Perspectives in Psychiatric Care Vol. 41, No. 4, October-December, 2005 151

Blackwell Publishing, Ltd.Oxford, UKPPCPerspectives in Psychiatric Care0031-5990© Blackwell Publishing 2005October–December 2005414

GUEST EDITORIAL

Guest EditorialGuest Editorial

Guest Editorial

The Primacy of Psychotherapy

Kathleen Wheeler was co-chair of the National Panel that developedthe Psychiatric Mental Health Nurse Practitioners Competenciesand is currently writing a book on psychotherapy and theadvanced practice psychiatric nurse. She is a professor at theFairfield University School of Nursing in Fairfield, CT and has aprivate psychiatric nursing practice with certificates as a clinicalspecialist in psychiatric mental health nursing, psychoanalysisand psychotherapy, hypnosis, and eye movement desensitizationreprocessing.

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sychotherapy has been identified as an important com-petency that all psychiatric mental health nurse practitioners(PMHNP) must achieve according to the Psychiatric MentalHealth Nurse Practitioner Competencies (2003). Historically,psychiatric clinical nurse specialists (PCNS) have alwayspracticed psychotherapy but many PMHNP programs didnot include a course, content, or practicum for teachingbasic techniques. With the competencies delineated, andthe endorsement of these by the Commission on CollegiateNursing Education (CCNE) for accreditation, it is clear thatall graduate advanced practice psychiatric nurse programsseeking CCNE accreditation must teach these skills.

The challenge for educators is how to teach this contentwhile including other requisite competencies and essentialsthat are also required of graduate nursing curricula withoutincreasing the total credit load. To remain competitive,programs need to offer a graduate degree in a reasonableamount of time and credits; thus, psychotherapy skills mustbe acquired expeditiously in a short amount of time. Theplethora of psychological theories, approaches, and techniquesmakes it difficult for faculty to teach the most salient skillsneeded to achieve competency in this area. The novice nursepsychotherapist needs to know several models that have themost utility and some idea of when and how to use techniquesgermane to these approaches for the specific client problemsencountered in clinical practice.

Since Peplau’s 1952 seminal book

Interpersonal Relations inNursing

, no contemporary overarching nursing frameworkhas been proposed to unite disparate psychotherapeuticapproaches into one that is user friendly, and at the sametime parsimonious and comprehensive. The textbooks usedin advanced practice psychiatric graduate programs areprepared for and by psychologists, psychiatrists, and othermental health disciplines. Clearly, there is a need for a nursing

framework and textbooks specific to conducting psychotherapyas an advanced practice psychiatric nurse.

It is also important to note that numerous studies havedocumented that what is most important for positive clientoutcome is the therapeutic relationship, not the model ortechnique employed. Yet how many psychiatric nursepractitioner programs focus on relationship-building skillsand what percent of didactic time in our curriculum is spenton teaching the student how to develop a therapeutic allianceand advanced communication skills beyond what wastaught at an undergraduate level? And then how are theseessential competencies reflected in our certification exams?

However, it is not just these pragmatic concerns aboutcurricula and exam content that mitigate against the primacyof psychotherapy in psychiatric advanced nursing practice.Societal and philosophical issues underlie the devaluation ofthe therapeutic relationship. The psychosocial model forpsychiatric nursing is based on the healing relationship andthe subjective intuitive stance in knowing another person. Thisis rooted in qualitative data and is dissonant with the outcome-driven, quantitative philosophy of contemporary westernpsychiatry, which is a reductionistic, biological paradigm.

This paradigm, coupled with prescriptive authority foradvanced practice psychiatric nurses, has contributed to psy-chopharmacology as the dominant treatment interventionfor practice. Increasingly, psychiatric nursing conferences andjournals focus on psychopharmacology as the primarysolution for various disorders. Drug companies fund theresearch that is promoted both in journals and at nationalconferences, and nurses get paid to share the latest researchas participants get free lunches, dinners, pens, videos, etc.for attending these sessions. In addition, consumer demandfor a quick fix has contributed to the centrality of medicationas the solution to mental health problems. However, not allpatients are helped by medication and the 50% compliancerates and somewhat lower efficacy rates suggest that drugtherapy is not enough.

Viewing mental illness as purely biologically determinedand chemical manipulation as the answer may assuage ourown anxiety but keeps us in the dark about the person weare treating. Our choice of treatment modality determineshow we view mental illness, and what we initially say or dofor the person who comes for help reveals our bias. Forexample, when a client comes in with anxiety, do youautomatically reach for the prescription pad? Sometimes a

152 Perspectives in Psychiatric Care Vol. 41, No. 4, October-December, 2005

Guest Editorial

symptom such as anxiety can herald change and may actuallyindicate that the person is getting better. Frequently, clientswill temporarily experience anxiety when changing towardshealthy ways of relating to others or making positivechanges in their life situation. Reframing the anxiety for theclient as actually indicating that positive internal changemay be occurring, and exploring anxiety management skillsmay be much more helpful than prescribing a benzodiazepine.The latter serves to pathologize the person’s experience;however, the former response can only happen if the nurseunderstands underlying psychodynamics. Understandingpsychodynamic issues is imperative in order to make senseof what is happening for the client in the treatment. Adynamic formulation helps to establish clarity about what canand cannot be changed and the best way to proceed with thetherapeutic process. Yet how many psychiatric nurse practi-tioner programs today teach psychodynamic psychotherapy?

The current managed care environment of mental healthprecludes developing a relationship and a corporate mental-ity does not foster a nurturing context for the client or thenurse psychotherapist who wants to connect in a meaningfulway. Indeed, some managed care forms mandate that theprovider justify why medication is not prescribed if furthertreatment is to be authorized. Practicing in the medicalmodel, MHNPs usually have only 15 min for appointmentsand are expected to prescribe drugs. Graduate psychiatricnursing students who want to learn psychotherapy arechallenged as they are often placed in practicum sites thathave no value for the practice of psychotherapy and areexpected to learn prescribing and how to “managepatients.” This lowers the standard of care for the client,diminishes the value and role of the psychiatric advancedpractice nurse, and negates a holistic approach to care.

Most psychiatric nurses I know went into the field hopingto emotionally engage with clients. Intuitively, nurses knowabout healing moments and the power of relationship; yet,here in the most powerful of relationships, the psychothera-peutic relationship, they are frequently frustrated in learningthe basics of treatment. Occasionally, with a very experi-enced preceptor, students are encouraged to “listen to theirclient and let their story unfold”; but often, particularly withpreceptors who have not had adequate training in psycho-therapy, students are told to medicate and there is no time totalk. One poignant example brought this home to merecently. A student recounted in group supervision how aclient had come in, tearful and depressed about an abortion

she had just had. The student prescribed Paxil as thepreceptor suggested and made an appointment for 2 weekslater to evaluate the medication’s effectiveness. There was nosuggestion that perhaps the client needed to talk and processthe event; medication was the answer to the problem. This alltoo common mentality overrides clinical judgment and com-mon sense and diminishes the possibility of helping clients whoare experiencing feelings that accompany loss and trauma.

I believe we are at a crossroad in our development asadvanced practice psychiatric nurses. There is a growing dis-enchantment with the increasing emphasis on psychophar-macology at conferences. We have followed our psychiatristcolleagues who prescribe in our zeal for credibility andpractice autonomy, yet important psychotherapeutic issuesabout prescribing remain to be examined. These include theinfluence of psychotropic medication on the therapeuticrelationship, when to prescribe, and how to work withclients who would benefit from but do not want to takemedication. Elevating the level of discourse from what andhow much to prescribe to how and when and under whatconditions can serve to lead us to a reconnection to those wecare for as well as to ourselves.

Psychiatric advanced practice graduate education canaddress some of these challenges through curricular changethat ensures that psychodynamic theory, cultivating selfawareness, developing a therapeutic alliance, increasedemphasis on holistic care, adequate psychotherapy practicatime, and both individual and group supervision arefoundational for all programs. In addition, enhancing studentawareness through discussion of the powerful social andphilosophical forces that interfere with holistic practice isimperative. Inherent in these changes is the opportunity forour own personal growth and a lifetime of professionalsatisfaction. As a new healing consciousness emerges, thenext step is to reaffirm the primacy of psychotherapy aswe shape the future paradigm for our specialty.

Kathleen Wheeler, PhD, APRN-BC

Author contact: kwheeler@mail.fairfield.edu, with a copy to theEditor: mary@artwindows.com

References

Psychiatric Mental Health Nurse Practitioner Competencies (2003).[WWW document]. URL http://www.nonpf.com [accessed on June10, 2005]

Peplau, H. (1952).

Interpersonal relations in nursing

. New York: Putnam’s Sons.