Ms. H, an attractive, petite, 42-year-old full-time housewife came to psychotherapy initially for severe bulimia, vomiting as many as 40 times each day for the past yea
Ms. H, an attractive, petite, 42-year-old full-time housewife came to psychotherapy initially for severe bulimia, vomiting as many as 40 times each day for the past year. She had previously been diagnosed with PTSD, anorexia nervosa, DDNOS, dependent personality disorder, panic anxiety, major depressive disorder, and polysubstance dependence. In the past, Ms. H self-medicated with alcohol, Vicodin, Xanax, and OxyContin. The Vicodin and OxyContin were taken to relieve her long-standing severe back pain. She was hospitalized twice for polysubstance abuse, and medications taken after hospitalization included Paxil (60 mg each day) and Depakote (250 mg twice daily). Ms. H was physically and emotionally abused as a child by a sadistic father and a neglectful, narcissistic mother. At intake, in addition to the bulimia, she reported depressive symptoms, trouble concentrating, anxiety, and periods of depersonalization and feeling dizzy and confused. She forgot periods of time; for example, she found herself in the grocery store and could not remember how she got there. This occurred particularly when she was stressed and anxious. She denied self-harm and suicide ideation. She had been married for 22 years and reported long-standing marital difficulties.
The history of childhood trauma and her tumultuous psychiatric history indicated that a long period of stabilization most likely would be needed. The APPN explained to Ms. H about her RZ and how it would be helpful to learn some strategies so she could stay regulated and in her RZ. The APPN worked with Ms. H once a week initially and, after several months, began twice-weekly psychotherapy, which continued over the next 5 years. Within 6 months of beginning treatment, her bulimia subsided. Much of the content of beginning sessions focused on building in resources and later on the abuse she suffered from her husband, which was ongoing and included emotional, sexual, and physical abuse. Ms. H initially appeared frightened and confused, especially when asked about her feelings. The therapist supported and validated Ms. H and told her that she was being abused as she vacillated between thinking that she deserved such punishment to feeling anger at her husband. She had idealized her husband, and as she began to see him more realistically, she also began to see herself in a different light, and her self-esteem increased. She began to assert herself more, and her marital relationship further deteriorated because her abusive husband was enraged that he was losing control of her. Plans for her safety were made, and 2 years after starting therapy, she filed for divorce and moved out of their house. This represented a significant turning point because stabilization was not possible previously as long as she was not safe. Her medication was changed to 20 mg of Prozac, and she found a full-time job shortly after the divorce. Over the course of treatment, various stabilization strategies were gradually integrated, which helped to widen her RZ so she could stay regulated. These included safe/calm place, container, circle of strength, rating negative feelings, basic self-care, yoga, progressive muscle relaxation, journaling, grounding, cognitive restructuring, walking, and deep breathing, in addition to other soothing activities. All were new to Ms. H; she had never practiced any of these before therapy.
Through mindfulness, Ms. H learned to manage her dissociative symptoms, and these periods decreased dramatically as she was able to stay in the present, understand the triggers, and talk about some of her traumatic experiences. Her back pain all but disappeared as she became aware that the triggers for these episodes were linked to feelings of anger. Her identification of her feelings in the present, the ability to experience these feelings, and understanding the meaning of her symptoms were crucial to her development of affect-regulation skills. Along with the deepening of her identity apart from her husband, her sense of humor and keen intelligence emerged. Some of her early childhood trauma was processed with EMDR therapy, but much of the work in psychotherapy focused on increasing resources, psychoeducation, and support, with the therapist bearing witness to her struggle and courage. Her healing reflected the return and expansion of her full consciousness through the integration of adaptive memory networks with dissociated neural networks. This was accomplished by creating positive experiences through the therapeutic relationship, learning and practicing specific resources, and weaving a narrative that connected her old and new memory experiences into a coherent tapestry reflecting a stronger, more resilient sense of self.
POST-MASTER’S TRAUMA TRAINING AND CERTIFICATION REQUIREMENTS
The APPN who wishes to attain competency treating traumatized patients should pursue additional training and ongoing supervision. Working with dissociative patients requires a high level of clinical expertise to do so successfully. The International Society for the Study of Dissociation (ISSD) offers post-master’s training in the treatment of DDs but not certification. The program consists of nine monthly or biweekly sessions of 2.5 hours, which are held in many major cities listed on the website (www.issd.org). The sessions are designed to focus on readings and clinical situations. A distance-learning module is also available, along with advanced coursework.
In addition, integrative trauma psychotherapy programs are offered in large cities in the United States. An Integrative Trauma Psychotherapy Certificate Program is offered at Fairfield University and includes Basic Training in EMDR and the Trauma Resilience Model (TRM), a somatic therapy described in Chapter 11. See fairfield.edu/resiliencetraining.
CONCLUDING COMMENTS
Stabilization and safety are always the first order of business for any psychotherapy. This ensures that the processing needed to integrate the dissociated memory networks will not destabilize the patient. Enhancing resources ensures that positive adaptive memory networks exist for the eventual linking of dysfunctional material so that integration can occur. Strategies for stabilization are basic tools that all APPNs need to know to work with patients who present for psychotherapy. These skills build on the stress management techniques that registered nurses are familiar with. This foundation is deepened by understanding how and when to tailor specific stabilization strategies. Competency in stage 1 (stabilization) reflects the beginning-level skills needed for APPN practice.
There is a wide spectrum of trauma responses, and stabilization is needed before processing trauma. The limiting diagnosis of PTSD does not capture the complexity of traumatic experiences and their sequelae. Neurophysiological research demonstrates the importance of even subtle negative life events on the developing brain when a state of helplessness occurs (see Chapter 2). The physiological changes that occur and the perpetuation of those changes over time are determined by the meaning of life events in relation to past trauma (Shapiro, 2018). The learned associated responses embedded in memory networks are modified in the safety of the therapeutic relationship. Managing arousal and altering procedural memories begin the work of healing trauma.
The patients of severe childhood trauma are chronically disenfranchised and re-create betrayal and abandonment scenarios wherever they go, especially in the psychotherapeutic relationship as early attachment schemas are reactivated. Most complex child-onset trauma requires painstaking work as resources are increased and a narrative is woven about the nuances of the meaning of the events as the trauma is processed. Individuals who are survivors of childhood abuse present treatment challenges and the complexity and severity of symptoms can seem insurmountable to even the most experienced psychotherapist. However, healing occurs in this relationship with patience, caring, and skill. Novice APPN psychotherapists who continue to train and obtain supervision to develop skill in trauma treatment will be richly rewarded in their work. The APPN’s presence bears witness with empathic resonance, creating the atmosphere needed for the most vulnerable of patients to be whole again. Those of us who work with this population marvel at the remarkable capacity for endurance, compassion, depth of character, and resilience of the human spirit. The honor of assisting in the growth of another person changes the patient and the therapist. In the healing journey with another, we heal ourselves.
DISCUSSION QUESTIONS
1.Discuss the spectrum of trauma-related diagnoses with respect to specific symptoms that overlap. Pick one trauma-related DSM diagnosis and identify what might be some, and differential diagnoses.
2.Identify goals of treatment for trauma.
3.What happens physiologically during dissociation, and what would you observe in the patient who dissociated during a session?
4.Fill out the DES, which is included in Chapter 3 on yourself and score it. Keep track with a log of all the times you notice yourself dissociating over the course of the next week.
5.How would you know whether a person was stabilized and ready to go on to processing?
6.Discuss why a person who has been traumatized as a child most likely has pervasive feelings of guilt.
7.Develop a comprehensive plan of all the potential issues and strategies that you need to teach a patient who has flashbacks.
8.Explain why mindfulness underlies all stabilization, why you should develop this skill, and how you plan to do so.
9 Practice the progressive muscle relaxation exercise and the safe/calm place exercise in Appendices 13.2 and 1.7 with a friend or family member. Ask for feedback so that you can improve.
Case Study Chapter 24
Ms. K, a 60-year-old divorced, home health aide, presented for outpatient psychotherapy a week after discharge from a 5-day inpatient stay at the local psychiatric hospital after her ex-husband moved in with another woman. Ms. K had subsequently recurrent suicidal thoughts and voluntarily admitted herself. She was started on fluoxetine 30 mg and participated in group therapy but remained depressed after discharge.
In her initial session with the therapist, Ms. K scored 40 on the Beck Depression Inventory (BDI), indicating severe depression and described sadness, loss of interest in pleasurable activities, guilt, loss of energy, tearfulness, hopelessness, fatigue, loss of appetite, middle of the night insomnia, a 10-pound weight loss, and concentration problems over the past month. The patient’s identified complaint at the time of intake was, “I am helpless, hopeless and will never have a good life.” She denied memory problems, substance abuse, delusions, or present suicidal ideation. Her depression, lack of social supports, hopelessness, and no spouse were risk factors for suicide. However, she did not have an organized plan to hurt herself and her voluntary hospitalization for previous suicidal ideation as well as current denial of suicidal thoughts indicated that the risk for self-harm was present but not high. The APPN knew that risk might increase as she began to feel better and that Ms. K should continue to be closely monitored. There was no history of mania, hypomania, or illicit drug use. Two prior episodes of depression were reported. The first episode was 10 years previously when she suffered an automobile accident that fractured her left arm and lacerated her face after she was thrown face first through the passenger side of a non-safety-plate windshield. She was diagnosed with major depressive disorder after this event and treated with fluoxetine for a year. Eight years after this accident, she was diagnosed with breast cancer and underwent a mastectomy followed by a course of chemotherapy and radiation. She was treated at that time with CBT for 16 sessions and venlafaxine for 2 years with a partial response.
Ms. K had a history of early traumatic relationships. She reported that her early childhood was marked by emotional and physical abuse from her rageful, alcoholic father and emotional neglect by her mother. Although she had amnesia for much of her childhood, one of her few early memories was of her father demeaning her and calling her “stupid” when she made a mistake. Her mother too was berated by her father and Ms. K felt her mother was afraid to intercede on her daughter’s behalf. Her father insisted that she adhere to a strict regimen throughout her childhood; when she did not comply, he was angry and punishing. For example, she recalled that when she was learning to tie her shoes around the age of 4, her father slapped her across the face each time she did not correctly remember the proper sequence of steps to accomplish this task. She was expected to take care of her two younger sisters at an early age and was not allowed to play with other children. At the age of 10, her parents divorced, leaving her with her depressed, emotionally unavailable mother and her two sisters. Her mother remarried a year later and her stepfather frequently beat her while her mother did nothing about it. The continuing emotional and physical abuse interfered with her ability in school. She finally left home at age 17 and lived at a convent where she took classes to become a home health aide. At age 20, she met her ex-husband whom she married several months later.
She reported that her marriage of 30 years was not happy and that she was physically and emotionally abused by her husband, who was an alcoholic with frequent angry outbursts. On several occasions, he had punched and slapped her. Her husband had divorced her 10 years previously, leaving her without alimony or financial security. In fact, he financially exploited her by coming to her for money whenever he ran out. She had no children and expressed great regret at never being able to conceive but believed that she did not deserve children anyway. Her parents were both deceased at the time of intake and her relationship with her two sisters was distant and passive. Ms. K had been able to work full-time as a home health aide until her recent hospitalization and lived alone. She stated that she was hardworking and conscientious and liked helping others. Her work was a significant area of gratification for her.
Ms. K had recently had a physical exam at her nurse practitioner’s office with complete blood count (CBC) with differential and chemistry profile all within normal limits. After a comprehensive psychiatric assessment and history, a diagnosis of major depressive disorder, recurrent, severe without psychotic features was made. In addition, her chronic dysphoria and poor self-esteem warranted an additional diagnosis of persistent depressive disorder (dysthymia). Medical diagnoses included obesity, type 2 diabetes, and hypertension. Medications included IC lisinopril–HCTZ 10/12.5, Toprol XL 100 mg, and Actoplus Met 15/500 mg. A Global Assessment of Functioning (GAF) score was 45/60 at intake. A treatment plan was developed using the practice treatment guidelines from the American Psychiatric Association (2010).
Practice guidelines suggest that frequent monitoring to assess suicidality and response to psychopharmacology is important in the acute phase of treatment. CBT and IPT are identified as the psychotherapeutic approaches that have the best documented efficacy. In addition, the guidelines state that if CBT was used before with some success yet did not result in longer-term change, a combination of psychodynamic and CBT approaches should be utilized. Ms. K’s stated goal for therapy was first and foremost “to sleep better” and second to “be less lonely.” Collaborative goals were set to sleep 6 hours a night within a month and to develop two new friends within 3 months. Sessions were scheduled for once a week for the next 40 weeks.
The acute phase of treatment aims to eliminate the symptoms and restore psychosocial functioning. Although Ms. K acknowledged that her depression was significant, she was passive and subdued in sessions and resisted attempts to discuss her feelings, focusing instead on her physical symptoms of fatigue, insomnia, and anorexia. She was not enthusiastic about the antidepressant medication, saying that she had tried it in the past and it was not particularly helpful. Trazodone 50 mg was prescribed at night for sleep. Given her tumultuous early relationship history, it was felt that stabilization was needed with supportive psychodynamic psychotherapy and cognitive behavioral education strategies designed to increase her resources so she could more easily stay in her resilient zone. Therapeutic communication techniques for stabilization as outlined in Figure 4.1, Table 4.6 based on the treatment hierarchy for this book were used. Patient outcome measures chosen to monitor progress were the Beck Depression Inventory (BDI) and the Sense of Belonging Instrument (SBI) because of their ease of administration, adequate normative data, appropriateness to goals of treatment, and the ability to provide both symptom-specific as well as a more holistic outcome measure. The SBI addressed the latter and would reflect the patient’s stated outcome “to be less lonely.” At the beginning of her second session, she scored 58 on the SBI, indicating a low sense of belonging. This was explained to Ms. K as important so that the APPN could monitor her functioning and improvement as therapy progressed.
Integrated treatment with the APPN both prescribing and conducting the psychotherapy was thought to be the most effective model to ensure coordination of care. Also, given her proclivity to focus on her physical symptoms and difficulty with emotional expression, it was felt that integrated rather than split treatment might help to provide a model for uniting her emotions with her physical symptoms. In this way, splitting and resistance to emotional exploration might be ameliorated. In light of her negative comments about her medication and her difficulty with identifying and expressing her feelings, the APPN did not increase her fluoxetine and joined with her initially in discussing her physical symptoms as the focus of treatment. Further testing with the Toronto Alexithymia Scale (TAS) indicated significant difficulties in identifying and describing feelings with an overall score of 62, with 51 or more significant for alexithymia. This is common for those who have suffered early trauma. It is therefore important that the APPN provide an emotional vocabulary through empathically linking the patient’s feelings to events and her somatic symptoms.
As treatment evolved, the APPN felt that by Ms. K giving voice to her life narrative, she might be able to remember childhood events and integrate her dysfunctional memories into more adaptive memory networks. In doing so, the implicit beliefs that claimed responsibility for her own neglect and abuse could change by deepening her understanding of her family of origin and her ex-husband’s psychopathology. One of the most powerful experiences in therapy, particularly for someone who has been disempowered and disrespected, is to be carefully listened to and taken seriously by another person. Ms. K’s fear of dependency and abandonment issues were great and, as such, the APPN attended to the relationship and used countertransferential feelings as a source of data and a barometer for how the work was progressing. At times, there was significant deadness in the sessions with Ms. K filling the hour with her litany of somatic complaints and the APPN struggling to maintain a sense of emotional engagement, wishing that the sessions would end. The APPN noted these times gently to Ms. K and explored her underlying feelings contributing to this way of communicating. Ms. K was able to articulate that she protected herself from caring too much about coming to therapy.
After 16 sessions, outcome indicators showed a significant decrease in symptoms on the BDI with a score of 26, indicating moderate depression as the patient entered the continuation phase of treatment. As her depression abated, her self-esteem increased and she was able to go back to work. She began to take increasing responsibility for her role in creating her loneliness and the unhealthy ways of getting her dependency needs met though passivity and withdrawing. Given the recurrent and chronic nature of Ms. K’s depression and the improvement noted with combined psychotherapy and medication, ongoing psychodynamic psychotherapy was continued on a one time a week basis. At the 30th session, the APPN reviewed with Ms. K the number of sessions that were left and explored her feelings about the upcoming termination.
APPN: We have 10 more sessions left.
Ms. K: Okay, well, how can we speed this up? I don’t think that this has helped that much.
APPN: How frustrating to feel the lack of progress here and so little time left. Can you tell me more how you are feeling?
Ms. K: Well, I am not blaming you but I need more direction and more from you.
APPN: Tell me more about what you need from me.
Ms. K: I don’t know. I know you tried to do your best.
APPN: How does that feel for you to tell me that?
Ms. K: Scary, like you won’t like me now and won’t want to see me anymore.
APPN: That I will abandon you by not caring if you say what you need?
Ms. K: Well, I guess. It seems that this has brought out so much sadness that instead of feeling better, I just want to avoid the loneliness and pain. I guess I just shut down and am scared when I think about therapy ending.
In this session, Ms. K linked her withdrawing (defense) to her pain (anxiety) and this is an important step in understanding how she creates her own loneliness (response). Her ability to self-reflect had markedly improved. Over the next several months, she continued to deepen her emotional awareness about how the termination of therapy revived earlier pain of significant abandonment experiences relating to her childhood. At the 40th session, the BDI and the SBI were administered with scores of 20 and 40, respectively, indicating significant improvement on both indicators. Her GAF was 70/60. Ms. K continued to come every 4 to 6 weeks for medication management and psychotherapy over the next 6 months. Given the severity of her initial depression and the long-term nature of her chronic dysthymia, she remained on 30 mg of fluoxetine and returned every 3 months for ongoing support in the maintenance phase of treatment. This is consistent with the American Psychiatric Association’s practice guideline recommendations for the maintenance phase of treatment.
Ms. K’s therapy was unremarkable in the sense that there are many stories like hers in mental health clinics for those who have been ravaged by trauma. Yet what is remarkable is that it is the Ms. Ks who most need and benefit from the APPN’s expertise, time, and caring. When a patient is psychologically savvy and engaging to work with, it is interesting and easy to invest the psychic energy needed to affect positive changes. Ms. K found relief in knowing that someone was willing to listen to her about her physical complaints and this led to discussing and linking her somatic symptoms to her emotional issues in a safe, supportive environment. Understanding the connection between conditioned somatic and emotional responses to internal and external sources allowed Ms. K to enhance self-regulatory skills. This understanding coupled with her experiencing emotions in an empathic relationship with the APPN facilitated integration of neural connections and healing. Careful attention was paid to pacing each session to what Ms. K could handle so that she would not be overwhelmed. She initially believed that her problems were all her own fault and that she did not deserve to get any better. Although demoralized and “resistant,” she gradually began to look forward to her sessions and never missed once after the first month of treatment.
CONCLUDING COMMENTS
In addition to using measuring instruments and framing the goals of therapy according to the overall model of therapy used, it is incumbent on the therapist to check throughout therapy and at termination whether the specific collaborative goal(s) the patient and therapist identified are being met. For example, the problem of social isolation for Ms. K was addressed by the collaborative goal, “to feel less lonely.” Thus, the specific outcome identified was to develop two new friends within 3 months. Her other problem of insomnia was addressed by the goal “to sleep better” and was measured by setting a specific date 1 month hence, by which she would be able to sleep 6 hours a night. Both goals were met and were clearly measurable, patient-centered, and easily quantified. Because APPNs are used to developing nursing care plans, identification of collaborative specific outcomes for psychotherapy is usually easily accomplished. An excellent adjunct to assist in developing specific goals, objectives, and interventions for psychotherapy treatment is The Complete Psychotherapy Treatment Planner (Jongsma, Peterson, & Bruce, 2014).
Integrating outcome measures into your clinical practice is prudent not only to determine whether collaborative goals are being met but also to meet the growing mandate for linking reimbursement to quality indicators. In addition, administering selected instruments at intake and throughout treatment allows the APPN to monitor the treatment process. Tracking the process of therapy can provide valuable information related to dynamics and determinants that help us to understand the process of therapeutic change. Which intervention is most effective for what problem for which population at which time in treatment? Not only does this assist with practice decisions for individual patients, but these data can also be disseminated to colleagues through reporting a single case or through a case series (a collection of cases with a similar problem or presentation). The case study has traditionally been the primary means of inquiry, teaching, and learning in psychotherapy.
DISCUSSION QUESTIONS
1.
What tools do you believe would be appropriate outcome measures for psychodynamic, cognitive behavior, and interpersonal psychotherapy approaches? Review the instruments included in this book and identify specific tools reflecting indicators theoretically consistent for each model.
2.
A patient says that he or she will be stopping psychotherapy after the current session. You do not believe this is in the person’s best interests. Discuss how you would handle this.
3.
Compare and contrast several practice guidelines available for a specific diagnosis. Identify any discrepancies. How would you go about choosing the best one for use for a patient you are seeing for outpatient psychotherapy?
4.
You have a patient who has not paid you in several months but says that he or she will. Discuss how you would deal with this situation and how you would decide whether to terminate.
5.
Review the ANA Code of Ethics. Do you believe that it adequately addresses issues related to the APPN conducting psychotherapy? If yes, state how it does so; if not, discuss how it does not and whether you feel it should.
6.
Discuss the importance of outcome measurement for APPNs conducting psychotherapy.
7.
Review the literature and identify three or four other specific outcome measures not listed in this chapter that you think would be good holistic indicators of improvement in psychotherapy. Provide the instrument’s name, the concept measured, type of tool, why it would be an appropriate holistic measure, normative data (reliability and validity), and how to obtain it.
8.
What psychotherapy approaches “fit” the best with how you like to work? How do you plan to continue to expand the ways you work with patients?
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