a relationship-based model for psychiatric nursing practice

A Relationship-Based Model for Psychiatric Nursing Practiceppc_285 151..159

Kathleen Wheeler, PhD, APRN, PMHCNS-BC, PMHNP-BC, FAAN

Kathleen Wheeler, PhD, APRN, PMHCS-BC, PMHNP-BC, FAAN, is a Professor, Fairfield University School of Nursing, Fairfield, Connecticut, USA.

Search terms:Attachment, mental illness, neurophysiology,psychotherapy

Author contact:[email protected], with a copy to theEditor: [email protected]

First Received March 16, 2010; Final Revisionreceived July 29, 2010; Accepted forpublication August 4, 2010.

doi: 10.1111/j.1744-6163.2010.00285.x

PURPOSE: This article synthesizes research and theory in information processing,infant development, attachment theory, and trauma, and proposes a treatmentframework for psychiatric nursing practice.CONCLUSIONS: The primacy of the nurse–patient relationship is central tohealing, and elements of the psychotherapeutic relationship are delineated.PRACTICE IMPLICATIONS: This model has the potential to serve as a practiceframework for psychiatric nursing, for all levels of psychiatric nursing practice.

The confluence of recent theory and research on learning,trauma, infant development, and attachment validates thecentrality of the relationship that nursing espouses. Thisarticle proposes a relationship-based model founded on asynthesis of this literature. Adaptive Information Processing(AIP) theory provides a neurophysiologic explanation formental health and the treatment of mental illness. Assump-tions and concepts based on nursing’s meta-paradigm aredelineated. The phases of treatment, stabilization and pro-cessing, and interventions for each phase are described. Thisframework, embedded within a holistic nursing paradigm,provides a compass for basic and advanced levels of practicein all settings for the many roles of psychiatric nurses and isrelevant and applicable for psychotherapists of any discipline.The treatment framework presented in this article furtherdevelops and refines the framework in the book Psycho-therapy for the Advanced Practice Psychiatric Nurse (Wheeler,2008).

Holistic Paradigm

A holistic worldview espouses the interrelationship and inter-dependence of all dimensions of the person. Each of thesedimensions can be a focus for interventions: beliefs, physical,images/sensations, and emotions, with their expression inbehavior embedded within relationships in the larger contextof community and culture. Even a small change in onedimension affects all the others (see Figure 1). Interventionsmay target any component to facilitate healing. For example, anurse may suggest a cognitive technique, such as a thoughtdiary, as a first step in changing maladaptive thought patterns;

thus, beliefs are targeted for change. Changing thoughts thenchanges emotions, which in turn changes behavior and rela-tionships. Interventions aimed toward the physical compo-nent might include diet changes, exercise, and/or medication.Strategies targeting images and/or sensations includeimaging exercises, art, dream work, and increasing awarenessof bodily sensations associated with a particular situation,person, or event. Examples of interventions targeting emo-tional components are the identification and expression offeelings through narrative or journaling feelings. Relation-ship change may be targeted specifically through interper-sonal psychotherapy or couples therapy while a contingencycontract might be used to target a behavioral change. Theresulting change in any one arena reverberates and affects allspheres to potentiate healing and integration. Relationship isalways the vehicle through which this change is mediated.

Mental Illness

Integral to any paradigm of mental health is an understand-ing about assumptions regarding mental illness. Luhrmann(2000), a cultural anthropologist, identified two frameworksfor understanding mental illness: psychodynamics, originallyFreudian but which has been expanded to include all thosemodels that espouse mental illness as the result of environ-mental and psychosocial problems (nurture), and a biophysi-cal model that posits a chemical imbalance (nature) asthe etiology of mental illness. The solution to the chemicalimbalance is medication, while psychotherapy and casemanagement approaches address the psychosocial andenvironmental problems. The truth, however, is that both

Perspectives in Psychiatric Care ISSN 0031-5990

151Perspectives in Psychiatric Care 47 (2011) 151–159 © 2010 Wiley Periodicals, Inc.

nature and nurture contribute to genetic expression. It hasbeen estimated that approximately one third to one half ofour genetic makeup depends on environmental stimulationfor activation (Huttenlocher, 2002; Lipton, 2005). In additionto genetic vulnerabilities, structural defects, insults to thecentral nervous system, prenatal viruses, medical and neuro-logical disorders, and adverse experiences also contribute tomental health problems.

Research has found that adverse experiences such as loss,trauma, neglect, and abuse in childhood underlie a widerange of both medical and psychiatric disorders in later life(Felitti et al., 1998; Lang et al., 2008; Norman et al., 2006).These experiences and events, large or small, are traumas withthe long-term sequelae dependent on the person’s develop-mental stage, genetic vulnerability, coping skills, hardiness,and relationships with others, in addition to socioculturalfactors (Antai-Otong, 2002; Scaer, 2005; Stien & Kendall,2004). Large disturbing events include such major traumas asincest, war, and natural disasters, while small disturbingevents, adverse experiences that happen to many peopleduring life, include emotional neglect, humiliation, chronicmisattunement, chronic loneliness, betrayals, family instabil-ity, poverty, etc. (Shapiro, 2001). The latter are adverse experi-ences that happen to many people at some point in life. Whatis experienced by the person as traumatic is stored in the brainas dysfunctional, disconnected information. The causes andconsequences of trauma transcend the diagnosis of post-traumatic stress disorder, and adverse life events can contrib-ute to a wide range of physical, emotional, and socialproblems (Robinson & Larson, 2010; Scaer, 2005; Teicher,Polcari, Andersen, & Navalta, 2003).

Complex and enduring neurobiologic responses to child-hood stress and trauma have been well documented (Scaer,

2005; Schore, 2003; Stien & Kendall, 2004; Teicher et al.,2003). Cumulative, profound, and long-lasting changes fromadverse emotional and environmental events affect the devel-oping brain (Binder et al., 2008; Bradley et al., 2008; Glad-stone et al., 2004; Heim et al., 2000; Mirescu, Peters, & Gould,2004). These negative experiences may affect ongoing auto-nomic nervous system responses and decrease neural plastic-ity so the person’s ability to respond to stress is diminished.

The resulting autonomic changes can produce chronichyper- or hypoarousal due, in part, to the hypersecretion ofcorticotropin-releasing factor (CRF). Increased CRF is asso-ciated with excess dopamine in the thalamic pathways of thebrain. This leads to neuronal oversensitivity because of itsexcitatory role in neurotransmission. Insufficient serotoninor GABA activity leads to oversensitivity because of theinhibitory role of these neurotransmitters. Autonomic dys-regulation and the ensuing cascading neurotransmitterchanges can result in reactions such as behavioral agitation,anxiety, depression, anorexia, insomnia (Bradley et al., 2008),serious chronic illness including hypertension, osteoporosis,immunsuppression, diabetes, dyslipidemia, and cardiovascu-lar disease (Charney, 2004), and many psychiatric and sub-stance abuse disorders (Hartwell, Tolliver, & Brady, 2010).

AIP

AIP provides a neurophysiologic explanatory theory formental health and illness. AIP posits that we normally take ininformation, process it, and store it as memory adaptively;thus, learning occurs (Shapiro, 2001; Solomon & Shapiro,2008). There is thought to be an innate self-healing quality inthe brain that strives for neurophysiologic harmony. Just asthe body strives for homeostasis, the brain naturally regulatesand processes information through neural transmission.

The forces driving AIP are information processing andlearning. For example, if we have something disturbinghappen, we talk about the event to a friend, thus processingthe information until we feel better (Shapiro, 2001). However,if the event is experienced as overwhelming to the individual,processing may be aborted because of the massive influx ofhormones and neurotransmitters. These chemicals do notallow for the flow of information as usual to adaptive memorynetworks. Reminders, or triggers, of the unprocessed experi-ence, such as cognitions, sensations, images, sounds, andemotions, may trigger aspects of the original event withoutconscious awareness of what the present feeling is related to.The original physiological state is automatically recreated (seeFigure 2). These maladaptive experiences are thought to bethe basis of many mental health problems and psychiatric dis-orders (Scaer, 2005; Shapiro, 2001; Solomon & Shapiro, 2008;Stien & Kendall, 2004).

The developing brain is particularly vulnerable becauseneural networks are forming. Through experience, synapses

Community and Culture

Interventions

Behavior

Relationships

Images/Sensations

Physical

EmotionBeliefs

Adaptive Information Processing

Figure 1. Adaptive Information Processing Relationship-BasedModel

A Relationship-Based Model for Psychiatric Nursing Practice

152 Perspectives in Psychiatric Care 47 (2011) 151–159 © 2010 Wiley Periodicals, Inc.

change and brain changes occur. The fundamental compo-nent of the neural network and information processing is theneuron with interconnecting neural networks activatedsimultaneously as a result of environmental interactions(Gabbard, 2006; Lipton, 2005). Thus, the first 3 years of lifeare particularly critical when neural networks are most mal-leable or plastic (Schore, 1994; Siegel, 1999, 2006). The righthemisphere of the brain develops more rapidly than the lefthemisphere and is associated with the somatic, or body self,and regulation of emotion, and the autonomic nervoussystem is based on the infant’s relationship with a significantcaretaker(s). The early-forming right brain stores the tem-plate for attachment relationships (Schore, 2005). Affectattunement, that is, the caretaker’s emotional connectionwith the infant, is necessary so limbic and cortical structurescan develop optimally (Siegel, 1999). Schore’s (1994) researchon attachment demonstrates that social interactions earlyin life result in the stimulation of neurotransmitters andneural growth that shape the brain. Freud would call rightbrain functions our “unconscious” (Gabbard, 2006). Theseunconscious, or implicit emotional memories, includecomplex attachment feelings and somatic sensations thatform through interaction and experiences with caregivers.

Mirror neurons, located in several areas of the brain, havebeen found to play an important role in attachment and thedevelopment of empathy in infancy (Siegel, 2006). Theseneurons fire when the infant watches someone else dosomething, for instance, smiling. Mirror neurons areresponsive to nonverbal cues, for example, if mom issmiling, the same neurons fire in the infant’s brain as if heor she were smiling. In other words, the infant’s brainmirrors another brain, resulting in dyadic states of con-sciousness or “shared mind.” This has significant implica-tions for understanding the importance of attachmentrelationships for affect regulation and learning. In attune-ment during infant development, both the parent’s and the

infant’s brains coregulate, which hardwires the infant’sbrain so that it is more able to self-regulate (Schore, 2003;Siegel, 2006). This research supports the importance of anattachment relationship for the coregulation of biology andmood.

The left hemisphere, which develops later, is primarilyresponsible for language, logic, and problem solving. It is con-sidered the part of the brain that puts words to our experi-ence. Because the brain develops from the bottom-up,implicit or procedural memory is largely stored in the limbicor emotional brain. These areas regulate physiology whileexplicit or conscious memory is largely semantic (words) andstored in higher regions of the brain. The sequential acquisi-tion of information is a primary task of development withmemory distributed across neural networks in the brain(Schore, 2003; Stien & Kendall, 2004; See Figure 3). Thedevelopment of the brain is “use dependent,” that is, patternsof emotion, body sensations, and cognitions become encodedthe more the neuron is triggered and, eventually, neuronsform neural networks that are “wired together.” The brainbecomes increasingly differentiated, complex, and moreplastic (Siegel, 2002; Stien & Kendall, 2004). Lower areas ofthe brain, such as the brainstem and limbic brain, are lessplastic, or malleable, while the cortex is able to changethroughout life. Thus, relationship and attachment templatesare harder to change than explicit, more conscious memoriesin higher regions of the brain.

Memories are contained or stored in webs of interlinkingneurons in templates or patterns (neural networks), and eachindividual has a unique biochemical profile or templateformed through experiences with others. Changing thesetemplates involves changing the pattern of receptors in neuralnetworks, and this can occur through life events, experiences,psychotherapy, and/or with some medications. Increasingthe availability of a neurotransmitter at the synaptic site witha psychotropic medication may temporarily decrease the

Figure 2. Information Processing Interrupted

Figure 3. Brain Development and Memory



number of receptors for that neurotransmitter. However,medication cannot change relationships, beliefs, and behav-ior; only emotional experiences in a psychotherapeutic rela-tionship can do this. Brain imaging studies document theeffect of both medications and psychotherapy on brain func-tioning and physiology in both cortical and limbic areas of thebrain (Furmark et al., 2002; Goldapple et al., 2004). Furtherresearch suggests that psychotherapy is superior to medica-tion for sustained reductions in symptoms (Dobson et al.,2008; van der Kolk et al., 2007).

The capacity to learn, as well as retrieve previous learning,depends on the specific mood or feelings at the moment, thatis, on the person’s physiology at the time of the experience.This is termed state-dependent learning (Rossi, 1996).Retrieval of information is best when the physiological statein which one learns the information is the same as the currentsituation. For example, feelings of loss (which is a specificphysiological state) can trigger previous losses. Essentially allpresent states are dependent on previous physiological statesthat are encoded in neural networks. Individuals literally slipinto different states of consciousness off and on throughoutthe day, usually without really being aware of the subtle physi-ological changes of state (Pert, Dreher, & Ruff, 1998).

Memories that are traumatic in nature are stored differ-ently than those that are not associated with a massive influxof neurotransmitters. Aspects of traumatic memories may beunconscious, dissociated, and stored as fragments in proce-dural memory because when the brain is hyperaroused, infor-mation processing is interrupted, resulting in incompletestorage. The attendant emotions, sensations, thoughts, andimages may be dissociated and fragmented from each otherand from explicit or conscious memory (van der Kolk, 2003).These dissociated memories are composed of procedural orimplicit memory cues (Scaer, 2005). The greater the amountof memory dissociated, the less the person is conscious andable to be in the present.

In order to integrate these isolated, disrupted, or dysfunc-tional memories and reconnect with adaptive memory neuralnetworks, information processing must occur. Healthy func-tioning is reflected in optimal integration and coordination ofneural networks, with synaptic impulses and energy flowingunimpeded from one cluster of networks to another. Healingoccurs: “When the brain is operating efficiently, multipleassemblies of neurons are firing in unison, and information isflowing freely from one area to another” (Stien & Kendall,2004, p. 19).

Relationship: The Context for Practice

AIP’s basic tenets, trauma, research, and theory (Briere &Scott, 2006; Chu, 1998; Najavits, 2002; Shapiro, 2001;Solomon & Shapiro, 2008), and attachment and infant devel-opment research (Porges, 2005; Schore, 1994, 2003; Siegel,

1999, 2002, 2006) provide the psychobiological foundationfor a relationship-based framework for psychiatric nursingpractice. Assumptions based on nursing’s meta-paradigminclude the following:

Person

• Persons strive for neurophysiologic regulation or harmony• Persons are composed of beliefs, physical, emotional andimage/sensation dimensions embedded in relationships withothers• Behavior is the manifestation of these components

Environment

• A disturbing event or experience has the potential todisrupt information processing or memory (learning)• Relationship provides the ambient environment necessaryfor healing to occur

Health

• Health is a state of free-flowing energy throughout neuralnetworks in the brain• Healing occurs through connection and integration ofdysfunctional memories with adaptive memory networks

Nursing

• The goal of nursing interventions is healing• The therapeutic nurse–patient relationship is the vehiclefor healing• Nursing interventions are aimed at enhancing stabilizationand/or adaptive processing of information

The nurse–patient relationship provides the ambianceneeded for the reconnection and integration of neural net-works that facilitate therapeutic change to occur. Norcross(2002) found that it is the psychotherapy relationship itselfthat predicts the success of any psychological treatment.Indeed, Peplau (1952) described the nurse–patient relation-ship as therapeutic in and of itself. Cozolino (2002), inreferring to the psychotherapeutic relationship, says: “Thissimultaneous activation of cognition, emotion, enhancedperspective, and the emotional regulation offered by the rela-tionship may provide an optimal environment for neuralchange” (p. 53). Siegel (2003) noted that the therapeutic rela-tionship serves as an attachment relationship and assists thepatient toward more autonomous self-regulation throughcoregulation of internal states. Stern et al. (1998) proposedthat implicit relational knowledge stored nonverbally is theheart of therapeutic change.

Elements of the psychotherapeutic relationship thatpromote change include caring, connection, narrative, and



anxiety management (Wheeler, 2008). These are pantheoreti-cal concepts and apply to all practice settings and all phasesof the treatment framework proposed here for psychiatricnursing.

Caring has been identified as foundational for nursingpractice (Dossey, Keegan, & Guzzetta, 2008; Morse, Solberg,Neander, Bottorff, & Johnson, 1990; Schoenhofer, 2002).Watson (1999) defined caring as the moral ideal of nursing, inwhich the relationship between the whole self of the nurseand the whole self of the patient protects the vulnerability andpreserves the humanity and dignity of the patient. Character-istics of the advanced practice nurse–patient relationshipinclude the mutuality of nonromantic love based on agenuine knowing of the person, trust, and respect reflected inan acceptance of, and authentic appreciation for, the otherperson (Thomas, Finch, Schoenhofer, & Green, 2005). Thenurse and the patient were viewed as coparticipants in theprocess of healing, and this provided the healing context forneural restructuring to occur.

In tandem with caring, emotional connection is crucial fortherapeutic outcomes to occur. This connection or the“thera-peutic alliance”has been found to be more important for suc-cessful outcomes than what technique the therapist actuallyuses (Lambert & Barley, 2002). Connection is cultivatedthrough validating the patient’s feelings, asking questionsabout the main concern, setting collaborative goals, pointingout strengths, and communicating empathy. Cozolino (2006)posits that empathic connection stimulates biochemicalchanges in the brain and that this enhances learning and plas-ticity. Empathic resonance can be thought of as a physiologi-cal state of consciousness that assists to connect, attune, andcoregulate with the patient (Siegel, 2006). Emotional changesand affect regulation involve implicit memory and occurthrough right brain-to-right brain communication or limbicresonance in the therapeutic alliance (Amini et al., 1996;Schore, 2005). These dyadic states of consciousness have beenproposed to lead to an increased capacity for self-regulation(Siegel, 2006). One can speculate that subcortical limbic areasare activated through relationship as state-dependent limbicmemories are recreated, which allows for connection tohigher cortical areas of the brain.

Narrative is the third component and integral to theprocess of healing. Putting words and feelings to experience iskey to strengthening the ability to regulate emotions. Attach-ment research supports this idea in that parents who makesense of their world in narrative have the most securelyattached infants (Siegel, 2003, 2006). It is the parents’ neuralintegration that is the underpinning of the attunement thatfosters the development of a coherent narrative. The identifi-cation and expression of feelings is salubrious to health andserves a regulatory function for the developing brain (Pertet al., 1998; Siegel, 2002). Narrative, primarily a left brainfunction, helps to connect the right hemisphere which

houses, largely, images, sensations, and feelings, with the lefthemisphere. This processing assists in connecting subcorticalareas with higher cortical areas. Narrative integratesemotional memory through changing implicit-memoryto explicit-memory networks, which are more available forconscious processing (Bradley et al., 2008; Siegel, 2006).

Anxiety management is the fourth component and is ofparamount importance so learning and change can occur.Managing anxiety is a cornerstone of Peplau’s (1952) modelfor psychiatric nursing. Her delineation of the levels ofanxiety and suggestions for interventions remain importantto psychiatric nursing. She posited that good interpersonalrelationships reduce anxiety. Recent neurobiological researchlends support to this idea (Dobbs, 2008; Fuchs, 2004; Schore,2005). The emotional arousal inherent in the therapeuticrelationship may provide a portal of opportunity for theintegration of neural networks and regulation of neurophysi-ology in the brain.Although some emotional arousal is neces-sary in order to learn, high levels of emotional arousal limitcerebral efficiency by decreasing frontal cortex activation, andthese can destabilize the person as well as prevent processingof information (Scaer, 2005). Arousal needs to be modulatedso that the patient does not feel helpless and disempoweredbecause feelings of vulnerability are often triggered by theinequity of power in the therapeutic relationship.

Decreasing sympathetic nervous system arousal canbe accomplished through many venues, including stressmanagement strategies, mindfulness, the therapeutic rela-tionship, therapeutic communication techniques, medica-tion, and psychotherapy. On the other hand, low levels ofarousal or parasympathetic nervous system dominance mayrequire increased arousal with such modalities as art, bodywork, or sensate focusing exercises. Thus, a therapeuticwindow, not too much sympathetic (fight or flight) activationnor too much parasympathetic (freeze) activation, provides aportal of opportunity for therapeutic interventions. Scaer(2005), a neurologist, states: “Healing is a physical processwithin the brain that produces a physiological pattern-. . . that promotes homeostasis and optimal emotional

arousal”(p. 168). Optimal arousal is promoted through stabi-lization strategies that modulate physiology so that anambient therapeutic window is available for healing to occur.

Treatment Framework

Stabilization

A hierarchical treatment framework for psychiatric nursingpractice is depicted in Figure 4. Using Maslow’s hierarchy ofneeds superimposed on this frame, the nurse, through thepatient’s history and mental health assessment, prioritizeswhere to target interventions, taking into consideration thepatient’s strengths, current resources, needs, and culture. The



lower on Maslow’s hierarchy, the lower on the treatmentframework and the more active the nurse’s interventionsmust be. That is, if the person is not safe or is hungry, thoseneeds take priority over higher level needs such as self-actualization. Stabilization is a priority and may involve inpa-tient hospitalization or case management in order to increaseexternal resources. Internal resources such as the ability tomanage emotions and regulate both positive and negativeaffect are also necessary once external resources are in placefor stabilizing the patient. If adaptive memory networks arepresent, internal resources may only need to be strengthened.In other patients, internal resources may need to be created.These interventions serve to help increase the function ofthe prefrontal cortex, the problem solving and regulatory partof the brain through cortical top-down mechanisms (Fuchs,2004).

Stabilization strategies to increase internal resourcesenhance the ability of the person to make physiological“state”changes. These strategies might include cognitive behavioraltechniques, stress management, mindfulness, psychoeduca-tion, relaxation and deep breathing techniques, supportivepsychotherapy, imagery, self-soothing, affect regulation strat-egies, and medication in addition to the person’s own actualpositive memories. Stabilization has been achieved when thepatient is safe, able to self-soothe, control impulses, regulatemoods, and communicate honestly. Some patients may neverachieve sustained stabilization and are involved with onecrisis after another, so nursing interventions are directedtoward crisis management. Even if not in crisis, the personwho has had significant childhood trauma or has seriousmental illness may need ongoing resource development andcontinuing efforts toward stabilization.

Stabilization strategies are relevant for all those who aresignificantly emotionally or cognitively compromised.

Processing

Once stabilized, the patient is ready to move to processing.Processing promotes neural integration and association ofdysregulated memory by removing the blocks to the flow ininformation and energy; thus, new learning occurs. Process-ing is more likely to occur when multiple dimensions of theoriginal state-dependent memory are targeted, that is, whenbeliefs, emotions, and physical sensations are accessed forthe specific adverse life experience. This provides a portalof opportunity to retrieve the original fragmented state-dependent memory. The aim of the processing phase isto integrate all aspects of the fragmented memory intoconsciousness by allowing access to all dimensions of thememory: emotion, sensations, cognitions, beliefs, and imagesassociated with the trauma (Shapiro, 2001). Processing earlyattachment problems may occur through the therapeuticrelationship as dimensions of early relationship memories(transference) are activated in the therapeutic relationship.Through narrative and using psychotherapeutic strategiessuch as psychodynamic, somatic reexperiencing, and inter-personal, psychotherapy can be utilized. Other processingtherapies for specific traumas may include cognitive process-ing, systematic desensitization, exposure therapy, hypno-therapy, and eye movement desensitization and reprocessing(Gelinas, 2003). Whether an unspecified early adverse experi-ence or a specific identified trauma, processing connectsadaptive memory networks with the dysfunctional material,resulting in new learning and new neural connections. It isimportant during processing that a therapeutic window ofarousal is maintained so the person is not retraumatized.

In addition to the stabilization and processing strategiesoutlined above, therapeutic communication techniquescan also be used to decrease or increase arousal basedon a continuum from supportive to expressive (Gabbard,2004; Wheeler, 2008). Within the psychobiological treatmentframework presented here, communication techniques canbe thought of as those useful for stabilization or processing.Those techniques lower on the continuum are used to providesupport and stabilize the patient, while those higher on theframework are more arousing and may lead to processing.The latter may trigger implicit memory networks that may beexperienced as overwhelming or threatening, particularly tothe unstable patient (see Figure 5).

Overall, it is important for the nurse to keep in mind thatany positive change most likely involves two steps forwardand one step backward. The nurse helps the person to under-stand that the increased anxiety or depression during treat-ment may actually be because of recent positive changes.Emotion is a powerful agent of change and is synonymous

Figure 4. Treatment Hierarchy FrameworkReprinted from Wheeler (2008), Psychotherapy for the AdvancedPractice Psychiatric Nurse, with permission from Elsevier.



with disruption (Damasio, 1999). The positive change maycorrespond to a proliferation of synapses that can have a dis-organizing effect on the brain and behavior (Stien & Kendall,2004). This follows a developmental biological principle that“there can be no reorganization without disorganization”(Scott, 1979, p. 233). This is true especially for those patientswho do not have many adaptive memory networks and arelikely to be uncomfortable with positive experiences until thereorganized neural circuitry becomes reinforced and stabi-lized. The nurse needs to assure the patient that the setback isa temporary “state” that can be managed together whilestaying the therapeutic course as they continue to build upresources with confidence.

Thus, although this framework is discussed here as a phasemodel, with stabilization first and processing next, seldom dothe phases occur as a two-stage model. More likely, periods ofstabilization follow periods of processing to assuage destabili-zation, with aspects of the traumatic material reworked overand over again as the process unfolds. It is important to notethat some patients require a long period of stabilization whileothers may need less stabilization and quickly move on toprocessing. This depends on whether there are adaptivememory networks and the nature of the person’s previousexperiences. Processing is achieved once the patient has adap-tive relationships, work is productive, affect is stable, thereis good decision-making, and congruence exists betweenbehavior, thoughts, and emotions. Clinical checklists for sta-bilization and processing are available in Wheeler (2008).These changes restore consciousness, changing implicit toexplicit memories, and may result in not only state changesbut trait changes as well (Shapiro, 2001; Solomon & Shapiro,2008).

Healing occurs as formerly disrupted or dysfunctionalmemory networks are recreated and connected with adaptivememory networks. As healing occurs and the components ofthe person are integrated, increased hope and future vision-ing are enhanced. This is an excellent opportunity for psycho-education. For example, the individual who was physically orsexually abused as a child may truly not know what a healthydating relationship is. Bibliotherapy, imagery, discussion, androle-playing may help to teach the person about healthy rela-tionship behaviors and attitudes.

Conclusion

The Relationship-Based Model and treatment frameworkfor psychiatric nursing practice presented here are based on asynthesis of research and theory on neurobiology, attach-ment, infant development, and trauma and are relevant for allpsychotherapeutic relationships. Earlier models were basedon psychosocial theory. Synthesizing and applying recentneuroscience deepens the way we think about and work withall patients and offers a potential heuristic model for nursingeducation. The nurse serves as an attachment figure andcoregulator of internal states, assisting the patient towardgreater self-regulation. The presence of the nurse in thehealing relationship restores harmony, connection, integra-tion, and healing. This is reflected on a cellular level in theconnection and integration of neural networks as well as inthe coherence of relationship with others.

Although current nursing practice often does not allow forthe development of long-term psychotherapeutic relation-ships, it is the moment-to-moment nurse–patient relation-ship through implicit and explicit communications thatpotentiates change in the patient’s state. Subtle, nonverbalcues, such as one’s tone of voice, posture, gaze, and respira-tions, are noted and either serve to enhance or discourageconnection. It is largely the right brain-to-right brain connec-tion through relationship with another that allows for anambient environment so healing can occur. Through thenurse–patient relationship, the patient has the opportunity toachieve a new level of integration and a deeper sense of con-nection with self, others, and the world.

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