~~~~
The Clinical Nurse Specialist as Brief Psychotherapist
by Betsy Shires, RN, MS, and Trudy Tappan, RN, PhD
As managed care continues toflourish, the
psychiatric clinical nurse specialist may function as a case manager for a managed care company or as a
utilization review nursefor a hospital, community provider, or administrator. Stressing the strengths of the psychiatric clinical nurse specialist as brief therapist, the autlzm reviews elements of the brief treatment model, including assessment,focus of treatment, knowledge of community resources, patient education, group skills, crisis intervention, and treatment planning.
M e n t a l health insurance benefits are shrinking rapidly in today’s world. Both inpatient and outpahent insurance coverage mandate specific ceilings on coverage and stipulate how benefits may be used (Feldman, 1992). Managed care companies employ mental health case managers who authorize specific numbers of outpatient visits or hospital days. Many reviewers want to see results in 12 visits or less. These changes have created an impetus for the increased use of a brief psychotherapy model for providing care. The orientation and education of mental health nurse clinical specialists prepare them well to use a brief psychotherapy model. Nurses are accustomed to brief contacts with clients on medical units, in clinics, and in physicians’ offices. In addition, nurses offer a variety of positive attributes that fit well in a managed care or brief therapy model. Such strengths include: excellent assessment skills, a knowledge of community resources, a focus on health rather than illness, the ability to set goals, a developmental perspective, group skills, the ability to teach, and crisis intervention skills. The Clinical Nurse Specialist as Brief Therapist Assessment skills. Clinical specialists have excellent assessment skills and understand the importance of a thorough assessment as part of the initial client interview. In brief therapy, assessment represents the b e p ning of a collaborative process between client and nurse to identify problems and to plan actions (Wells & Giannetti, 1990).The nurse recognizes when to refer the client for a physical exam to rule out conditions such as thyroid disorder or anemia, which can mimic psychiatric symptoms. Furthermore, if the client has diabetes, lupus, or other medical-surgicalconditions, the nurse is familiar with how these conditions may affect a client emotionally. Using a mental status exam, the nurse can triage clients with acute symptoms of panic, thought disorder, or neuro-vegetative signs of depression for a medication evaluation by a psychiatrist. In addition, the clinical nurse specialist has the skills to screen clients for substance abuse disorders early in
Perspectives in PsychiatricCare Vol.28, No. 4, October-December,1992
15
The Clinical Nurse Specialist as Brief Psychotherapist
the treatment process. Clients who require detoxification can be referred for hospital or outpatient detoxification, depending on medical history, current symptomatology, physical condition, and mental status. Clients are given appropriate treatment, while unnecessary hospital admissions are avoided. Knowledge of community resources. According to Budman and Gurman (1988), therapeutic experiences often occur outside the therapist’s office. Nurses may recommend mild exercise as a way of coping with stress, or can refer clients to self-help groups such as Overeaters Anonymous, Al-Anon, or Compassionate Friends. These adjuncts to therapy, which are low-cost or free, can be continued after the brief treatment experiencehas ended. Nurses, like other brief therapists, believe that being in the world is more important than being in therapy (Budman & Gurman).
Nurses, like other brief therapists, believe that being in the world is more important than being in therapy
Health focus. Nurses are comfortable in identifying and enhancing the strengths of clients. Like other brief psychotherapists, the nurse has a health rather than an illness orientation and is comfortable with building on the client’s existing strengths, skills, and capacities (Budman & Gurman, 1988). For instance, in working with a client who has been traumatized by incest, the nurse may use the term ”survivor” rather than “victim,” developing this theme as part of the treatment process. Client education. Education is an important element of the nurse’s basic orientation in caring for clients. Teaching clients about their use of medication or the benefits of relaxation techniques is part of the nurse’s repertoire. Clients who have survived much trauma 16
need education regarding coping. Adult children of alcoholics can be taught family roles and the effects of this disease on others, while shy adolescents can be taught social skius. Goal setting. Clinical specialists have strong treatment-planning skills and understand the importance of establishing a focus and clear goals with the client early in treatment, which is imperative in the brief therapy process (Budman & Gurman, 1988).Because the clinical specialist is educated to involve the client in goal setting, h s important step is included when the clinical specialist functions as brief therapist. Some commonly occurring foci include: loss, developmental issues, interpersonal cofict, and substance abuse (Budman& G m a n ) . Developmental perspective. The clinical nurse specialist assumes that individuals are continually evolving and changing, for nurses are well acquainted with change theory. Further, clinical specialistsoperate within a developmental framework, having cared for people during their maternity, pediatrics, and geriatric experiences. Specific developmental issues commonly addressed in therapy include intimacy, infertility, and balancing career and famdy responsibilities. Group skills. Clinical specialists have group skills that are particularly helpful in treating families and specific target populations, such as the bereaved and persons trying to cope with divorce or job loss. Group therapy is an effective and efficient use of healthcare dollars, offering clients the opportunity to learn how others cope in similar situations. Nurses have always worked with groups and f a d e s and are skilled at keeping the group focused and fostering cohesion. Budman and Gurman (1988) recommend that spouses, siblings, and significant others take part in therapy, since interaction with others likely contributes to the client’s focal problem. Th~sview is congruent with the values embraced by clinical specialists. Crisis intervention skills. The skilled brief therapist identifies the role that defenses play in symptomology, deciding when to confront defenses and when to assist clients to shore up their defenses to cope with crises. The c h c a l specialist helps the client to reframe or normalize life events when possible. For example, in introducing Perspectives in Psychiahic Care Vol. 28, No. 4, October-December,1992
the client to the brief therapy process, the clinical specialist may note: “In my experience most people can successfully work on this issue in about six sessions.” Setting the tone for brief therapy is important. When the nurse lets the client know that a great deal can be accomplished in a limited number of sessions, the client’s sense of competenceand hope is enhanced. Creating a Working Atmosphere Once the tone is set, the next challenge for the brief therapist is to create a working atmosphere. This atmosphere is created in a variety of ways, including spacing sessions, referring to outside sources of help, being sensitive to what issues are appropriate for brief psychotherapy, using homework assignments, summarizing each session, and attending to substance abuse issues before other psychotherapy concerns are explored. Spacing sessions. An important element of brief psychotherapy is its brevity, whch usually includes 612 sessions (Wells & Giannetti, 1990).The initial treatment contract should specify the projected schedule and number of sessions. A person in an acute crisis may be seen twice a week for one week, then once a week for two weeks. The therapist often increases the length between sessions as the client improves. For a client with chronic problems, six sessions might cover a 3-6 month period. Most experts in brief psychotherapy understand that the clients may return for ”tune-up sessions” months or years after the initial treatment. Other clients may never return. Using the brief treatment model and short visits (1530 minutes), the clinical specialist in private practice with a psychiatrist might monitor medication for chronic clients. Because the nurse is educated in psychophamacology, she or he is in a unique position to assess compliance, side effects, and misinformation. Moreover, the clinical specialist can assess if other physicians, such as primary care providers or specialists, have prescribed medication. Clients are referred to the psychiatrist when there are problems. Style. The therapist needs to be sensitive to issues that are appropriate for brief treatment. Nurturance, self-care, Perspectivesin Psychiatric Care Vol. 28, No. 4, October-December, 1992
grief, and loss are all appropriate treatment themes. Personality reconstruction and exploration of abandonment issues are not workable in time-limited therapy. In brief therapy, the therapist is active and uses homework assignments to extend treatment outside the therapy hour. Homework places responsibility on the client to be active, while providing a focus for discussion. Examples of homework include: keeping a diary that focuses on body awareness, reviewing family photographs, interviewing family members about a particular event, or identifying self-talk.
Personality reconstruction and exploration of abandonment issues are not workable in
time-limited therapy.
Self-talk that is punitive, judgmental, or harsh needs to be examined. The therapist does not review specific homework assignments, but instead allows clients to share what they wish. With help, the client may develop a more soothing or nurturing way to give messages to him/herself. Even after therapy has ended, this process of introspection may be continued in other situations. For example, months after therapy has ended a client may use the technique of journal keeping to cope with a new event, such as a relocation or job change. Providing a summary at the end of each session involves detailing what has been accomplished and outlining the work that remains. This practice helps to keep the client focused. Dual diagnosis. The importance of substance abuse assessment in all mental health clients cannot be overemphasized. In the initial interview, a drug/alcohol hstory should be obtained that includes family history of substance abuse. Clinical specialists need to be aware that certain clients are at high risk for developing substance 17
The Clinical Nurse Specialist as Brief Psychotherapist
abuse problems. High-risk clients are those individuals who use chemicals as a coping mechanism, those with a strong family history of substance abuse, and individuals who have other compulsive tendencies. For high-risk clients, an assessment should include any consequences of substance abuse, such as financial, employment, legal, or interpersonal difficulties. In addition, the clinical specialist teaches the high-risk client to avoid the use of minor tranquilizers, particularly benzodiazepines, as another primary prevention method to decrease the possibility of cross-addictionor dependence.
For clients with dual diagnoses, primary substance abuse must be confronted before other psychotherapy concerns can be tackled.
For clients with dual diagnoses, primary substance abuse must be confronted before other psychotherapy concerns can be tackled. Clients cannot successfully cope with problems with relationships or employment until they are sober. Some clients who initially appear depressed or anxious no longer harbor these problems after sobriety is achieved. Clients who are depressed after detoxification require further evaluation, such as a referral to a psychiatrist for a medication evaluation. Treatment planning. The success or failure of brief treatment is often tied to the strength of the initial treatment plan. The pertinent points of an effective treatment plan include: a) establishment of goals mutually agreed upon by client and therapist in the first session; b) establishment of the number and spacing of sessions; c) clarification of specific focus or themes, as well as therapy techniques to be used during each session; d) use of homework assignments when relevant; e) linkage to appropriate community resources; f> identification of necessary collateral contacts, such as referral to the psy18
chiatrist for medication evaluation; g) interventions for specific risk factors, such as substance abuse, lethality, or assault potential; h) provision of a summary at the end of each session to solidify the focus; and i) a method to evaluate therapy by the client and therapist at the conclusion of treatment. Conclusion
Frances and Clarkin (1981) note that psychotherapy, like drugs, can produce addiction and complications if prescribed in an unselective fashion. Managed care can provide a legitimate approach to helping others without fostering dependency or wasting valuable healthcare dollars. The clinical specialist needs to educate those in charge of managed care about the value of nursing skills and to obtain provider status with managed-care companies. Nurse therapists are in an excellent position to claim a share of the present managed-care market. Indeed, as the marketplace shifts, the clinical nurse specialist offers the education and skills to meet the challenge of rationed care. References Budman, S., & Gurman, A. (1988). T k e o y and practice of brief therapy. New York Guilford Press. Feldman, S. (1992). Managed mental health services. Springfield, IL: Charles C. Thomas. Frances, A,, & Clarkin, J. (1981). No treatment as the prescription of choice. Archives of General Psychiatry, 38,542-545. Wells, R, & Giannetti, V. (Eds.).(1990).Handbook of briefpsychofhwapies. New York: Plenum Press.
Perspectivesin PsychiatricCare Vol. 28, No. 4, October-Deeember,1992
The Clinical Nurse Specialist as Brief Psychotherapist
by Betsy Shires, RN, MS, and Trudy Tappan, RN, PhD
As managed care continues toflourish, the
psychiatric clinical nurse specialist may function as a case manager for a managed care company or as a
utilization review nursefor a hospital, community provider, or administrator. Stressing the strengths of the psychiatric clinical nurse specialist as brief therapist, the autlzm reviews elements of the brief treatment model, including assessment,focus of treatment, knowledge of community resources, patient education, group skills, crisis intervention, and treatment planning.
M e n t a l health insurance benefits are shrinking rapidly in today’s world. Both inpatient and outpahent insurance coverage mandate specific ceilings on coverage and stipulate how benefits may be used (Feldman, 1992). Managed care companies employ mental health case managers who authorize specific numbers of outpatient visits or hospital days. Many reviewers want to see results in 12 visits or less. These changes have created an impetus for the increased use of a brief psychotherapy model for providing care. The orientation and education of mental health nurse clinical specialists prepare them well to use a brief psychotherapy model. Nurses are accustomed to brief contacts with clients on medical units, in clinics, and in physicians’ offices. In addition, nurses offer a variety of positive attributes that fit well in a managed care or brief therapy model. Such strengths include: excellent assessment skills, a knowledge of community resources, a focus on health rather than illness, the ability to set goals, a developmental perspective, group skills, the ability to teach, and crisis intervention skills. The Clinical Nurse Specialist as Brief Therapist Assessment skills. Clinical specialists have excellent assessment skills and understand the importance of a thorough assessment as part of the initial client interview. In brief therapy, assessment represents the b e p ning of a collaborative process between client and nurse to identify problems and to plan actions (Wells & Giannetti, 1990).The nurse recognizes when to refer the client for a physical exam to rule out conditions such as thyroid disorder or anemia, which can mimic psychiatric symptoms. Furthermore, if the client has diabetes, lupus, or other medical-surgicalconditions, the nurse is familiar with how these conditions may affect a client emotionally. Using a mental status exam, the nurse can triage clients with acute symptoms of panic, thought disorder, or neuro-vegetative signs of depression for a medication evaluation by a psychiatrist. In addition, the clinical nurse specialist has the skills to screen clients for substance abuse disorders early in
Perspectives in PsychiatricCare Vol.28, No. 4, October-December,1992
15
The Clinical Nurse Specialist as Brief Psychotherapist
the treatment process. Clients who require detoxification can be referred for hospital or outpatient detoxification, depending on medical history, current symptomatology, physical condition, and mental status. Clients are given appropriate treatment, while unnecessary hospital admissions are avoided. Knowledge of community resources. According to Budman and Gurman (1988), therapeutic experiences often occur outside the therapist’s office. Nurses may recommend mild exercise as a way of coping with stress, or can refer clients to self-help groups such as Overeaters Anonymous, Al-Anon, or Compassionate Friends. These adjuncts to therapy, which are low-cost or free, can be continued after the brief treatment experiencehas ended. Nurses, like other brief therapists, believe that being in the world is more important than being in therapy (Budman & Gurman).
Nurses, like other brief therapists, believe that being in the world is more important than being in therapy
Health focus. Nurses are comfortable in identifying and enhancing the strengths of clients. Like other brief psychotherapists, the nurse has a health rather than an illness orientation and is comfortable with building on the client’s existing strengths, skills, and capacities (Budman & Gurman, 1988). For instance, in working with a client who has been traumatized by incest, the nurse may use the term ”survivor” rather than “victim,” developing this theme as part of the treatment process. Client education. Education is an important element of the nurse’s basic orientation in caring for clients. Teaching clients about their use of medication or the benefits of relaxation techniques is part of the nurse’s repertoire. Clients who have survived much trauma 16
need education regarding coping. Adult children of alcoholics can be taught family roles and the effects of this disease on others, while shy adolescents can be taught social skius. Goal setting. Clinical specialists have strong treatment-planning skills and understand the importance of establishing a focus and clear goals with the client early in treatment, which is imperative in the brief therapy process (Budman & Gurman, 1988).Because the clinical specialist is educated to involve the client in goal setting, h s important step is included when the clinical specialist functions as brief therapist. Some commonly occurring foci include: loss, developmental issues, interpersonal cofict, and substance abuse (Budman& G m a n ) . Developmental perspective. The clinical nurse specialist assumes that individuals are continually evolving and changing, for nurses are well acquainted with change theory. Further, clinical specialistsoperate within a developmental framework, having cared for people during their maternity, pediatrics, and geriatric experiences. Specific developmental issues commonly addressed in therapy include intimacy, infertility, and balancing career and famdy responsibilities. Group skills. Clinical specialists have group skills that are particularly helpful in treating families and specific target populations, such as the bereaved and persons trying to cope with divorce or job loss. Group therapy is an effective and efficient use of healthcare dollars, offering clients the opportunity to learn how others cope in similar situations. Nurses have always worked with groups and f a d e s and are skilled at keeping the group focused and fostering cohesion. Budman and Gurman (1988) recommend that spouses, siblings, and significant others take part in therapy, since interaction with others likely contributes to the client’s focal problem. Th~sview is congruent with the values embraced by clinical specialists. Crisis intervention skills. The skilled brief therapist identifies the role that defenses play in symptomology, deciding when to confront defenses and when to assist clients to shore up their defenses to cope with crises. The c h c a l specialist helps the client to reframe or normalize life events when possible. For example, in introducing Perspectives in Psychiahic Care Vol. 28, No. 4, October-December,1992
the client to the brief therapy process, the clinical specialist may note: “In my experience most people can successfully work on this issue in about six sessions.” Setting the tone for brief therapy is important. When the nurse lets the client know that a great deal can be accomplished in a limited number of sessions, the client’s sense of competenceand hope is enhanced. Creating a Working Atmosphere Once the tone is set, the next challenge for the brief therapist is to create a working atmosphere. This atmosphere is created in a variety of ways, including spacing sessions, referring to outside sources of help, being sensitive to what issues are appropriate for brief psychotherapy, using homework assignments, summarizing each session, and attending to substance abuse issues before other psychotherapy concerns are explored. Spacing sessions. An important element of brief psychotherapy is its brevity, whch usually includes 612 sessions (Wells & Giannetti, 1990).The initial treatment contract should specify the projected schedule and number of sessions. A person in an acute crisis may be seen twice a week for one week, then once a week for two weeks. The therapist often increases the length between sessions as the client improves. For a client with chronic problems, six sessions might cover a 3-6 month period. Most experts in brief psychotherapy understand that the clients may return for ”tune-up sessions” months or years after the initial treatment. Other clients may never return. Using the brief treatment model and short visits (1530 minutes), the clinical specialist in private practice with a psychiatrist might monitor medication for chronic clients. Because the nurse is educated in psychophamacology, she or he is in a unique position to assess compliance, side effects, and misinformation. Moreover, the clinical specialist can assess if other physicians, such as primary care providers or specialists, have prescribed medication. Clients are referred to the psychiatrist when there are problems. Style. The therapist needs to be sensitive to issues that are appropriate for brief treatment. Nurturance, self-care, Perspectivesin Psychiatric Care Vol. 28, No. 4, October-December, 1992
grief, and loss are all appropriate treatment themes. Personality reconstruction and exploration of abandonment issues are not workable in time-limited therapy. In brief therapy, the therapist is active and uses homework assignments to extend treatment outside the therapy hour. Homework places responsibility on the client to be active, while providing a focus for discussion. Examples of homework include: keeping a diary that focuses on body awareness, reviewing family photographs, interviewing family members about a particular event, or identifying self-talk.
Personality reconstruction and exploration of abandonment issues are not workable in
time-limited therapy.
Self-talk that is punitive, judgmental, or harsh needs to be examined. The therapist does not review specific homework assignments, but instead allows clients to share what they wish. With help, the client may develop a more soothing or nurturing way to give messages to him/herself. Even after therapy has ended, this process of introspection may be continued in other situations. For example, months after therapy has ended a client may use the technique of journal keeping to cope with a new event, such as a relocation or job change. Providing a summary at the end of each session involves detailing what has been accomplished and outlining the work that remains. This practice helps to keep the client focused. Dual diagnosis. The importance of substance abuse assessment in all mental health clients cannot be overemphasized. In the initial interview, a drug/alcohol hstory should be obtained that includes family history of substance abuse. Clinical specialists need to be aware that certain clients are at high risk for developing substance 17
The Clinical Nurse Specialist as Brief Psychotherapist
abuse problems. High-risk clients are those individuals who use chemicals as a coping mechanism, those with a strong family history of substance abuse, and individuals who have other compulsive tendencies. For high-risk clients, an assessment should include any consequences of substance abuse, such as financial, employment, legal, or interpersonal difficulties. In addition, the clinical specialist teaches the high-risk client to avoid the use of minor tranquilizers, particularly benzodiazepines, as another primary prevention method to decrease the possibility of cross-addictionor dependence.
For clients with dual diagnoses, primary substance abuse must be confronted before other psychotherapy concerns can be tackled.
For clients with dual diagnoses, primary substance abuse must be confronted before other psychotherapy concerns can be tackled. Clients cannot successfully cope with problems with relationships or employment until they are sober. Some clients who initially appear depressed or anxious no longer harbor these problems after sobriety is achieved. Clients who are depressed after detoxification require further evaluation, such as a referral to a psychiatrist for a medication evaluation. Treatment planning. The success or failure of brief treatment is often tied to the strength of the initial treatment plan. The pertinent points of an effective treatment plan include: a) establishment of goals mutually agreed upon by client and therapist in the first session; b) establishment of the number and spacing of sessions; c) clarification of specific focus or themes, as well as therapy techniques to be used during each session; d) use of homework assignments when relevant; e) linkage to appropriate community resources; f> identification of necessary collateral contacts, such as referral to the psy18
chiatrist for medication evaluation; g) interventions for specific risk factors, such as substance abuse, lethality, or assault potential; h) provision of a summary at the end of each session to solidify the focus; and i) a method to evaluate therapy by the client and therapist at the conclusion of treatment. Conclusion
Frances and Clarkin (1981) note that psychotherapy, like drugs, can produce addiction and complications if prescribed in an unselective fashion. Managed care can provide a legitimate approach to helping others without fostering dependency or wasting valuable healthcare dollars. The clinical specialist needs to educate those in charge of managed care about the value of nursing skills and to obtain provider status with managed-care companies. Nurse therapists are in an excellent position to claim a share of the present managed-care market. Indeed, as the marketplace shifts, the clinical nurse specialist offers the education and skills to meet the challenge of rationed care. References Budman, S., & Gurman, A. (1988). T k e o y and practice of brief therapy. New York Guilford Press. Feldman, S. (1992). Managed mental health services. Springfield, IL: Charles C. Thomas. Frances, A,, & Clarkin, J. (1981). No treatment as the prescription of choice. Archives of General Psychiatry, 38,542-545. Wells, R, & Giannetti, V. (Eds.).(1990).Handbook of briefpsychofhwapies. New York: Plenum Press.
Perspectivesin PsychiatricCare Vol. 28, No. 4, October-Deeember,1992
