Agenda Objectives 4:15 Introduction to Todays Forum (Lusk) 1. - - PDF document

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APNA 29th Annual Conference Session 3047: October 30, 2015 Lusk 1

Pamela Lusk, DNP, RN, PMHNP-BC, FAANP Candice Knight, PhD, EdD, APN, PMHCNS-BC, PMHNP-BC Mary D. Moller, DNP, ARNP, PMHCNS-BC, CPRP, FAAN Rick Pessagno, DNP, APN, PMHNP-BC, FAANP

APNA Graduate Education Council

Sessions 3047, 3054 October 30, 2015

Disclosure

 Pam Lusk has no conflicts of interest to disclose  Candice Knight has no conflicts of interest to disclose  Mary Moller has no conflicts of interest to disclose  Rick Pessagno has no conflicts of interest to disclose

Agenda

4:15 Introduction to Today’s Forum (Lusk) 4:20 Strategies used at NYU (Knight) 4:35 Strategies used at PLU (Moller) 4:50 Strategies used at Rutgers (Pessagno) 5:00 Transition to Graduate Education Council for discussion 5:15 Discussion/workshop small group assignment 6:45 Discussion ends

Objectives

• 1. Identify the basic knowledge, skills, and attitudes

needed by the PMHNP to provide psychotherapy.

• 2. Discuss various individual, group, and family

psychotherapy learning and training opportunities that can be employed in PMHNP programs.

• 3. Create a forum where individual, family, and

group psychotherapy PMHNP learning

• pportunities can be shared.

Graduate Programs for Advanced Practice Nurses ‐Our Fourth “P”

 Physical Assessment  Pharmacology  Pathophysiology

PSYCHOTHERAPY

Scopes & Standards of PMH Nursing (2014)

 Standard 5f. Psychotherapy  The Psychiatric-Mental Health Advanced Practice Registered Nurse conducts individual, couples, group and family psychotherapy using evidence- based psychotherapeutic frameworks and nurse- patient therapeutic relationships.

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APNA 29th Annual Conference Session 3047: October 30, 2015 Lusk 2

Peplau

 1956 Report form National Working Conference on Graduate Education in Psychiatric Nursing (NLN & NIMH). “The Education of the Clinical Specialist in Psychiatric Nursing: Peplau had begun to differentiate the clinical specialist as a psychiatric nurse prepared at the master’s level who concentrated on the psychotherapeutic role of the nurse. (Anderson, 1995, p 79).

Psychotherapy in the Past

 Mental Health Care System

 Emphasis on psychosocial models  Availability of mental health funding  Abundant time to practice & process cases

 Graduate PMH Advanced Practice Programs

 Hildegard Peplau’s interpersonal model  Focus on individual, group, & family therapy  Longer psychotherapy theory & clinical hours  Expert supervision in psychotherapy

Current Influences: Psychotherapy

 Mental Health Care System

 Emphasis on biological model  Managed care – focus on medication management  Split treatment  Quick-fix consumers

 Graduate PMH Advanced Practice Programs

 Less curriculum time for psychotherapy courses  Reduced clinical hours  Less faculty & preceptor psychotherapy expertise  Time constraints in clinical agencies

So What Now Is Needed?

 What are the basic knowledge, skills, and attitudes needed by the PMHNP to provide psychotherapy?

Knowledge

 Professional and ethical guidelines  Psychopathology  Common factors research  Foundational knowledge in basic theoretical

• rientation

 Assessment and diagnosis  Knowledge of basic science, evidence-based practice

Skills

 Ability to develop rapport and trust  Adapting interpersonal style and structure to suit the client  Ability to conduct diagnostic assessment  General case conceptualization skills  Treatment planning  Risk assessment/ management  Report writing

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APNA 29th Annual Conference Session 3047: October 30, 2015 Lusk 3

Attitudes

 Accurate empathy  Compassion  Sensitivity to individual differences  Genuineness  Lifelong learning

(Roth & Piling 2007, 2008)

Candice Knight

Essential Psychotherapy Content

Common Factors Schools, Subtypes Toolbox Skills ID & Dev Theoretical Orientation History, Ethics, Research Integration of Therapy & Meds Depth Psychotherapies

Essential Psychotherapy Content

 Common Factors (Elements of Effective Therapy), depth  Schools of Therapy and Major Subtypes, breadth  Developing “Toolbox Skills”  Identifying & Developing a Conceptual Framework  Special Topics: Ethics, research, special populations  Depth Psychotherapy

 Group Therapy, depth  Couple and Family Therapy, depth  Behavioral Therapy (CBT), depth  Cognitive Therapy (CBT), depth  Dialectical Behavior Therapy (DBT), depth  Play Therapy, depth  Motivational Interviewing, depth  Emotion-Focused Therapy (EFT), depth

Content – Course #1: Individual Psychotherapy

 Common Factors and Developing a Theoretical Orientation, depth

 Interpersonal skills & forming an alliance

 Psychodynamic, breadth

 Classical, Interpersonal, Ego, Object Relations, Self, Individual, Brief

 Humanistic-Existential, breadth

 Person-Centered, Gestalt, Existential, Emotion-Focused

 Behavioral, breadth

 Classical & Operant Conditioning, Stress Mgmt, Syst Desensitization

 Cognitive, breadth

 Information Processing, REBT (Ellis), Cognitive (Beck)

 Post-Modern, breadth

 Solution-Focused, Narrative, Feminist

 Integrative, breadth

 Motivational Interviewing, EMDR, DBT, Schema

Content – Course #1: Individual Psychotherapy Tool Box Skills (Experiential Training)

 Common Factors & Theor Orient

 Empathic understanding  Facilitative listening, presence  Developing the narrative  Selecting direction/choice points  Pacing and timing  Id & developing a theor orient

 Psychoanalytic

 Interpretation  Free association  Transference,

countertransference, resistance

 Life recollection review

 Humanistic-Existential

 Awareness and focusing  Here-and-now  Process

 Behavioral

 Stress mngt (breathing/prog rel)  Systematic desensitization

 Cognitive

 Cognitive restructuring  Thought stopping

 Postmodern

 Miracle question  Transforming the story  Empowering the client

 Integrative

 ID ambivalence, change talk  Rating intensity of discomfort  Distress tolerance skills

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APNA 29th Annual Conference Session 3047: October 30, 2015 Lusk 4 Current Curriculum (8 courses)

 1. Individual Psychotherapy  Common factors, depth

Schools/subtypes, tool box, id/dev theor orientation, hx, ethics, research, breadth

 30 hr th + 30 hr exp trng/sim

 2. Group, Couple, Family Therapy  Group, couple, family, depth

 30 hr th + 30 exp trng/sim

 3. Foundations of APPN  Assessment/diagnosis  Behavioral therapy, depth  Cognitive therapy, depth

 30 hr th (15 hr thrpy hr th)  30 hr exp trng/sim (15 hr thrpy)  160 therapy pr + 30 hr sup

 4. Psychopharmacology  Psychopharm (some therapy)

 30 hr th (2 hr thrpy hr th)

 5. Child & Adol APPN Theory  Psychopathology & treatment  Play therapy & DBT, depth

 30 hr th (15 hr thrpy hr th)  + 15 hr exp trng/sim

 6. Child & Adol APPN Pr & Sup

 250 pr + 30 hr sup (integrated)

 7. Adult & Gero APPN Theory  Psychopathology & treatment  Motivational Interviewing, depth  Emotion-focused therapy, depth

 30 hr th (15 hr thrpy hr th)  + 15 hr exper trng

 8. Adult & Gero APPN Pr & Sup

 250 pr + 30 hr sup (integrated)

Curriculum Hours

 180 Theory hrs (total):

 107 psychotherapy 

73 assessment/dg, psychopathology, psychopharm

 750 Practicum hrs: 160 hrs su, 250 hrs fall, 250 hrs sp

 350 hrs psychotherapy

 60 hrs may be training at psychotherapy training institutes  30 hrs may be personal individual or group psychotherapy

 450 hrs of diagnostics & psychopharmacology

 120 Experiential Training/Sim:

 105 hr psychotherapy  15 hr assessment/diagnosis

 90 Supervision Hours

 30 hr psychotherapy  60 hr integrated treatment

Essential Psychotherapy Process

Didactic Experiential Training/ Simulation

Practicum Supervision Personal Therapy

Training Institutes

Psychotherapy Process

Didactic Learning

(180 hrs)

Experiential Training

(120 hrs)

 Reading  Lecture & Discussion  Demonstrations by expert faculty & trainers

 DVDs  Live demonstration

 Student as Authentic Self in small groups of 6 - rotating as client, therapist, supervisor (formative)  Standardized Patients (summative - 20% of grade)  Courses

 #1: tool box skills  #2: member & leader of group

therapy and family therapist & pt

 #3: behavioral & cognitive thrpy  #5: play therapy & DBT  #7: MI and EFT

Psychotherapy Process

Practicum (750 hrs) Supervision (90 hrs)  Individual, group, couple & family therapy  Preceptors competent in psychotherapy  Patients across the lifespan  Psychotherapy practicum hour requirements (350 hrs)

 Creative practicum sites

 Faculty practices  Nurse-run clinics  Training institutes  Undergraduate students  Trained psychologists,

psychiatrists, social workers, & LPCs as well as APPNs

 Case Consultation  Self-Exploration  Method

 Videotape  Transcribing sessions  On-line clinical

discussions & case studies

 Direct observation at

practicum sites

Psychotherapy Process

Personal Therapy Training Institutes

 Clinical Hours Allocated for Personal Therapy (30 hours)  Purpose:

 Internalize template/model  Work through blind spots & issues  Understand being a patient  Enhance own skills & techniques

 Develop Assignments

 In-class simulation  Genograms & life recollections  Self-reflective journals

 Develop Referral Sources

 College counseling services  PMH-APRN private practices  Institutes

 Clinical Hours Allocated for Training (60 hours)  Development of Training Institutes by PMH-APRNs  Training through Prof Org  Encouragement of Life- Long, Post-Graduate Training ___________________  Requirement of 25 Therapy Hours for ANCC Recertification

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APNA 29th Annual Conference Session 3047: October 30, 2015 Lusk 5

Psychotherapy Curriculum

3 Psychotherapy Modalities

Individual Group Couple & Family Content

Common Factors Schools & Subtypes Toolbox Skills Conceptual Framework Depth Therapies

Process

Didactic Exp Training Practicum Supervision Personal Therapy Inst Training

Mary Moller

 Graduate level1:1, group and family therapy courses  1:1 psychotherapy course included major theorists and therapies and module on motivational interviewing (Corey)  Course Objectives:

 Discuss the concept of nurse as psychotherapist in the

context of psychiatric advanced practice care across the lifespan with a variety of patient populations.

 Evaluate advanced practice psychiatric nursing models as

frameworks for establishment of the therapeutic alliance, all phases of the therapeutic relationship, and decision tree for identification of appropriate psychotherapeutic modalities for utilization in the treatment relationship across the life span.

 Discriminate among major psychotherapeutic modalities of

care across the lifespan to encompass theoretical foundations, treatment assumptions, and major interventions.

 Psychodynamic psychotherapy taught via film analyses

Pacific Lutheran University Film Analysis for Psychodynamic Psychotherapy

 The Snake Pit: Psychodynamic psychotherapy with psychosis, PTSD, ECT, historical perspectives  Ordinary People: Psychodynamic psychotherapy; adolescent depression, suicide, family dynamics, survivor guilt, PTSD  Good Will Hunting: Psychodynamic psychotherapy with adolescent trauma  The Three Faces of Eve: Psychodynamic psychotherapy with dissociative identity disorder  I Never Promised You a Rose Garden: psychodynamic psychotherapy with psychosis  Now, Voyager: Psychodynamic therapy; family dynamics

Grading Criteria

 Identify the major therapeutic modalities utilized by the therapist 20 points _____  Describe the theoretical basis and philosophical underpinnings of the techniques associated with this modality. 30 points _____  Describe the therapist interventions with specific film examples and verbatim quotes to include critique of:

 Therapist strategies and implementation techniques with

examples 15 points_______

 Prescribed length of time and determination of transition

between and intensity of actual therapeutic interventions 20 points _______

 Desired/actual patient outcome measures for the selected

strategies and interventions 15 points______

Other Suggested Movies

• Depression/Suicide

Ordinary People

• Schizophrenia

Docu: Out of the Shadow

• Mania
• Mr. Jones—first 45 minutes
• Anxiety disorders

Matchstick men

• PTSD/Dissociation

Fearless

• Personality disorders

Sleeping with the Enemy

• Substance Use

Clean and Sober; Requiem for a Dream

• Eating disorders

Documentary: Perfect Illusions‐Eating Disorders and the Family

• Autism

Autism: The Musical

• Alzheimer’s disease

A Song for Martin; Iris

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APNA 29th Annual Conference Session 3047: October 30, 2015 Lusk 6

Group Psychotherapy

 In the clinical setting at Northwest Center for Integrated Health (Puyallup, WA) PLU PMHNP DNP students co-lead 12 week trauma recovery CBT program and conduct outcomes research

Rick Pessagno

Rutgers University

1. Two modalities taught : Individual and Group Therapy but Family Therapy & Couples and family systems theory included. 2. Development of a Psychotherapy Theory course includes experiential learning of demonstrations of various therapies by experienced nurse therapists. 3. Utilization of APA (American Psychological Association) DVD on Being a Psychotherapist. 4. Theoretical orientation is selected by the student; the graduate experience supports individual development of the student’s own theoretical orientation. 5. Strongly encourage all students to be actively involved in their own personal therapy during the program. 6. Clinical Supervision – 3 hours every other week; develops group skills; keep students in the same supervision group. 7. Use numerous DVD’s with therapy demonstrations: Corey “Stan” Therapy DVD and Psychotherapy.net

Rutgers Continued

 Corey’s Group Therapy demonstration DVD  Individual Therapy : Each student develops a PPT presentation on an individual orientation for a specific disorder

• r patient population.

 Group Therapy : Each student develops a Group – select a patient population, orientation, client selection, number of sessions, marketing plan, evaluation tool  Family Therapy – students selection from a list of movies and apply a family therapy intervention, also use a Genogram having each student complete and then share in their clinical supervision group (2nd term of practicum).  Couples therapy presentation relative to various couples issues (addictions, extramarital affair, same sex couples, blended families, dealing chronic and terminal illness).

Rutgers continued

 Role play for individual, group, and family sessions during clinical supervision.  Utilizing state psychiatric hospitals for individual and group therapy experiences.  Support and encourage participation in various trainings during graduate training including EMDR, CBT, Psychodynamic, Play Therapy, Psychodrama, Couples; as well as any other therapy CEU programs.  Challenge identifying clinical sites where APN’s are providing psychotherapy – limited experiences.

Group Discussion

 What should be taught/facilitated?  Clinical experiences available  In-depth training in modalities?  Simulation  Handouts (film assignment, other panel members provide materials)

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APNA 29th Annual Conference Session 3047: October 30, 2015 Lusk 7

Questions?

Therapy Competencies

 Do each of these exemplars give the student the

• pportunity to develop core therapy competencies?

Basic Therapeutic Competencies Concise List (Roth & Piling 2008)

 Knowledge and understanding of mental health problems  Knowledge of, and ability to operate within professional and ethical guidelines  Knowledge of a model of therapy, and the ability to understand and employ the model to practice  Ability to engage client  Ability to foster and maintain a good therapeutic alliance, and grasp the client’s perspective and “world view”

Basic Therapeutic Competencies Concise List (continued)

 Ability to deal with emotional content of sessions  Ability to manage endings  Ability to undertake generic assessment (relative history and identifying suitability for intervention)  Ability to make use of supervision  UK – Improving Access to Psychological Therapies IAPT Programme

(Roth & Piling, 2008)

Workshop:

 Interactive / sharing of other exemplars from participants.

References:

 American Psychiatric Nurses Association. (2014). Psychiatric-Mental Health Nursing: Scopes and Standards of Practice (2nd Ed. Silver Springs, MD; Nursebooks .org.  Anderson, C. Ed.(1995). Psychiatric Nursing 1946 to 1994. A Report on the State of the Art. St. Louis, MO: Mosby.  Corey, G. (2012). Theory and Practice of Counseling and Psychotherapy, DVD: the Case of Stan and Lecturettes. Belmont, CA: Thomson Higher Education.  Corey, G. (2013). Theory and Practice of Counseling and Psychotherapy. Belmont, CA: Thomson Higher Education.  Halbur, D. and Halbur, K. (2014). Developing your theoretical orientation in counseling and psychotherapy (3rd edition). Pearson, Saddlebrook, NJ.

References (continued):

 Mahoney, M. J. (1998). Essential themes in training of psychotherapists. Psychotherapy in Private Practice, 17(1), 43-59.  Manring, J., Greenberg, R. P., Gregory, R., & Gallinger, L. (2011). Learning psychotherapy in thedigital age. Psychotherapy, 48(2), 119-126.  McElroy, E., Greiner, D., & de Chesnay, M. (1991). Application of the skill acquisition model to the teaching of psychotherapy. Archives of Psychiatric Nursing 5(2), 113-117.  Reilly, C., & McDanel, H. (2005). Cognitive therapy: a training model for advanced practice nurses. Journal of Psychosocial Nursing & Mental Health Services, 43(5), 27.  Roth, A. & Piling, S. (2007). The competencies required to deliver effective cognitive and behavioral therapy for people with depression and with anxiety

• disorders. London, Department of Health.

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APNA 29th Annual Conference Session 3047: October 30, 2015 Lusk 8

References (continued):

 Roth, A. & Piling, S. (2008). Using an evidence-based methodology to identify the competencies required to deliver effective cognitive and behavioural therapy for depression and anxiety disorders. Behavioral and Cognitive Psychotherapy. 36, 129-147.

 Stride, S. M., Daly, A. R., & Jackson, Jr., D. L. (2010). Collaboration: teaching graduate students postmodern psychotherapy. Journal of Systematic Therapies, 29(1), 1-17.  Van Rijn, B., Sills, C., Hunt, J., Sivanath, S., Gildebrand, K., & Fowlie, H. (2008). Developing clinical effectiveness in psychotherapy training: Action research. Counseling and Psychotherapy Research, 8(4), 261-268.  Wedding, D. & Niemiec, R.M. (2014). Movies and Mental Illness: Using Films to Understand Psychopathology. Boston: Hogrefe Publishing.  Wheeler, K. (Ed.) (2014). Psychotherapy for the advanced practice psychiatric

• nurse. New York, NY: Springer.