iPsychotherapy for the Advanced Practice Psychiatric Nurse 2 ii Kathleen Wheeler, PhD, PMHCNS-BC, PMHNP-BC, APRN, FAAN, is a professor and coordinator of the Psychiatric Mental Health Nurse Practitioner Program at Fairfield University School of Nursing in Fairfield, Connecticut. She has practiced as an advanced practice psychiatric nurse specializing in trauma for the past 30 years. She is certified as a clinical specialist in adult psychiatric-mental health nursing and a psychiatric-mental health nurse practitioner. She has additional certifications in psychoanalysis and psychotherapy, hypnosis, and eye movement desensitization and reprocessing (EMDR). Dr. Wheeler served as co-chair of the national panel that developed the 2003 Psychiatric-Mental Health Nurse Practitioner (PMHNP) Competencies and is the president of the EMDR International Association. The first edition of her book, Psychotherapy for the Advanced Practice Psychiatric Nurse, was awarded an AJN Book of the Year Award and the American Psychiatric Nurses Association (APNA) Media Award. She has also received awards from APNA for Excellence in Practice and Excellence in Education; is a distinguished alumna of Cornell University–New York Hospital School of Nursing where she received her BSN; and is a Fellow in the American Academy of Nursing. She received her MA and PhD in nursing from New York University. 3 iiiPsychotherapy for the Advanced Practice Psychiatric Nurse A How-To Guide for Evidence-Based Practice Second Edition KATHLEEN WHEELER, PhD, PMHCNS-BC, PMHNP-BC, APRN, FAAN 4 ivCopyright © 2014 Springer Publishing Company, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, [email protected] or on the Web at www.copyright.com. Springer Publishing Company, LLC 11 West 42nd Street New York, NY 10036 www.springerpub.com Acquisitions Editor: Margaret Zuccarini Composition: Exeter Premedia Services Private Ltd. ISBN: 978-0-8261-1000-8 e-book ISBN: 978-0-8261-1008-4 Supplemental material ISBN: 978-0-8261-3625-1 Supplemental material is available from www.springerpub.com/wheeler-ancillary 13 14 15 / 5 4 3 2 1 The author and the publisher of this Work have made every effort to use sources believed to be reliable to provide information that is accurate and compatible with the standards generally accepted at the time of publication. Because medical science is continually advancing, our knowledge base continues to expand. Therefore, as new information becomes available, changes in procedures become necessary. We recommend that the reader always consult current research, specific .

1. iPsychotherapy for the Advanced Practice Psychiatric Nurse
2
ii
Kathleen Wheeler, PhD, PMHCNS-BC, PMHNP-BC, APRN,
FAAN, is a professor and coordinator
of the Psychiatric Mental Health Nurse Practitioner Program at
Fairfield University School of Nursing in
Fairfield, Connecticut. She has practiced as an advanced
practice psychiatric nurse specializing in trauma for
the past 30 years. She is certified as a clinical specialist in adult
psychiatric-mental health nursing and a
psychiatric-mental health nurse practitioner. She has additional
certifications in psychoanalysis and
psychotherapy, hypnosis, and eye movement desensitization and
reprocessing (EMDR). Dr. Wheeler served
as co-chair of the national panel that developed the 2003
Psychiatric-Mental Health Nurse Practitioner
(PMHNP) Competencies and is the president of the EMDR
International Association. The first edition of
her book, Psychotherapy for the Advanced Practice Psychiatric
Nurse, was awarded an AJN Book of the Year
Award and the American Psychiatric Nurses Association
(APNA) Media Award. She has also received
awards from APNA for Excellence in Practice and Excellence in

2. Education; is a distinguished alumna of
Cornell University–New York Hospital School of Nursing where
she received her BSN; and is a Fellow in the
American Academy of Nursing. She received her MA and PhD
in nursing from New York University.
3
iiiPsychotherapy for the Advanced Practice Psychiatric
Nurse
A How-To Guide for Evidence-Based Practice
Second Edition
KATHLEEN WHEELER, PhD, PMHCNS-BC, PMHNP-BC,
APRN,
FAAN
4
ivCopyright © 2014 Springer Publishing Company, LLC
All rights reserved.
No part of this publication may be reproduced, stored in a
retrieval system, or transmitted in any form or by any means,
electronic, mechanical,
photocopying, recording, or otherwise, without the prior
permission of Springer Publishing Company, LLC, or
authorization through payment
of the appropriate fees to the Copyright Clearance Center, Inc.,

3. 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax
978-646-8600,
[email protected] or on the Web at www.copyright.com.
Springer Publishing Company, LLC
11 West 42nd Street
New York, NY 10036
www.springerpub.com
Acquisitions Editor: Margaret Zuccarini
Composition: Exeter Premedia Services Private Ltd.
ISBN: 978-0-8261-1000-8 e-book
ISBN: 978-0-8261-1008-4 Supplemental material
ISBN: 978-0-8261-3625-1
Supplemental material is available from
www.springerpub.com/wheeler-ancillary
13 14 15 / 5 4 3 2 1
The author and the publisher of this Work have made every
effort to use sources believed to be reliable to provide
information that is accurate
and compatible with the standards generally accepted at the
time of publication. Because medical science is continually
advancing, our
knowledge base continues to expand. Therefore, as new
information becomes available, changes in procedures become
necessary. We
recommend that the reader always consult current research,
specific institutional policies, and current formularies or drug
guides before
performing any clinical procedure or prescribing or
administering any drug(s). The author and publisher shall not be
liable for any special,

4. consequential, or exemplary damages resulting, in whole or in
part, from the readers’ use of, or reliance on, the information
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book. The publisher has no responsibility for the persistence or
accuracy of URLs for external or third-party Internet Web sites
referred to in
this publication and does not guarantee that any content on such
Web sites is, or will remain, accurate or appropriate.
Library of Congress Cataloging-in-Publication Data
Wheeler, Kathleen, 1947– author, editor of compilation.
Psychotherapy for the advanced practice psychiatric nurse : a
how-to guide for evidence-based practice/Kathleen Wheeler.—
Second edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-8261-1000-8—ISBN 978-0-8261-1008-4 (e-book)
I. Title.
[DNLM: 1. Psychiatric Nursing. 2. Advanced Practice Nursing.
3. Evidence-Based Nursing. 4. Nurse-Patient Relations. 5.
Psychotherapeutic
Processes. WY 160]
RC440
616.89’0231—dc23
2013041328
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vRave Reviews and Awards for Psychotherapy for the Advanced
Practice Psychiatric Nurse, First Edition
2008 American Psychiatric Nurses Association Media Award
2008 AJN Book of the Year Award
“Wheeler emphasizes Shapiro’s adaptive information processing
model; this scholarly psychotherapy text offers other important
contemporary
contributions to the field of psychiatric nursing. It is a valuable
read for the APPN psychotherapist as well as for clinicians from
other mental
health disciplines, who will learn much about the
neurophysiology of psychotherapy. What distinguishes this
book from others of its type is its
perspective on treatment from a nursing framework and the
integration of evidence-based psychotherapy models with
current research from the
affective neurosciences and the field of traumatology.”

6. Journal of Trauma & Dissociation
Robert M. Greenfield, PhD
Private Practice, Staten Island, New York
“Dr. Wheeler’s book is for all levels of advanced practice
psychiatric nursing. Students and faculty in academic settings,
beginning practitioners,
and experienced psychotherapists will find it useful
educationally, clinically, and as a resource. It includes material
from practical case examples
to complete presentations of neurophysiology of psychotherapy.
It supports, from a practice-based perspective, the ‘National
Competencies for
Psychiatric Mental Health Nurse Practitioners’ and the ‘Scope
and Standards for Practice of Psychiatric Nursing.’ In a
thorough,
comprehensive, research-based manner, this text clarifies and
refines the role and practice of the nurse psychotherapist. This
is a pioneering
presentation of psychiatric nursing literature in today’s world.
It will be used and referred to over and over until it is dog-
eared and tattered, as
the reviewers’ texts have become.”
APNA Newsletter
Susan Jacobson, PMHNP, CNS, and Linda Manglass, APRN-BC
“The text provides excellent examples (e.g., boxes, figures, case
studies), websites, and other bibliographic resources to explain
or illustrate
specific aspects of the APPN role including how to assess,
accomplish, and document the therapeutic alliance and other
therapeutic tasks. All in
all, this primer clearly stands as a timely exemplar for anyone
who wants to develop clinical expertise as a therapist. It can
easily serve as an

7. excellent reference as well for any seasoned APPN that wishes
to home in on a particular skill set. Students and APPNs alike
should buy the
text to support their clinical work with patients.”
Perspectives in Psychiatric Care
Margaret England, PhD, RN, CNS
“This is a much needed introduction to the ‘how to’ of
psychotherapy for beginning advanced practice psychiatric
nurses, including those nurses
who have prescriptive authority. This easy-to-read book is like
having a mentor ready at all times to prepare and assist the
advanced practice
psychiatric nurse for competent practice based in knowledge
and wisdom…. I thoroughly enjoyed reading the well researched
and written
chapters. The author holds the appropriate credentials and has
the experience to make her a very credible authority…. The
quality of this book
is outstanding and the need for it is great. There are no books in
the field that compare. I am a practicing advanced practice
nurse prescriber as
well as a college professor who teaches psychiatric mental
health nursing theory and practice. It would have been
wonderful to have this book all
those years ago when I first began my psychiatric nursing
practice.”
Doody Review, July, 11, 2008; 4 stars
Leona F. Dempsey, PhD
6
vivii

8. viii
Contents
Contributors
Foreword Judith Haber, PhD, APRN, BC, FAAN
Foreword Jeanne A. Clement, EdD, APRN, PMHCNS-BC,
FAAN
Preface
Acknowledgments
Part I. Getting Started
1. The Nurse Psychotherapist and a Framework for Practice
Kathleen Wheeler
2. The Neurophysiology of Trauma and Psychotherapy
Kathleen Wheeler
3. Assessment and Diagnosis
Pamela Bjorklund
4. The Initial Contact and Maintaining the Frame
Kathleen Wheeler
Part II. Psychotherapy Approaches
5. Supportive and Psychodynamic Psychotherapy
Kathleen Wheeler
6. Eye Movement Desensitization and Reprocessing Therapy
Kathleen Wheeler
7. Motivational Interviewing
Edna Hamera

9. 8. Cognitive Behavioral Therapy
Sharon M. Freeman Clevenger
9. Interpersonal Psychotherapy
Patricia D. Barry and Kathleen Wheeler
10. Humanistic–Existential and
Solution
-Focused Approaches to Psychotherapy
Candice Knight
11. Group Therapy
Richard Pessagno
12. Family Therapy
Candice Knight
Part III. Psychotherapy With Special Populations
13. Stabilization for Trauma and Dissociation
Kathleen Wheeler
14. Dialectical Behavior Therapy for Complex Trauma

10. Barbara J. Limandri
7
15. Psychopharmacotherapy and Psychotherapy
Lisabeth Johnston
16. Psychotherapeutic Approaches for Addictions and Related
Disorders
Susie Adams and Deborah Antai-Otong
17. Psychotherapy With Children
Kathleen R. Delaney with Janiece DeSocio and Julie A. Carbray
18. Psychotherapy With Older Adults
Georgia L. Stevens, Merrie J. Kaas, and Kristin Hjartardottir
Part IV. Documentation, Evaluation, and Termination
19. Reimbursement and Documentation
Mary Moller
20. Termination and Outcome Evaluation

11. Kathleen Wheeler
Afterword
Index
8
ix
x
Contributors
Susie Adams, PhD, APRN, PMHNP-BC, PMHCNS-BC, FAANP
Professor and Director, PMHNP
Program, Vanderbilt University School of Nursing, Nashville,
Tennessee
Deborah Antai-Otong, MS, RN, PMHCNS-BC, FAAN
Continuous Readiness Officer, Behavioral Health
Consultant and Provider, Department of Veterans Affairs,
Veteran Integrated Service Network, Arlington,
Texas

12. Patricia D. Barry†, PhD, PMHCNS-BC, APRN Psychotherapist
and Consultant, Private Practice,
Hartford, Connecticut
Pamela Bjorklund, PhD, RN, PMHCNS, PMHNP-BC Associate
Professor, Department of Graduate
Nursing, College of St. Scholastica, Duluth, Minnesota
Julie A. Carbray, PhD, APN, PMHCNS-BC Clinical Professor,
Administrative Director, Pediatric Mood
Disorders Clinic, Institute for Juvenile Research, Chicago,
Illinois
Sharon M. Freeman Clevenger, PhD, PMHCNS-BC CEO,
Indiana Center for Cognitive Behavior
Therapy, PC, Secretary/Treasurer, International Association for
Cognitive Psychotherapy; Diplomate, Fellow
and ACT Certified Trainer/Consultant; Academy of Cognitive
Therapy; Associate Faculty, Indiana Purdue
University, Fort Wayne, Indiana
Kathleen R. Delaney, PhD, DNSc, APRN, PMHNP-BC, FAAN
Professor, Rush College of Nursing,
Chicago, Illinois

13. Janiece DeSocio, PhD, APRN, PMHNP-BC Interim Dean and
Director of the Doctor of Nursing Practice
Program, PMHNP Track Lead, Seattle University, Seattle,
Washington
Edna Hamera, PhD, APRN, PMHCNS-BC Associate Professor,
University of Kansas, School of Nursing,
Kansas City, Kansas
Kristin Hjartardottir, DNP, RN, PMHNP-BC University of
Minnesota, Boynton Health Services,
Minneapolis, Minnesota
Lisabeth Johnston, PhD, APRN, PMHCNS-BC Psychotherapist
and Psychopharmacologist, Private
Practice, West Hartford, Connecticut
Merrie J. Kaas, PhD, RN, PMHCNS-BC, FGSA, FAAN
Associate Professor, Specialty Director,
Psychiatric/Mental Health Graduate Nursing, Minneapolis,
Minnesota
Candice Knight, PhD, EdD, APN, PMHNP-BC, PMHCNS-BC
Coordinator, Psychiatric-Mental Health

14. Nurse Practitioner Program, New York University College of
Nursing, New York City, New York; Licensed
Psychologist and Psychiatric Nurse Practitioner, Wellspring
Center for Health and Wellbeing, Flemington,
9
New Jersey
Barbara J. Limandri, PhD, APRN, PMHNP-BC Professor of
Nursing, Linfield College, Portland, Oregon
Mary Moller, DNP, ARNP, APRN, PMHCNS-BC, CPRP, FAAN
Associate Professor, Specialty Director,
Psychiatric Mental Health Nursing, Yale University School of
Nursing, New Haven, Connecticut
Richard Pessagno, DNP, RN, PMHNP-BC, CGP Clinical
Assistant Professor, Specialty Director,
Psychiatric Nurse Practitioner Program, Rutgers, The State
University of New Jersey, College of Nursing,
Newark, New Jersey

15. Georgia L. Stevens, PhD, APRN, PMHCNS-BC Director, P.A.L.
Associates, Partners in Aging & Long-
Term Caregiving, Washington, DC; Best Georgia
Geropsychiatric Nurse Coordinator, Behavioral Health
System Baltimore, Baltimore, Maryland
†Deceased.
10
xi
xii
Foreword
JUDITH HABER, PhD, APRN, BC, FAAN
The Ursula Springer Leadership Professor in Nursing
Associate Dean for Graduate Programs
College of Nursing
New York University

16. The second edition of Psychotherapy for the Advanced Practice
Psychiatric Nurse by Kathleen Wheeler is destined
to surpass the high impact of the first edition. This landmark
book has fulfilled its promise as a
groundbreaking publication that has established a new
generation of psychiatric nursing scholarship. Most
important is its reaffirmation of the essential cornerstone of
advanced practice psychiatric nursing practice:
therapeutic use of self in the psychotherapeutic relationship.
Today, psychotherapy is regarded as an essential advanced
practice competency fundamental to advanced
psychiatric nursing practice. Validation about the importance of
psychotherapy is evident in major
professional documents that guide 21st-century implementation
of advanced practice clinical practice roles.
The newly revised Psychiatric-Mental Health Nurse Practitioner
Competencies (2013) and the Scope and
Standards of Psychiatric-Mental Health Nursing Practice (2007)
both reaffirm that individual, group, and
family psychotherapy are core population competencies for
psychiatric-mental health nurse practitioners and
clinical nurse specialists.
Dr. Wheeler and the psychiatric nursing leaders she has chosen

17. as contributors reflect a strong
complement of clinical and academic talent; outstanding nursing
professionals whose wealth of clinical and
teaching experience inform the psychotherapy discussion
presented in each chapter. The in-depth discussion
of psychotherapeutic models used to achieve quality clinical
outcomes is enhanced by the presentation of the
“best available evidence” to support the efficacy of
psychotherapy. The neuroscience foundation informs the
biological basis for the effectiveness of psychotherapy, an
essential intellectual discussion that establishes
psychotherapy as more than a healing art and propels it into the
realm of science and evidence-based practice.
The unique consideration of culture to psychotherapy, that is,
awareness of cultural differences, cultural
sensitivity, and cultural competence, addresses how culture
interfaces with the practice of psychotherapy. New
chapters on motivational interviewing, dialectical behavior
therapy, eye movement desensitization and
reprocessing therapy (EMDR), therapeutic approaches to
addictions, new Current Procedural Terminology
(CPT) codes, and reimbursement promise to make this second
edition a “must have” for advanced practice
psychiatric nurses and their colleagues. From a teaching–

18. learning perspective, the rich examples in each
chapter provide learning anchors that facilitate contextual
learning for students, and that support
integration of theory and clinical practice. I am confident that
the second edition of Psychotherapy for
the Advanced Practice Psychiatric Nurse will make an even
greater contribution to the academic and clinical
practice literature. I salute Dr. Wheeler, a close colleague for
over 30 years, for continuing this important
project and creating an innovative new edition!
11
xiii
xiv
Foreword
JEANNE A. CLEMENT, EdD, APRN, PMHCNS-BC, FAAN
Associate Professor Emeritus
The Ohio State University

19. Psychotherapist
Central Ohio Behavioral Medicine, Inc.
Six years ago, Dr. Kathleen Wheeler and a carefully selected
group of expert practitioners gave all advanced
practice psychiatric nurses a gift. The gift was one of the first
books written by and for advanced practice
nurses. Psychotherapy for the Advanced Practice Psychiatric
Nurse is a book with carefully crafted, empirically
supported frameworks for the practice of psychotherapy and it
enabled us to re-embrace the bedrock of our
practice: the therapeutic use of self. In addition to updating the
knowledge, skills, and processes of practice,
this second edition expands upon the most crucial elements
involved in building upon our practice bedrock:
self-knowledge, self-acceptance, genuine presence, belief in
change, and lifelong learning.
Although all the therapies in this book are evidence-based, this
book is not only about the knowledge,
processes, and skills of therapy, but it also highlights the
importance of developing ourselves personally.
Openness to self-knowledge and self-acceptance is a necessary
condition to effective and ethical practice. “The
force and spirit of who the therapist is as a human being most

20. dramatically stimulates change, especially the
personal attitudes that we display in the relationship” (Kottler,
2003, p. 3). As nurse therapists, we create
environments in which the people with whom we are privileged
to work are able to discover who they are and
to rediscover and/or develop new strengths. We may be seen as
role models at times, but “modeling takes the
form of presenting not only an ideal to strive for but also a real,
live person who is flawed, genuine and
sincere” (Kottler, 2003, p. 32). The therapist’s positive,
directed energy sincerely conveys hope and belief in
the person’s ability to change.
Prior to 2003, psychiatric-mental health clinical nurse
specialists (PMHCNS) practiced psychotherapy;
now all psychiatric advanced practice nurses in doctoral and
master’s programs must meet this competency.
“The burgeoning mental health needs of the population demand
access to highly qualified providers.
Psychiatric mental health advanced practice nurses (PMH-
APRN) include both the clinical nurse specialist
and the nurse practitioner. Both are prepared at the graduate
level in research, systems, and direct patient care
to provide psychiatric evaluations and treatment, including
psychopharmacological interventions and

21. individual, family and group therapy, as well as primary,
secondary and tertiary levels of prevention across the
lifespan. They are a vital part of the workforce required to meet
increasing population mental health needs”
(APNA, 2010).
After 54 years as a nurse, in that time both a psychiatric nurse
and a therapist, I am still learning
and delighted to have a second edition of this text. For the
experienced therapist, it is both validating
and enlightening. For those who are neophyte practitioners, this
book provides the evidence base for
psychotherapy, teaches the beginner the competencies essential
in order to conduct therapy, and emphasizes
the importance of relationship and lifelong learning.
Congratulations and thank you to Kathleen Wheeler and
the group of expert practitioners and educators who have
contributed to this excellent revision.
REFERENCES
American Psychiatric Nurses Association (APNA). (2010).
APNA Position Statement: Psychiatric Mental Health Advanced
Practice Nurses.
Retrieved from:

22. www.apna.org/i4a/pages/index.cfm?pageid=4354
Kottler, J. (2003). On being a therapist (3rd ed.). San Francisco,
CA: Jossey-Bass.
12
http://www.apna.org/i4a/pages/index.cfm?pageid=4354
13
xv
xvi
Preface
Six years have passed since publication of the first edition of
Psychotherapy for the Advanced Practice Psychiatric
Nurse. At the time the book was published, it was the only book
in print written specifically for advanced
practice psychiatric nurses (APPNs). It was warmly welcomed

23. into the APPN community with positive
reviews, several awards, and adoption by many APPN programs.
Since then, a number of other books for
APPNs have been published and the number of graduate
psychiatric nursing programs and APPNs has
steadily increased (Hanrahan, Delaney, & Stuart, 2011).
These past 6 years have been marked by significant
developments for APPNs: master’s graduate
programs transitioning to Doctoral Nursing Practice (DNP)
programs, the Consensus Model for APRN
Regulation (Licensure, Accreditation, Certification &
Education, also known as LACE), revised Psychiatric-
Mental Health Nurse Practitioner (PMHNP) Competencies,
endorsement of the PMHNP as the one APPN
role by American Psychiatric Nurses Association (APNA) and
International Society of Psychiatric Nursing
(ISPN), a new Diagnostic and Statistical Manual (DSM), new
Current Procedural Terminology (CPT) codes
for reimbursement, the Patient Protection Affordable Care Act,
integrated behavioral care, parity of mental
health with medical illness, American Nurses Credentialing
Center (ANCC) discontinuation of all APPN
exams except PMHNP (across the life span) in 2014, and the
Institute of Medicine (IOM) 2010 report on

24. the Future of Nursing advocating removal of scope-of-practice
barriers for advanced practice nurses. What do
these cataclysmic changes in nursing, mental health, and health
care portend for APPNs and the practice of
psychotherapy7
Since the completion in 2003 of the Psychiatric-Mental Health
Nurse Practitioner Competencies and
the adoption of these standards for evaluation by CCNE for
accreditation, psychotherapy has been recognized
as an essential competency that all PMHNPs must achieve. This
has been reaffirmed with the revision of the
PMHNP Competencies in 2013. The challenge for nurse
educators is how to teach these competencies in
addition to the essentials that are also required for graduate
nursing curricula without increasing the total
credit load. Psychotherapy skills must be acquired expeditiously
in a short amount of time.
A 2009 survey of APPNs found that APPN practice involved
prescribing, diagnostic assessments, and
psychotherapy combined with medication management (vs.
solely conducting individual psychotherapy; Drew
& Delaney, 2009). Many of the jobs available to APPN
graduates are in community mental health centers

25. with 15- to 30-minute medication checks the norm. APPN
graduates are encouraged to negotiate for longer
sessions as needed and for a broader role that includes
psychiatric evaluations and psychotherapy if they wish
as well as prescribing medication. The marginalization of
psychiatrists to the prescriber role should serve as a
warning to APPNs who embrace a prescriber-only role without
such negotiation. Often more seasoned
APPNs develop their own preferred private practice once
confidence is gained.
It has been more than 60 years since Peplau proposed that it is
the relationship between the
nurse and the patient through which recovery and health are
achieved. Relationship-centered care
has been the hallmark of psychiatric nursing. This book expands
Peplau’s interpersonal paradigm from a two-
person model to a more contemporary holistic perspective.
Interpersonal neuroscience and attachment
research validate the scientific basis of the centrality of this
relationship for healing. The overall framework for
practice proposed in this book is based on relationship science
with adaptive information processing providing
the neurophysiological explanatory mechanism of action.
APPNs who understand neuroscience can decide

26. what treatment to use for which problem based on results from
brain-imaging studies, psychotherapy outcome
studies, and practice guidelines.
The nurse psychotherapist must have a context for practice, an
overarching framework for when and how
to use techniques germane to various evidence-based
psychotherapy approaches for the specific client
problems encountered in clinical practice. Given the complexity
of people, no one-size-fits-all model is
presented in this book. It is rare for a therapist to adhere to only
one model in a pure form; most often the
clinically skilled therapist bases treatment choices on a
formulation of the person’s problem that takes into
14
xvii
account such factors as the developmental history, pattern of
relating, behavioral analysis, coping skills, and
support system. Ethical psychotherapy practice demands no
less. If the APPN has a solid theoretical

27. understanding to guide interventions and training in several
evidence-based approaches, it is possible to adapt
the therapy to the needs of the patient rather than requiring that
the patient adapt to the demands of the
therapist’s orientation.
The skillful therapist must know how to respond, engage, and
accurately assess the problem in order to
formulate a treatment plan. A comprehensive and accurate
assessment at the beginning of treatment as well as
throughout psychotherapy serves as a compass to guide
treatment. This book strives to assist the beginning
therapist in accurate assessment through a comprehensive
psychodynamic understanding of the client.
Understanding development and psychodynamic issues is
imperative in order to make sense of what is
happening for the client in the treatment. Even if the therapist
decides to use behavioral or cognitive
techniques, such as a thought diary, to track lifelong false
negative beliefs rather than psychodynamic
psychotherapy, understanding the client as fully as possible
assists in making treatment recommendations.
This knowledge is essential when collaborating with other
mental health providers.

28. How then does one learn psychotherapy if not in a pure form
through adherence to a specific model?
Psychotherapy is a learned skill like any other. The learning
process begins with studying each component and
practicing the technique and then blending it back together
again with what you already know as each
separate skill is acquired. Remember how you learned to take
blood pressure or any other nursing skill? This
can only be accomplished through learning discrete steps and
practicing competencies in a skill set until that
skill becomes automatic. If it seems like hard work at first, it
probably means you are doing it well.
The contributing authors to this book are all expert APPNs.
Throughout, liberal use of examples and
case studies provide pragmatic examples for the novice as well
as the expert nurse psychotherapist to use as a
guide for practice. To aid the readers, Springer Publishing
Company offers the appendices, figures, and tables
that appear in this book in pdf format at
www.springerpub.com/wheeler-ancillary. The aim is to provide
helpful strategies, starting with the first contact through
termination. These authors have integrated the best
evidence-based approaches into a relationship-based framework
for APPN psychotherapy practice. This how-

29. to compendium of evidence-based approaches honors our
heritage, reaffirms the centrality of relationship for
psychiatric advanced practice, and celebrates the excellence,
vitality, depth, and breadth of knowledge of our
specialty. We are fortunate to have the expertise of these
esteemed colleagues and I am honored and
pleased to be able to share and disseminate their clinical
wisdom. This book is a testament to the
bright, exciting future of psychotherapy practice for APPNs.
This book, however, will only be as useful as the depth of the
APPNs’ own acceptance and knowledge of
self. Compassion and wisdom cannot be taught in a book.
Nurses who are healers understand that they can
only accompany the patient on his or her journey if they have
begun their own self-healing and that self-
healing is a continuous process whereby one continues to
develop clarity about one’s own strengths and
weaknesses. As an early supervisor of mine told our class at the
beginning of graduate studies: “Don’t walk
around in someone’s head with muddy boots.” Openness and
curiosity to self-discovery are essential in order
to cultivate self-knowledge. Much of the work of psychotherapy
takes place in the shared consciousness of two
people and it is in those healing moments of connection that

30. both participants grow. Indeed, the opportunity
for personal growth in the transition from nurse to nurse
psychotherapist is an exciting, rewarding journey
leading toward a lifetime of professional satisfaction.
Kathleen Wheeler
REFERENCES
Drew, B., & Delaney, K. (2009). National survey of psychiatric
mental health advanced practice nursing: development, process,
and finding.
Journal of the American Psychiatric Nurses Association, 15,
101–110. doi: 10.1177/1078390309333544
Hanrahan, N. P., Delaney, K. R., & Stuart, G. W. (2012).
Blueprint for development of the advanced practice psychiatric
nurse workforce.
Nursing Outlook, 60(2), 91–106.
doi:10.1016/j.outlook.2011.04.007
15
http://www.springerpub.com/wheeler-ancillary

31. xviiixixAcknowledgments
I am very grateful to the expert clinicians and scholars who
contributed chapters to this book. …
AmericanNursesAssociation
8515GeorgiaAvenue,Suite400
SilverSpring,MD20910-3492
1-800-274-4ANA
http://www.Nursingworld.org
PublishedbyNursesbooks.org

32. ThePublishingProgramofANA
http://www.Nursesbooks.org/
TheAmericanPsychiatricNursesAssociation(APNA),theInternati
onalSocietyofPsychiatric-
MentalHealthNurses(ISPN),andtheAmericanNursesAssociation(
ANA)arenational
professionalassociations.Thisjointpublication,PsychiatricMental
HealthNursing:Scope
andStandardsofPractice,2ndEdition,reflectsthethinkingoftheprac
ticespecialtyof
psychiatric-
mentalhealthnursingonvariousissuesandshouldbereviewedinconj
unction
withstateboardofnursingpoliciesandpractices.Statelaw,rules,andr
egulationsgovernthe
practiceofnursing,whilePsychiatricMentalHealthNursing:Scopea
ndStandardsof
Practice,2ndEditionguidespsychiatric-
mentalhealthnursesintheapplicationoftheir
professionalskillsandresponsibilities.
TheAmericanPsychiatricNursesAssociation(APNA)isyourresour

33. ceforpsychiatric-mental
healthnursing.Aprofessionalorganizationwithmorethan9,000mem
bers,wearecommitted
tothepracticeofpsychiatricmentalhealth(PMH)nursing,healthand
wellnesspromotion
throughidentificationofmentalhealthissues,preventionofmentalhe
althproblemsandthe
careandtreatmentofpersonswithpsychiatricdisorders.Tofacilitate
professional
advancement,APNAprovidesqualitypsychiatric-
mentalhealthnursingcontinuingeducation;
awealthofresourcesforestablished,emerging,andprospectivePMH
nurses;anda
communityofdynamiccollaboration.APNAchampionspsychiatric-
mentalhealthnursingand
advocatesformentalhealthcarethroughthedevelopmentofpositions
onkeyissues,the
widespreaddisseminationofcurrentknowledgeanddevelopmentsin
PMHnursing,and
collaborationwithconsumergroups,topromoteevidence-
basedadvancesinrecovery-focused
assessment,diagnosis,treatment,andevaluationofpersonswithmen
talillnessand
substanceusedisorders.Formoreinformation:www.apna.org.

34. TheInternationalSocietyofPsychiatric-
MentalHealthNursesexiststouniteandstrengthen
thepresenceandthevoiceofspecialtypsychiatric-
mentalhealthnursingwhileinfluencing
healthcarepolicytopromoteequitable,evidence-
basedandeffectivetreatmentandcarefor
individuals,families,andcommunities.http://www.ispn-psych.org
TheAmericanNursesAssociationistheonlyfull-
serviceprofessionalorganization
representingtheinterestsofthenation’s3.1millionregisterednursest
hroughits
constituent/statenursesassociationsanditsorganizationalaffiliates
.TheANAadvancesthe
nursingprofessionbyfosteringhighstandardsofnursingpractice,pro
motingtherightsof
nursesintheworkplace,projectingapositiveandrealisticviewofnurs
ing,andbylobbying
theCongressandregulatoryagenciesonhealthcareissuesaffectingnu
rsesandthepublic.
Copyright©2014AmericanNursesAssociation,AmericanPsychiatr
icNursesAssociationand
InternationalSocietyofPsychiatric-
MentalHealthNurses.Allrightsreserved.Reproduction

35. ortransmissioninanyformisnotpermittedwithoutwrittenpermissio
noftheAmerican
NursesAssociation(ANA).Thispublicationmaynotbetranslatedwit
houtwrittenpermission
ofANA.Forinquiriesortoreportunauthorizeduse,email[email prot
ected]
ISBN-13:978-1-55810-557-7SAN:851-348106/2014
Firstprinting:June2014
Contents
Contributors
Preface
ScopeofPracticeofPsychiatric-MentalHealthNursing
OriginsofthePsychiatric-
MentalHealthAdvancedPracticeNursingRole
CurrentIssuesandTrends

36. PrevalenceofMentalDisordersacrosstheLifespan:CriticalFacts
SubstanceAbuseDisorders:PrevalenceandComorbidities
ChildrenandOlderAdults
DisparitiesinMentalHealthTreatment
OpportunitiestoPartnerwithConsumersforRecoveryandWellness
StructureofaPerson-Centered,Recovery-
OrientedPublicHealthCareModel:Unifying
Efforts
Prevention:ThePromiseofBuildingResiliency
ScreeningandEarlyIntervention
IntegratedCare
TechnologyofaPublicHealthModelofMentalHealthCare
EmergingModelsofAcuteCare
WorkforceRequirementsforaPublicHealthModelofMentalHealth

37. Care
Psychiatric-
MentalHealthNursingLeadershipinTransformingtheMentalHealth
System
DefinitionofPsychiatric-MentalHealthNursing
PhenomenaofConcernforPsychiatric-MentalHealthNurses
Psychiatric-MentalHealthNursingClinicalPracticeSettings
CrisisInterventionandPsychiatricEmergencyServices
AcuteInpatientCare
IntermediateandLong-TermCare
PartialHospitalizationandIntensiveOutpatientTreatment
ResidentialServices
Community-BasedCare
AssertiveCommunityTreatment(ACT)

38. LevelsofPsychiatric-MentalHealthNursingPractice
Psychiatric-MentalHealthRegisteredNurse(PMH-RN)
Psychiatric-
MentalHealthAdvancedPracticeRegisteredNurse(PMH-APRN)
ConsensusModel:LACE(Licensure,Accreditation,Certificationan
dEducation)andAPRN
Roles
PrimaryCare
Psychotherapy
PsychopharmacologicalInterventions
CaseManagement
Program,System,andPolicyDevelopmentandManagement
PsychiatricConsultation–LiaisonNursing(PCLN)

39. ClinicalSupervision
Administration,Education,andResearchPractice
Self-Employment
OtherSpecializedAreasofPractice
IntegrativePrograms
Telehealth
ForensicMentalHealth
DisasterPsychiatric-MentalHealthNursing
EthicalIssuesinPsychiatric-MentalHealthNursing
RespectfortheIndividual
CommitmenttotheHealthcareConsumer
AdvocacyfortheHealthcareConsumer

40. ResponsibilityandAccountabilityforPractice
DutiestoSelfandOthers
ContributionstoHealthcareEnvironments
AdvancementoftheNursingProfession
CollaborationtoMeetHealthNeeds
PromotionoftheNursingProfession
StandardsofPsychiatric-MentalHealthNursingPractice
StandardsofPracticeforPsychiatric-MentalHealthNursing
Standard1.Assessment
Standard2.Diagnosis
Standard3.OutcomesIdentification
Standard4.Planning
Standard5.Implementation

41. Standard5A.CoordinationofCare
Standard5B.HealthTeachingandHealthPromotion
Standard5C.Consultation
Standard5D.PrescriptiveAuthorityandTreatment
Standard5E.Pharmacological,Biological,andIntegrativeTherapies
Standard5F.MilieuTherapy
Standard5G.TherapeuticRelationshipandCounseling
Standard5H.Psychotherapy
Standard6.Evaluation
StandardsofProfessionalPerformanceforPsychiatric-
MentalHealthNursing
Standard7.Ethics

42. Standard8.Education
Standard9Evidence-BasedPracticeandResearch
Standard10.QualityofPractice
Standard11.Communication
Standard12.Leadership
Standard13.Collaboration
Standard14.ProfessionalPracticeEvaluation
Standard15.ResourceUtilization
Standard16.EnvironmentalHealth
Glossary
References
Abbreviations

43. AppendixA.Psychiatric-
MentalHealthNursing:ScopeandStandardsofPractice(2007)
Index
Contributors
APNAandISPNJointTaskForceMembers
KrisA.McLoughlin,DNP,APRN,PMHCNS-BC,CADC-
II,FAAN—APNACo-Chair
CatherineF.Kane,PhD,RN,FAAN—ISPNCo-Chair
KathleenDelaney,PhD,PMH-NP,FAAN
SaraHorton-Deutsch,PhD,APRN,PMHCNS,RN,ANEF
AmandaDuWick,BSN,RN-BC
KayFoland,PhD,RN,PMHNP-BC,PMHCNS-BC,CNP
SusanL.W.KrupnickMSN,PMHCNS-BC,ANP-BC,C-PREP

44. SueM.Odegarden,MA,MS,BSN
BethanyJ.Phoenix,PhD,RN,CNS
PeggyPlunkett,MSN,APRN,PMHCNS-BC
DianeSnow,PhD,RN,PMHNP-BC,CARN,FAANP
VictoriaSoltis-Jarrett,PhD,PMHCNS/NP-BC
ChristineTebaldi,MSN,APRN,PMHNP-BC
EdilmaL.Yearwood,PhD,PMHCNS-BC,FAAN
ANAStaff
CarolJ.Bickford,PhD,RN-BC,CPHIMS—Contenteditor
MaureenE.Cones,Esq.—Legalcounsel
YvonneDaleyHumes,MSA—Projectcoordinator
EricWurzbacher,BA—Projecteditor

45. AbouttheAmericanPsychiatricNursesAssociation
TheAmericanPsychiatricNursesAssociation(APNA)isyourresour
ceforpsychiatric-mental
healthnursing.Aprofessionalorganizationwithmorethan9,000mem
bers,wearecommitted
tothepracticeofpsychiatric-
mentalhealth(PMH)nursing,healthandwellnesspromotion
throughidentificationofmentalhealthissues,preventionofmentalhe
althproblemsandthe
careandtreatmentofpersonswithpsychiatricdisorders.Tofacilitate
professional
advancement,APNAprovidesqualitypsychiatric-
mentalhealthnursingcontinuingeducation;
awealthofresourcesforestablished,emerging,andprospectivePMH
nurses;anda
communityofdynamiccollaboration.APNAchampionspsychiatric-
mentalhealthnursingand
advocatesformentalhealthcarethroughthedevelopmentofpositions
onkeyissues,the
widespreaddisseminationofcurrentknowledgeanddevelopmentsin
PMHnursing,and
collaborationwithconsumergroups,topromoteevidence-
basedadvancesinrecovery-focused
assessment,diagnosis,treatment,andevaluationofpersonswithmen

46. talillnessand
substanceusedisorders.Formoreinformation:www.apna.org.
AbouttheInternationalSocietyofPsychiatric-MentalHealthNurses
TheInternationalSocietyofPsychiatric-
MentalHealthNurses(ISPN)existstouniteand
strengthenthepresenceandthevoiceofspecialtypsychiatric-
mentalhealthnursingwhile
influencinghealthcarepolicytopromoteequitable,evidence-
basedandeffectivetreatment
andcareforindividuals,families,andcommunities.http://www.ispn
-psych.org
AbouttheAmericanNursesAssociation
TheAmericanNursesAssociation(ANA)istheonlyfull-
serviceprofessionalorganization
representingtheinterestsofthenation’s3.1millionregisterednursest
hroughits
constituent/statenursesassociationsanditsorganizationalaffiliates
.TheANAadvancesthe
nursingprofessionbyfosteringhighstandardsofnursingpractice,pro

47. motingtherightsof
nursesintheworkplace,projectingapositiveandrealisticviewofnurs
ing,andbylobbying
theCongressandregulatoryagenciesonhealthcareissuesaffectingnu
rsesandthepublic.
AboutNursesbooks.org,ThePublishingProgramofANA
Nursesbooks.orgpublishesbooksonANAcoreissuesandprograms,i
ncludingethics,
leadership,quality,specialtypractice,advancedpractice,andthepro
fession’senduring
legacy.Bestknownforthefoundationaldocumentsoftheprofessiono
nnursingethics,scope
andstandardsofpractice,andsocialpolicy,Nursesbooks.orgisthepu
blisherforthe
professional,career-
orientednurse,reachingandservingnurseeducators,administrators,
managers,andresearchersaswellasstaffnursesinthecourseoftheirpr
ofessional
development.
Preface

48. In2011,theAmericanPsychiatricNursesAssociation(APNA)andth
eInternationalSocietyof
Psychiatric-
MentalHealthNurses(ISPN)appointedajointtaskforcetobeginthere
viewand
revisionofPsychiatric-
MentalHealthNursing:ScopeandStandardsofPractice,publishedin
2007bytheAmericanNursesAssociation(ANA07).Thetaskforceme
mberswerecomprised
ofpsychiatric-
mentalhealthnursingclinicaladministrators,staffnurses,nursingfa
culty,and
psychiatricadvancedpracticeregisterednursesworkinginpsychiatri
cfacilitiesandthe
community.ThistaskforceconvenedinJuly2011toconductananalys
isoftheexisting
documentandbegincraftingsectionsincorporatingtheresultsofthea
nalysis.
InaccordancewithANArecommendations,thisdocumentreflectsthe
templatelanguageof
themostrecentpublicationofANAnursingstandards,Nursing:Scope
andStandardsof
Practice,SecondEdition(ANA10).Inaddition,theintroductionhasb

49. eenrevisedtohighlight
theleadershiproleofpsychiatric-
mentalhealthnursesinthetransformationofthemental
healthsystemasoutlinedinAchievingthePromise,thePresident’sNe
wFreedom
CommissionReportonMentalHealth(UnitedStatesDepartmentofH
ealthandHuman
Services03)andtheInstituteofMedicine’sReport(IOM)TheFutureo
fNursing(2010).The
prevalenceofmentalhealthissuesandpsychiatricdisordersacrossthe
agespan,andthe
disparitiesinaccesstocareandtreatmentamongdiversegroupsattestt
othecriticalrole
thatpsychiatric-
mentalhealth(PMH)nursingmustcontinuetoplayinmeetingthegoal
sfora
healthysociety.Safetyissuesforpersonswithpsychiatricdisordersa
ndthenursesinvolvedin
therecoveryprocessesofpersonswithmentaldisordersaremajorprio
ritiesforPMHnursing
inanenvironmentoffiscalconstraintsanddisparitiesinreimburseme
ntformentalhealth
services.
DevelopmentofthiseditionofPsychiatric-

50. MentalHealthNursing:ScopeandStandardsof
Practiceincludedatwo-
stagefieldreviewprocess:1)reviewandfeedbackfromtheboardsof
theAmericanPsychiatricNursesAssociationandtheInternationalSo
cietyofPsychiatric-
MentalHealthNursingand2)postingofthedraftforpubliccommentat
www.ISPN-psych.org
withlinksfromtheANAwebsite,www.nursingworld.org,andtheAP
NAwebsite,
www.apna.org.Noticeofthepubliccommentperiodwasdistributedt
onursingspecialty
organizations,stateboardsofnursing,nursingschools,facultygroup
s,andstatenurses
associations.Allgroupswereencouragedtodisseminatenoticeofthe
postingstoalloftheir
membersandotherstakeholders.Thefeedbackwascarefullyreviewe
dandintegratedwhen
appropriate.
ScopeofPracticeofPsychiatric-MentalHealthNursing
Psychiatric-
mentalhealthnursingisthenursingpracticespecialtycommittedtopr

51. omoting
mentalhealththroughtheassessment,diagnosis,andtreatmentofbeh
avioralproblems,
mentaldisorders,andcomorbidconditionsacrossthelifespan.Psychi
atric-mentalhealth
nursinginterventionisanartandascience,employingapurposefuluse
ofselfandawide
rangeofnursing,psychosocial,andneurobiologicalevidencetoprod
uceeffectiveoutcomes.
Introduction
Bydevelopingandarticulatingthescopeandstandardsofprofessiona
lnursingpractice,the
nursingprofessionbothdefinesitsboundariesandinformssocietyabo
uttheparametersof
nursingpractice.Thescopeandstandardsalsoguidethedevelopment
ofstatelevelnurse
practiceactsandtherulesandregulationsgoverningnursingpractice.
Becauseeachstatedevelopsitsownregulatorylanguageaboutnursin
g,thedesignated
limits,functions,andtitlesfornurses,particularlyattheadvancedpra
cticelevel,maydiffer
significantlyfromstatetostate.Nursesmustensurethattheirpracticer

52. emainswithinthe
boundariesdefinedbytheirstatepracticeacts.Individualnursesareac
countablefor
ensuringthattheypracticewithinthelimitsoftheirowncompetence,p
rofessionalcodeof
ethics,andprofessionalpracticestandards.
Levelsofnursingpracticearedifferentiatedaccordingtothenurse’se
ducationalpreparation.
Thenurse’srole,position,jobdescription,andworksettingfurtherdef
inepractice.The
nurse’srolemaybefocusedonclinicalpractice,administration,educa
tion,orresearch.
Thisdocumentaddressestherole,scopeofpractice,andstandardsofpr
acticespecificto
psychiatric-
mentalhealthnursing.Thescopestatementdefinespsychiatric-
mentalhealth
nursinganddescribesitsevolutioninnursing,thelevelsofpracticebas
edoneducational
preparation,currentclinicalpracticeactivitiesandsites,andcurrentt
rendsandissues
relevanttothepracticeofpsychiatric-
mentalhealthnursing.Thestandardsofpsychiatric-

53. mentalhealthnursingpracticeareauthoritativestatementsthatdescri
betheresponsibilities
forwhichitspractitionersareaccountable.
HistoryandEvolutionofPsychiatric-MentalHealthNursing
Psychiatric-
mentalhealthnursingbeganwithlate19thcenturyreformmovements
tochange
thefocusofmentalasylumsfromrestrictiveandcustodialcaretomedi
calandsocial
treatmentforthementallyill.The“firstformallyorganizedtrainingsc
hoolwithinahospital
forinsaneintheworld”wasestablishedbyDr.EdwardCowlesatMcLe
anAsylumin
Massachusettsin1882(Church85).Theuseoftrainednurses,ratherth
an“keepers,”was
centraltoCowles’efforttoreplacethepublicperceptionof“insanity”
asdevianceorinfirmity
withabeliefthatmentaldisorderscouldbeamelioratedorcuredwithpr
opertreatment.The
McLeannursetrainingschoolwasthefirstintheUnitedStatestoallow
mentheopportunity
tobecometrainednurses(Boyd98).Eventually,asylumnursingprogr
amsestablished

54. affiliationswithgeneralhospitalssothatgeneralnursingtrainingcoul
dbeprovidedtotheir
students.
Earlyon,trainingforpsychiatricnurseswasprovidedbyphysicians.T
hefirstnurse-organized
trainingcourseforpsychiatricnursingwithinageneralnursingeducat
ionprogramwas
establishedbyEffieJaneTayloratJohnsHopkinsHospitalin1913(Bo
yd98).Thiscourse
servedasaprototypeforothernursingeducationprograms.Taylor’sc
olleagueHarrietBailey
publishedthefirstpsychiatricnursingtextbook,NursingMentalDise
ase,in1920(Boling03).
Undernursingleadership,psychiatric-
mentalhealthnursingdevelopedabiopsychosocial
approachwithspecificnursingmethodsforindividualswithmentaldi
sorders.ThePMHnurse
alsobegantoidentifythedidacticandclinicalcomponentsoftrainingn
eededtocarefor
personswithmentaldisorders.Inthepost-
WWIera,“nursinginnervousandmentaldiseases”
wasaddedtocurriculumguidesdevelopedbytheNationalLeaguefor
NursingEducationand
waseventuallyrequiredinalleducationalprogramsforregisterednur

55. ses(Church85).
Thenextwaveofmentalhealthreformandexpansioninpsychiatricnur
singbeganduring
WorldWarII.Thepublichealthsignificanceofmentaldisordersbeca
mewidelyapparent
whenasignificantproportionofpotentialmilitaryrecruitsweredeem
edunfitforserviceasa
resultofpsychiatricdisability.Inaddition,publicattentionandsymp
athyforthelargenumber
ofveteranswithcombat-
relatedneuropsychiatriccasualtiesledtoincreasedsupportfor
improvingmentalhealthservices.Asapsychiatricnurseconsultantto
theAmerican
PsychiatricAssociation,LauraFitzsimmonsevaluatededucationalp
rogramsforpsychiatric
nursesandrecommendedstandardsoftraining.Theserecommendati
onsweresupportedby
professionalorganizationsandbackedwithfederalfundingtostrengt
heneducational
preparationandstandardsofcareforpsychiatricnursing(Silverstein
08).

56. Thenationalfocusonmentalhealth,combinedwithadmirationforthe
heroismshownby
nursesduringthewar,ledtotheinclusionofpsychiatricnursingasone
ofthecoremental
healthdisciplinesnamedintheNationalMentalHealthAct(NMHA)o
f1946.Thisactgreatly
increasedfundingforpsychiatricnursingeducationandtraining(Silv
erstein08)andledtoa
growthinuniversity-
levelnursingeducation.In1954,HildegardPeplauestablishedthefirs
t
graduatepsychiatricnursingprogramatRutgersUniversity.
Thepost-
warerawasmarkedbygrowingprofessionalizationinpsychiatric-
mentalhealth
nursing(PMH).FundingprovidedbytheNMHAledtoarapidexpansio
nofgraduate
programsandthestartofpsychiatric-
mentalhealthnursingresearch.In1963,thefirst
journalsfocusedonpsychiatric-
mentalhealthnursingwerepublished.In1973,theANAfirst
publishedtheStandardsofPsychiatric-
MentalHealthNursingPracticeandbegancertifying

57. generalistsinpsychiatric-
mentalhealthnursing(Boling03).Peplau’sInterpersonalRelations
inNursing(1992),whichemphasizedtheimportanceofthetherapeuti
crelationshipin
helpingindividualstomakepositivebehaviorchanges,articulatedth
epredominant
psychiatric-mentalhealthnursingapproachoftheperiod.
Theprocessofdeinstitutionalizationbeganinthelate1950swhenthe
majorityofcarefor
personswithpsychiatricillnessbegantoshiftawayfromhospitalsand
towardcommunity
settings.ContributingfactorsincludedtheestablishmentofMedicare
andMedicaid,changing
rulesgoverninginvoluntaryconfinement,andthepassageoflegislati
onsupporting
constructionofcommunitymentalhealthcenters(Boling03).Althou
ghpsychiatric-mental
healthnursespreparedattheundergraduatelevelcontinuedtoworkpri
marilyinhospital-
basedandpsychiatricacutecaresettings,manyalsobegantopracticei
ncommunity-based
programssuchasdaytreatmentandassertivecommunitytreatment.
MentalhealthcareintheUnitedStatesbegananothertransformationi

58. nthe1990s,the
“DecadeoftheBrain.”Thedramaticincreaseinthenumberofpsychiat
ricmedicationsonthe
market,combinedwitheconomicpressurestoreducehospitalstays,re
sultedinbriefer
psychiatrichospitalizationscharacterizedbyuseofmedicationtosta
bilizeacutesymptoms.
Shorterhospitalstaysandhigherpatientacuitybegantoshiftpsychiatr
icnursingpractice
awayfromtheemphasisonrelationship-
basedcareadvocatedbyPeplauandtoward
interventionsfocusedonstabilizationandimmediatesafety.Psychiat
ric-mentalhealthnursing
educationbegantoincludemorecontentonpsychopharmacologyand
thepathophysiologyof
psychiatricdisorders.
Morerecenttrendsinpsychiatric-
mentalhealthnursingincludeanemphasisonintegrated
careandtreatmentofthosepersonswithco-
occurringpsychiatricandsubstanceuse
disorders,aswellasintegratedcareandtreatmentofthosewithco-
occurringmedicaland
psychiatricdisorders.Integratedcareemphasizesthatbothtypesofdi
sordersareprimary

59. andmustbetreatedassuch.
SincetheSubstanceAbuseandMentalHealthServicesAdministratio
n(SAMHSA)has
declaredthatrecoveryisthesinglemostimportantgoalinthetransfor
mationofmental
healthcareinAmerica(SAMHSA06),psychiatric-
mentalhealthnursingismovingtointegrate
person-centered,recovery-
orientedpracticeacrossthecontinuumofcare.Thiscontinuum
includessettingswherepsychiatric-
mentalhealthnurseshavehistoricallyworked,suchas
hospitals,aswellasemergencyrooms,jailsandprisons,andhomeless
outreachservices.
Psychiatric-
mentalhealthnursingisalsotaskedwithdevelopingandapplyinginno
vative
approachesincaringforthelargepopulationofmilitarypersonnel,vet
erans,andtheir
familiesexperiencingwar-
relatedmentalhealthconditionsasaresultofmilitaryconflicts.
Majordevelopmentsinthenursingprofessionhaveacorrespondingef
fectwithinpsychiatric-
mentalhealthnursing.TheInstituteofMedicine’s(2010)report,TheF

60. utureofNursing:
LeadingChangetoAdvanceHealthhasstrengthenedtheroleofpsychi
atric-mentalhealth
nursesasmentalhealthpolicyandprogramdevelopmentleadersinbot
hnationaland
internationalarenas.Nursing’semphasisontheuseofresearchfindin
gstodevelopand
implementevidence-
basedpracticeisdrivingimprovementsinpsychiatric-mentalhealth
nursingpractice.
OriginsofthePsychiatric-
MentalHealthAdvancedPracticeNursingRole
Specialtynursingatthegraduatelevelbegantoevolveinthelate1950s
inresponsetothe
passageoftheNationalMentalHealthActof1946andthecreationofth
eNationalInstitute
ofMentalHealthin1949.TheNationalMentalHealthActof1946ident
ifiedpsychiatric
nursingasoneoffourcoredisciplinesfortheprovisionofpsychiatricc
areandtreatment,

61. alongwithpsychiatry,psychology,andsocialwork.Nursesplayedan
activeroleinmeeting
thegrowingdemandforpsychiatricservicesthatresultedfromincreas
ingawarenessofpost-
warmentalhealthissues(Bigbee&Amidi-
Nouri00).Theprevalenceof“battlefatigue”ledto
recognizingtheneedformorementalhealthprofessionals.
Thefirstdegreeinpsychiatric-
mentalhealthnursing,amaster’sdegree,wasconferredat
RutgersUniversityin1954undertheleadershipofHildegardPeplau.I
ncontrasttoexisting
graduatenursingprogramsthatfocusedondevelopingeducatorsandc
onsultants,graduate
educationinpsychiatric-
mentalhealthnursingwasdesignedtopreparenursetherapiststo
assessanddiagnosementalhealthproblemsandpsychiatricdisorders
andprovideindividual,
group,andfamilytherapy.Psychiatricnursespioneeredthedevelopm
entoftheadvanced
practicenursingroleandledeffortstoestablishnationalcertificationt
hroughtheAmerican
NursesAssociation.
TheCommunityMentalHealthCentersActof1963facilitatedtheexp

62. ansionofpsychiatric-
mentalhealthclinicalnursespecialist(PMHCNS)practiceintocomm
unityandambulatory
caresites.PMHCNSswithmaster’sanddoctoraldegreesfulfilledacru
cialroleinhelping
deinstitutionalizedmentallyillpersonsadapttocommunitylife.Trai
neeshipstofundgraduate
educationprovidedthroughtheNationalInstituteofMentalHealthpl
ayedasignificantrole
inexpandingthePMHCNSworkforce.Bythelate1960s,PMHCNSspr
ovidedindividual,
group,andfamilypsychotherapyinabroadrangeofsettingsandobtain
edthird-party
reimbursement.PMHCNSsalsofunctionedaseducators,researchers
,andmanagers,and
workedinconsultation-
liaisonpositionsorintheareaofaddictions.Theserolescontinue
today.
Anothersignificantshiftoccurredasresearchrenewedtheemphasiso
ntheneurobiologic
basisofmentaldisorders,includingsubstanceusedisorders.Asmoree
fficaciouspsychotropic
medicationswithfewersideeffectsweredeveloped,psychopharmac
ologyassumedamore

63. centralroleinpsychiatrictreatment.TheroleofthePMHCNSevolved
toencompassthe
expandingbiopsychosocialperspective,andthecompetenciesrequir
edforpracticewerekept
congruentwithemergingscience.Manypsychiatric-
mentalhealthgraduatenursingprograms
addedneurobiology,advancedhealthassessment,pharmacology,pat
hophysiology,andthe
diagnosisandmedicalmanagementofpsychiatricillnesstotheircurri
cula.Similarly,
preparationforprescriptiveprivilegesbecameanintegralpartofadva
ncedpractice
psychiatric-
mentalhealthnursinggraduateprograms(Kaas&Markley98).
Othertrendsinmentalhealthandthelargerhealthcaresystemalsospar
kedsignificant
changesinadvancedpracticepsychiatricnursing.Thesetrendsinclud
ed:
■AshiftinNationalInstituteofMentalHealth(NIMH)fundsfromedu
cationtoresearch,
leadingtoadramaticdeclineinenrollmentinpsychiatricnursinggrad
uateprograms
(Taylor99);

64. ■Anincreasedawarenessofphysicalhealthproblemsinmentallyillp
ersonslivingin
communitysettings(Chafetzetal.05);
■Ashifttoprimarycareasakeypointofentryforcomprehensivehealth
care,including
psychiatriccare;and
■Thegrowthandpublicrecognitionofthenursepractitionerroleinpri
marycaresettings.
Inresponsetothesechallenges,psychiatricnursinggraduateprogram
smodifiedtheir
curriculatoincludegreateremphasisoncomprehensivehealthassess
ment,referral,and
managementofcommonphysicalhealthproblems,andacontinuedfo
cusoneducational
preparationtomeetthestatecriteriaandprofessionalcompetenciesfo
rprescriptive
authority.Thetremendousexpansionintheuseof“nursepractitioners
”inprimarycare
settingshadmadenursepractitioner(NP)synonymouswith“advance
dpracticeregistered

65. nurse”insomestatenursepracticeactsandformanyinthegeneralpubl
ic.Inresponseto
conditionsincludingpublicrecognitionoftherole,marketforces,and
state
regulations,psychiatric-
mentalhealthnursingbeganutilizingtheNursePractitionertitleand
modifyinggraduatepsychiatricnursingprogramstoconformtorequi
rementsforNP
credentialing(Wheeler&Haber04;Delaneyetal.99).ThePsychiatric
-MentalHealthNurse
PractitionerrolewasclearlydelineatedbythepublicationofthePsych
iatric-MentalHealth
NursePractitionerCompetencies(NationalPanel03),theproductofa
panelwith
representationfromabroadbaseofnursingorganizationssponsoredb
ytheNational
OrganizationofNursePractitionerFaculty(NONPF).
Whetherpracticingunderthetitleofclinicalnursespecialist(CNS)or
NP,Psychiatric-Mental
HealthAdvancedPracticeRegisteredNursessharethesamecorecom
petenciesofclinical
andprofessionalpractice.Althoughpsychiatric-

66. mentalhealthnursingismovingtowarda
singlenationalcertificationfornewgraduatesofadvancedpracticepr
ograms,titled
Psychiatric-
MentalHealthNursePractitioner,personsalreadycredentialedasPsy
chiatric-
MentalHealthClinicalNurseSpecialistswillcontinuetopracticeund
erthistitle(NCSBN
JointDialogueGroupReport08).
CurrentIssuesandTrends
…
Rubric Detail
Select Grid View or List View to change the rubric's layout.
Content
Name: NRNP_6650_Week1_Discussion_Rubric
· Grid View
· List View
Outstanding Performance
Excellent Performance
Competent Performance

67. Proficient Performance
Room for Improvement
Main Posting: Response to the discusion question is reflecive
with critical analysis and synthesis representive of knowledg
gained from the course readings for the module and current
credible sources.
Points Range: 44 (44%) - 44 (44%)
• Thoroughly responds to the discusion question(s)
• Is reflecive with critical analysis and synthesis representive of
knowledg gained from the course readings for the module and
current credible sources.
• Supported by at least 3 current, credible sources
Points Range: 40 (40%) - 43 (43%)
• Responds to the discusion question(s)
• Is reflecive with critical analysis and synthesis representive of
knowledg gained from the course readings for the module.
• 75% of post has exceptional depth and breadth
• Supported by at least 3 credible references
Points Range: 35 (35%) - 39 (39%)
• Responds to most of the discusion question(s)

68. • Is somewhat reflecive with critical analysis and synthesis
representive of knowledg gained from the course readings for
the module.
• 50% of post has exceptional depth and breadth
• Supported by at least 3 credible references
Points Range: 31 (31%) - 34 (34%)
• Responds to some of the discusion question(s)
• One to two criteria are not addressed or are superficially
addresed
• Is somewhat lacking reflection and critical analysis and
synthesis
• Somewhat represents knowledge gained from the course
readings for the module.
• Post is cited with fewer than 2 credible references
Points Range: 0 (0%) - 30 (30%)
• Does not respond to the discusion question(s)
• Lacks depth or superficially addresses criteria

69. •lacks reflection and critical analysis and synthesis
• Does not represent knowledge gained from the course readings
for the module.
• Contains only 1 or no credible references
Main Posting: Writing
Points Range: 6 (6%) - 6 (6%)
• Written clearly and concisely
• Contains no grammatical or spelling errors
• Fully adheres to current APA manual writing rules and style
Points Range: 5.5 (5.5%) - 5.5 (5.5%)
• Written clearly and concisely
• May contain one or no grammatical or spelling error
• Adheres to current APA manual writing rules and style
Points Range: 5 (5%) - 5 (5%)
• Written concisely
• May contain one to two grammatical or spelling error

70. • Adheres to current APA manual writing rules and style
Points Range: 4.5 (4.5%) - 4.5 (4.5%)
•Writtten somewhat concisely
• May contain more than two2 spelling or grammatical errors
• Contains some APA formatting erros
Points Range: 0 (0%) - 4 (4%)
• Not written clearly or concisely
• Contains more than two spelling or grammatical errors
• Does not adhere to current APA manual writing rules and style
Main Posting: Timely and full participation
Points Range: 10 (10%) - 10 (10%)
• Meets requirements for timely and full participation
• Posts main discussion by due date
Points Range: 0 (0%) - 0 (0%)
Points Range: 0 (0%) - 0 (0%)
Points Range: 0 (0%) - 0 (0%)
Points Range: 0 (0%) - 6 (6%)
• Does not meet requirement for full participation
First Reponse

71. Post to colleague's main post that is reflective and justified with
credible sources.
Points Range: 9 (9%) - 9 (9%)
• Response exhibits critical thinking and application to practice
settings
• Responds to questions posed by faculty
• The use of scholarly sources to support ideas demonstrates
synthesis and understanding of learning objectives
Points Range: 8.5 (8.5%) - 8.5 (8.5%)
• Response exhibits critical thinking and application to practice
settings
Points Range: 7.5 (7.5%) - 8 (8%)
• Response has some depth and may exhibit critical thinking or
application to practice setting
Points Range: 6.5 (6.5%) - 7 (7%)
• Response is on topic, may have some depth
Points Range: 0 (0%) - 6 (6%)
• Reponse may not be on topic, lacks depth
First Reponse: Writing
Points Range: 6 (6%) - 6 (6%)
• Communication is professional and respectful to colleagues

72. • Response to faculty questions are fully answered if posed
• Provides clear, concise opinions and ideas that are supported
by two or more credible sources
• Response is effectively written in Standard Edited English
Points Range: 5.5 (5.5%) - 5.5 (5.5%)
• Communication is professional and respectful to colleagues
• Response to faculty questions are answered if posed
• Provides clear, concise opinions and ideas that are supported
by two or more credible sources
• Response is effectively written in Standard Edited English
Points Range: 5 (5%) - 5 (5%)
• Communication is mostly professional and respectful to
colleagues
• Response to faculty questions are mostly answered if posed
• Provides opinions and ideas that are supported by few credible
sources
• Response is written in Standard Edited English

73. Points Range: 4.5 (4.5%) - 4.5 (4.5%)
• Responses posted in the discussion may lack effective
professional communication
• Response to faculty questions are somewhat answered if posed
• Few or no credible sources are cited
Points Range: 0 (0%) - 4 (4%)
• Responses posted in the discussion lack effective
• Response to faculty questions are missing
• No credible sources are cited
First Reponse: Timely and full participation
Points Range: 5 (5%) - 5 (5%)
• Meets requirements for timely and full participation
• Posts by due date
Points Range: 0 (0%) - 0 (0%)
Points Range: 0 (0%) - 0 (0%)
Points Range: 0 (0%) - 0 (0%)
Points Range: 0 (0%) - 4 (4%)
• Does not meet requirement for full participation
Second Reponse: Post to colleague's main post that is reflective
and justified with credible sources.

74. Points Range: 9 (9%) - 9 (9%)
• Response exhibits critical thinking and application to practice
settings
• Responds to questions posed by faculty
• The use of scholarly sources to support ideas demonstrates
synthesis and understanding of learning objectives
Points Range: 8.5 (8.5%) - 8.5 (8.5%)
• Response exhibits critical thinking and application to practice
settings
Points Range: 7.5 (7.5%) - 8 (8%)
• Response has some depth and may exhibit critical thinking or
application to practice setting
Points Range: 6.5 (6.5%) - 7 (7%)
• Response is on topic, may have some depth
Points Range: 0 (0%) - 6 (6%)
• Response may not be on topic, lacks depth
Second Reponse: Writing
Points Range: 6 (6%) - 6 (6%)
• Communication is professional and respectful to colleagues
• Response to faculty questions are fully answered if posed
• Provides clear, concise opinions and ideas that are supported

75. by two or more credible sources
• Response is effectively written in Standard Edited English
Points Range: 5.5 (5.5%) - 5.5 (5.5%)
• Communication is professional and respectful to colleagues
• Response to faculty questions are answered if posed
• Provides clear, concise opinions and ideas that are supported
by two or more credible sources
• Response is effectively written in Standard Edited English
Points Range: 5 (5%) - 5 (5%)
• Communication is mostly professional and respectful to
colleagues
• Response to faculty questions are mostly answered if posed
• Provides opinions and ideas that are supported by few credible
sources
• Response is written in Standard Edited English
Points Range: 4.5 (4.5%) - 4.5 (4.5%)
• Responses posted in the discussion may lack effective
professional communication

76. • Response to faculty questions are somewhat answered if posed
• Few or no credible sources are cited
Points Range: 0 (0%) - 4 (4%)
>• Responses posted in the discussion lack effective
• Response to faculty questions are missing
• No credible sources are cited
Second Reponse: Timely and full participation
Points Range: 5 (5%) - 5 (5%)
• Meets requirements for timely and full participation
• Posts by due date
Points Range: 0 (0%) - 0 (0%)
Points Range: 0 (0%) - 0 (0%)
Points Range: 0 (0%) - 0 (0%)
Points Range: 0 (0%) - 0 (0%)
• Does not meet requirement for full participation
Total Points: 100
Name: NRNP_6650_Week1_Discussion_Rubric

77. Required Readings
American Nurses Association. (2014). Psychiatric-mental health
nursing: Scope and standards of practice (2nd ed.). Washington,
DC: Author.
· Standard 5A “Coordination of Care” (page 54)
Note: Throughout the program you will be reading excerpts
from the ANA’s Scope & Standards of Practice for Psychiatric-
Mental Health Nursing. It is essential to your success on the
ANCC board certification exam for Psychiatric/Mental Health
Nurse Practitioners that you know the scope of practice of the
advanced practice psychiatric/mental health nurse. You should
also be able to differentiate between the generalist RN role in
psychiatric/mental health nursing and the advanced practice
nurse role.
Breeskin, J. (2011). Procedures and guidelines for group
therapy. The Group Psychologist, 21(1). Retrieved from
http://www.apadivisions.org/division-
49/publications/newsletter/group-psychologist/2011/04/group-
procedures.aspx
Khawaja, I. S., Pollock, K., & Westermeyer, J. J. (2011). The
diminishing role of psychiatry in group psychotherapy: A
commentary and recommendations for change. Innovations in

78. Clinical Neuroscience, 8(11), 20-23.
Koukourikos, K., & Pasmatzi, E. (2014). Group therapy in
psychotic inpatients. Health Science Journal, 8(3), 400-408.
Lego, S. (1998). The application of Peplau's theory to group
psychotherapy. Journal of Psychiatric and Mental Health
Nursing, 5(3), 193-196. doi:10.1046/j.1365-2850.1998.00129.x
McClanahan, K. K. (2014). Can confidentiality be maintained in
group therapy? Retrieved from
http://nationalpsychologist.com/2014/07/can-confidentiality-be-
maintained-in-group-therapy/102566.html
Nichols, M., & Davis, S. D. (2020). The essentials of family
therapy (7th ed.). Boston, MA: Pearson.
· Chapter 1, “Introduction Becoming a Family Therapist” (pp.
1–5)
· Chapter 1, “The Evolution of Family Therapy” (pp. 6-22)
U.S. Department of Health & Human Services. (2014). HIPAA
privacy rule and sharing information related to mental health.

79. Retrieved from
http://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/underst
anding/special/mhguidancepdf.pdf
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced
practice psychiatric nurse: A how-to guide for evidence-based
practice. New York, NY: Springer.
· Chapter 11, “Group Therapy” (pp. 407–428)
Document: Midterm Exam Study Guide (Word document)
Document: Final Exam Study Guide (Word document)
Required Media
Laureate Education (Producer). (2015). Microskills: Family
counseling techniques 1 [Video file]. Baltimore, MD: Author.
Note: The approximate length of this media piece is 32 minutes.