Varcarolis's Canadian Psychiatric Mental Health Nursing, Canadian Edition, 1st Edition Class Notes

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Varcarolis’s Canadian Psychiatric Mental Health NursingChapter 01: Mental Health and Mental IllnessThoughts About Teaching the TopicThe instructor will probably devote an hour or less to this material and will probablyemphasize (1) the mental health–mental illness continuum; (2) the mental health assessment,using both the factors that influence mental health and the five criteria of mental health; and(3) the importance of becoming conversant with theDSM-5.The learning activities found on the Evolve Web site will assist students to operationalizethis general knowledge. Activities can be used in class or assigned as independent work.Key Terms and Conceptsclinical epidemiologyco-morbid conditionDiagnostic and Statistical Manual of Mental Disorders,fifth edition (DSM-5)electronic health careepidemiologyevidence-informed practiceincidencemental healthmental illnessNursing Interventions Classification (NIC)Nursing Outcomes Classification (NOC)prevalenceresilienceObjectives1. Describe the two conceptualizations of mental health and mental illness.2. Explore the role of resilience in the prevention of and recovery from mental illness, andconsider your own resilience in response to stress.3. Identify how culture influences our view of mental illnesses and behaviours associatedwith them.4. Define and identify attributes of positive mental health.5. Discuss the nature/nurture origins of psychiatric disorders.6. Summarize the social determinants of health in Canada.7. Explain how findings of epidemiological studies can be used to identify areas for medicaland nursing interventions.STUDY NOTES

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1-28. Identify how theDSM-5can influence a clinician to consider a broad range of informationbefore making a diagnosis.9. Describe the specialty of psychiatric mental health nursing.10. Compare and contrast aDSM-5medical diagnosis with a NANDA nursing diagnosis.Chapter OutlineTeaching StrategiesMental Health andMental IllnessThe validity of several concepts is explored, beginningwith the idea that mental illness is what a culture regardsas unacceptable and that mentally ill individuals are thosewho violate social norms. This is shown to be aninadequate definition by pointing out that politicaldissidents are not necessarily mentally ill. Anothermisconception to be discussed is that a healthy personmust be logical and rational, with the point being madethat each of us has irrational dreams and experiencesirrational emotions. All human behaviour lies somewherealong a continuum of mental health and mental illness.Mentally healthy persons are those who are in harmonywith themselves and their environment. Such individualsmay possess medical deviation or disease, as long as thisdoes not impair reasoning, judgement, intellectualcapacity, and the ability to make harmonious personal andsocial adaptations. Instead of a definition ofmentalhealth, traits possessed by the mentally healthy areidentified as happiness, control over behaviour, appraisalof reality, effectiveness in work, and a healthy self-concept. The misconception that mental illness isincurable or treatment is unsuccessful is refuted bycontrasting people with cardiovascular disease withpeople with mental illness.Contributing FactorsMany factors can affect the severity and progression of amental illness, as well as the mental health of a personwho does not have a mental illness (Figure 1-3). Ifpossible, these influences need to be evaluated andfactored into an individual’s plan of care.ResilienceResilienceis associated withadaptationand means thatrather than falling victim to negative emotions, resilientpeople recognize their feelings, readily deal with them,and learn from experience. Accessing and developingresilience assists people to recover from painfulexperiences and difficult events. It is characterized byoptimism and a sense of mastery and competence.According to the Substance Abuse and Mental HealthServices Administration (SAMHSA) (2011), a recoveryprocess includes the following components: self-directed,individual, empowering, holistic, nonlinear, strengths-based, peer-supported, respect, responsibility, and hope.

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1-3CultureIn determining the mental health or mental illness of anindividual, we must consider the norms and influence ofculture. Cultures differ in their views of mental illness, themeaning ascribed to experiences of health or illness, andthe behaviour categorized as mental illness. Althoughsome disorders such as bipolar disorder and schizophreniaare found throughout the world, other syndromes areculture bound (e.g., running amok, pibloktoq, andanorexia nervosa). TheDSM-5provides informationabout cultural variations for each of the clinical disorders,a description of culture-bound syndromes, and an outlineof cultural formulations for evaluating and reporting theimpact of the individual’s cultural context.Perceptions of MentalHealth and MentalIllnessMental Illness VersusPhysical IllnessA distinction between mental and physical illnesses isoften made. It frequently implies that psychiatricdisorders are all “in the head,” whereas the majority ofphysical illnesses are considered to be beyond personalresponsibility.Nature Versus NurtureThe most prevalent and disabling mental disorders havestrong biological influences. Examples are schizophrenia,bipolar disorder, major depression, obsessive-compulsiveand panic disorders, post-traumatic stress disorder, andautism. Nurses are cautioned to remember that we do nottreat diseases; rather we care holistically for people.Factors that affect a person’s mental health includesupport systems, family influences, developmental events,cultural or subcultural beliefs and values, health practices,and negative influences impinging upon one’s life. Eachmust be evaluated and factored into a plan of care. Figure1-3 identifies some influences that can affect a person’smental health. Currently, the diathesis–stress model, inwhich diathesis represents biological predisposition, andstress represents the environmental aspect, is the mostaccepted explanation for mental illness.

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1-4Social Influences onMental Health CareSelf-Help MovementGroups of people with mental illnesses began to advocatefor their rights and the rights of others with mental illness;they fight stigma, discrimination, and forced treatment.Decade of the BrainThe last decade of the 1900s was designated as theDecade of the Brain” by then U.S. president George H.W.Bush. The goal was to make legislators and the generalpublic aware of the advances that had been made inneuroscience and brain research (Tandon, 2000).Mental Health forCanadians: Striking aBalanceOne of the first national reports,Mental Health forCanadians: Striking a Balance(Epp, 1988), sought toreview mental health–related policies and programs.Three challenges in mental health were identified at thattime: (1) reducing inequities, (2) increasing prevention,and (3) enhancing coping. These challenges continue, andthe more recent Mental Health Commission of Canadastrategy (2012) identified similar challenges: (1)promoting mental health across the lifespan; (2) fosteringrecovery and well-being for people while upholding theirrights; (3) providing timely access to treatment andsupports; (4) reducing disparities; (5) recognizing thedistinct circumstances, rights, and cultures in addressingmental health needs of individuals and communities; and(6) ensuring effective leadership and collaboration acrosssectors, agencies, and communities.Human Genome ProjectThis project lasted from 1990 to 2003 and strengthenedbiological and genetic explanations for psychiatricconditions (Cohen, 2000). Although researchers havebegun to identify strong genetic links to mental illness (asyou will see in the chapters on clinical disorders), it willbe some time before we understand the exact nature ofgenetic influences on mental illness.Changing Directions,Changing Lives: TheMental Health Strategyfor CanadaThe Mental Health Commission of Canada released areport titledToward Recovery & Well-Being: AFramework for a Mental Health Strategy for Canadain2009. Up to this time, Canada did not have a national planfor the development of a mental health strategy. This putforward the vision and broad goals for the strategy thatwas released in 2012:Changing Directions, ChangingLives: The Mental Health Strategy for Canada.The aim of the strategy is to improve the mental healthand well-being for all Canadians. Six key strategicdirections (see Box 1-2) were outlined in the report.Epidemiology of MentalDisordersTheepidemiology of mental disordersmay be defined asthe quantitative study of the distribution of mentaldisorders in human populations. Epidemiologists canidentify high-risk groups and high-risk factors associated

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1-5with illness onset, duration, and recurrence. The furtherstudy of risk factors for mental illness may then lead toimportant clues about the causes of various mentaldisorders.Incidence—the number of new casesof mentaldisorders in a healthy population within a givenperiod—andprevalence—the total number of cases, newand existing, in a given population during a specificperiod of time, regardless of when the subjects becameill—provide information that can be used to improveclinical practice and plan public-health policies.Applications ofEpidemiologyClinical epidemiologyis briefly explained as a broad fieldthat addresses what happens to people with illnesses oncethey are seen by providers of clinical care.Classification of MentalDisordersPresently there are two major classification systems formental disorders in Canada: theDiagnostic and StatisticalManual of Mental Disorders(DSM-5)and theInternational Statistical Classification of Diseases andRelated Health Problems, tenth revision (ICD-10-CA)(WHO, 2011).DSM-5In theDSM-5, each of the over 350 mental disorders isconceptualized as a clinically significant behavioural orpsychological syndrome or pattern that occurs in anindividual and is associated with present distress ordisability or with a significantly increased risk ofsuffering death, pain, disability, or an important loss offreedom.DSM-5supports accurate diagnostic assessmentby providing information about culturally diversepopulations.ICD-10-CAThis document helps to identify epidemiological trendsamong populations in an effort to report and manage theglobal burden of disease.What is PsychiatricMental Health Nursing?Psychiatric mental health nurses work with knowledge,skill and compassion alongside people throughout thelifespan. They assist healthy people who are in crisis orwho are experiencing life problems, as well as those withlong-term mental illness. Their patients may includepeople with concurrent disorders (e.g., a mental disorderand a coexisting substance disorder), homeless people andfamilies, people in jail, individuals who have survivedabusive situations, and people in crisis. Psychiatric mentalhealth nurses work with individuals, couples, families,and groups in every nursing setting: in hospitals, inpatients’ homes, in halfway houses, in shelters, in clinics,in storefronts, on the street—virtually everywhere.NursingClassifications/NIC/NOCTheNursing Interventions Classification (NIC)is a toolused to standardize, define, and measure nursing care. TheNursing Outcomes Classification (NOC)is a reference

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1-6that provides standardized outcomes, definitions, andmeasures to describe patient outcomes influenced bynursing practice (Moorhead, 2008, p. 15).Evidence-InformedPracticeThe nursing diagnosis classification systems form afoundation for the novice or experienced nurse toparticipate in evidence-informed practice— that is, carebased on the collection, interpretation, and integration ofvalid, important, and applicable patient-reported,clinician-observed, and research-derived evidence.Levels of PsychiatricMental Health ClinicalNursing PracticeLevels of psychiatric mental health nursing clinicalpractice are differentiated by educational preparation,professional experience, and certification.Basic LevelA psychiatric mental health registered nurse holds adiploma or baccalaureate degree in nursing or psychiatricnursing and may become certified. Certificationdemonstrates that the nurse has met the profession’sstandards of knowledge and experience in the specialty.Advanced PracticeAn advanced-practice registered nurse–psychiatric mentalhealth (APRN-PMH) will have preparation at the master’sdegree or higher level in psychiatric nursing and will havethe designation clinical nurse specialist or nursepractitioner.Future Challenges andRoles for PsychiatricMental Health NursesFuture trends for psychiatric nursing indicate the need tostrengthen current roles and develop novel approaches topatient care. Key trends will affect the future ofpsychiatric nursing: the aging of the population,increasing cultural diversity, ever-expanding technology,and advocacy for broader social determinants of mentalhealth.The growing number of older Canadians withAlzheimer’s disease and other dementias will requireincreased skilled nursing care in institutions. Healthierolder adults will need services at home, in retirementcommunities, or in assisted-living facilities.Cultural diversity is steadily increasing in Canada. Recentimmigrants represent about 16% of Canada’s population(Ali, 2002).These new Canadians add to and form an important partof our social, cultural, and economic institutions. Goingforward, psychiatric mental health nurses will need toincrease their cultural competence—that is, theirrelational practice and awareness of the uniqueexperiences and views of their patients regarding mentalhealth, illness, and response to treatment.

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1-7Technology is also important in areas of the nurse’scommunication, patient care, and patient teaching. TheInternet and telehealth can provide individuals with healthlines to care from a totally new perspective. This willmean that psychiatric nurses must remain current andbecome more active in providing patient care in new andinnovative ways.Psychiatric nurses will also need to remain current withtechnological advances that can shape their practice.There will be an increased need for nurses to understandresearch and help promote and propose research areas thataddresses prevention of mental illness and early treatmentand intervention, as new methodologies become available.Finally, the psychiatric nurse will have an advocacy rolein protecting the rights of patients with psychiatricdisabilities, particularly those rights that concern thebroader social determinants of health and mental health.This role needs to continue to evolve. The nurse must bevigilant about provincial or territorial and nationallegislation affecting health care to identify potentialdetrimental effects on the mentally ill.We know that mental health care looks much differenttoday from how it looked a half century ago. We havemore and better services for more individuals, but we alsoknow that we still have individuals who do not receivedecent mental health care. As concerned professionals, weneed to continue to make required improvements towardthe goal of serving those who are in need of mental healthcare in local, rural, and remote geographical areas.

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Varcarolis’s Canadian Psychiatric Mental Health NursingChapter 02: Historical Overview of Psychiatric Mental Health NursingThoughts About Teaching the TopicThe instructor will incorporate this historical overview in an introduction to a course as aprereading and to set the context for topics to follow (e.g., ethics, therapeutic relationships,care in acute and community settings, and so on). The learning activities found on the EvolveWeb site will assist students to operationalize this general knowledge. Activities can be usedin class or assigned as independent work.Key Terms and Conceptsadvanced-practice nursing (APN)asylumsCanadian Federation of Mental Health Nursescustodial caredeinstitutionalizationDorothea Dixmoral treatmentPhilippe PinelRegistered Psychiatric Nurses of CanadaWeir ReportWilliam TukeObjectives1. Identify the sociopolitical, economic, cultural, and religious factors that influenced thedevelopment of psychiatric mental health nursing.2. Summarize the influence of psychiatric treatment trends on the role of the nurse.3. Identify the factors that led to the separate designations of registered nurse and registeredpsychiatric nurse.4. Analyze the factors that have enhanced and delayed the professionalization of psychiatricmental health nursing.5. Consider the future potentials and challenges for psychiatric mental health nursing inCanada.Chapter OutlineTeaching StrategiesTrends in approaches to the treatment of mental illnesshave contributed to the emergence and evolution of therole of psychiatric nursing. These trends stem largelyfrom societal values, politics, culture, and economics.Early Mental Illness CareEarly asylums were eighth-century Middle Eastern

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2-2retreats from society, with the view that after severalmonths of rest, people with mental illness could be cured(Weir, 1932). These early treatment centres, guided byIslamic beliefs, provided a compassionate and peacefulenvironment in which to care for people with mentalillnesses.In medieval Western Europe, strong religious influencesinspired the belief that mental illness was the cause ofspiritual failings or sin, resulting in treatments that werepunitive. By the fifteenth century, several asylums hadbeen built across Europe, and patients were often chainedor caged, and cruelty or neglect was the norm (Digby,1983).In late-1700s France, more humane treatments weredeveloped—literally removing the chains of the patients,talking to them, and providing a calmer, soothingenvironment.In England, similarly, the use of social and psychologicalapproaches emerged as “moral treatment” (Digby, 1983).This revolutionary way of treating people with mentalillness swept across Europe and influenced the design ofearly asylums in North America.Early Canadian MentalHealth CareCanada’s context draws on this history but is uniquelyinfluenced by the history, immigration patterns and theland itself. Canada’s Aboriginal peoples had a variety ofholistic approaches to treating mental illness—treatingmind, body, and soul—and included sweat lodges, ani-mistic charms, potlatch, and Sundance (Kirkmayer, Brass,& Tait, 2000).Sixteenth-century colonial settlers from France andEngland brought their own approach, with responsibilityfor care falling upon the family and religious orders, suchas the Grey Nuns, who provided early care in Canada(Hardill, 2006).By the 1800s, migration to Canada increased alongsideurbanization, and the European model of asylums wasestablished.Early Canadian AsylumsAsylums were built in country-like settings, providingoccupational therapies such as farming. Toward the end ofthe nineteenth century, asylum care became moreacceptable, with family support systems becoming diluteddue to rapid urbanization (Cellard & Thifault, 2006). Thelack of success in treating mental illnesses, combined withovercrowding in many asylums, meant that minimal—orcustodial—care was the norm.

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2-3Many sought to reform these approaches, among themDorothea Dix, a retired school teacher from New Englandwho was the superintendent of nurses during theAmerican Civil War. Dix was educated in the asylumreform movements in England while she was thererecuperating from tuberculosis. Passionate about socialreform, she began advocating for the improved treatmentand public care of people with mental illness.Early PsychiatricTreatmentsBy the end of the nineteenth century, the new field ofpsychiatry sought medical cures for mental illness. Withfew medications available other than heavily alcohol-based sedatives, doctors used many experimentaltreatments—for example, leeching (using bloodsuckingworms), spinning (tying the patient to a chair andspinning it for hours), hydrotherapy (forced baths), andinsulin shock treatment (injections of large doses ofinsulin to produce daily comas over several weeks).By the mid-twentieth century, treatment choices expandedto include electroconvulsive therapy (see Chapter 14) andlobotomies, through which nerve fibres in the frontal lobewere severed. With these more invasive treatments, morepatient monitoring beyond custodial care led to therecruitment of nurses to work in these experimentalmedical institutions.Bringing Nurses toAsylumsNo nurses were working in Canadian psychiatric settingsprior to the late 1800s. Asylums used predominantly maleattendants to provide custodial care for patients. Theincreased medicalization of psychiatry prompted a needfor more specially trained providers, especially for femalepatients (Connor, 1996).The first psychiatric institution in Canada offered a 2-yeardiploma (to women only) in Kingston, Ontario, in 1888(Kerrigan, 2011). The curriculum, which was taught byphysicians, included courses in physiology, anatomy,nursing care of the sick, and nursing care of the insane(Legislature of the Province of Ontario, 1889).Shifts in Control OverNursingIn the early 1900s, the Canadian Nurses Association’s(CNA) desires to professionalize nursing werecontentious, mostly because physicians wanted controlover nursing education; patriarchal society structuresdevalued nursing knowledge; nursing skills were seen asnatural women’s work; and hospitals relied on theeconomical service hours of nursing students (Anthony &Landeen, 2009).In 1932, a joint Canadian Medical Association and CNAreport—the “Weir Report ”—concluded that drastic

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2-4changes were needed in nursing education programs,including standardization of curriculum, work hours,instructor training, and that care of people with mentalillnesses needed to be integrated into all generalistprograms (Fleming, 1932). A split between Western andEastern Canada in training programs occurred, with thewestern provinces creating the specialty-focusedpsychiatric nursing training programs and the registeredpsychiatric nurse designation separately, and the easternand Atlantic provinces offering a generalist training.Deinstitutionalizationand the Role ofPsychiatric NursingPsychiatric nursing continued to take place predominantlyin hospital settings until the 1960s, whendeinstitutionalization shifted care into communities. Sincethen, a wide range of community-based mental healthservices eventually developed (e.g., crisis management,consultation-liaison, primary care psychiatry), creatingnew settings and skill requirements for psychiatric mentalhealth nurses.University EducationThe first shift from hospital to university educationoccurred in the 1930s, with the first degree offered at theUniversity of Toronto in 1942.In Western Canada, the shift to the role of registeredpsychiatric nurse, and the increased range of practicesettings into community settings brought about radicalchanges in educational programs over the past 20 years.Psychiatric nurse diploma training continued until 1995,when Brandon University began its baccalaureateprogram in psychiatric mental health nursing. RegisteredPsychiatric Nurses of Canada (RPNC) issued a positionstatement in 2008 advocating for baccalaureate degreeentry to practice for RPNs due to the increasinglycomplex needs and roles of the registered psychiatricnurse (Registered Psychiatric Nurses of Canada, 2008a).Further, the first graduate program in psychiatric nursingfor registered psychiatric nurses began at BrandonUniversity in January 2011.National CertificationSince 1995, the Canadian Nurses Association has offeredregistered nurses certification in psychiatric mental healthnursing; this certification exam is one of the mostcommonly written (CNA, 2011b)Advanced PracticeAdvanced-practice nursing (APN)includes the roles ofnurse practitioner and clinical nurse specialist (CNA,2008). Each province has its own regulations guiding thelicensing and scope of practice for APN. The clinicalnurse specialist (CNS) role has been well established inpsychiatry since the 1970s. CNSs can providepsychotherapy and have worked as consultants, educators,and clinicians in inpatient and outpatient psychiatry

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2-5throughout Canada.Nurse practitioners, on the other hand, work asconsultants or collaborative team members and candiagnose, prescribe and manage medications, and can alsoprovide psychotherapy. While the role of psychiatricnurse practitioner has been well established in the UnitedStates, the role has remained virtually nonexistent inCanada.Future DirectionsBased on its success in the United States, the role ofadvanced-practice nurse in psychiatric mental health careis another one that is certain to develop in Canada in thefuture. The changes in public perception of mental illnessand decreases in stigma are beginning to increase the roleof mental health promotion and illness prevention inschools and workplace settings.Evidence-informed approaches to treatment have led tothe creation of related nursing roles, education, andresearch.

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Varcarolis’s Canadian Psychiatric Mental Health NursingChapter 03: Relevant Theories and Therapies for Nursing PracticeThoughts About Teaching the TopicWhen students have completed a growth and development course prior to the psychiatricnursing course, a review of personality theories by reading may be sufficient. It’s wise,however, to offer a self-paced activity or a match exercise and remind students that they areresponsible for the content, whether or not it is included in a lecture. The chapter’sexplanation of therapies is succinct, yet it is sufficient in detail to permit learners to grasp thematerial. However, because learners have a limited frame of reference for therapies, mostwould rather explore what those in the field think rather than discuss or debate amongthemselves. Use of a film, followed by a discussion, may help learners grasp the basicprinciples and concepts of therapy.Key Terms and Conceptsautomatic thoughtsbehavioural therapybiofeedbackclassical conditioningcognitive-behavioural therapy (CBT)cognitive distortionsconditioningconsciouscounter-transferencedefence mechanismsegoextinctionidinterpersonal psychotherapymilieu therapynegative reinforcementoperant conditioningpositive reinforcementpreconsciouspsychodynamic therapypunishmentreinforcementsuperegotransference

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3-2unconsciousObjectives1. Evaluate the premises behind the various therapeutic models discussed in this chapter.2. Describe the evolution of therapies for psychiatric disorders.3. Identify ways each theorist has contributed to the nurse’s ability to assess a patient’sbehaviours.4. Drawing on clinical experience, provide the following:a. An example of how a patient’s irrational beliefs influenced behaviourb. An example of counter-transference in your relationship with a patientc. An example of the use of behaviour modification with a patient5. Identify Peplau’s framework for the nurse–patient relationship.6. Choose the therapeutic model that would be most useful for a particular patient or patientproblem.Chapter OutlineTeaching StrategiesMajor Theories ofPersonalityThe contributions of Freud, Erikson, Sullivan, Peplau, andMaslow are summarized.Sigmund Freud’sPsychoanalytic TheoryThrough the use of talk therapy and free association, Freudcame to believe that there were three levels of psychologicalawareness. He used the image of an iceberg to describe theselevels of awareness.1.Conscious—the part of the mind he compared to the tipof the iceberg. It contains all the material a person isaware of at any one time, including perceptions,memories, thoughts, fantasies, and feelings.2.Preconscious—just below the surface of awarenesswhich contains material that can be retrieved rathereasily through conscious effort.3.Unconscious—this includes all repressed memories,passions, and unacceptable urges lying deep below thesurface. Emotions associated with trauma are often“placed” in the unconscious because the individualfinds it too painful to deal with them. It is usually toodifficult to retrieve unconscious material without theassistance of a trained therapist.Personality structure is described as three categories ofexperience:1.Id—source of drives and instincts; includes geneticinheritance; reflexes, wishes that motivate us; uses pleasureprinciple, is not logical, and lacks the ability to problemsolve.2.Ego—develops because the needs, wishes, and demands ofthe id cannot be satisfactorily met through primaryprocesses and reflex action. The ego emerges in the fourthor fifth month of life and follows the reality principle,which says to the id, “You have to delay gratification for

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3-3right now” and sets a course of action.3.Superego—internal representative of values, ideals, andmoral standards of society; strives for perfection asopposed to seeking pleasure or engaging reason. Thesuperego consists of the conscience (all the “should nots”internalized from parents) and the ego ideal (all the“shoulds” internalized from parents).In a mature and well-adjusted individual, the three systems ofthe personality work together as a team under the leadership ofthe ego.Freud suggested that ego defence mechanisms are developedto reduce anxiety by denying, falsifying, or distorting reality toprevent conscious awareness of threatening feelings. Thesemechanisms operate unconsciously.He further wrote that the individual proceeds through a seriesof psychosexual stages of development from infancy toadulthood. Each stage (except latency) refers to the bodilyzone that produces the main source of gratification during thestage. Each stage has its own conflict to be resolved:1.Oral—0 to 1 year: weaning2.Anal—1 to 3 years: toilet training3.Phallic—3 to 6 years: oedipal conflict4.Latency—6 to 12 years: hides sexuality from disapprovingadults5.Genital—12 to 20 years: genital sexualityClassical PsychoanalysisClassical psychoanalysis, among the least practised therapiesand the most expensive, calls for protracted one-on-onetherapy with an analyst. It makes use of free association andworking through transference to uncover unconscious feelingsand thoughts that interfere with the patient’s life. The patient ismore active than the therapist.Psychodynamic TherapyThe psychodynamic approach to therapy “understands thatunconscious dynamics exist within normal human conscious-ness and that it is possible in therapy to engage many aspectsof the human psyche in ways that are useful, creative, andhealing” (Canadian Association for Psychodynamic Therapy,n.d., para. 2).The best candidates for brief psychotherapy are relativelyhealthy and well-functioning individuals, sometimes referredto as the “worried well,” who have a clearly circumscribedarea of difficulty and are intelligent, psychologically minded,and well motivated for change. Patients with psychosis, severedepression, borderline personality disorders, and severecharacter disorders often are not appropriate candidates for thistype of treatment. Supportive therapies, which are within thescope of practice of the basic-level psychiatric nurse, areuseful for these patients. A variety of supportive therapies are

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