Unique Qualities of Nurse Psychotherapists

The history of the one-to-one nurse-patient relationship and nurses conducting psychotherapy is detailed by Lego (1999) and Beeber (1995). Table 1-3 highlights the important events. The late 1940s were marked by the development of eight programs for the advanced preparation of nurses who cared for psychiatric patients. An extremely important debate took place over the next few decades about the nurse’s role as psychotherapist. This culminated in the 1967 American Nurses’ Association Position Paper on Psychiatric Nursing, which clarified the role of the clinical specialist in psychiatric nursing as psychotherapist, and certification for the specialty began in 1979. In the 1990s, PMHNP programs were developed, and this culminated in the PMHNP competencies that included psychotherapy as an essential competency required for all PMHNPs (Wheeler & Haber, 2004). The APPN role of psychotherapist has solid historical roots from the inception of advanced practice psychiatric-mental health nursing, whereas the prescribing role is a much more recent step in the evolution of the discipline (Bailey, 1999).

Table 1-3 Timeline of History of the Nurse Psychotherapist

After the issue of whether nurses should do psychotherapy was resolved, the literature examined the unique qualities that nurses might possess as psychotherapists compared with those in other disciplines who practice psychotherapy. Several strengths were cited: nurses’ ability to be patient because they have worked with the chronically ill and have respect for others limitations, are realistic, and possess excellent observational skills, resourcefulness, innovation, and creativity (Smoyak, 1990); nurses view of the patient in a holistic way, crisis orientation, and a knowledge of general health concerns (Lego, 1973); and familiarity of daily life and experience of the hospitalized patients (Balsam & Balsam, 1974). Nurses usually have had a breadth of life experience and exposure to many different ages, ethnicities, occupations, socioeconomic status, cultures, and personalities. The novice nurse psychotherapist is well served through experience with communicating and connecting with those from diverse backgrounds. This quality of nurses being close to the patient’s everyday experience is crucial for connection and collaboration. This connection is reflected in the public perception of nurses as positive and trustworthy. A 2005 Gallup poll found that nurses top the list of most ethical professions, with Americans rating nurses among the most trusted professionals. Eighty-two percent of respondents rated nurses’ honesty and ethics as “very high” or “high,” with medical doctors in third place at 65% (Gallup, 2005).

An additional quality that nurses bring to the role of psychotherapist is a pragmatic, problem- solving approach using the nursing process as an overall framework for practice. Usually, the patient has tried many things to feel better, and therapy is often a last resort. The patient’s problems have brought the person into treatment, and if these problems could be solved outside of therapy with friends or family, she or he would have already done so. The problem-solving approach needed in the psychotherapeutic process is the same as in the nursing process. Both involve an assessment, diagnosis, plan, intervention, and evaluation. Nurses are used to collaborating with patients and thinking about what will solve the problem, what the patient’s perspective is, what the person wants, and what the patient’s strengths are. These approaches are derived from a problem-solving, health-oriented, holistic model and are fundamental to nursing practice and the nurse-patient relationship.

In my experience working with graduate psychiatric nursing students, this problem-solving approach is useful but one that novice nurse psychotherapists often struggle with. Because nurses are used to taking care of people and are action oriented, beginning students often want to rescue the patient and help the patient to feel better. Helping the patient feel better is not the main goal of psychotherapy, and a focus on amelioration of symptoms may even be counterproductive to the process, although feeling better overall most likely will be a by-product of successful therapy. In a well-intended effort to help the person feel better, the nurse may be too directive, and this is antithetical to promoting empowerment. Letting the psychotherapeutic process unfold takes time, and that has typically not been a part of nursing practice, especially within the current health care system.

Requisites for Nurse Psychotherapists

Nurse psychotherapists have the honor of participating in the healing process, and as Dossey and associates (2005) point out, in the nurse-patient relationship, the nurse becomes “the patient’s environment” (p. 50). Through consciousness, intent, and presence, the nurse psychotherapist’s therapeutic use of self facilitates others in their healing. To counter the learned patterns of nursing practice (i.e., busyness, task-focused, and control), the nurse psychotherapist needs to cultivate reflection, mindfulness, and patience. The nurse psychotherapist creates a healing presence of unconditional acceptance, patience, lovingness, nonjudgmental attitude, understanding, good listening skills, honesty, and empathy. These qualities are the essence of presence (McKivergin, 1997) and allow the nurse psychotherapist to “be with” rather than “doing to” the patient. Scaer (2005), a neurologist specializing in trauma, says that presence involves a personal interaction that contributes to physiologic changes in the person. He states, “This healing, empathic presence affects and alters the parts of the brain that process pain, fear, anxiety, and distress” (p. 167). Presence may facilitate healing by modulating negative emotions by enhancing neurotransmitters and hormones that promotes optimum autonomic functioning.

According to Dossey and coworkers (2005), qualities essential for nurse healers include expansion of consciousness and continuing one’s own journey toward wholeness. This can be accomplished through many different venues: nature, relationships, counseling, meditation, mindfulness, self-awareness exercises, spiritual practices, chanting, prayer, journaling, openness to receiving one’s own healing treatments, and reflective activities such as hiking, walking, or rowing. These activities enable the nurse to enhance the development of mindfulness, patience, and authenticity. Mindfulness is a skill that can be learned through practice and discipline and can used as a tool in the psychotherapeutic process. The vast literature on the development of mindfulness crosses many disciplines and orientations, from Buddhism to psychoanalysis. Mindfulness is discussed further in Chapter 10.

Safran and Muran (2000) state that mindfulness in psychotherapy has three characteristics:

Peplau (1991) stressed the need for self-awareness in the nurse-patient relationship and stated, “The extent to which each nurse understands her own functioning will determine the extent to which she can come to understand the situation confronting the patient and the way he sees it” (p. x). However, with the rise of psychopharmacology and biologic psychiatry, self-awareness has not been a priority. Self-awareness is key to understanding others, and it reduces the likelihood that therapists will act out their own agendas and use patients for gratification or self-esteem needs. For example, one novice nurse psychotherapist was so rewarded emotionally by his work with a particular patient that he went out of his way to meet with her when she needed him and to schedule additional office hours when he would not normally be in the office. The patient responded with gratitude, which enhanced the self-esteem of the nurse who was conscientious and overly responsible for this patient. It was only through supervision that he began to understand how his need for recognition fueled the overly accommodating stance, how his objectivity about the psychotherapeutic process had been compromised, and how this cultivated an unhealthy dependency in the patient.

We all have preconceptions that are brought to every situation. It is not as important to eliminate these as to be aware of what they are and how they may influence our work. The extent of a nurse’s self-knowledge determines the extent to which s/he can understand another person. Neuroimaging studies have confirmed that being aware of another’s mind is related to a person’s ability to monitor his/her own mental state (Keenan, 2003). A person does not have to be a paragon of mental health to help another. Some feel that to be truly empathic, a person should have experienced psychological suffering, which can serve to deepen the work in psychotherapy. Personal therapy and supervision are helpful for the novice nurse psychotherapist to cultivate emotional genuineness, authenticity, and objectivity. Supervision is not therapy, but it does assist the therapist in discussing difficult cases and understanding his/her own blind spots and how personal issues may impact the therapeutic relationship. Ongoing group or individual supervision after graduation is necessary for continued growth and an ethical practice. Seasoned psychotherapists usually seek supervision and consultation throughout their professional lives. A sample of suggestions for discussion that may be covered in supervision is included in Appendix I-1 (p. 131).

Irvin Yalom (2002) cogently makes a case for therapy for the therapist:

The student of psychotherapy who undergoes his/her own psychotherapy has a model for what the psychotherapeutic process is and understands the power and the process of psychotherapy in an immediate, experiential way that no amount of reading or didactic can convey. Many expert psychotherapists report that they have experienced various modes of psychotherapy and this has enhanced their own technique as the skills others use are incorporated into their own practice.

In addition to self-awareness, self-care is fundamental in caring for others. When a flight takes off, the airline attendant announces that all adults must put the oxygen mask over their faces first before securing the mask on a child. This is an appropriate metaphor for all caregivers. Much has been written about the trauma inherent in nursing. Various terms have been used to describe this phenomenon, such as burnout, compassion fatigue, and vicarious or secondary traumatization. Burnout may occur for many reasons: our collective history as a profession of women, the patriarchal medical system and nurses’ subservient role, stressful health care environments, and caring for and witnessing trauma and pain in others. Most often, recognition of personal and professional trauma is unrecognized and therefore unaddressed. Sequelae of trauma may include emotional numbing, detachment, hypervigilance, perfectionism, controlling behaviors, emotional lability, attentional problems, and low self-esteem, all of which mitigate the ability to adopt the psychotherapeutic stance necessary for conducting psychotherapy. It is only in the recognition of one’s own trauma that s/he can transcend it and be of help to others (Conti-O’Hare, 2002).

Caring

Caring has been identified as central to nursing and as the foundation for practice (Dossey, 2005; Morse et al., 1990; Schoenhofer, 2002). Caring encompasses and expands Carl Rogers’ idea of unconditional positive regard that has been adopted by most disciplines as essential in helping relationships (Rogers, 1951). A phenomenologic study delineated the characteristics of the advanced practice nurse-patient relationship that are foundational to caring (Thomas et al., 2005). They include the mutuality of nonromantic love based on a genuine knowing of the person, trust, and respect reflected in an acceptance of and authentic appreciation for the other. Every person is approached with acceptance and unconditional love with the nurse and patient as co-participants in the process of healing. Inherent in caring is respect for the autonomy and agency of the other person. Fundamental to caring is the understanding of another person’s unique configuration of attitudes, feelings, and values from that person’s perspective.

The antithesis to empowerment is authority; in this situation, the therapist knows what is best for the person. The process of psychotherapy cultivates dependency because there is unavoidable inequality in the relationship with the patient, who naturally feels disempowered by needing help at a vulnerable time. This reality and the inevitable transference-countertransference responses create dependent feelings in the patient. The psychotherapist’s competence lies in understanding that the patient’s autonomy is always in the foreground of the process. The overall goal for patients is to deepen their understanding of themselves in order to make their own decisions. Caring is fundamental to creating an atmosphere conducive to the cultivation of empowerment.

Research has found that spirituality emerges as a significant theme in caring and is related to a deepening sense of patients’ inner peace, emotional well-being, and hope in the context of personal crisis (Edmands et al., 1999). Caring results in enhanced personhood for the nurse and the patient. The authors of the study speculate that the personhood of the patient is enhanced because of the advanced practice nurse’s ability to address all domains—behavioral, psychosocial, addictive, psychosomatic, and mental health care.