60 experience abuse
abuse rates in community & LTC settings increased during COVID pandemic
-Psychological abuse more prevalent than physical abuse
-neglect & self-neglect also occur

Types of Elder Abuse
-Emotional abuse
-Sexual abuse
-Financial exploitation
-Neglect
-Abandonment
-Physical abuse

Which of the following are factors that contribute to elder abuse? Select all that apply.

-cognitive impairment
-aggressive behaviors
-lower household income
-psychological distress
-need for activities of daily living assistance
-shared living environment
-sharing expenses with other members living in the household
-participation in household chores
-cognitive impairment
-aggressive behaviors
-lower household income
-psychological distress
-need for activities of daily living assistance
-shared living environment

Elder abuse: Almost % of abusers are caregivers, and /_ of perpetrators are adult children or spouses
60%, 2/3

These offenders are well-intentioned. They become a caregiver expecting to provide adequate care but are beleaguered by the amount of care and lash out verbally or physically.

Match the type of offender with the description:
-Narcissistic offenders
-Sadistic offenders
-Overwhelmed offenders
-Domineering or bullying offenders
-Impaired offenders
Overwhelmed offenders

These offenders are well-intentioned but have personal problems that render them unqualified to provide care. This includes caregivers who are of advanced age, have physical or mental limitations, or have developmental disabilities.

Match the type of offender with the description:
-Narcissistic offenders
-Sadistic offenders
-Overwhelmed offenders
-Domineering or bullying offenders
-Impaired offenders
Impaired offenders

These offenders are motivated by anticipated personal gain and not the desire to help others. They tend to be socially sophisticated and gain a position of trust over the elder. Maltreatment most often occurs in the form of neglect and financial exploitation.

Match the type of offender with the description:
-Narcissistic offenders
-Sadistic offenders
-Overwhelmed offenders
-Domineering or bullying offenders
-Impaired offenders
Narcissistic offenders

These offenders are motivated by power and control and are prone to outbursts of rage. Their abuse is chronic and includes physical, psychological, and forced coercion.

Match the type of offender with the description:
-Narcissistic offenders
-Sadistic offenders
-Overwhelmed offenders
-Domineering or bullying offenders
-Impaired offenders
Domineering or bullying offenders

These offenders derive feelings of power and importance by humiliating and harming others. Signs of abuse include bite, burn, and restraint marks, as well as forms of physical and sexual assault.

Match the type of offender with the description:
-Narcissistic offenders
-Sadistic offenders
-Overwhelmed offenders
-Domineering or bullying offenders
-Impaired offenders
Sadistic offenders

Elder abuse screening
-screening is critical as victims may

fear of retaliation from their abuser
fear of being removed from the home
-impaired cognition may be unable to report the abuse
-Assessing functional & cognitive status
provides baseline for identifying their degree of dependence & vulnerability
-disheveled appearance or evidence of poor hygiene may raise suspicion of abuse
-Bruising & burns suggest physical abuse

EASI
The Elder Abuse Suspicion Index

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