Midterm Exam: NR 605 / NR605 (2026–2027 Latest Update) Psychiatric Mental Health Across the Lifespan I | Diagnosis & Management | Verified Q&A | 100% Accurate – Chamberlain

…..DLDD Midterm Exam: NR 605 / NR605 (2026–2027 Latest Update) Psychiatric Mental Health Across the Lifespan I | Diagnosis & Management | Verified Q&A | 100% Accurate – Chamberlain Q. Explain the difference between the Biomedical model and the Holistic Model ANSWERS The Holistic approach is truly the pillar of all recovery care models. This approach ensures that the patient is treated through healing. In contrast, in a holistic model, symptoms are seen as a form of communication and are useful for understanding the meaning of the dysregulation and disharmony that are occurring for this person at a given time. Holistic therapy respects the complexity of each unique individual, appreciating the relationship between the client's mind, body, and spirit and recognizing the interdependence of all parts of the human system. Biomedical's goal is to cure with symptom relief treatment. Medications but it does not give way to view the patient as an individual with different causations of their symptoms. They just decide to treat the symptoms. Symptoms are often thought to be the cause of the patient's problem Q. What are the main goals of psychotherapy? ANSWERS Some of the goals of psychotherapy include the reduction of symptoms, improvement of functioning, relapse prevention, increased empowerment, and achievement of the specific collaborative goals set with the patient. Q. _________ refers to the ability of an individual, family, or community to cope with adversity and trauma, and adapt to challenges through individual physical, emotional, and spiritual attributes and access to cultural and social resources (adapted from SAMHSA, 2014). ANSWERS Resilience Q. Explain the resilient zone. Name some strategies that may aid your patient cope when feeling resistant especially during psychotherapy. ANSWERS The optimal physiological state for the work of therapy and reflects the person's natural rhythm and flow of energy and vitality. Although the person may feel sad, happy, angry, and other emotions when in their RZ, the person is able to both feel and think at the same time. The RZ zone is the patient's best physiological state for thinking clear and functioning well. If the person becomes too anxious and hyperaroused, resistances or defenses may increase, and the work of therapy will be thwarted, perhaps not consciously, but nevertheless, the person's brain will not be able to integrate memories or gain insight. Some ways to combat is by decreasing arousal levels such as deep breathing exercises or imagery, focusing on sensations in the body, mindfulness exercises, and self-regulation strategies, presence of supportive relationships and attachments as well as the avoidance of frequent and prolonged stress. Q. Lets talk about Maslow Hiearchy of needs: ANSWERS Maslow states that before higher level needs can be established,, lower level needs have to achieved. For Example: Physiological needs- air, food, water, shelter, clothing, sleep Safety- security of body, employment, morality of family, health, property Love/Belonging- friendship, family, intimacy, connection with others Esteem- self esteem, respect, achievement, confidence Self-actualization- morality, creativity, spontaneity, lack of prejudice, acceptance of facts Q. What are stabilization strategies? ANSWERS Stabilization strategies assist the person to be better able to make state changes, that is, to change one's present physiology in order to function more effectively in the moment. So pretty much stabilization is the way a PMHNP can assess a patients life currently before they are able to participate effectively in their psychotherapy. If a patient lacks stabilization via housing, it is up the PMHNP to secure such. If the patient lacks stabilization in relationships, they need to be provided with strategies to combat and then they are able to process accordingly. Stabilization widens their RZ zone. Q. Lets discuss the Health Belief Model ANSWERS The H.B.M l is used to explain and predict health behaviors. According to the Health Belief Model, a person's belief about a perceived threat of illness combined with belief in the effectiveness of the recommended action predict the person's willingness to change. The model includes several constructs: perceived seriousness, perceived susceptibility, perceived benefits of treatment, perceived barriers to treatment, cues to action, and self-efficacy, as seen below. Q. The construct that clients must believe they are susceptible to a disease or disorder is ______. Lets use Sonia for an example who has been struggling with her anxiety as a 24- year old grad student. ANSWERS Perceived susceptibility. Sonia REALIZES that she has anxiety stemming from COVID. Q. ___________ is the construct that clients must believe the disease has serious consequences if left unattended. ANSWERS Perceived severity Sonia has noted that her anxiety is significantly impacting her schoolwork. Q. What is the construct that clients believe that taking action reduces their susceptibility. ANSWERS Perceived benefits Sonia believes that seeking care will help her to stay in school. Q. _____ is the construct that the benefits of acting are greater than the barriers perceived. Sonia doesn't have a lot of spare time, but she feels like her mental health is important. ANSWERS Perceived barriers Q. _____ is the construct when clients are exposed to something that causes them to act such as a friend, commercial or a conversation with their provider. Sonia's roommate has been seeing a PMHNP and has benefitted from mindfulness exercises and cognitive behavioral therapy. ANSWERS Cue to action Q. This construct is when clients feel they can succeed when performing an action. Sonia believes that seeing a provider can help her to make positive changes in her mental health ANSWERS Self-efficacy Q. Lets discuss the Transtheoretical Model of change. What is it? ANSWERS The Transtheoretical Model of Change assumes that behavior changes take place over time and that people move through stages of decision-making to make changes to behavior. This theory includes several stages: precontemplation, contemplation, preparation, action, and maintenance. The PMHNP must recognize the client's current stage of change to best help them move forward. Q. In this stage of the Transtheorical Model, the patient is unaware or NOT interested in change. ANSWERS Pre-contemplation phase. This would be a great phase for the PMHNP to explore some emotional responses to the said subject. Q. In this stage, the client has been thinking about change. ANSWERS Contemplation stage Q. The _____ stage is when the clients prepare a plan for change. ANSWERS Preperation stage. In this stage is where the client could get clearance for their weight loss. Just prep for the suspected change. Q. The ____ stage is when the client changes old habits and gains new habits. They are actually living out their plans. They have chosen a plan! ANSWERS Action phase! Q. _____ is the last phase and this is where patients continue with their healthy behaviors and sustain healthier lifestyles. ANSWERS Maintenance phase Q. Peplau's Roles: ANSWERS Stranger: The nurse approaches the patient with respect and courtesy, recognizing the patient's individuality. This role helps build trust and rapport. Resource person: The nurse provides information and knowledge to the patient. Teacher: The nurse plays a key role in educating the patient. Leader: The nurse guides the patient and their family through the decision-making process for their care. Surrogate: The nurse provides emotional support and comfort to the patient, and may step in as a caregiver. Counselor: The nurse creates a safe and non-judgmental space for the patient to express their thoughts, feelings, and concerns. Lets explain CPT codes. What are they used for? Clinical Procedural terminology codes are codes are a quick language used by providers to insurance companies to detail the services rendered during patient visits. CPT codes are managed by the American Medical Association If a patient was being billed ONLY for psychotherapy, what would their billing code begin with? 908xx What are E/M codes and how are they used? evaluation and management are codes there were created so mental health professionals will be able to bill more accurately, instead of just billing as a psychotherapy code. This overall aided in a better reimbursement for the provider The evaluation component of E/M refers to the collection and assessment of relevant information related to the patient and the management component refers to the planning of treatment or further assessment and includes prescribing medication Explain what an evaluation/management code may look like? These usually begin with 99xxx. The third digit will describe if the patient is a new/existing client, the fourth will describe where the services were rendered and the fifth digit explains the level of complexity. What documentation must by in your psychotherapy notes to receive a full reimbursement? target symptoms goals of therapy method of monitoring outcomes frequency of treatment clinical records to support relevant medical history results of diagnostic tests or procedures prognosis or progress to date estimated duration of treatment Always remember, a patient is considered new if they have not been seen by your or a provider in your practice in the past 3 years. A patient is established if they have been seen by your or another provider in your practice in 3 years. What would an OUTPATIENT E/M code look like? 9920x. Then the fifth digit will tell the severity 2- straightforward- 99202 straightforward like injections 3- LOW-99203- 1-2 chronic conditions and 2 or more of ROS 4-MODERATE-99204- 1-3 hpi, 1-2 chronic conditions, 2 or more ROS elements 5-HIGH-99205- used for complex patients- 3-4 chronic conditions, 2-3 history elements and a complete ROS As far as INPATIENT E/M codes, what do they look like? 9922x (99221) This would say that this is an INITIAL INPATIENT care encounter by the admitting provider and it requires three of the following: a complete history, a comprehensive exam, and a moderate complexity of medical decision making (99222) this is an INITIAL INPATIENT care encounter with a MODERATE severity presenting problem and requires: comprehensive medical history, comprehensive exam and HIGH complexity medical decision making (99223) the is the HIGHEST level for an initial inpatient encounter with a HIGHHHH severity presenting problem which requires: comprehensive medical hx, comprehensive exam, and high complexity medical decision making. As far as INPATIENT codes, what would code 99222 tell the insurance company? this is an INITIAL INPATIENT care encounter with a MODERATE severity presenting problem and requires: comprehensive medical history, comprehensive exam and HIGH complexity medical decision making As far as INPATIENT codes, what would code 99223 tell the insurance company? the is the HIGHEST level for an initial inpatient encounter with a HIGHHHH severity presenting problem which requires: comprehesive medical hx, comprehensive exam, and high complexity medical decision making. As far as INPATIENT codes, what would code 99224 tell the insurance company? curve ball this is actually AN INPATIENT FOLLOW UP ENCOUNTER and it requires 2 of these 3: problem focused history, problem focused examination, straightforward or low complexity medical decision making Remember that psychotherapy codes are always 908xx! Lets quiz!! _________ is a psychotherapy code for a duration of 16-37 minutes. 90832 _________ is a psychotherapy code for a duration of 16-37 minutes used as an add-on code to an E/M code. 90833 !!!!!!! _________ is a psychotherapy code for a duration of 38-52 minutes. 90834 _________ is a psychotherapy code for a duration of 38 or more minutes used as an add on code to an E/M code. 90836 _________ is a psychotherapy code for a duration of 53 minutes or more. 90837 _________ is for FAMILY psychotherapy when the client is not present. 90846 _________ is for FAMILY psychotherapy with the client present. 90847 ______ PSYCHOTHERAPY CODE ISS 90853!!! GROUP!!!!! What is the treatment hierarchy model for a therapist? This is a similar model to Maslows. This model aids the therapist with assessing and drawing up a treatment plan. So it says that whatever need is not met, it is best to aid the patient with such and then move forward. This model is not in stone and a patient can progress and regress as such. Tell me different levels in the hierarchy model ( the therapist hiearchy model) Foundational needs external resources internal resources stabilization What are the main three elements of the therapeutic alliance between patient and therapist? the collaborative nature of the relationship the warm emotional bond between the patient and therapist the agreement of treatment plan and goals between the therapist and patient What are some elements/questions that should be asked or included during the initial contact of the therapeutic alliance? You need to a full psych eval. Assess suicide factors, discussing key symptoms, stressors, protective factors, documentation. what are some questions you can ask to assess a patient's belief system? What helps you cope with adversity? •What gives you a sense of meaning and purpose in life? •What matters most to you in life? •What are your beliefs about health/illness/therapy/seeking help? •To what extent do your spiritual/religious beliefs comfort you? •What enables you to stay healthy/get better/find comfort/continue living? •What do those spiritual/religious practices bring to your life? Name some signs of countertransference Extending sessions longer than usual •Being late for sessions •Forgetting the session •Seeing the person socially •Violating confidentiality •Dreams about the patient •Difficulty staying awake during sessions •Anger at the patient's inability to change •Arguing or irritability that occurs in sessions •Sexual or aggressive fantasies about the patient •Rescue fantasies and offering advice and "fix it" statements •Anxiety or guilt about what you did or did not say •Thinking a lot about or being preoccupied with the patient outside of sessions •Dreading the session •Postponing confrontations or questions about lateness or absence •Unnecessary reassurances and oversolicitousness •Denying the pathology, conflict, or resistance •Allowing the person to run up a high unpaid bill •Ignoring the therapist's errors and the subsequent effect on the patient's behaviors •Therapist's body feelings, images, and thoughts during the session What are the phases of therapy? Initiation phase Working phase Termination phase What happens in the Initiation phase of therapy? This is where the patient and the pmhnp get to build the therapeutic alliance. A MSE is completed. Client safety is established such as assessing suicide and completing a suicide contract or a safety plan. Set goals, assess readiness, listen, go over concerns/expectations, identity any IMMEDIATE needs, establish boundaries, discuss confidentiality, What happens in the working phase of therapy? In the working phase the main goal is to use cognitive restructuring to help challenge and change the patients maladaptive behaviors. The working phase of therapy is when therapeutic interventions typically take place. The content of the working phase is driven by the client's diagnosis, identified goals, and the selected treatment modality. review concerns, emotions Assess underlying beliefs Utilize therapeutic techniques and communications Mindfullness, CBT techniques I.D. Maladaptive challenges or behaviors Develop coping skills/strategies Address resistance/setbacks What happens in the termination phase of therapy? Usually lasts 10 minutes before the end of the session. You are focusing on wrapping up the therapeutic process. Discuss goals and evaluate them Consolidate information gained Adjust the patient's feelings Discuss potential challenges Schedule f/u ENCOURAGE INDEPENDENCE Reflect and provide feedback Provide resources Reasons to terminate: 1.Mutually agreed on based on achievement of goals 2.Preplanned based on number of sessions 3.Forced termination because therapist graduates or changes clinical assignment 4.Forced termination because the patient moves 5.Forced termination because patient cannot afford fee or insurance will not pay 6.Patient terminates because he or she feels not helped 7.Therapist refers patient elsewhere because therapist feels there is no value in continuing 8.Setting ends the treatment for any reason The PMHNP should prepare a termination letter that delineates the reasons for termination and provides recommendations regarding further treatment if applicable. Supporting documentation and a copy of the letter should be retained in the client's records. If a client is in crisis, "the licensed health professional is responsible for the patient's care until treatment is ended by the patient or until treatment is no longer necessary" (Wheeler, 2022, p. 918). Failure to pay or insurance authorization denial is not acceptable grounds for termination during a crisis. The PMHNP has an obligation to continue care using a reduced or sliding scale fee schedule or to refer the client to a specific organization that provides care at a lower cost. Explain paradoxical intervention and provide an example. This is a skilled therapeutic approach mainly used for patients who cannot see any possibilities and who are severely self defeating. The goal is to aid the patient in no longer viewing the behavior as their enemy but instead in a curious way which can help lead to change. Avoid using in the beginning of the relationship because it can come off as sarcasm For example: A patient who has insomnia, instead of telling them go to sleep. Tell them to stay up for hours and try not to sleep. The goal is for the patient to become reflective about the behavior. What is SAFE-T? This is the suicide assessment five-step evaluation and triage tool. It aids with assessing patients suicide risk. 1.) You assess risk factors: suicidal bx, access to firearms, fam history, triggers, changes in treatment, past psych hx 2.) Protective factors: internal: ability to cope with stress, religious beliefs, frustration tolerance external: kids, family, social supports, pets 3.) Suicide inquiry: thoughts, plans, intents: Ask parents in youths and assess for HI as well 4.)Determine the risk level and intervention: High- Admission, Mod-admission may be necessary, Low- keep them o/p along with Crisis numbers 5.) Document Environment setups: Visible clock for the patient and provider neutral tones Avoid sitting behind the desk. You dont want barriers between you and the patient. You want to be at eye level with the patient. Time of session is usually around 45-50 minutes. Initial is 90 minutes Discuss fees Avoid personal artifacts or pictures of family to avoid distractions Disclosure exceptions: . If you threaten to harm someone else, I am required under the law to take steps to inform the intended victim and appropriate law enforcement agencies. 2. If you threaten to cause severe harm to yourself, I am permitted to reveal information to others if I believe it is necessary to prevent the threatened harm. 3. If you reveal or I have reasonable suspicion that any child, elderly person, or incompetent person is being abused or neglected, the law requires that I report this to the appropriate county agency. 4. If a court of law orders me to release information, I am required to provide that specific information to the court. 5. If you have been referred to me by a court of law for therapy or testing, the results of the treatment or tests ordered may have to be revealed to the court. 6. If you are or become involved in any kind of lawsuit or administrative procedure (such as worker's compensation), where the issue of your mental health is involved, you may not be able to keep your records or therapy private in court. 7. If you see me in couples, group, or family therapy, I ask that each member of the therapy promise to keep whatever happens in treatment confidential. However, I cannot guarantee that others will keep this agreement. 8. In order to provide you the best treatment I can, there will be times when I may seek consultation from another licensed mental health professional. In these consultations, I make every effort to avoid revealing your identity. The consultant is also legally bound to keep the information confidential, although the exceptions to confidentiality apply to them as well. Similarly, when I am away or unavailable, my practice is covered by a licensed therapist. I may inform the on-call therapist about your situation to facilitate your getting appropriate support should you need it in my absenc Documentation: Informs the provision of care and provides a review of past proceedings Supports the continuity of care when referrals or interdisciplinary care occurs Legal Implications Records may be shared during civil proceedings, such as for divorce or custody cases Courts may subpoena records for criminal proceedings Court-ordered counseling records may be shared with the court Risk Management Documentation of high-risk situations can be protective in litigation and should include: situation severity of threat all possible interventions considered colleague consultations intervention implemented follow-up Process notes vs. progress notes. Let me know the difference Process notes are the PMHNP personal notes. It does not have to be shared unless ok'ed by the patient. These notes are private Progress notes: HPI, CC, etc and these can be subpoened. These are legal documents technically What theorist is the father of the psychoanalytic psychotherapy? Explain his theory Sigman Freud Freud identified three levels of awareness: the preconscious, the conscious, and the unconscious. His theory postulates that all actions are based on unconscious sexual or aggressive drives. Psychological symptoms result from conflicts between three parts of the mind: the id, ego, and superego. The _______ is the primitive (uncivilized), instinctive, unconscious, basic urges, seeks pleasure, demands immediate satisfaction. THE ID! The ______ is Rational, logical, mostly conscious, allows the mind to satisfy id's urges appropriately and safely, moderates between id and superego. Its the negotiator. EGO! The ____ has a sense of right and wrong, both conscious and unconscious, internalized morals. The inner moral guide and tells you to act ethical and right. It can make you feel guilty/shameful when you dont live up to your ideals Supergo! The superego is what is going to tell you right from wrong Who is the theorist that is responsible for the PSYCHOSOCIAL developmental stages theory? explain Erik Erikson. It says that at each developmental stage we are faced with a challenge that we must overcome. Lets go through Erikson's developmental stages 1.) Trust vs. Mistrust- Infancy-Hope 2.) Autonomy vs. Shame & Doubt- Early Childhood- Will 3.) Initiative vs. Guilt- 3-6 y.o- Purpose (encouragment) 4.) Industry vs. Inferiority- 7-11 y.o, Competence 5.) Identity vs. Role Confusion- 12-18- Fidelity 6.) Intimacy vs. Isolation- 19-29- Love 7.) Generativity vs Stagnation- 30-64 years old-Care 8.) Integrity vs. Despair- 65+- wisdom Explain Peplau's theory Peplau developed a nursing theory that recognizes nurses as more than their general role (6 roles). He also believed that the nurse and client relationship goes through 4 phases What are the 4 phases of Peplau's nursing theory? 1.) Orientation phase occurs when the nurse and client meet as strangers and includes the nursing assessment and identification of the client's needs. 2.) Identification-phase involves the selection of the intervention and sets goals 3.) Exploitation- , the nurse and client collaborate to explore and understand the problem and exploit all possible options to resolve the client's problem 4.) Resolution- which involves the termination of the therapeutic relationship. What are the 6 roles of Peplau's nursing theory? Stranger Teacher- nurse imparts relevant knowledge and provides instructions and training Resource person- nurse provides specific information needed by the client, answers questions, and interprets clinical data Counselor Surrogate- nurse helps clarify domains of dependence, interdependence, and independence and acts as an advocate for the client Leader- helps client take maximum responsibility for meeting treatment goals Name the therapy: __________ is an approach used to help clients who are experiencing emotional distress or problems in living. It is appropriate for clients experiencing specific stressful situations, including clients with psychotic personality organization, those with a preoccupied or overly emotional attachment style, and those with immature defenses. The goals of therapy include problem-solving, management of feelings and life stressors, and symptom relief. Sessions are less frequent than with psychoanalysis. This therapy is used for stabilization, problem solving, anxiety reduction and resource building. Grounding techniques, deep breathing, building coping strategies. These sessions can be 1x weekly and can last 30 min to 1 hour. This therapy aims at making people feel safe and supported. It is for those who have poor ego strength and whose potential for decompensation is high. Supportive psychotherapy. The therapist may use suggestion advice, confrontation, clarification. Free association is contraindicated due these patient's emotional state. AVOID Supportive psychotherapy is generally indicated for those patients for whom classic psychoanalysis or insight-oriented psychoanalytic psychotherapy is typically contraindicated—those who have poor ego strength and whose potential for decompensation is high. Very fragile people in current distress. Supportive therapy helps the patient to adapt better to problems and to live more comfortably with his or her psychopathology. To restore the disorganized, fragile, or decompensated patient to a state of relative equilibrium, the therapist's primary goal is to suppress or control symptomatology and to stabilize the patient in a protective and reassuring benign atmosphere that militates against overwhelming external and internal pressures. The ultimate goal is to maximize the integrative or adaptive capacities so that the patient increases the ability to cope while decreasing vulnerability by reinforcing assets and strengthening defenses. Supportive therapy uses several methods, either singly or in combination, including warm, friendly, strong leadership; partial gratification of dependency needs; support in the ultimate development of legitimate independence; help in developing pleasurable activities (e.g., hobbies); adequate rest and diversion; removal of excessive strain, when possible; hospitalization, when indicated; medication to alleviate symptoms; and guidance and advice in dealing with current issue. What patients would be best for supportive therapy? 1) individuals in acute crisis or a temporary state of disorganization and inability to cope (including those who might otherwise be well functioning) whose intolerable life circumstances have produced extreme anxiety or sudden turmoil (e.g., individuals going through grief reactions, illness, divorce, job loss, or who were victims of crime, abuse, natural disaster, or accident); (2) patients with chronic severe pathology with fragile or deficient ego functioning (e.g., those with latent psychosis, impulse disorder, or severe character disturbance); (3) patients whose cognitive deficits and physical symptoms make them particularly vulnerable and, thus, unsuitable for an insight-oriented approach (e.g., certain psychosomatic or medically ill persons); and (4) individuals who are psychologically unmotivated, although not necessarily characterologically resistant to a depth approach (e.g., patients who come to treatment in response to family or agency pressure and are interested only in immediate relief or those who need assistance in very specific problem areas of social adjustment as a possible prelude to more exploratory work). Name the therapy: _________ is appropriate for clients with unresolved, disorganized attachment styles and clients with a neurotic defense schema. It is along with dialectical behavioral therapy, is the preferred form of psychotherapy for clients with a borderline personality disorder or borderline character structure. The goals of therapy include processing of relational trauma and learning emotional self-regulation. Therapy sessions are typically provided several times per week. Helps to bring conflict to the surface. Techniques used include transference, counterconditioning, and desensitization to past traumatic relationships. These sessions can be up to 1-3 times a week lasting 30 min- 1 hr. Expressive psychotherapy- The persons best suited for the expressive psychotherapy approach have reasonably well-integrated egos and the capacity to both sustain and detach from a bond of dependency and trust. They are, to some degree, psychologically minded and self-motivated, and they are generally able, at least temporarily, to tolerate doses of frustration without decompensating. They must also have the ability to manage the rearousal of painful feelings outside the therapy hour without additional contact. Patients must have some capacity for introspection and impulse control, and they should be able to recognize the cognitive distinction between fantasy and reality. Limited regression is encouraged. .Desensitization occurs as relationships are no longer perceived as dangerous, and triggers of fear, anger, distrust, and avoidant behaviors are changed so that relationships are seen as a source of support rather than pain. Name the therapy: __________ is used for clients who experience anxiety disorders, obsessive-compulsive disorder, depressive disorders, personality disorders, and sexual dysfunction. It may also be helpful for clients whose personality traits are interfering in their relationships (APSA, n.d.). The goals include the development of a deeper understanding of self and a desire to create change. Mainly for people with a strong ego and strong coping mechanisms. Long-term process that is usually for deep seeded issues and is usually the most in depth. This therapy can be at a length of years 3-5 years and the sessions can last at least up to 50 minutes about 4-5 times a week. Psychoanalysis Clients who are likely to benefit from psychoanalysis include reality-oriented clients with mature defenses and a strong sense of self and clients with neurotic to healthy personality organization. To be successful, the client should be able to think in the abstract and be self-motivated. Contraindications include clients who are not motivated, those who have poor impulse control, clients who are concrete thinkers, and those amid a major physical or emotional crisis. recollection: reconstructing the memory of past events repetition: using transference to replay emotions and interactions in a safe space working through: integrating repressed memories into current consciousness free association: client talks spontaneously about anything that comes to mind which allows for thoughts and feelings to surface more easily transference: client redirects feelings for a significant person in their lives, typically a figure from childhood, onto the psychotherapist, then explores the relationship to resolve conflict interpretation: the psychotherapist interprets the client's discussions to identify unconscious feelings and learn new behavior patterns Name the therapy: _________ is a time-limited form of psychotherapy. It occurs fewer days per week over a shorter length of time as opposed to psychoanalysis, typically 20-30 sessions with a termination date set at the beginning of therapy (Wheeler, 2022). Goals include enhancement of self-awareness and understanding the impact of the past on present behavior (APA, n.d.). It is used when the client has a specific issue or conflict such as difficulty in relationships, school or work, or communication. Therapeutic techniques include pressure, or encouragement, to examine feelings and situations; challenge to defenses, and head-on collision to overcome defenses. It is useful in helping persons with depression, anxiety, and posttraumatic stress disorder (PTSD), among others. Brief psychodynamic therapy Establish a therapeutic alliance •Set a termination date (within 30 sessions) •Deal with initial resistances •Gather historical and other data •What is the most important problem? Why now? What has been done so far? •What does the patient think caused the problem? What does the patient want from therapy? •Select the symptoms (focus) most amenable to treatment within the first three sessions •Define the precipitating event •Identify developmental issues and defenses to understand how to proceed •Share the case formulation with the patient •Enlist the patient as an active participant through a verbal contract •Use the most effective techniques to help the patient •Identify resistances or alliance ruptures, and address them with the patient •Be sensitive to how the past is influencing the present •Examine countertransference feelings •Give homework (optional) •Stress the need for continuing work Lets review the different forms of coping mechanisms: Displacement, Denial, Repression, Regression, Rationalization, Projection, Sublimation, Intellectualization _______ occurs when a person expresses an emotion, such as anger or frustration, towards a "safe" person rather than towards the cause of the emotion. Aleksander received an inferior performance evaluation at work. When he arrived home after a long day, he shouted at his 3-year-old daughter for leaving her toys out in the playroom. Displacement ________ occurs when a person refuses to admit to reality or an obvious fact. Frieda drinks 5-6 alcoholic beverages each night when she comes home from work. She typically drinks until she passes out; however, she never drinks during the day and never misses work due to her drinking, though her drinking has impacted her relationship with her spouse. She does not believe that her drinking is a problem because she goes to work and pays bills on tim Denial ________ occurs when painful memories are "forgotten." The memories become subconscious and continue to impact behavior. Gabriella presents to therapy with concerns about anxiety and difficulty forming relationships. She suffered childhood abuse; however, she has little memory of the incidents. Repression ________ occurs when a person transfers unacceptable impulses into socially acceptable forms. Ahmad recently experienced a nasty breakup with his girlfriend after she cheated on him. While he would like to call her to vent his anger and frustration, instead, he channels his energy into training for a marathon. sublimation __________ involves ascribing (attributes) one's feelings to another person. Anderson has been having an affair with his secretary at work. He has become highly suspicious of his wife and frequently accuses her of being attracted to her boss. Projection ________ occurs when a person uses intellectual thought or learning to suppress an emotional aspect of a situation. Cieran's boss is routinely rude and abrupt with him. Today she accused him of arriving late to work though he was on time. Rather than confront his boss, Cieran wonders whether his boss has difficulties at home that make her irritable. Intellectualization _________ involves creating rational explanations to avoid the emotional consequences of a situation. Levi asked his coworker Marilyn out on a date. She declined the invitations. When telling his friend about the incident, he states he wasn't all that attracted to her anyway. Rationalization ________ occurs when a person reverts to early developmental coping mechanisms based on Freud's stages of psychosexual development. Ramona is sexually assaulted when walking home from work late at night. Following the assault, she begins sucking her thumb for comfort. Regression What did Freud believe about defense mechanisms? He believed that they are ways to aid a person with avoiding anxiety Who are the main founders of the humanistic-existantial theory? Andrew Maslows- Hiearchy of Needs Carl Rogers- Person Centered Therapy Fritz Perls- Gesalt therapy Explain Carl Rogers theory-Person Centered Theory This theory stressed the importancy of empathy, positive regard and being genuine within communication as a therapist. This theory aids with encouraging self-discovery and self growth for the patient. The therapist aids in helping the patient to interventions or new habits vs just telling them. It enforces self-image, self- growth and self actualization and congruence Explain Fritz & Laura Perls theory- Gesalt Theory The term gestalt refers to the overall totality of a person with an understanding that a person must be viewed as a being who is integrated as a whole rather than divided into parts taken out of context (Knight, 2022). Gestalt involves the assumption that while an individual may come close to understanding the experience of another, one can never fully comprehend another's experience. To gain understanding, the therapist observes how the client relates to the environment and moves from one experience to the next (Mann, 2021). The role and function of the therapist involve inviting the client into an active partnership to learn about themselves and experience how they are in the present moment. Emphasis is placed on the client adopting an experimental attitude to explore new behaviors and focusing on the here and now rather than past experiences. Often the therapist addresses the clients' nonverbal body language to explore these gestures as cues to rich information that the client may not be aware of. In addition to attending to the clients' nonverbal language, the therapist may also emphasize language patterns and personality. For example, the therapist may ask the client if their words are congruent with what they are experiencing. Gesalts therapy also comes with its own defense mechanisms: Introjection, Deflection, Confluence, Retroflection and Projection ______ is when a person uncritically accepts ones behavior or belief. Anderson believes he is a loser and is unable to get a job because his dad told him he was a loser at age 6. Introjection Greta did not meet an important project deadline at work and then beraded her husband for arriving home late. ______ occurs when a person disowns aspects of themselves by assigning them to the environment. Projection __________ occurs when a person turns back on themselves what they would like to do to another. Shante's mother yells at her for no reason, instead of yelling back at her she bites her lip. Retroflection _________ occurs when a person blurs the differentiation between the self and the environment. Adam bullies a kid at school to gain acceptance into a gang that he wants to join. confluence _______ occurs when a person uses distraction to avoid sustained contact. David constantly changes the subject when talking to avoid discussing their financial hardships. Deflection What nursing theorists mirror some of the humanistic philosophies? Travelbee who emphasizes on freewill Josephine Paterson & Loretta Zderad-believed nursing education should be founded in experience, and that a nurse's training should focus as much on the nurse's ability to relate to and interact with patients as a scientific and medical background. A phenomenological perspective Jean Watson-Watson’s Theory of Human Caring emphasizes a caring relationship with patients that includes Carl Rogers’s unconditional acceptance and positive regard as well as creating caring moments of healing _________ is a form of time-limited, evidence-based, structured psychotherapy, that posits that social and interpersonal factors can impact symptoms of psychiatric disorders. It focuses on the interactions between the self and others. Interpersonal Psychotherapy-The role of the therapist in IPT therapy is to help the client identify and address interpersonal issues that may be contributing to an exacerbation of psychiatric symptoms. As with many other forms of psychotherapy, therapists providing IPT should communicate unconditional positive regard using a warm, nonjudgmental approach. It is also important to provide an analysis of the client's communication skills, asking the client to provide input about what the client intended to communicate as well as providing feedback about what was actually communicated. The therapist may then use techniques such as coaching or role-play to help the client improve communication skills Interpersonal therapy focuses on what main areas? role dispute- Conflicts with a significant other—a partner, other family member, coworker, or close friend role transition- Economic or family change—the beginning or end of a relationship or career, a move, promotion, retirement, graduation, diagnosis of a medical illness grief-loss or death interpersonal deficit-A history of social impoverishment, inadequate or unsustaining interpersonal relationships Name the three phases of IPT therapy and what happens during this therapy? Initial phase- 1st session. I.D SPECIFIC/MAIN relationship issues: grief, role transition, interpersonal issues or deficits. Middle phase- Addresses working through the actual issue that was identified in phase one. Termination phase: Consolidates progresses and aids with them to combat future issues. Focus on what has been learned. Name the stage of ITP: In what stage are the following goals completed in? Give the syndrome a name; provide information about the prevalence and characteristics of the disorder Describe the rationale and nature of the therapy Conduct the interpersonal inventory to identify the current interpersonal problem area(s) associated with the onset or maintenance of the psychiatric symptoms Review significant relationships, past and present Identify interpersonal precipitants of episodes of psychiatric symptoms Select and reach consensus about the interpersonal problem area(s) and treatment plan with patient The Initial Phase Name the stage of ITP: In what stage are the following goals completed in? Implement strategies specific to the identified problem area(s) Encourage and review work on goals specific to the problem area Illuminate connections between symptoms and interpersonal events during the week Work with the patient to identify and manage negative or painful affects associated with his or her interpersonal problem area The Middle phase Name the stage of ITP: In what stage are the following goals completed in? Discuss termination explicitly Educate the patient about the end of treatment as a potential time of grieving; encourage the patient to identify associated emotions Review progress to foster feelings of accomplishment and competence Outline goals for remaining work; identify areas and warning signs of anticipated future difficulty Formulate specific plans for continued work after termination of treatmen The Termination phase Who are the founders of ITP? (KlarnaW) Gerald L. Klerman and Myrna Weissman What is the Biomedical Model of Health? Focuses on biological aspects of illness, prioritizes diagnosis and medical treatments such as medication or surgeries Excludes emotional/social/spiritual influences What is the Holistic Model of Care? Emphasizes treating the person as a whole. Includes emotional well-being/social factor/spiritual health. Supports patient-centered approaches and long-term wellness What are specific psychotherapy techniques? Active listening Emotional connection Empathy Fostering trust What is active listening? Demonstrating full attention to clients by paraphrasing and summarizing their concerns What is emotional connection? Establishing rapport through empathy and genuine understanding? What is demonstrating empathy? Validating emotions to help clients feel seen and heard What is fostering trust? Maintaining confidentiality and consistency in interactions? What does resilience mean? The ability of an individual, family, or community to cope with adversity and trauma, and adapt to challenges through individual physical, emotional, and spiritual attributes, and access to cultural and social resources What are stabilization strategies? Techniques like grounding exercises, mindfulness, and relaxation techniques. Aim to reduce emotional distress and ensure the client feels secure. What are the Peplau's Roles? Stranger Resource Teacher Counselor Surrogate Leader Peplau's Roles: Stranger The nurse offers a welcoming environment to build initial rapport; creates an environment to built trust Peplau's Roles: Resource The nurse acts an an information source for the patient's needs and treatment; provides specific information needed by the client, answers questions, and interprets clinical data Peplau's Roles: Teacher The nurse provides education about mental health topics or coping strategies; imparts relevant knowledge and provides instructions and training Peplau's Roles: Counselor The nurse listens actively and provides emotional support; helps the client understand and integrate meaning into life's circumstances, provides guidance and encouragement for change Peplau's Roles: Surrogate The nurse steps into roles that the patient cannot manage themselves temporarily; helps clarify domains of dependence, interdependence, and independence (acts as an advocate) Peplau's Roles: Leader The nurse guides collaborative decision-making and helps set achievable goals; helps the client take maximum responsibility for meeting treatment goals What is the Maslow's Hierarchy of Needs? Basic needs (safety, food) precede higher-level needs (self-actualization) What is in the bottom of the pyramid (most important) in Maslow's? Physiological (air, food, water, shelter, clothing, sleep) What is in the 4th spot of the pyramid in Maslow's? Safety (security of body, of employment, of resources, of morality, of the family, of health, and of property) What is in the 3rd spot of the pyramid in Maslow's? Love/Belonging (friendship, family, intimacy, sense of connection with others) What is in the 2nd spot of the pyramid in Maslow's? Esteem (self-esteem, respect, achievement, confidence) What is in the top of the pyramid (least important) in Maslow's? Self-actualization What does self-actualization look like? Represents the highest level of personal growth and fulfillment, includes traits like creativity, independence, and striving to reach one's full potential How do adverse childhood events affect mental health? Adverse childhood events increase the likelihood of depression, anxiety, and PTSD How does mental health affect physical health? Prolonged stress is linked to chronic diseases such as diabetes and heart disease How do social outcomes and mental health relate? Mental health may affect relationship-building and resilience in adulthood What is the Health Belief Model? A person's belief about a perceived threat of illness combined with belief in the effectiveness of the recommended action predict the person's willingness to change What the stages of the Health Belief Model? 1. Perceived susceptibility 2. Perceived severity 3. Perceived benefits 4. Perceived barriers 5. Cue to action 6. Self-efficacy What is perceived susceptibility? Clients must believe they are susceptible to the condition What is perceived severity? Clients must believe the condition has serious consequences if left unattended What is perceived benefits? Clients must believe that taking action reduces their susceptibility What is perceived barriers? Clients must believe that the benefits of acting are greater than the barriers perceived What is cue to action? Clients are exposed to something that causes them to act, such as an ad or discussion with a provider What is self-efficacy? Client feel they can succeed when performing an action What is the transtheoretical model of change? Assumes that behavior changes take place over time and that people move through stages of decision-making to make changes to behavior. Explains why people act the way they do and why they may or may not change their behavior What are the stages in the transtheoretical model of change? 1. Precontemplation 2. Contemplation 3. Preparation 4. Action 5. Maintenance What is Precontemplation? Clients are not aware or interested in change (smoking) What is contemplation? Clients begin thinking about change (walking past a quit smoking ad) What is preparation? Clients plan for change (circling a date on the calendar as prep) What is action? Clients change old habits and gain new, healthier habits (throwing cigarettes away and exercising) What is maintenance? Clients continue with healthier behaviors (fit runner) What are CPT codes? Standardized codes used by medical professionals to communicate services completed to Medicare and other insurance companies for reimbursement 99XXY How are CPT codes billed? Providers can bill for stand-alone psychotherapy using psychiatry specialty codes, but if the encounter includes diagnosing and/or prescribing medication, a medical evaluation and management (E/M) base code should be used with an add-on psychotherapy procedure code. How are the CPT codes selected? Type of client, location of service, and level of service XX=20 New client office/outpatient visit XX=21 Established client office/outpatient visit XX=24 Consultation for office/outpatient XX=22 Inpatient care How are CPT codes rated/based on? Straightforward, low, moderate, or high Based on three components: number of diagnoses, amount of data being reviewed, and risk of mortality/morbidity Y=2 Straightforward, used by office staff for procedures such as injections, outpatient Y=3 Low, 1-2 chronic conditions, history components, and 2 of ROS elements, outpatient Y=4 Moderate, 1-3 HPI or 1-2 chronic conditions, history of components, 2 or more ROS, outpatient Y=5 High, 3 chronic conditions or 4 HPI elements, 2-3 history elements and a complete ROS, outpatient q 99221 Initial inpatient, complete history, comprehensive exam, moderation complexity medical decision making 99222 Initial inpatient, moderate severity, comprehensive medical history, comprehensive exam, high complexity medical decision making 99223 Highest level with high severity initial inpatient, comprehensive medical history, comprehensive exam, high complexity medical decision making 99224 Subsequent inpatient encounters, at least 2 of the three components (problem focused history, problem focused examination, straightforward or low complexity medical decision making) 90832 Psychotherapy duration 16-37 minutes 90833 Psychotherapy duration 16-37 minutes used as an add on code to a E/M code 90834 Psychotherapy duration 38-52 minutes 90836 Psychotherapy duration 38 or more minutes used as an add on code to an E/M code 90837 Psychotherapy duration 53 or more minutes 90846 Family psychotherapy client not present 90847 Family psychotherapy with client present 90853 Group psychotherapy Why would a PMHNP refer to a social worker? Address clients' needs for social support or with vocational counselors to assist with employment needs Who else would a PMHNP refer to? Therapists who specialize in certain populations Telehealth services or support groups for patients who lack easy access to psychotherapy What documentation requirements are necessary for reimbursement for psychotherapy? Target symptoms Goals of therapy Method of monitoring outcomes Frequency of treatment Clinical records to support relevant medical history Results of diagnostic tests or procedures Prognosis or progress to date Estimated duration of treatment PLUS use of standard format: CC, HPI, ROS, past psych hx, MMSE, diagnostic formulation, tx plan What is migration? The process of relocating to a new country or culture What is acculturation? Adapting to the dominant culture while retaining original cultural identity What is acculturative stress? Psychological stress from navigating cultural differences What is Amok? Malaysian dissociative episode characterized by a period of brooding, followed by an outburst of violent, aggressive, or homicidal behavior Prevalent among males between 20-45 years old Frequently diagnosed with schizophrenia Treated with antipsychotic medications What is Ataque do Nervios? Latin American episode characterized by uncontrollable shouting, attacks of crying, trembling, heat in the chest rising to the head, verbal/physical aggression, sense of being out of control Prevalent among females Treatment includes safety plans, talking down, rubbing alcohol, short-acting benzos What is possession syndrome? Prevalent in south Asian culture, women, 15-35 years Treatment is avoided What is Shenjing Shuariruo? Characterized by weakness, emotional, excitement, nervous symptoms, sleep disturbances Condition must last at least 3 months, lower the efficiency of work, study, or social function, causing mental distress, or precipitate treatment seeking Polypharmacy is common How can the therapeutic relationship be enhanced? Asking detailed questions about the patient's main concern Having a validating affect Explaining the therapy process as it unfolds Listening empathetically without minimizing or offering "fix it" statements Goal consensus and collaboration What are the three common elements included in the therapeutic relationship? Empathy Congruence Unconditional positive regard What should be included in the initial contact? Location, frequency of sessions, payment, gathering information, establishing rapport/expectations, safety needs What the elements of the frame? Process for contacting the provider What to do in case of an emergency Adherence to a schedule Fees Confidentiality Boundaries of therapeutic relationship What is the best practice for starting an initial contact? Providing a written therapy contract (not required) What is the SAFE-T? Suicide Assessment Five-step Evaluation and Triage What is included in the SAFE-T? Identify risk factors (note those that can be modified to reduce risk) Identify protective factors (note those that can be enhanced) Conduct suicide inquiry (suicidal thoughts, plans, behaviors, intent) Determine risk level/intervention (determine risk and choose appropriate interventions to address and reduce risk) Document (assessment of risk, rationale, intervention, and follow-up) Therapeutic communication: Broad opening "Where shall we begin?" Therapeutic communication: Information giving "I recommend that you take this medication at bedtime because it makes you feel tired" Therapeutic communication: Giving recognition "You were able to do well this week with the goals we set last week" Therapeutic communication: Restating "You cannot study and have trouble concentrating" Therapeutic communication: Suggestion "Some people find it helpful to keep a journal of their thoughts during the week" Therapeutic communication: Clarification "Would you tell me more about what you mean by upset?" Therapeutic communication: Reflection "You are asking me what to do about your wife's drinking and are very frustrated by the situation" Therapeutic communication: Exploring "How did you feel when your friend said that to you?" Therapeutic communication: Focusing "Yes, your relationship with your mother is important, and it may help you understand better what does on for you in other relationships by discussing this further" Therapeutic communication: Observation "It seems that whenever you begin to talk about your mother, you change the subject" Therapeutic communication: Immediacy "Perhaps you are feeling that I am not giving you what you need here" Therapeutic communication: Interpretation "From what you have told me, it seems that whenever you get close in a relationship, you become anxious and then protect yourself by finding fault with the other person" What is countertransference? Reflects feelings that the therapist has toward the patient and is similar in some respects to transference. Involves past significant relationships and includes attitudes, feelings, and thoughts about another person Can have a negative impact on the therapeutic alliance (undermines trust) What are signs of countertransference? Extending sessions longer than usual, being late to sessions, forgetting sessions, seeing the person socially, violating confidentiality, dreams about the person, difficulty staying awake during sessions, anger, arguing, sexual/aggressive fantasies, rescue fantasies, anxiety/guilt, thinking a lot about the patient, dreading the sessions, postponing confrontations, unnecessary reassurances, denying, allowing the person to run up a high bill, ignoring What are boundary violations? Actions that blur professional boundaries (dual relationships) What is paradoxical intervention? Using unexpected approaches to change behavior (prescribing the symptom) What is paradoxical interventions used for? Used for patients who are said to be highly resistant and experiencing much conflict about change Ask the person to embrace the behavior that the therapy is aiming to diminish What are process notes? Personal tool for the therapist to record thoughts, feelings, observations, or hypotheses during or immediately following the session. Private Clients, other providers, and insurance companies may request access - not obligated to share Clients must provide authorization before the provider shares Document therapists observations and internal reflections, include providers thoughts verbatim What are progress notes? Contain treatment plan (history, diagnosis, medical details, progress summaries) Considered a part of the medical record and may be shared with providers, insurance companies, and the client Focus on treatment goals and outcomes More formal Therapy phase: Initial Establish trust and goals Therapy phase: Working Implement interventions Therapy phase: Terminations Conclude therapy effectively What are grounds for termination? Goals achieves Therapist moves/Patient moves Patient unable to pay or insurance will not pay What is included in documentation and required? Standard format of chief complaint, history of present illness, review of systems, past psychiatric history, mental status exam, diagnostic formulation, treatment plan What is included in a safety plan for suicide? Created for any client at risk for self-harm Includes a prioritized list of coping strategies and resources the client can use when thinking about suicide or self-harm Process for contacting the provider, what to do in case of an emergency, adherence to a schedule, feeds, confidentiality, and boundaries What are the legal components of safety plans? Records may be shared during civil proceedings such as for divorce or custody cases Courts may subpoena records for criminal proceedings Court-ordered counseling records may be shared with the court What is the safety assessment in a safety plan? Includes questions regarding suicidal and homicidal thoughts Thoughts of self-harm What is a suicide contract? Not a legal document An agreement between the client and the therapist Involves a commitment by the client May not be effective in a crisis Legal requirements of disclosure in court-mandated clients Providers may be required to share information with the court and discuss the limits of confidentiality with the client When do you terminate the therapeutic relationship? When goals are met When the therapeutic relationship is no longer effective What is premature termination? When a client is terminated due to the client's inability to afford treatment, feeling that therapy is no longer beneficial, or relocation out of the therapist's service area What are the questions to assess belief systems? What helps you cope with adversity? What gives you a sense of meaning and purpose in life? What matters most to you in your life? What are your beliefs about health/illness/therapy/seeking help? To what extent do your spiritual/religious beliefs comfort you? What enables you to stay healthy/get better/find comfort/continue living? What do those spiritual/religious practices bring to your life? What are the communication techniques? Translating emotions Non-verbal communication Information verification/dissemination Communication techniques: Translating emotions Sharing observations, empathy, hope, humor, feelings Communication techniques: Non-verbal communication Active listening, using touch, using silence Communication techniques: Information verification/dissemination Providing information, clarifying, focusing, paraphrasing, validation, asking relevant questions What are the components of the therapy contract? Therapeutic relationship, scheduling, missed appointments, fees (Not required) What is transference? Client directs their feelings towards a significant person in their lives Unconscious process May be positive or negative How is transference useful in therapy? Provides perspective into the client's relationships and offers an opportunity to help the client gain insight Psychosocial Development Theory - Freud Explains personality development and the acquisition of social skills and social attitudes PDT: Oral Years: 0-1 years Focuses on oral activities (sucking, tasting) Oral fixation (addiction to smoking or eating) PDT: Anal Years: 1-3 Focuses on controlling bowels/bladder Toilet training anal retentive or anal expulsive PDT: Phallic Years: 3-6 Focuses on genitals and differences between sexes Vanity, envy, passivity, confused identity PDT: Latent Years: 6-puberty Peer/social relationships and gender roles Critical stage to develop social skills and confidence PDT: Genital Years: puberty-adult Sexual desires and urges directed toward others Transfer of fixation from earlier stages Psychosocial Stages of Development Erikson's eight stages of human development, named to emphasize the importance of social experience to the resolution of the crises that characterize each stage PSD: Infancy 0-1 Trust vs Mistrust Hope Tryst or mistrust that basic needs, such as nourishment and affection, will be met PSD: Early child