DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS FIFTH E D I T I O N AMERICAN PSYCHIATRIC ASSOCIATION DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS F ! F T H E D I T ¡ O N DSM-5 A División of American PsychiatricAssodation Washington, DC London, England Copyright © 2013 American Psychiatric Association DSM and DSM-5 are trademarks of the American Psychiatric Association. Use of these terms is prohibited without permission of the American Psychiatric Association. ALL RIGHTS RESERVED. Unless authorized in writing by the APA, no part of this book may be reproduced or tised in a manner inconsistent with the APA's copyright. This prohibition applies to unauthorized uses or reproductions in any form, including electronic applications. Correspondence regarding copyright permissions should be directed to DSM Permissions, American Psychiatric Publishing, 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209­ 3901. Manufactured in the United States of America on acid-free paper. ISBN 978-0-89042-554-1 (Hardcover) ISBN 978-0-89042-555-8 (Paperback) American Psychiatric Association 1000 Wilson Boulevard Arlington, VA 22209-3901 www .psych.org The correct citation for this book is American Psychiatric Association: Diagnostic and Statisti- cal Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Associa­ tion, 2013. Library of Congress Cataloging-in-Publication Data Diagnostic and statistical manual of mental disorders : DSM-5. — 5th ed. p . ; cm. DSM-5 DSM-V Includes index. ISBN 978-0-89042-554-1 (hardcover : alk. paper) — ISBN 978-0-89042-555-8 (pbk. : alk. paper) L American Psychiatric Association. II. American Psychiatric Association. DSM-5 Task Forcé. III. Title: DSM-5. IV. Title: DSM-V. [DNLM: 1. Diagnostic and statistical manual of mental disorders. 5th ed. 2. Mental Disorders— classification. 3. Mental Disorders—diagnosis. WM 15] RC455.2.C4 616.89W5—dc23 2013011061 British Library Cataloguing in Publication Data A CIP record is available from the British Library. Text Design—Tammy J. Cordova Manufacturing—Edwards Brothers Malloy Contents DSM-5 C lassification...................... ............................................. xiii Preface........................................................... .................................. xli Section 9 DSM-5 Basics Introduction........................................................................................5 Use of the M an ua l...........................................................................19 Cautionary Statement for Forensic Use of DSM-5................ .25 Section 11 íiiagnostic [email protected] snd (#od©s Neurodevelopmental Disorders.................... ................................ 31 Schizophrenia Spectrum and Other Psychotic D isorders.. . . . .87 Bipolar and Related Disorders.....................................................123 Depressive Disorders .............................

1. DIAGNOSTIC AND STATISTICAL
MANUAL OF
MENTAL DISORDERS
FIFTH E D I T I O N
AMERICAN PSYCHIATRIC ASSOCIATION
DIAGNOSTIC AND STATISTICAL
MANUAL OF
MENTAL DISORDERS
F ! F T H E D I T ¡ O N
DSM-5
A División of American PsychiatricAssodation
Washington, DC
London, England
Copyright © 2013 American Psychiatric Association
DSM and DSM-5 are trademarks of the American Psychiatric
Association. Use of these terms
is prohibited without permission of the American Psychiatric
Association.

2. ALL RIGHTS RESERVED. Unless authorized in writing by the
APA, no part of this book may
be reproduced or tised in a manner inconsistent with the APA's
copyright. This prohibition
applies to unauthorized uses or reproductions in any form,
including electronic applications.
Correspondence regarding copyright permissions should be
directed to DSM Permissions,
American Psychiatric Publishing, 1000 Wilson Boulevard, Suite
1825, Arlington, VA 22209-
3901.
Manufactured in the United States of America on acid-free
paper.
ISBN 978-0-89042-554-1 (Hardcover)
ISBN 978-0-89042-555-8 (Paperback)
American Psychiatric Association
1000 Wilson Boulevard
Arlington, VA 22209-3901
www .psych.org
The correct citation for this book is American Psychiatric
Association: Diagnostic and Statisti-
cal Manual of Mental Disorders, Fifth Edition. Arlington, VA,
American Psychiatric Associa-
tion, 2013.
Library of Congress Cataloging-in-Publication Data
Diagnostic and statistical manual of mental disorders : DSM-5.
— 5th ed.
p . ; cm.

3. DSM-5
DSM-V
Includes index.
ISBN 978-0-89042-554-1 (hardcover : alk. paper) — ISBN 978-
0-89042-555-8 (pbk. : alk. paper)
L American Psychiatric Association. II. American Psychiatric
Association. DSM-5 Task Forcé.
III. Title: DSM-5. IV. Title: DSM-V.
[DNLM: 1. Diagnostic and statistical manual of mental
disorders. 5th ed. 2. Mental Disorders—
classification. 3. Mental Disorders—diagnosis. WM 15]
RC455.2.C4
616.89W5—dc23
2013011061
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
Text Design—Tammy J. Cordova
Manufacturing—Edwards Brothers Malloy
Contents
DSM-5 C lassification......................
............................................. xiii
Preface...........................................................
.................................. xli
Section 9
DSM-5 Basics
Introduction............................................................................

4. ............5
Use of the M an ua
l...........................................................................19
Cautionary Statement for Forensic Use of DSM-5................ .25
Section 11
íiiagnostic [email protected] snd (#od©s
Neurodevelopmental Disorders....................
................................ 31
Schizophrenia Spectrum and Other Psychotic D isorders.. . . .
.87
Bipolar and Related
Disorders.....................................................123
Depressive Disorders
................................................................... 155
Anxiety Disorders........................
.................................................. 189
Obsessive-Compulsive and Related D isorders........................
235
Trauma- and Stressor-Related Disorders...................................
265
Dissociative D
isorders................................................................ 291
Somatic Symptom and Related
Disorders.................................309
Feeding and Eating
Disorders.....................................................329
Elimination D
isorders...................................................................355
Sleep-Wake Disorders........................................
..........................361
Sexual D
ysfunctions.....................................................................423

5. Gender D ysphoria ............................................
............................451
Disruptive, Impulse-Control, and Conduct
Disorders...............461
Substance-Related and Addictive D
isorders.............................481
Neurocognitive
Disorders............................................................. 591
Personality Disorders.............................................................
.. 645
Paraphilic
Disorders..................................................................... 685
Other Mental D isorders................................................ .
............707
Medication-lnduced Movement Disorders
and Other Adverse Effects of M ed ica tion ..............................
709
Other Conditions That May Be a Focus of Clinical Attention ..
715
Section III
Emerging Measures and Models
Assessment
Measures.................................................................733
Cultural Formulation.....................................................
................749
Alternative DSM-5 Model for Personality D
isorders.................761

6. Conditions for Further S
tudy....................................................... 783
Highlights of Changes From DSM-IV to DSM-
5.........................809
Glossary of Technical Term
s....................................................... 817
Glossary of Cultural Concepts of D istress..............
..................833
Alphabetical Listing of DSM-5 Diagnoses and Codes
(ICD-9-CM and ICD-10-
CM)....................................................... 839
Numerical Listing of DSM-5 Diagnoses and Codes
(ICD-9-
CM)................................................................................. 863
Numerical Listing of DSM-5 Diagnoses and Codes
(ICD-10-CM)..........
.....................................................................877
DSM-5 Advisors and Other C
ontributors...................................897
Index 917
DSM-5 Task Forcé
David J. Kupfer, M.D.
Task Forcé Chair
D a r r e l A» Regier, M.D., M.P.H.

7. Task Forcé Vice-Chair
William E. Narrow, M.D., M.P.H.,
Research Director
Dan G. Blazer, M.D., Ph.D., M.P.H.
Jack D. Burke Jr., M.D., M.P.H.
William T. Carpenter Jr., M.D.
F. Xavier Castellanos, M.D.
Wilson M. Compton, M.D., M.P.E.
Joel E. Dimsdale, M.D.
Javier I. Escobar, M.D., M.Sc. .
Jan A. Fawcett, M.D.
Bridget F. Grant, Ph.D., Ph.D. (2009-)
Steven E. Hyman, M.D. (2007-2012)
Dilip V. Jeste, M.D. (2007-2011)
Helena C. Kraemer, Ph.D.
Daniel T. Mamah, M.D., M.P.E.
James P. McNulty, A.B., Sc.B.
Howard B. Moss, M.D. (2007-2009)
Susan K. Schultz, M.D., Text Editor
Emily A. Kuhl, Ph.D., APA Text Editor
Charles P. O'Brien, M.D., Ph.D.
Roger Peele, M.D.
Katharine A. Phillips, M.D.
Daniel S. Pine, M.D.
Charles F. Reynolds III, M.D.
Maritza Rubio-Stipec, Sc.D.
David Shaffer, M.D.
Andrew E. Skodol II, M.D.
Susan E. Swedo, M.D.
B. Timothy Walsh, M.D.
Philip Wang, M.D., Dr.P.H. (2007-2012)

8. William M. Womack, M.D.
Kimberly A. Yonkers, M.D.
Kenneth J. Zucker, Ph.D.
Norman Sartorius, M.D., Ph.D., Consultant
APA División of Research Staff on DSM-5
Darrel A. Regier, M.D., M.P.H.,
Director, División o f Research
William E. Narrow, M.D., M.P.H.,
Associate Director
Emily A. Kuhl, Ph.D., Sénior Science
Writer; Staff Text Editor
Diana E. Clarke, Ph.D., M.Sc., Research
Statistician
Lisa H. Greiner, M.S.S.A., DSM-5 Field
Triáis Project M anager
Eve K. Moscicki, Sc.D., M.P.H.,
Director, Practice Research Network
S. Janet Kuramoto, Ph.D. M.H.S.,
Sénior Scientific Research Associate,
Practice Research Network
Jennifer J. Shupirika, Assistant Director,
DSM Operations
Seung-Hee Hong, DSM Sénior Research
Associate
Anne R. Hiller, DSM Research Associate

9. Alison S. Beale, DSM Research Associate
Spencer R. Case, DSM Research Associate
Joyce C. West, Ph.D., M.P.P.,
Health Policy Research Director, Practice
Research Network
Farifteh F. Duffy, Ph.D.,
Quality Care Research Director, Practice
Research Network
Lisa M. Countis, Field Operations
Manager, Practice Research Network
Amy Porfiri, M.B.A. Christopher M. Reynolds,
Director ofFinance and Administration Executive Assistant
APA Office of the Medical Director
James H. S c u lly Jr., M.D.
Medical Director and CEO
Editorial and Coding Consuitants
Michael B. First, M.D. M aria N. Ward, M.Ed., RHIT, CCS-P
DSM-5 Work Groups
ADHD and Disruptive Behavior Disorders
David Sh a ffer , M .D.
Chair
R Xavier Ca stella n o s, M.D.
Co-Chair

10. Paul J. Frick, Ph.D., Text Coordinator
Glorísa Canino, Ph.D.
Terrie E. Moffitt, Ph.D.
Joel T. Nigg, Ph.D.
Luis Augusto Rohde, M.D., Sc.D.
Rosemary Tannock, Ph.D.
Eric A. Taylor, M.B.
Richard Todd, Ph.D., M.D. (d. 2008)
Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic,
and DIssocíatíve Disorders
K atharine A. P h illip s , M.D.
Chair
Michelle G. Craske, Ph.D., Text
Coordinator
J. Gavin Andrews, M.D.
Susan M. Bógels, Ph.D.
Matthew J. Friedman, M.D., Ph.D.
Eric Hollander, M.D. (2007-2009)
Roberto Lewis-Fernández, M.D., M.T.S.
Robert S. Pynoos, M.D., M.P.H.
Scott L. Rauch, M.D.
H. Blair Simpson, M.D., Ph.D.
David Spiegel, M.D.
Dan J. Stein, M.D., Ph.D.
M urray B. Stein, M.D.
Robert J. Ursano, M.D.
Hans-XJlrich Wittchen, Ph.D.
Childhood and Adolescent Disorders
Daniel S. F in e , M .D. .

11. Chair
Ronald E. Dahl, M.D.
E. Jane Costello, Ph.D. (2007-2009)
Regina Smith James, M.D.
Rachel G. Klein, Ph.D.
Jam es F. Leckman, M.D.
Ellen Leibenluft, M.D.
Judith H. L. Rapoport, M.D.
Charles H. Zeanah, M.D.
Eatíng Disorders
B. Timothy W a ls h , M.D.
Chair
Stephen A. Wonderlich, Ph.D.,
Text Coordinator
Evelyn Attia, M.D.
Anne E. Becker, M.D., Ph.D., Sc.M.
Rachel Bryant-Waugh, M.D.
Hans W. Hoek, M.D., Ph.D.
Richard E. Kreipe, M.D.
Marsha D. Marcus, Ph.D.
Jam es E. Mitchell, M.D.
Ruth H. Striegel-Moore, Ph.D.
G. Terence Wilson, Ph.D.
Barbara E. Wolfe, Ph.D. A.P.R.N.
Mood Disorders
Ja n A. F a w ce tt, M.D.

12. Chair
Ellen Frank, Ph.D., Text Coordinator
Jules Angst, M.D. (2007-2008)
William H. Coryell, M.D.
Lori L. Davis, M.D.
Raymond J. DePaulo, M.D.
Sir David Goldberg, M.D.
James S. Jackson, Ph.D.
Kenneth S. Kendler, M.D., Ph.D.
(2007-2010)
Mario Maj, M.D., Ph.D.
Husseini K. Manji, M.D. (2007-2008)
Michael R. Phillips, M.D.
Trisha Suppes, M.D., Ph.D.
Carlos A. Zarate, M.D.
Neurocognítive Disorders
DILIP V. JESTE, M.D. (2007-2011)
Chair Emeritus
D a n G. B lazer, M.D., Ph.D., M.P.H.
Chair
R o n a ld C. Petersen , M.D., Ph.D.
Co-Chair
Mary Ganguli, M.D., M.P.H.,
Text Coordinator
Deborah Blacker, M.D., Sc.D.
Waraehal Faison, M.D. (2007-2008)
Igor Grant, M.D.
Eric J. Lenze, M.D.

13. Jane S. Paulsen, Ph.D.
Perminder S. Sachdev, M.D., PhD.
Neurodevelopmental Disorders
Susan E. Sw edo , M.D.
Chair
Gillian Baird, M.A., M.B., B.Chir.,
Text Coordinator
Edwin H. Cook Jr., M.D.
Francesca G. Happé, Ph.D.
James C. Harris, M.D.
Walter E. Kaufmann, M.D.
Bryan H. King, M.D.
Catherine E. Lord, Ph.D.
Joseph Piven, M.D.
Sally J. Rogers, Ph.D.
Sarah J. Spence, M.D., Ph.D.
Fred Volkmar, M.D. (2007-2009)
Amy M. Wetherby, Ph.D.
Harry H. Wright, M.D.
Personality and Personality Disorders1
Andrew E. Skodol, M.D.
Chair
John M. Oldham , M.D.
Co-Chair
Robert F. Krueger, Ph.D., Text
Coordinator
Renato D. Alarcon, M.D., M.P.H.
Cari C. Bell, M.D.

14. Donna S. Bender, Ph.D.
Lee Anna Clark, Ph.D.
W. John Livesley, M.D., Ph.D. (2007-2012)
Leslie C. Morey, Ph.D.
Larry J. Siever, M.D.
Roel Verheul, Ph.D. (2008-2012)
1 The members of the Personality and Personality Disorders
Work Group are responsible for the
alternative DSM-5 model for personality disorders that is
included in Section III. The Section II
personality disorders criteria and text (with updating of the
text) are retained from DSM-IV-TR.
Psychotic Disorders
W illiam T. C arpenter Jr., M.D.
Chair
Deartna M. Barch, Ph.D., Text
Coordinator
Juan R. Bustillo, M.D.
W olfgang Gaebel, M.D.
Raquel E. Gur, M.D., Ph.D.
Stephan H. Heckers, M.D.
Dolores Malaspina, M.D., M.S.P.H.
Michael J. Owen, M.D., Ph.D.
Susan K. Schultz, M.D.
Rajiv Tandon, M.D.
Ming T. Tsuang, M.D., Ph.D.
Jim van Os, M.D.

15. Sexual and Gender Identity Disorders
Kenneth J. Zucker, P h .D.
Chair
Lori Brotto, Ph.D., Text Coordinator
Irving M. Binik, Ph.D.
Ray M. Blanchard, Ph.D.
Peggy T. Cohen-Kettenis, Ph.D.
Jack Drescher, M.D.
Cynthia A. Graham, Ph.D.
Martin P. Kafka, M.D.
Richard B. Krueger, M.D.
Niklas Lángstróm, M.D., Ph.D.
Heino F.L. Meyer-Bahlburg, Dr. rer. nat.
Friedemann Pfáfflin, M.D.
Robert Taylor Segraves, M.D., Ph.D.
SIeep-Wake Disorders
C h a rle s F. Reynolds III, M.D.
Chair
Ruth M. O'Hara, Ph.D., Text Coordinator
Charles M. Morin, Ph.D.
Alian I. Pack, Ph.D.
Kathy P. Parker, Ph.D., R.N.
Susan Redline, M.D., M.P.Fí.
Dieter Riemann, Ph.D.
Somatic Symptom Disorders
Joel E. Dimsdale, M .D .
Chair
James L. Levenson, M.D., Text

16. Coordinator
Arthur J. Barsky III, M.D.
Francis Creed, M.D.
Nancy Frasure-Smith, Ph.D. (2007-2011)
Michael R. Irwin, M.D.
Francis J. Keefe, Ph.D. (2007-2011)
Sing Lee, M.D.
Michael Sharpe, M.D.
Lawson R. Wulsin, M.D.
Substance-Related Disorders
C h a r le s P. CXBrien, M .D ., Ph.D .
Chair
Thomas J. Crow ley, M .D.
Co-Chair
W ilson M. Compton, M.D., M.P.E.,
Text Coordinator
Marc Auriacombe, M.D.
Guilherme L. G. Borges, M.D., Dr.Sc.
Kathleen K. Bucholz, Ph.D.
Alan J. Budney, Ph.D.
Bridget F. Grant, Ph.D., Ph.D.
Deborah S. Hasin, Ph.D.
Thomas R. Kosten, M.D. (2007-2008)
Walter Ling, M.D.
Spero M. Manson, Ph.D. (2007-2008)
A. Thomas McLellan, Ph.D. (2007-2008)
Nancy M. Petry, Ph.D.
Marc A. Schuckit, M.D.
Wim van den Brink, M.D., Ph.D.

17. (2007-2008)
DSM-5 Study Groups
D iagnostic Spectra and DSM/ICD Harmonization
Steven E. H ym an , M.D.
Chair (2007-2012)
William T. Carpenter Jr., M.D. William E. Narrow, M .D.,
M.P.H.
Wilson M. Compton, M.D., M.P.E. Charles P. O'Brien, M.D.,
Ph.D.
Jan A. Fawcett, M.D. John M. Oldham, M.D.
Helena C. Kraemer, Ph.D. Katharine A. Phillips, M.D.
David J. Kupfer, M.D. Darrel A. Regier, M.D., M.P.H.
Lifespan Developmental Approaches
Eric J. Lenze, M.D.
. Chair
. Susan K. Schultz, M.D.
Chair Emeritus
Daniel S. Pine, M.D.
Chair Emeritus
Dan G. Blazer, M.D., Ph.D., M.P.H. Daniel T. Mamah, M .D.,
M.P.E.
F. Xavier Castellanos, M.D. Andrew E. Skodol II, M.D.
Wilson M. Compton, M.D., M.P.E. Susan E. Swedo, M.D.
Gender and Cross-Cultural Issues
K imberly A. Y onkers, M.D.

18. Chair
R oberto Lewis-Fernández, M.D., M.T.S.
Co-Chair, Cross-Cultural Issues
Renato D. Alarcon, M.D., M.P.H. Leslie C. Morey, Ph.D.
Diana E. Clarke, Ph.D., M.Sc. William E. Narrow, M .D.,
M.P.H.
Javier I. Escobar, M.D., M.Sc. Roger Peele, M.D.
Ellen Frank, Ph.D. _ Philip Wang, M.D., Dr.P.H. (2007-2012)
James S. Jackson, Ph.D. William M. Womack, M.D.
Spiro M. Manson, Ph.D. (2007-2008) Kenneth J. Zucker, Ph.D.
James P. McNulty, A.B., Sc.B.
Psychiatric/General Medical Interface
Lawson R. W ulsin , M.D.
Chair
Ronald E. Dahl, M.D. Richard E. Kreipe, M.D.
Joel E. Dimsdale, M.D. Ronald C. Petersen, Ph.D., M.D.
Javier I. Escobar, M.D., M.Sc. Charles F. Reynolds III, M.D.
Dilip V. Jeste, M.D. (2007-2011) Robert Taylor Segraves, M.D.,
Ph.D.
Walter E. Kaufmann, M.D. B. Timothy Walsh, M.D.
Impairment and Disability
Jane S. Paulsen, Ph .D.
Chair
J. Gavin Andrews, M.D. Hans W. Hoek, M.DV Ph.D.
Glorisa Canino, Ph.D. Helena C. Kraemer, Ph.D.
Lee Anna Clark, Ph.D. William E. Narrow, M.D., M.P.H.
Diana E. Clarke, Ph.D., M.Sc. David Shaffer, M.D.
Michelle G. Craske, Ph.D.

19. Diagnostic Assessment Instruments
Ja c k D. Burke Jr., M.D., M.P.H.
Chair
Lee Anna Clark, Ph.D. Helena C. Kraemer, Ph.D.
Diana E. Clarke, Ph.D., M.Sc. William E. Narrow, M.D.,
M.P.H.
Bridget F. Grant, Ph.D., PhD. David Shaffer, M.D.
DSM-5 Research Group
W illiam E. N arrow , M.D., M.P.H.
Chair
Jack D. Burke Jr., M.D., M.P.H. David J. Kupfer, M.D.
Diana E. Clarke, PhD., M.Sc. Darrel A. Regier, M.D., M.P.H.
Helena C. Kraemer, PhD. David Shaffer, M.D.
Course Specifiers and Glossary
WOLFGANG GAEBEL, M.D.
Chair
Ellen Frank, PhD. Dan J. Stein, M.D., Ph.D.
Charles P. O'Brien, M.D., Ph.D. Eric A. Taylor, M.B.
Norman Sartorius, M.D., PhD ., David J. Kupfer, M.D.
Consultant Darrel A. Regier, M.D., M.P.H.
Susan K. Schultz, M.D.
DSM-5
Classification
Before each disorder ñame, ICD-9-CM codes are provided,
followed by ICD-10-CM codes
in parentheses. Blank lines indicate that either the ICD-9-CM or

20. the ICD-XO-CM code is not
applicable. For some disorders, the code can be indicated only
according to the subtype or
specifier.
ICD-9-CM codes are to be used for coding purposes in the
United States through Sep~
tember 30, 2014. ICD-10-CM codes are to be used starting
October 1, 2014.
Following chapter titles and disorder ñames, page numbers for
the corresponding text
or criteria are included in parentheses.
Note for all mental disorders due to another medical condition:
Indícate the ñame of
the other medical condition in the ñame of the mental disorder
due to [the medical condi-
tion]. The code and ñame for the other medical condition should
be listed first immedi-
ately before the mental disorder due to the medical condition.
Neurodevelopmental Disorders (31)
Intellectual Disabilities (33)
319 (..........) Intellectual Disability (Intellectual Developmental
Disorder) (33)
Specify current severity:
|F70} Mild
fP71) Moderate
(FT2) Severe
(F73) Profound
315.8 (F88) Global Developmental Delay (41)

21. 319 (F79) Unspecified Intellectual Disability (Intellectual
Developmental
Disorder) (41)
Communication Disorders (41)
315.39 (f£v ' Language Disorder (42)
315.39 tíT'C Speech Sound Disorder (44)
315.35 fFé'̂ - Childhood-Onset Fluency Disorder (Stuttering)
(45)
Note: Later-onset cases are diagnosed as 307.0 (F98.5) adult-
onset fluency
disorder.
315.39 {FEO ,89) Social (Pragmatic) Communication Disorder
(47)
307.9 (FUt, ̂ Unspecified Communication Disorder (49)
xiv DSM-5 Classification
Autism Spectrum Disorder (50)
299.00 (F84.0) Autism Spectrum Disorder (50)
Specify if: Associated with a known medical or genetic
condition or envi-
ronmental factor; Associated with another neurodevelopmental,
men-
tal, or behavioral disorder
Specify current severity for Criterion A and Criterion B:
Requiring very
substantial support, Requiring substantial support, Requiring

22. support
Specify if: With or without accompanying intellectual
impairment, With
or without accompanying language impairment, With catatonía
(use
additional code 293.89 [F06.1])
Attention-Deficit/Hyperactivity Disorder (59)
__ «__ |...........) Attention-Deficit /Hyperactivity Disorder (59)
Specify whether:
314.01 '/ Combined presentation
314.00 ' Predominantly inattentive presentation
314.01 ' Predominantly hyperactive/impulsive presentation
Specify if: In partial remission
Specify cmrevá. severity: Mild, Moderate, Severe
314.01 í *r' 'J;} Other Specified Attention-Deficit/Hyperactivity
Disorder (65)
314.01 i-' *0 Unspecified Attention-Deficit/Hyperactivity
Disorder (66)
Specific Learning Disorder (66)
__.__ f,__ .__i Specific Learning Disorder (66)
Specify if:
315.00 ” With impairment in reading (specify if with word
reading
accuracy, reading rate or fluency, reading comprehension)
315.2 ' , K ¿ With impairment in written expression (specify if
with spelling

23. accuracy, grammar and punctuation accuracy, clarity or
organization of written expression)
315.1 ' ' > ; With impairment in mathematics (specify if with
number sense,
memorization of arithmetic facts, accurate or fluent
calculation, accurate math reasoning)
Specify current severity: Mild, Moderate, Severe
Motor Disorders (74)
315.4 ‘ Developmental Coordination Disorder (74)
307.3 ,* Stereotypic Movement Disorder (77)
Specify if: With self-injurious behavior, Without self-injurious
behavior
Specify if: Associated with a known medical or genetic
condition, neuro-
developmental disorder, or environmental factor
Specify current severity: Mild, Moderate, Severe
Tic Disorders
307.23 *' ^5.2) Tourette’s Disorder (81)
307.22 Persisten! (Chronic) Motor or Vocal Tic Disorder (81)
Specify if: With motor tics only, With vocal tics only
DSM-5 Classification xv
307.21 Provisional Tic Disorder (81)
307.20 (F95.8) Other Specified Tic Disorder (85)

24. 307.20 (F95.9) Unspecified Tic Disorder (85)
Other Neurodevelopmental Disorders (86)
315.8 (F88) Other Specified Neurodevelopmental Disorder (86)
315.9 *v'}Vv Unspecified Neurodevelopmental Disorder (86)
Schizophrenia Spectrum
and Other Psychotic Disorders (87)
The following specifiers apply to Schizophrenia Spectrum and
Other Psychotic Disorders
where indicated:
aSpecify if: The following course specifiers are only to be used
after a 1-year duration of the dis-
order: First episode, currently in acute episode; First episode,
currently in partial remission;
First episode, currently in full remission; Múltiple episodes,
currently in acute episode; Múl-
tiple episodes, currently in partial remission; Múltiple episodes,
currently in full remission;
Continuous; Unspecified
b Specify if: With catatonía (use additional code 293.89
[FOó.l])
cSpecify current severity of delusions, hallucinations,
disorganized speech, abnormal psycho-
motor behavior, negative symptoms, impaired cognition,
depression, and mania symptoms
301.22 Schizotypal (Personality) Disorder (90)
297.1 Delusional Disordera/ c (90)
Specify whether: Erotomanic type, Grandiose type, Jealous

25. type, Persecu-
tory type, Somatic type, Mixed type, Unspecified type
Specify if: With bizarre contení
298.8 Brief Psychotic Disorderb' c (94)
Specify if: With marked stressor(s), Without marked stressor(s),
With
postpartum onset
295*40 ; , Schizophreniform Disorderb/ c (96)
Specify if: With good prognostic features, Without good
prognostic fea-
tures
295.90 >, ■ . Schizophreniaa/ D/ c (99)
___? ; Schizoaffective Disorder3' b/ c (105)
Specify whether:
295.70 ; > Bipolar type
295.70 Depressive type
___.__ í__ ....J Substance/Medication-Induced Psychotic
Disorder0 (110)
Note: See the criteria set and corresponding recording
procedures for
substance-specific codes and ICD-9-CM and ICD-10-CM
coding.
Specify if: With onset during intoxication, With onset during
withdrawal
■_ (......... } Psychotic Disorder Due to Another Medical
Condition0 (115)

26. Specify whether:
293.81 With delusions
293.82 With hallucinations
xvi DSM-5 Classification
293.89 Catatonía Associated With Another Mental Disorder
(Catatonía
Specifier) (119)
293.89 (F06.1} Catatonic Disorder Due to Another Medical
Condition (120)
293.89 *í Unspecified Catatonía (121)
Note: Code first 781.99 (R29.818) other symptoms involving
nervous and
musculoskeletal systems.
298.8 (F28| Other Specified Schizophrenia Spectrum and Other
Psychotic
Disorder (122)
298.9 Unspecified Schizophrenia Spectrum and Other Psychotic
Disorder (122)
Bipolar and Related Disorders (123)
The following specifiers apply to Bipolar and Related Disorders
where indicated:
aSpecify: With anxious distress (specify current severity: mild,
moderate, mpderate-severe, severe);
With mixed features; With rapid cycling; With melancholic

27. features; With atypical features;
With mood-congruent psychotic features; With mood-
incongruent psychotic features; With
catatonía (use additional code 293.89 [F06.1]); With peripartum
onset; With seasonal pattem
__ ■__i___*__1 Bipolar I Disorder3 (123)
___( _ . _ J Current or most recent episode manic
296.41 i?.: Mild
296.42 r:l* Moderate
296.43 / Severe
296.44 With psychotic features
296.45 - , In partial remission
296.46 In full remission
296.40 ?r.V 7 Unspecified
296.40 {F31.0) Current or most recent episode hypomanic
296.45 f In partial remission
296.46 In full remission
296.40 'fr*;. Unspecified
__ .__ ' _.. _ Current or most recent episode depressed
296.51 Mild
296.52 ^ Moderate
296.53 ff 31.4) Severe
296.54 With psychotic features
296.55 v ' 1* , In partial remission
296.56 ' In full remission
296.50 .''W ^ Unspecified
296.7 :* Current or most recent episode unspecified
296.89 ' í Bipolar II Disorder3 (132)
Specify current or most recent episode: Hypomanic, Depressed
Specify course if full criteria for a mood episode are not
currently met: In
partial remission, In full remission
Specify severity if full criteria for a mood episode are not

28. currently met:
Mild, Moderate, Severe
DSM-5 Olassiíication
301,13 Cyclothymic Disorder (139)
Specify if: With anxious di stress
___.__ i . .. ? Substance/Medication-Induced Bipolar and
Related Disorder (142)
Note: See the criteria set and corresponding recording
procedures for
substance-specific codes and 1CD-9-CM and ICD-10-CiVÍ
coding.
Specify if: With onset during intoxication, With onset during
withdrawa!
293,83 i _ , I Bipolar and Related Disorder Due to Another
Medical Condition
(145)
Specify if:
' / , ' With manic features
/ :̂ ' With manic- or hypomanic-Tike episode
' -", * 7 With mixed features
296.89 T ̂/ Other Specified Bipolar and Related Disorder (148)
296.80 ' /' Unspecified Bipolar and Related Disorder (149)
Depressive Disorders (155)

29. The following specifiers apply to Depressive Disorders where
indicated:
aSpecify: With anxious distress (specify current severity: mild,
moderate, moderate-severe,
severe); With mixed features; With melancholic features; With
atypical features; With mood-
congruent psychotic features; With mood-incongment psychotic
features; With catatonía
(use additional code 293.89 [F06.1]); With peripartum onset;
With seasonal parlera
296=99 (F34ÍÍ) Disruptive Mood Dysregulation Disorder (156)
,.a ,Major Depressive Disordera (160)
Single episode
296.21 ;V?/2áÍ¡ Mild
296.22 F32, i) Moderate
296.23 fF3P/<! Severe
296.24 'r Oí''" With psychotic features
296.25 cA/í In partial remission
296.26 ./V j] In full remission
296.20 y * ' Unspecified
" . í Recurren! episode
296.31 Mild
296.32 Moderate
296.33 7 -37^ Severe
296.34 (P3&2Í With psychotic features
296.35 'F3SA1) ín partial remission
296,36 r33/42| ín full remission
296.30 Unspecified
300.4 < ̂*í * Persistent Depressive Disorder 'sthymia)a (168)
Specify if: In partial remission, In full remission
Specify if: Eariy onset, Late onset

30. Specify i*: With puré dysthvmic syndrome; With persisten!
major depres-
sive episode; With intermittent major depressive episode.s, with
curren!
xviii DSM-5 Classification
625.4
293.83
311
311
309.21
312.23
300.29
300.23
300.01
300.22
300.02
episode; With intermiiíent major depiessive episodes, wirhoat
curren;
episode

31. Specify current severity: Mild, Moderate, Severe
ÍN94.3j Premenstrual Dysphoric Disorder (171)
{___ J Substance/Medication-Induced Depressive Disorder
(175)
Note: See the criteria set and corresponding recording
procedures for
substance-specifie codes and ICD-9-CM and ICD-10-CM
coding.
Specify if: With onset during intoxication, With onset during
withdrawa i
Depressive Disorder Due to Another Medical Condition (18C)
Specify if:
/ ' y' ‘ With depressive features
'' 0C, Oo With major depressive-like episode
Wz') ̂ , With mixed features
(F32.8) Other Specified Depressive Disorder (183)
l Unspecified Depressive Disorder (184)
Anxiety Disorders (189)
(F9S,0) Separation Anxiety Disorder (190)
ÍF94,0) Selective Mutism (195)
(__■ j Specific Phobia (197)
Specify if:
IF4C121 Sf Animal
(F40.228) Natural environment
I__ J Blood-injection-injury
fF40.230| Fear of blood

32. {F40,2r*, Fear of injections and transfusions
(F4G.232? Fear of other medical care
íf 40,233s Fear of injury
/ ' ' Situational
Other
Social Anxiety Disorder (Social Phobia) (202)
Specify if: Performance only
|F41 iJ| Panic Disorder (208)
' . _ i Panic Attack Specifier (214)
(P40*00f Agoraphobia (217)
lf4 íA ¡ Generalized Anxiety Disorder (222)
í ___ j Substance/Medication-Induced Anxiety Disorder (226)
Note: See the criteria set and corresponding recording
procedures for
substance-specific codes and ICD-9-CM and ICD-10-CM
coding.
Specify if: With onset during intoxication, With onset during
withdrawal,
With onset after meciication use
DSM-5 Classification
293.84 i/- Anxiety Disorder Due to Another Medical Condition
(230)

33. 300.09 ,C; Other Specified Anxiety Disorder (233)
300,00 V Unspecified Anxiety Disorder (233)
Obsessive-Compulsive and Related Disorders (235)
The following specifier applies to Obsessive-Compulsive and
Related Disorders where indicated:
* Specify if: With good or fair insight, With poor insight, With
absent ins igh l / d eiu s i ona i beHers
300.3 Obsessive-Compulsive Disordera (237)
Specify if: Tic-related
300.7 ' ̂ — Body Dysmorphic Disordera (242)
Specify if: With muscle dysmorphia
300.3 Hoarding Disorder3 (247)
Specify if: With excessive acquisition
312.39 " * ¿ Trichotillomania (Hair-Pulling Disorder) (251)
698.4 , ^ ' Excoriation (Skin-Picking) Disorder (254)
___.__ i , f Substance/Medication-Induced Obsessive-
Compulsive and
Related Disorder (257)
Note: See the criteria set and corresponding recording
procedures for
substance-specific codes and ICD--9-CM and ÍCD-10-CM
coding.
Specify if: With onset during intoxication, With onset during
wiíhdrawol,
With onset after medication use

34. 294.8 ÍF06.S) Obsessive-Compulsive and Related Disorder Due
to Another
Medical Condition (260)
Specify if: With …
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

35. 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.
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retrieval system, or transmitted in any form or by any means,
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36. photocopying, recording, or otherwise, without the prior
permission of Springer Publishing Company, LLC, or
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necessary. We
recommend that the reader always consult current research,
specific institutional policies, and current formularies or drug

37. guides before
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liable for any special,
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accuracy of URLs for external or third-party Internet Web sites
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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
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Special discounts on bulk quantities of our books are available
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For details, please contact:
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mailto:[email protected]
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

39. 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.”
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

40. 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
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

41. vivii
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

42. Kathleen Wheeler
7. Motivational Interviewing
Edna Hamera
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

43. 14. Dialectical Behavior Therapy for Complex Trauma
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

44. 20. Termination and Outcome Evaluation
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,

45. Veteran Integrated Service Network, Arlington,
Texas
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

46. Professor, Rush College of Nursing,
Chicago, Illinois
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

47. Candice Knight, PhD, EdD, APN, PMHNP-BC, PMHCNS-BC
Coordinator, Psychiatric-Mental Health
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,

48. Newark, New Jersey
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

49. New York University
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.

50. Dr. Wheeler and the psychiatric nursing leaders she has chosen
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

51. edition a “must have” for advanced practice
psychiatric nurses and their colleagues. From a teaching–
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

52. Associate Professor Emeritus
The Ohio State University
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

53. condition to effective and ethical practice. “The
force and spirit of who the therapist is as a human being most
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

54. to provide psychiatric evaluations and treatment, including
psychopharmacological interventions and
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

55. Practice Nurses.
Retrieved from:
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

56. in print written specifically for advanced
practice psychiatric nurses (APPNs). It was warmly welcomed
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

57. exams except PMHNP (across the life span) in 2014, and the
Institute of Medicine (IOM) 2010 report on
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

58. & Delaney, 2009). Many of the jobs available to APPN
graduates are in community mental health centers
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

59. the neurophysiological explanatory mechanism of action.
APPNs who understand neuroscience can decide
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

60. support system. Ethical psychotherapy practice demands no
less. If the APPN has a solid theoretical
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

61. mental health providers.
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

62. evidence-based approaches into a relationship-based framework
for APPN psychotherapy practice. This how-
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

63. takes place in the shared consciousness of two
people and it is in those healing moments of connection that
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

64. http://www.springerpub.com/wheeler-ancillary
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

65. PublishedbyNursesbooks.org
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.

66. TheAmericanPsychiatricNursesAssociation(APNA)isyourresour
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

67. substanceusedisorders.Formoreinformation:www.apna.org.
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

68. InternationalSocietyofPsychiatric-
MentalHealthNurses.Allrightsreserved.Reproduction
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

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

70. WorkforceRequirementsforaPublicHealthModelofMentalHealth
Care
Psychiatric-
MentalHealthNursingLeadershipinTransformingtheMentalHealth
System
DefinitionofPsychiatric-MentalHealthNursing
PhenomenaofConcernforPsychiatric-MentalHealthNurses
Psychiatric-MentalHealthNursingClinicalPracticeSettings
CrisisInterventionandPsychiatricEmergencyServices
AcuteInpatientCare
IntermediateandLong-TermCare
PartialHospitalizationandIntensiveOutpatientTreatment
ResidentialServices
Community-BasedCare

71. AssertiveCommunityTreatment(ACT)
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

72. PsychiatricConsultation–LiaisonNursing(PCLN)
ClinicalSupervision
Administration,Education,andResearchPractice
Self-Employment
OtherSpecializedAreasofPractice
IntegrativePrograms
Telehealth
ForensicMentalHealth
DisasterPsychiatric-MentalHealthNursing
EthicalIssuesinPsychiatric-MentalHealthNursing
RespectfortheIndividual
CommitmenttotheHealthcareConsumer

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

74. Standard5.Implementation
Standard5A.CoordinationofCare
Standard5B.HealthTeachingandHealthPromotion
Standard5C.Consultation
Standard5D.PrescriptiveAuthorityandTreatment
Standard5E.Pharmacological,Biological,andIntegrativeTherapies
Standard5F.MilieuTherapy
Standard5G.TherapeuticRelationshipandCounseling
Standard5H.Psychotherapy
Standard6.Evaluation
StandardsofProfessionalPerformanceforPsychiatric-
MentalHealthNursing

75. Standard7.Ethics
Standard8.Education
Standard9Evidence-BasedPracticeandResearch
Standard10.QualityofPractice
Standard11.Communication
Standard12.Leadership
Standard13.Collaboration
Standard14.ProfessionalPracticeEvaluation
Standard15.ResourceUtilization
Standard16.EnvironmentalHealth
Glossary
References

76. Abbreviations
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

77. SusanL.W.KrupnickMSN,PMHCNS-BC,ANP-BC,C-PREP
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

78. EricWurzbacher,BA—Projecteditor
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-

79. basedadvancesinrecovery-focused
assessment,diagnosis,treatment,andevaluationofpersonswithmen
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

80. .TheANAadvancesthe
nursingprofessionbyfosteringhighstandardsofnursingpractice,pro
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.

81. Preface
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

82. andStandardsof
Practice,SecondEdition(ANA10).Inaddition,theintroductionhasb
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.

83. DevelopmentofthiseditionofPsychiatric-
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

84. Psychiatric-
mentalhealthnursingisthenursingpracticespecialtycommittedtopr
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

85. cticelevel,maydiffer
significantlyfromstatetostate.Nursesmustensurethattheirpracticer
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

86. relevanttothepracticeofpsychiatric-
mentalhealthnursing.Thestandardsofpsychiatric-
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

87. tobecometrainednurses(Boyd98).Eventually,asylumnursingprogr
amsestablished
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

88. NursingEducationand
waseventuallyrequiredinalleducationalprogramsforregisterednur
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

89. preparationandstandardsofcareforpsychiatricnursing(Silverstein
08).
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

90. publishedtheStandardsofPsychiatric-
MentalHealthNursingPracticeandbegancertifying
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.

91. MentalhealthcareintheUnitedStatesbegananothertransformationi
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

92. psychiatricdisorders.Integratedcareemphasizesthatbothtypesofdi
sordersareprimary
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

93. fectwithinpsychiatric-
mentalhealthnursing.TheInstituteofMedicine’s(2010)report,TheF
utureofNursing:
LeadingChangetoAdvanceHealthhasstrengthenedtheroleofpsychi
atric-mentalhealth
nursesasmentalhealthpolicyandprogramdevelopmentleadersinbot
hnationaland
internationalarenas.Nursing’semphasisontheuseofresearchfindin
gstodevelopand
implementevidence-
basedpracticeisdrivingimprovementsinpsychiatric-mentalhealth
nursingpractice.
OriginsofthePsychiatric-
MentalHealthAdvancedPracticeNursingRole
Specialtynursingatthegraduatelevelbegantoevolveinthelate1950s
inresponsetothe
passageoftheNationalMentalHealthActof1946andthecreationofth
eNationalInstitute
ofMentalHealthin1949.TheNationalMentalHealthActof1946ident
ifiedpsychiatric

94. nursingasoneoffourcoredisciplinesfortheprovisionofpsychiatricc
areandtreatment,
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.

95. TheCommunityMentalHealthCentersActof1963facilitatedtheexp
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

96. medicationswithfewersideeffectsweredeveloped,psychopharmac
ologyassumedamore
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

97. uateprograms
(Taylor99);
■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

98. dpracticeregistered
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

99. petenciesofclinical
andprofessionalpractice.Althoughpsychiatric-
mentalhealthnursingismovingtowarda
singlenationalcertificationfornewgraduatesofadvancedpracticepr
ograms,titled
Psychiatric-
MentalHealthNursePractitioner,personsalreadycredentialedasPsy
chiatric-
MentalHealthClinicalNurseSpecialistswillcontinuetopracticeund
erthistitle(NCSBN
JointDialogueGroupReport08).
CurrentIssuesandTrends
…
COUPLE PSYCHOANALYTIC
PSYCHOTHERAPY AS THE TREATMENT
OF CHOICE:
Indications, Challenges and Benefits
Berta Aznar-Martínez, PhD, Carles Pérez-Testor, PhD, MD,

100. Montserat Davins, PhD, and Inés Aramburu, PhD
Universitat Ramon Llull
Including couple treatment in psychoanalysis has required the
setting of new
parameters beyond the classical psychoanalytical setting, in
which the treatment
is individual. This article aims to define the clinical criteria for,
and benefits of,
recommending couple treatment rather than individual
psychoanalysis or psy-
chotherapy, and to identify the challenges and demands that this
has entailed for
psychoanalysis, from the standpoint of the analysis itself and
also that of the
therapeutic relationship. Couple therapy is a very complex
endeavor since a host
of factors must be borne in mind. The present paper discusses
the specific
features of these factors and how they influence the diverse
mechanisms in the
analytical relationship. A clinical vignette is included in order
to demonstrate
the mechanisms that influence therapeutic work in couple

101. psychoanalytic
treatment.
Keywords: couple psychotherapy, therapeutic relationship,
transference, coun-
tertransference, psychoanalysis, conjoint treatment
In psychoanalysis, couple treatment has required the setting of
new parameters beyond the
classical psychoanalytical setting. Thanks to the contributions
of Dicks (1967), Pichon
Riviere (1971), and Kaës (1976), who might be seen as
representatives of the leading
psychoanalytical schools (English, Argentine, and French,
respectively) in the fields of
This article was published Online First March 23, 2015.
Berta Aznar-Martínez, PhD and Carles Pérez-Testor, PhD, MD,
Facultat de Psicologia,
Ciències de l’Educació i de l’Esport Blanquerna and Institut
Universitari de Salut Mental Vidal i
Barraquer, Universitat Ramon Llull; Montserat Davins, PhD,
Institut Universitari de Salut Mental
Vidal i Barraquer, Universitat Ramon Llull; Inés Aramburu,

102. PhD, Facultat de Psicologia, Ciències
de l’Educació i l’Esport Blanquerna and Institut Universitari de
Salut Mental Vidal i Barraquer,
Universitat Ramon Llull.
This article is based upon work supported by the agreement
between the Universitat Ramon
Llull and the Departament d’Economia i Coneixement de la
Generalitat de Catalunya.
Correspondence concerning this article should be addressed to
Berta Aznar-Martínez, PhD,
FPCEE Blanquerna. C/Císter 34. 08022. Barcelona, Spain. E-
mail: [email protected]
T
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105. al
lie
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.
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106. te
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107. of
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108. di
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at
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br
oa
dl
y.
Psychoanalytic Psychology © 2015 American Psychological
Association
2016, Vol. 33, No. 1, 1–20 0736-9735/16/$12.00
http://dx.doi.org/10.1037/a0038503
1
mailto:[email protected]
http://dx.doi.org/10.1037/a0038503

109. couple and family psychotherapy, couple treatment is now an
area of therapeutic action
that has brought new challenges.
Although this type of treatment is widely accepted among
psychoanalysts nowadays,
the need of couple therapy and the factors that make couple
psychotherapy the treatment
of choice rather than individual treatment are issues that are
still under discussion. Zeitner
(2003, p. 349) describes the typical ways in which couple
consultation and therapy are
practiced by psychoanalysts as a “supplemental or even second-
rate treatment which is
palliative, supportive, informative, or preparatory for the real
therapy—psychoanalysis or
psychotherapy,” a view which shows that couple treatment is
not held in high esteem by
some psychoanalysts. However, couple therapy has the potential
to provide valuable
insights concerning individual and shared psychic organization,
and also the dynamic
functioning of marriage (Scharff, 2001).

110. The purpose of this article, therefore, is to provide further
insight into the clinical
indications for couple psychotherapy, its benefits, and how to
go about this type of
treatment. It also aims to examine the new challenges and
demands that openness to
welcoming couples into therapy has brought for psychoanalysis,
from the standpoints of
the analysis itself and the therapeutic relationship. Couple
therapy has several clinical
characteristics which differentiate it from individual therapy
and these are highlighted in
the paper.
Why Couple Psychoanalytic Psychotherapy?
Couple therapy is an area of psychotherapeutic practice that is
long on history but short
on tradition (Gurman & Fraenkel, 2002). The evolving patterns
in theory and practice in
couple treatment over more than 80 years can be seen as having
four distinct phases: (a)
nontheoretical marriage counseling training (1930–1963); (b)
psychoanalytic experimen-

111. tation (1931–1966); (c) incorporation of family therapy (1963–
1985); and (d) refinement,
extension, diversification, and integration (1986 to the present
day) (Gurman & Fraenkel,
2002; Gurman & Snyder, 2011). According to Segalla (2004),
recent cultural shifts have
had a considerable impact on the ways in which psychoanalysis
and psychotherapy are
conducted and couple therapy has much to gain from
postmodern theorizing. Analysts
have mainly applied their methods to the individual rather than
to the troubled dyad
(Zeitner, 2003) even though 50% to 60% of their patients
seeking therapy do so because
of some kind of disorder in their intimate or other significant
relationships (Sager, 1976).
Moreover, as Gurman (2011) notes, partners in troubled
relationships are more likely to
suffer from anxiety, depression, suicidal impulses, substance
abuse, acute and chronic
medical problems, and many other pathologies.
In Segalla’s view (2004), emphasis on intersubjective and
relational perspectives has
had a major influence on the way the treatment process is

112. conceptualized. The dyad is seen
as an “interactive system” and the couple treatment is based on
awareness of this system
of mutual influence and regulation. Working with couples
affords compelling evidence for
the existence of a “psychology of interaction” and the ways in
which emotional difficulties
are, in part, determined by these factors (Dicks, 1967).
Similarly, de Forster and Spivacow (2006) hold that what
couple treatment adds to the
contribution of the classical Freudian model is the role of “the
intersubjective,” which
varies according to the type of psychic suffering. This
dimension has crucial importance
with regard to much of the distress in a relationship and must
have a place in the design
of therapy. All psychic functioning is constituted by both the
intrasubjective (in that
T
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s
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113. cu
m
en
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is
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by
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114. er
ic
an
Ps
yc
ho
lo
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A
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ia
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n
or

115. on
e
of
its
al
lie
d
pu
bl
is
he
rs
.
T
hi
s
ar

116. tic
le
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs

117. on
al
us
e
of
th
e
in
di
vi
du
al
us
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an
d
is

118. no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
2 AZNAR-MARTÍNEZ, PÉREZ-TESTOR, DAVINS, AND
ARAMBURU

119. the psychic determinants come from the inner world), and the
intersubjective (in that the
psychic determinants include the “other” and the intersubjective
context in which the
subject functions). The latter factors are fundamental in much
of the suffering which
occurs in a couple’s love life and relationship. Hence, in couple
treatment, certain factors
are of particular importance: “the partner, bidireccionality, the
unconscious interconnec-
tions and the interweaving of the phantasies of both partners”
(de Forster & Spivacow,
2006, p. 255). The psychic determinant of the suffering must be
sought in an aspect of the
functioning of the psyche which is not part of the Freudian
psychic apparatus but which
lies, rather, in the link between the members of the couple (the
“intersubjective”). If this
is not taken into account in the choice of a suitable treatment,
the intersubjective
dimension might be neglected in individual work. Since each
partner has become closely
associated with the other’s painful internal objects, conjoint

120. psychoanalytic couple therapy
has the potential of dealing with deeply ingrained, largely
unconscious constellations that
are usually thought to be treatable only by means of
psychoanalysis or intensive individual
analytic psychotherapy (Scharff, 2001). Nevertheless, it seems
clear that conjoint treat-
ments are vastly superior to individual treatments for couple
distress (Gurman, 1978).
As for the clinical criteria for recommending psychoanalysis or
intensive psychoan-
alytic psychotherapy versus couple treatment, Links and
Stockwell (2002) have described
the clinical indications for couple therapy in the case of
narcissistic personality disorder.
We believe that these criteria can be applied in any case where
couple therapy would seem
to be indicated. First, Links and Stockwell state that the
partners’ capacity for dealing
openly with feelings of anger or rage must be assessed before
deciding on couple
treatment, although these will be worked on during treatment if
one member of the couple
is unable to deal with or express feelings that might be

121. humiliating or that could prompt
an attack on the other partner. In such cases we believe that
individual treatment should
precede couple therapy. Second, the person’s level of
defensiveness, openness to the need
for a relationship, and ability to have this dependency gratified
should be evaluated as
well. If one of the partners does not want to continue and
improve the relationship the
treatment will not be useful. This is not necessarily the case
when both members of
the couple want to separate or divorce. The important point in
these circumstances is that
the aim of treatment is shared by both parties and this can be
assessed by the therapist
in the preliminary interviews. If, after some sessions, it
becomes clear that the objective
is not shared by both members, the treatment will not be
fruitful. Assessment of
vulnerability is important. Some people feel that having their
partners listening to
interpretations could be belittling and humiliating and couple
therapy could then be
counterproductive. Third, the complementarity of the couple
must be analyzed, together

122. with the roles each one plays in the couple. If this
complementarity exists, the couple can
often make progress. In other words, when the therapist can
show the couple that they are
both participating in the dynamics of their relationship and that,
whether they like it or not,
each of them is (or has been) benefitting from the relationship,
the treatment can be
helpful. If both partners can see that each of them has
personality aspects that benefit the
other, they will be better able to understand their situation (as
will be explained in more
detail below). If a couple fulfils these three criteria, they can
probably work together and
establish, or reestablish, a stable marriage with a significant
degree of complementarity
based on more positive symmetrical patterns.
Lemaire (1977) lists some conditions indicating couple
treatment, namely: (a) that
both members agree to having therapy, although as we shall see
below, this rarely
happens; (b) that they can distinguish between improved
communication and continuing
to stay together (when couples come to therapy they frequently

123. have communication
T
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s
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te
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by

124. th
e
A
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ic
an
Ps
yc
ho
lo
gi
ca
l
A
ss

125. oc
ia
tio
n
or
on
e
of
its
al
lie
d
pu
bl
is
he
rs

126. .
T
hi
s
ar
tic
le
is
in
te
nd
ed
so
le
ly
fo
r

127. th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al

128. us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa

129. dl
y.
3COUPLE PSYCHOANALYTIC PSYCHOTHERAPY
problems and improving communication is one of the first goals
of the treatment in order
to be able to explore other issues later on (phantasies, families
of origin . . .)); and (c) that
the therapist can intervene freely (more or less) without feeling
bothered by the contra-
dictions of the other two conditions. In this same vein, Bueno
Belloch (1994) and Castellví
(1994) emphasize that limits to couple treatment appear when:
(a) when one of the
partners is forced by the other to come to the therapy and there
is no change after some
sessions; (b) when it is feared that the new understanding that
each person acquires in
therapy can be used pathologically; (c) when both partners form
an alliance against the
therapist and frustrate all his or her efforts to bring about

130. change; and (d) when it becomes
necessary to suggest individual therapy for one of the partners
because the conflict cannot
be addressed in conjoint treatment.
According to de Forster and Spivacow (2006), another reason
for opting for couple
treatment is that our discipline must take a flexible approach,
catering to the needs of men
and women of our time, and to what society demands. Reforms
in divorce law, more
liberal attitudes about sexual expression, increased availability
of contraception, and the
greater economic and political power of women have all raised
the expectations of
committed relationships so that their requirements now go well
beyond economic viability
and assuring procreation (Gurman, 2011). Likewise, Segalla
(2004), drawing on her own
clinical practice and that of other psychoanalysts, states that the
demand for couple
therapy is now considerably greater, and this seems to suggest a
cultural shift in which
efforts are being made to save marriages rather than simply to
divorce. Moreover, there