ENDING THE IDENTITY CRISIS: THE RESURRECTION OF PSYCHOTHERAPY IN CONTEMPORARY PMH-APRN PRACTICE DONNA ROLIN, PHD, APRN, PMHCNS-BC, PMHNP-BC DAVID GOEN, MSN, APRN, PMHNP-BC, CCHP SHERRIE MARGIOTTA, MSN, APRN, PMHNP-BC ANGELA RETANO, RN, PMHNP-BC OVERVIEW History & Tradition of PMH-APRN Role Implications of the LACE Consensus Model Transition of Psychotherapy in PMH-APRN ROLE Review of Literature: Efficacy of Psychotherapy How is Psychotherapy Education Defined and Understood? How is PMH-APRN Curriculum on Psychotherapy Determined? What Psychotherapy Content is Being Taught to PMH-APRNs?... And How? Training: Three Evidence-Based Approaches Clinical Practice: Psychodynamic Style Five Psychodynamic Pearls of Wisdom Teaching Case Example DISCLOSURES HISTORY & TRADITION OF PMH-APRN ROLE Presenters do not have financial conflicts of interest to disclose. 1950 s: The PMH-CNS designation was the first Psychiatric APRN role Developed by Peplau in 1955 Advanced training in psychotherapy was a part of this role preparation PMH-CNS role emphasized therapeutic use of self, vital emphasis on nurse-patient relationship 1970 s: The Psychiatric Mental Health Nurse Practitioner (PMHNP) role developed Additional authority to prescribe medications PMHNP role placed a heavier emphasis on differential diagnosis and medication management resulting in a decreased emphasis on therapy. (5) OBJECTIVES HISTORY & TRADITION OF PMH-APRN ROLE Describe the importance of incorporating psychotherapy within the role of the APRN. Identify institutional and individual barriers to incorporation of psychotherapy within the APRN role will learn strategies to overcome these obstacles. Appreciate the importance of implementing psychotherapy into educational and/or clinical practice 1980 s: The American Psychiatric Nurses Association (APNA) was founded in 1986. 1990 s: Debate continues regarding role of the PMH-CNS vs. the PMHNP. PMHNP graduate curricula shifted emphasis to primary care model of assessment, psycho-education, brief therapy and interventions focusing on diagnosis and pharmacotherapy International Society of Psychiatric-Mental Health Nurses (ISPN) formed in 1999. The American Association of Colleges of Nursing (AACN) proposes the Doctor of Nursing Practice (DNP) to become advanced practice standard. 2000s: The AACN releases the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, & Education (LACE) document in 2008 To be fully implemented by 2015 PMHNP became the entry-level APRN designation to practice in 2010 (not PMHCNS) Rolin 1
IMPLICATIONS OF THE LACE CONSENSUS MODEL TRANSITION OF PSYCHOTHERAPY IN PMH-APRN ROLE Authors of the Development of PMHNP Competencies (Wheeler & Haber, 2004) noted The origin and purpose of educational preparation for the NP and the CNS were significantly different. The PMHNP conducts individual, group, and/or family psychotherapy. This is noteworthy because many of the existing PMHNP programs have no courses or practicum experiences in psychotherapy. PMHNPs licensed prior to LACE consensus model implementation were NOT likely educated to perform psychotherapy Disagreement about necessary therapy skill set for PMH-APRNs Lack of consensus about psychotherapies provided by advanced practice psychiatric nurses and the corresponding required training and skills has spurred debate over what exactly is being taught in psychiatric NP programs as psychotherapy and by whom (Jones & Minarik, 2012). PMH-APRNs AND THERAPEUTIC RELATIONSHIPS & STRATEGIES Main goal continues to be the therapeutic relationship which is an intricate part of nursing philosophy and care, irrespective of psychotherapy modality used (9). Parrish et al. identified 3 main therapeutic strategies used by APRNs: active listening, psychotherapy, and psychopharmacology; most common psychotherapy was CBT and IPT (10). PMH-APRNs BALANCING PSYCHOTHERAPY AND PSYCHIATRIC MANAGEMENT Nursing curriculums need to consider integrating psychotherapy education alongside medication management with an emphasis on developing the therapeutic relationship (12). Important for APRNs to present evidence of research demonstrating efficacy and costeffectiveness of psychotherapy (11). TRANSITIONING OF THE PMHCNS ROLE PREVALENCE OF MENTAL ILLNESS AMONG U.S. ADULTS ANCC Retiring PMHCNS Exams Impetus for redefining the place of psychotherapy in PMH-APRN Practice Formerly emphasized in PMHCNS role > PMHNP role Psychotherapy Systems: Organizations, Consultation Last application for PMHCNS Certification examination will be accepted on 12/31/16 http://nursecredentialing.org/adultpsychcns In 2014, an estimated 18.1% (43.6 million) U.S. adults age 18 and older experienced a mental disorder in the past year 4.2% (9.8 million) experienced a serious mental disorder with severe impairment TRANSITION OF PSYCHOTHERAPY IN PMH-APRN ROLE PREVALENCE OF MAJOR DEPRESSIVE DISORDER AMONG U.S. ADULTS INCREASING DEMAND FOR PMH-APRNs When looking at the growing popularity of integrated care models and changes in healthcare delivery the demand for PMHNPs & PMH-CNSs will increase (5). With the passage of the Affordable Care Act (ACA), PMH APRN s make ideal providers in healthcare settings that necessitate the integration of primary care and psychiatric care (6) (7). DECREASING UTILIZATION OF PSYCHOTHERAPY BY PMH-APRNs One of the challenges is the merging of the PMHNP and PMH-CNS roles to include psychotherapy in the APRN practice (8). Many factors have contributed to the steady decline of psychotherapy, including cost and availability of PMH APRNs (4). In 2014, an estimated 6.7% (15.7 million) U.S. adults aged 18 or older had at least one major depressive episode in the past year 4.3% (10.2 million) with severe impairment National Institute of Mental Health. 2014 SAMHSA NSDUH Mental Health Findings. https://www.nimh.nih.gov/health/statistics/prevalence/major-depression-among-adults.shtml Rolin 2
REVIEW OF LITERATURE: EFFICACY OF PSYCHOTHERAPY HOW IS PSYCHOTHERAPY EDUCATION DEFINED AND UNDERSTOOD? 3 Psychotherapy Modalities Most Researched for Treatment of Depression Cognitive Behavioral Therapy (CBT) Interpersonal Therapy (IPT) Psychodynamic psychotherapy (PsyDyn) American Psychiatric Association s Clinical Practice Guideline for MDD Recommends Psychotherapy (CBT, IPT, PsyDyn) Psychopharmacology Concurrent Psychopharmacology and psychotherapy In 2015, 10% of NIMH research funding was allocated to clinical trials research Only 5.4% funding psychotherapy trials High level forms of therapy Rigorous training requirements with requisite clinical supervision CBT Psychodynamic Insight-oriented modalities Gestalt Group psychotherapy Marriage / Family therapy Lower levels of therapy Supportive psychotherapy Psycho-education REVIEW OF LITERATURE: EFFICACY OF PSYCHOTHERAPY CBT founded by Aaron Beck, MD in the 1970s How one structures their experiences determines how they feel and behave Goal is to restructure dysfunctional, irrational thinking (13). IPT founded by Myrna Weissman, PhD and Gerald Klerman, MD in the 1980s for depression Psychiatric disorders occur within an interpersonal social context. Actively addresses two sources of depression: symptom function and social/interpersonal relationships (14). Psychodynamic psychotherapy founded by Sigmund Freud, MD at the end of the 19 th century Long-term approach (originally) that emphasizes the centrality of conflict among powerful desires, wishes, and fears (14). HOW IS PMH-APRN CURRICULUM ON PSYCHOTHERAPY DETERMINED? SCOPE, STANDARDS, & COMPETENCIES American Psychiatric Nurses Association Scope & Standards National Organization of Nurse Practitioner Faculties NP / PMHNP Competencies American Nurses Credentialing Center Certification Eligibility & Maintenance REVIEW OF LITERATURE: EFFICACY OF PSYCHOTHERAPY Extensive research on antidepressants for persons with depression, but less data on the effects of psychotherapy alone. Combination of medications and therapy shown to be the most effective strategy in treating depression (10). CBT and IPT have more extensive research showing efficacy with and without antidepressants than Psychodynamic psychotherapy for depression. However, all three psychotherapies showed effectiveness in treating depression. Review of literature revealed a significant GAP in research conducted by nurse scientists studying the use of CBT, IPT or Psychodynamic psychotherapy being utilized in practice by APRNs for depression. AMERICAN PSYCHIATRIC NURSES ASSOCIATION SCOPE AND STANDARDS OF PRACTICE FOR PMHN (2014) Scope: Psychotherapy defined denotes a formally structured relationship between the therapist (PMH-APRN) and the healthcare consumer for the explicit purpose of effecting negotiated outcomes. This treatment approach to mental disorders is intended to alleviate emotional distress or symptoms, to reverse or change maladaptive behaviors, and to facilitate personal growth and development Standard: The PMHAPRN conducts individual, couples, group, and family psychotherapy using evidence-based psychotherapeutic frameworks and the nurse-client therapeutic relationship. Competencies include: Uses knowledge of relevant biological, psychosocial, and developmental theories, as well as best available research evidence, to select therapeutic methods based on healthcare consumer needs. Applies therapeutic communication strategies based on theories and research evidence to reduce emotional distress, facilitate cognitive and behavioral change, and foster personal growth. Uses awareness of own emotional reactions and behavioral responses to others to enhance the therapeutic alliance. Rolin 3
NATIONAL ORGANIZATION OF NURSE PRACTITIONER FACULTIES COMPETENCIES PMHNP Competencies Updated in 2013 Follows LACE Consensus Model mandate for PMHNP educators to prepare graduates to treat clients across lifespan Core competencies based on both AACN s Master s and DNP Essentials for Graduate Education WHAT PSYCHOTHERAPY CONTENT IS BEING TAUGHT TO PMH-APRNS?... AND HOW? Evidence Based Psychotherapies Spectrum of Psychotherapies based on Preference of School / Program Traditional vs. Most Contemporary Focus of Substance Use Disorders Treatment Coverage Availablity of Preceptors Inter-Disciplinary Preceptors Scope, Standards, & Competencies of Practice None delineate what schools of psychotherapy to teach None specify how to provide psychotherapy clinical experiences NATIONAL ORGANIZATION OF NURSE PRACTITIONER FACULTIES COMPETENCIES Specific PMHNP 2013 Competencies Related to Psychotherapy Education Applies supportive, psychodynamic principles, cognitive-behavioral and other evidencebased psychotherapy/-ies to both brief and long term individual practice Demonstrates best practices of family approaches to care Applies recovery oriented principles and trauma focused care to individuals Uses self-reflective practice to improve care Applies therapeutic relationship strategies based on theories and research evidence to reduce emotional distress, facilitate cognitive and behavioral change, and foster personal growth SURVEY OF PMHN GRADUATE PROGRAMS (WHEELER & DELANEY, 2008) N=68 PMH-APRN Programs 84% offered PMHNP 62% offered PMHCNS 38% offered combined PMHNP/PMHCNS 80 different textbooks were used to teach psychotherapy Few programs required students to enroll in their own psychotherapy (encouraged though) Cited university restrictions Results supported a diversity of programs with plurality of psychotherapy approaches and models taught AMERICAN NURSES CREDENTIALING CENTER CERTIFICATION ELIGIBILITY Psychiatric - Mental Health Nurse Practitioner Certification eligibility criterion Clinical training in at least two psychotherapeutic treatment modalities Minimum of 500 faculty-supervised clinical hours (not specific to psychotherapy) http://nursecredentialing.org/familypsychmentalhealthnp SURVEY OF PMHN GRADUATE PROGRAMS (WHEELER & DELANEY, 2008) Psychotherapy Practicum Hours 50% programs had specified # practice hours specific to psychotherapy modalities 50% programs combined psychiatric & psychotherapy hours Some programs reported, student chooses 2 out of 3 treatment modalities Ranges for Psychotherapy Practicum Hours (If Specified Most Were Not) [Range of 500-900 clinical hours for total program] 50-440 Individual Therapy 30-250 Group Therapy 10-180 Family Therapy Rolin 4
SURVEY OF PMHN GRADUATE PROGRAMS (2014) CLINICAL PRACTICE: PSYCHODYNAMIC STYLE N=12 PMH-APRN Programs Ranges for Psychotherapy Practicum Hours (If Specified Most Were Not) [Range of 600-1000 clinical hours for total program] Specific Therapy Modalities indicated even fewer hours allocated to psychotherapy 45-100 Individual Therapy 50-200 Group Therapy 0-45 Family Therapy Alternatives to Psychotherapy Practicum Hours Reported by Some Programs Inclusion of some forms of Addiction Treatment hours Lab hours with 2-way mirrors, video-recordings, journaling, & reflection Logging Supportive Psychotherapy portions of visits in conjunction with Psychiatric Med Management Visits Model of the Mind FIVE PSYCHODYNAMIC PEARLS OF WISDOM Therapeutic Alliance Transference / Countertransference Defense Mechanisms Transitional Object Meaning and Symbolism TRAINING: THREE EVIDENCE BASED APPROACHES TEACHING CASE EXAMPLE Interpersonal Psychotherapy Institute http://iptinstitute.com Cognitive Behavioral Institute https://www.beckinstitute.org American Psychoanalytic Association http://www.apsa.org Rolin 5
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