Exploring psychotherapeutic issues and agents in clinical practice
As difficult as it may be for someone to decide to seek mental health care, following up with repeat appointments is more difficult. Many studies have explored the issues of mental health literacy, stigma, and financial and cultural barriers as reasons for individuals who are struggling with emotional and mental health problems to avoid seeking professional care (Nakash et al., 2018; Planey et al., 2019; Seidler et al., 2020; Stewart et al., 2019). A common route to that first appointment is discharge from an emergency department or a first hospitalization following a mental health crisis. Best practice in discharge planning is establishing an appointment with an outpatient therapist. How many actually show up for that first appointment, and how many continue with follow-up appointments? Approximately 20% of mental health clients miss appointments (Greeno et al., 2012; Mitchell & Selmes, 2007), resulting in financial loss to the agency and/or provider as well as clients' increased chance for rehospitalization, poor medication adherence, and suicidal crises (Greeno et al., 2012; Kheirkhah et al., 2016; Zhang et al., 2020). Reasons for no-shows include financial and transportation hardships, wait times, cultural perceptions, as well as age and gender differences (Greeno et al., 2012; Mitchell & Selmes, 2007).
Key to establishing care with a mental health professional is building a relationship based on trust and compassion. Establishing that relationship takes time, yet the beginning of that process occurs in the initial appointment and negotiation of a plan of care that the client can commit to. The current article focuses on the process of negotiating a plan of care that is collaboratively agreed upon and renegotiated as appropriate. When the plan of care is collaboratively developed, psychotherapy and pharmacotherapy adherence become non-issues because the client and provider trust one another and have established a clear path to achieve the desired goals.
Building the Therapeutic Relationship
A therapeutic relationship is one that is nonjudgmental, consistent, and reliable. Individuals seeking mental health care, however, often have experienced conflictual relationships with friends, family, and loved ones with patterns of destructiveness, invalidation, and inconsistency. In anticipation of the same from a provider whom they do not know, they may withhold or distort important personal information in the assessment process that delays the caring process. During the intake appointment, the provider attempts a careful and thorough assessment of the client's past and current events to conceptualize and clarify the client's desired outcomes and arrive at a plan that matches what the client wants and needs with what the clinician can realistically provide. The plan focuses on reality and trust in each other, even when both parties barely know one another sufficiently to have that trust.
In these times of clinic cost-effectiveness and insurance-driven reimbursement, the amount of time allocated to the crucial initial assessment has become so limited that relationship building is sacrificed for efficiency. Without the relationship, however, the client may feel not cared for and not return for continuing appointments. Spending time in these first hours of assessment allows the client to tell their story, explore alternative behaviors and outcomes, and reach an agreement on what, how, and when to learn ways of achieving those outcomes. The clinician and client can arrive at a written agreement that the client can commit to accomplish with the help of the nurse. The plan focuses on the client's strengths as a foundation to then work on problems to resolve with specific expectations that can be measured in realistic increments over time, and recognition of the role of the provider in helping achieve those expectations. It is a plan of caring for the other within respect for autonomy, independence, and appropriate dependence. There is a shift that occurs, placing the diagnosis into the position of meeting regulatory and reimbursement requirements and the problematic and painful behaviors into the position of problems to be solved.
Diagnoses within the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 2013) are heterogenous, whereas pharmacotherapy is transdiagnostic (Waszczuk et al., 2020), meaning psychiatric symptoms are mediated by neurophysiological dysfunction more than diagnostic categories, and are more amenable to treatment with medication. For example, individuals who experience hypervigilance, exaggerated startle, and difficulty modulating affect, especially anger, are demonstrating behaviors related to increased responsiveness to norepinephrine in the amygdala and/or insufficient modulation from the hippocampus and medial prefrontal cortex (Higgins & George, 2019). These behaviors, often associated with posttraumatic stress disorder, can be modulated by medications that tone down the sympathetic nervous system and counterbalanced with a serotonin agent. By thinking in terms of the neural circuitry and explaining the neural circuitry to the client, the clinician negotiates a plan of care with the client that includes medication to treat the neurochemical component and psychotherapy to treat the behavioral and consequential components. In taking this transdiagnostic approach to pharmacotherapy, the clinician describes symptom dimensions and how they account for illness severity and distress. In fact, studies of prescribing practices demonstrate that clinicians prescribe more in line with symptoms than the DSM diagnoses, and in doing so treatment outcomes are more effective (Perkins et al., 2020; Waszczuk et al., 2017). Treatment is more individualized and prioritizes symptoms within the context of neurobiology and how they affect the client's life and relationships.
Addressing symptoms from this direction reduces stigma and engages the client in thinking about their commitment to change and improving their quality of life. When the client understands how the brain circuitry contributes to symptoms and how medication can adjust that circuitry, they can feel empowered to work with the clinician to learn new ways of managing their response to the neural dysfunction as medication improves their brain functioning. Adherence to medication is no longer an issue and instead becomes a commitment to a holistic approach to recovery that includes the neurochemical and psychosocial elements of mental disorder.
Negotiating a Plan of Care
The intake appointment is a time for thorough assessment and case formulation, necessitating a detailed history of developmental process, family history, relationship history, past mental health care, and the current issue and symptomatology. There are guidelines for assessment and diagnosis that include interviewing schedules, measurement tools, and patient questionnaires. In addition, the clinician will gather previous medical records and physical examination and laboratory tests.
Gathering the information for assessment can be a procedural detail of questioning or a time to ask the client to tell their story in whatever manner feels comfortable. The clinician organizes the story to complete the picture and guides the client to provide greater depth of detail, as necessary. To engage the client, the clinician may ask “Is this how you see it? Or am I summarizing correctly?” As the clinician and client reach an understanding of the problem, the clinician moves into the case formulation phase by sharing a conceptualization of the overall effect of the problem in the client's life and inquires about how the client would like their life to be different. This inquiry permits a discussion of expectations on the part of the client and the clinician in achieving desired outcomes, a timeframe for meeting outcomes, how to measure progress, and when and how to change directions in the plan of care. Negotiating the plan of care is likely to be a conversation for a follow-up appointment rather than a conclusion to the intake appointment. Ending the intake appointment with a strategy for the client and clincian to think about what happened during the initial appointment and a return time to discuss how they can work together. By separating the assessment and planning of care, the clinician demonstrates thoughtfulness about the client and respect for the client's autonomy.
The follow-up appointment may be even more difficult for the client because they feel more vulnerable; hence, there is a greater chance of cancellation or no-show for the appointment. Mentioning this at the end of the intake appointment validates the courage it takes to proceed with the plan and provides an opportunity for the clinician to help the client commit to returning for the next appointment. Asking the client if it would help to have a reminder phone call or text message just prior to the appointment will help assure attendance (Dantas et al., 2018; Laitila et al., 2018; Teo et al., 2017).
Starting the follow-up appointment by inquiring how the client felt about the process and working with the clinician sets the stage for a collaborative relationship. The clinician then reviews the assessment data and problem formulation with the client and asks for confirmation for accuracy. At this point, the clinician reminds the client of informed consent in arriving at a treatment plan to solidify the notion that the client must agree with the plan for the working relationship to be effective. This is also an important time to encourage the client to express any concerns for the process and understanding about the reasoning for the plan of care. By engaging the client in a frank discussion about each person's role in the plan, the clinician invites the client to commit to working together and minimizes a power differential. When prescribing a medication, the client again has the power to seek more information before agreeing, disagreeing with a particular medication, or asking for more options. The clinician has the power to write the script and the client has the power to take the medication—it is shared power. The treatment alliance is based on recognition of shared power and responsibility, which is the critical link in having an effective therapeutic relationship (Lawrence et al., 2019; Yeandle et al., 2015).
Finally, providing the client with a written statement of the medication policy clarifies and formulizes how pharmacotherapy works in conjunction with psychotherapy. The policy statement should include specifics of what to expect of the prescribing process, how to deal with side effects, when and how to get refills, and addressing issues of scheduled medications (see sample prescribing practice policy [Table A, available in the online version of this article.]). The clinician verbally reviews the policy with the client, answers questions, and seeks the client's agreement.
Sample Prescribing Practice Policy
Achieving Continuity of Care
How to negotiate a plan of care that is collaborative and fits within the current climate of practice is a more difficult question to answer when clinical practice is based on time efficiency and insurance and agency accountability. New clinicians as well as veterans will say, “How can I do that when I am limited to a 45- or 60-minute intake appointment and a 30-minute follow-up medication appointment?” By setting a foundation for a therapeutic relationship in this initial and immediate follow-up appointment, premature termination, no-shows, missed medications or failure to pick up refill medications, re-hospitalizations, and emergency department visits can be averted. The clinician may need to negotiate with clinic administration to assure adequate time with the client and strongly advocate for best practices that ultimately are more cost-effective and satisfying to the client and clinician.
Foundational to psychiatric–mental health nursing is the therapeutic relationship with the client. Peplau (1952) asserted:
To encourage the patient to participate in identifying and assessing his problem is to engage him as an active partner in an enterprise of great concern to him. Democratic method applied to nursing requires patient participation. It depends upon working toward consent and understanding of prevailing problems, related reality factors, and existing conditions by all participants. The power for accomplishing the tasks at hand, in ways that develop or expand personality, resides in the consent and understanding that motivate all persons concerned.
Being an active partner in pharmacotherapy and psychotherapy is essential to the client's recovery. Collaborative care is what we do as psychiatric–mental health nurses. When advanced practice nurses insist on directing their full scope of practice, we demonstrate our commitment to our clients and our profession.
- American Psychiatric Association.(2013).Diagnostic and statistical manual of mental disorders (5th ed.).
- Dantas, L. F., Fleck, J. L., Cyrino Oliveira, F. L. & Hamacher, S. (2018). No-shows in appointment scheduling: A systematic literature review. Health Policy (Amsterdam), 122(4), 412–421 doi:10.1016/j.health-pol.2018.02.002 [CrossRef] PMID:29482948
- Greeno, C. G., Zimmerman, T., Kelly, M., Weaver, A. & Anderson, C. M. (2012). “What is therapy?” A therapist-developed intervention to reduce missed appointments in community mental health. Social Work in Mental Health, 10(1), 1–11 doi:10.1080/15332985.2011.620506 [CrossRef]
- Higgins, E. & George, M. S. (2019). The neuroscience of clinical psychiatry. Wolters Kluwer.
- Kheirkhah, P., Feng, Q., Travis, L. M., Tavakoli-Tabasi, S. & Sharafkhaneh, A. (2016). Prevalence, predictors and economic consequences of no-shows. [NPG.]. BMC Health Services Research, 16, 13 doi:10.1186/s12913-015-1243-z [CrossRef] PMID:26769153
- Laitila, M., Nummelin, J., Kortteisto, T. & Pitkänen, A. (2018). Service users' views regarding user involvement in mental health services: A qualitative study. Archives of Psychiatric Nursing, 32(5), 695–701 doi:10.1016/j.apnu.2018.03.009 [CrossRef] PMID:30201197
- Lawrence, R. E., Perez-Coste, M. M., Bailey, J. L., DeSilva, R. B. & Dixon, L. B. (2019). Coercion and the inpatient treatment alliance. Psychiatric Services (Washington, D.C.), 70(12), 1110–1115. doi:10.1176/appi.ps.201900132 [CrossRef] PMID:31480927
- Mitchell, A. J. & Selmes, T. (2007). A comparative survey of missed initial and follow-up appointments to psychiatric specialties in the United kingdom. Psychiatric Services (Washington, D.C.), 58(6), 868–871. doi:10.1176/ps.2007.58.6.868 [CrossRef] PMID:17535950
- Nakash, O., Cohen, M. & Nagar, M. (2018). “Why come for treatment?” Clients' and therapists' accounts of the presenting problems when seeking mental health care. Qualitative Health Research, 28(6), 916–926 doi:10.1177/1049732318756302 [CrossRef] PMID:29415635
- Peplau, H. (1952).Interpersonal relations in nursing: A conceptual frame of reference for psychodynamic nursing. G.P. Putnam and Sons.
- Perkins, E. R., Latzman, R. D. & Patrick, C. J. (2020). Interfacing neural constructs with the hierarchical taxonomy of psychopathology: ‘Why’ and ‘how’. Personality and Mental Health, 14(1), 106–122 doi:10.1002/pmh.1460 [CrossRef] PMID:31456351
- Planey, A. M., Smith, S. M., Moore, S. & Walker, T. D. (2019). Barriers and facilitators to mental health help-seeking among African American youth and their families: A systematic review study. Children and Youth Services Review, 101, 190–200 doi:10.1016/j.childyouth.2019.04.001 [CrossRef]
- Seidler, Z. E., Rice, S. M., Kealy, D., Oliffe, J. L. & Ogrodniczuk, J. S. (2020). What gets in the way? Men's perspectives of barriers to mental health services. The International Journal of Social Psychiatry, 66(2), 105–110 doi:10.1177/0020764019886336 [CrossRef] PMID:31692401
- Stewart, G., Kamata, A., Miles, R., Grandoit, E., Mandelbaum, F., Quinn, C. & Rabin, L. (2019). Predicting mental health help seeking orientations among diverse undergraduates: An ordinal logistic regression analysis. Journal of Affective Disorders, 257, 271–280 doi:10.1016/j.jad.2019.07.058 [CrossRef] PMID:31302515
- Teo, A. R., Forsberg, C. W., Marsh, H. E., Saha, S. & Dobscha, S. K. (2017). No-show rates when phone appointments are not directly delivered. Psychiatric Services (Washington, D.C.), 68(11), 1098–1100. doi:10.1176/appi.ps.201700128 [CrossRef] PMID:28967322
- Waszczuk, M. A., Zimmerman, M., Ruggero, C., Li, K., MacNamara, A., Weinberg, A., Hajcak, G., Watson, D. & Kotov, R. (2017). What do clinicians treat: Diagnoses or symptoms? The incremental validity of a symptom-based, dimensional characterization of emotional disorders in predicting medication prescription patterns. Comprehensive Psychiatry, 79, 80–88 doi:10.1016/j.comppsych.2017.04.004 [CrossRef] PMID:28495012
- Waszczuk, M. A., Eaton, N. R., Krueger, R. F., Shackman, A. J., Waldman, I. D., Zald, D. H., Lahey, B. B., Patrick, C. J., Conway, C. C., Ormel, J., Hyman, S. E., Fried, E. I., Forbes, M. K., Docherty, A. R., Althoff, R. R., Bach, B., Chmielewski, M., DeYoung, C. G., Forbush, K. T. & Kotov, R. (2020). Redefining phenotypes to advance psychiatric genetics: Implications from hierarchical taxonomy of psychopathology. Journal of Abnormal Psychology, 129(2), 143–161 doi:10.1037/abn0000486 [CrossRef] PMID:31804095
- Yeandle, J., Fawkes, L., Beeby, R., Gordon, C. & Challis, E. (2015). A collaborative formulation framework for service users with personality disorders. Mental Health Practice, 18(5), 25–28.
- Zhang, X., Felici, J., Gander, H., Mubariz, A. R. & Schanzer, B. (2020). Twelve-month analysis of nonattendance for initial assessment in a resident outpatient psychiatry clinic. Journal of Psychiatric Practice, 26(4), 337–343 PMID:32692133
Sample Prescribing Practice Policy
|To provide thorough services to all clients we have developed this policy for prescribing medications to clients receiving care. This policy is based on the state nursing practice act and current standards for clinical practice.
All clients who are registered with this clinic and receiving care from a therapist have access to a prescriber. Some therapists are also qualified as prescribers (psychiatric mental health nurse practitioners) and may prescribe for their therapy clients or refer to another prescriber if the situation warrants.
Medications are prescribed after a full assessment that includes health history, focused physical assessment such as vital signs and weight, and history of previous care. Initial prescriptions may be provided at that first assessment or require a follow up appointment pending medical records and/or laboratory assessments.
Prior to prescribing all medications are reviewed with the client (and family if a minor) regarding risks and benefits, reason for the medication being prescribed, and manner in which the medication will help. Clients will receive written instructions for taking the medication, and will sign a consent that they understand the medication and agree to take it.
Repeat prescribing is a partnership between client and prescriber that allows the prescriber to authorize a prescription so it can be repeatedly issued at agreed intervals, without the client having to consult the prescriber at each issue. The community pharmacy may order the repeat on behalf of the client under some managed prescription services.
All prescriptions are sent to the pharmacy through the electronic health record only. There will be no hard copy (written) prescriptions issued except under unique circumstances or as required by the DEA.
Renewal of prescriptions
After an initial trial of medication that includes gradual tapering of the dosage to achieve likely effectiveness, a medication can be renewed for no more than 90 days at a time unless a shorter time is required by DEA regulations.
Clients need to monitor the supply of medications available and request refill within no less than 7 work days prior to running out.
To request a refill, the client will call their pharmacy. The pharmacy will seek renewal from the prescriber as necessary. Although pharmacies vary, most require at least 4 days to refill a prescription.
Controlled substances (e.g., benzodiazepines, stimulants) can be prescribed for 30 days only without refill. Therefore, all refills require a direct prescription from the prescriber to the pharmacy as opposed to automatic refills.
Pre-authorization with third party payers
Some medications require a pre-authorization with third party payers. Commonly these include relatively new medications, expensive medications, and controlled substances.
The insurance company or pharmacy notify the prescriber of the need for pre-authorization. This requires the prescriber to complete additional documents and sometimes appeal documents. Completing the pre-authorization requires at least 5 work days that will likely delay receipt of medication. The client may call their insurance company to request an expedited review.
If the pre-authorization is denied, the prescriber may appeal the decision or develop an alternative treatment plan in collaboration with the client.
Medications controlled by the DEA require special consideration. These medications include benzodiazepines, stimulants, and pain medications.
This clinic does not provide pain management and will not prescribe these medications. Clients who need pain medications will be referred to a primary care provider and/or a pain management clinic.
Benzodiazepines are indicated for the treatment of anxiety; however, they are limited to short term (no more than 4 weeks) use due to their high potential for tolerance and dependency. Benzodiazepines will be prescribed within these clinical standards only and use beyond the 4-week limit require a written plan for tapering and discontinuing the medication as soon as clinically reasonable. The plan will include the schedule for tapering and be signed by both the client and the prescriber. Deviation from the plan may result in termination of treatment.
Stimulants such as amphetamines and methylphenidates are indicated for treatment of attentional disorders that require extensive assessment for diagnosis. When prescribed for the first time, the dosage needs to be modified based on effects until the therapeutic level is achieved. Therapeutic doses may vary widely depending on individual client variables. Once the client achieves the therapeutic effect, that dose will remain unaltered until further assessed. Refills require a direct prescription to the pharmacy and cannot be ordered early or additional doses authorized without a separate prescription. This usually requires an appointment with the prescriber.
Prior to refilling any controlled substance, the prescriber will review the Prescription Drug Monitoring Program (PDMP), a statewide online tool that provides information about prescriptions and medication dispensing of all schedule II–Iv controlled substances. Prescription refills can be denied if the PDMP shows that the client has received a prescription for the requested drug or related drug by anyone other than this prescriber.
Since medications affect changes in the body overall, it may be necessary for the prescriber to request laboratory assessments prior to prescribing medications and monitoring the effects of medications. The prescriber will explain these assessments prior to requesting these and inform the client of how to get the assessments.
Laboratory assessments are done at other locations not affiliated with this clinic, and the client is responsible for insurance coverage. The prescriber will provide referrals to the appropriate laboratories or outpatient services, including the PCP.
The client is responsible for getting all necessary laboratory assessments within a week of the request. If this cannot be done, the client needs to inform the prescriber to make other arrangements.
Occasionally random urine samples are necessary to assure appropriate treatment plans. When this is needed, the client will provide the sample.
Treatment adherence monitoring
The treatment plan, including prescribed medications, are negotiated collaboratively between the client and all the involved providers at this clinic. Additionally, collaboration with the primary care provider (PCP) and any other medical providers is essential for quality coordinated care.
Upon admission to this clinic the client will sign for permission to gather necessary medical records. The client is responsible for communicating with their PCP regarding medications provided by this clinic. The prescriber may also collaborate with the PCP regarding medication changes and laboratory tests needed for assessment of medication effects. The prescriber will inform the client of any communication with other providers as needed for continuity of care.
It is the client's responsibility to take medications as prescribed and to communicate with the prescriber any adverse or side effects experienced or difficulty in taking the medication. Usually side effects can be managed with time and dosage adjustments that your prescriber can help you find.
At every contact with the client, the prescriber will review all the medications the client is taking, the dosages, and frequencies. This is to clarify any drug-drug interactions, duplications, and contradictions.
If a client is significantly over or under using medication, the prescriber will discuss with the client and may not refill further prescriptions.
|The client will receive a copy o f these policies. Signature indicates receipt and understanding of the contents.|
|Signature of the client||Date|
|Printed name of the client:|