The Nurses’ Guide to Psychotherapy: A Reference book for Nurses providing psychotherapy by Eds Roles & Kalia [1] was written as a foundational textbook for new or experienced nurses who provide psychotherapy. Chapter 18 of this book, authored by Roles, Valiente, Rijo & Castonguay [2], titled Training and Psychotherapy, focuses on the training that a nurse might engage in from the many specific types of psychotherapies that exist, and the importance of this training to provide clinicians with a theoretical framework from which to practice. The chapter identifies that while different modalities of psychotherapy may have their own unique theories, approaches, and models, all psychotherapies share a core understanding of knowledge and skill accompanying the specific goal of improving mental health and wellness.

The Y model of psychotherapy [3], which was introduced in Chapter 16 of the Nurses’ Guide to Psychotherapy [1], outlines some of the core skills that a clinician should learn to obtain a level of skill and comfort, prior to engaging in psychotherapy training programs. The base of the Y, the core therapeutic skills, are those taught in many college, undergraduate, and terminal degree programs. Nursing, Social Work, Social Service Work, Medicine, Psychology, among others include these important therapeutic skills in their foundational programs. Part of these core therapeutic skills includes developing a therapeutic alliance which is fundamental for people accessing mental health support and ultimately leads to more positive outcomes [4]. Although in some cases therapeutic rapport may be difficult to develop, having therapeutic alliances offer a more person- centered and recovery-oriented treatment approach because they are rooted in human connection [4] and are therefore well worth the effort as an instrumentally important component of therapy. Within this relationship, practitioners use core skills to support the client(s), and may include general counselling skills [5] such as attentive behavior, questioning, confrontation, focusing, and reflection [6]. Active listening, attending skills, and reflecting on thoughts and emotions are used in many different types of psychotherapy [7] and can be included in all training programs or taken as a foundational component prior to engaging in further psychotherapy training. These core skills can be found in Figure 1, Y Model Restructured which was adapted in Roles & Kalia [1] to include headings of Structured and Unstructured Psychotherapies.

Structured psychotherapy is an approach to mental health interventions that is systematic, short-term and evidence-based [8]. The systematic approach used in structured psychotherapy often has protocol-based interventions, an approach where the majority of the treatment includes an outline that can be followed, but can still be collaborative with the client. Many modern psychotherapies utilized today would fall under this structured psychotherapy category and some may include cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), eye movement desensitization and reprocessing (EMDR) therapy, and compassion focused therapy (CFT) [8]. Unstructured psychotherapy, for the purpose of this summary, may include approaches that are noted to be less collaborative (in that the client may not be aware of the steps the therapist is taking in the advancement of the therapeutic intervention), they may have few if any systematic steps, and may have underpinnings that are heavily based in theory rather than protocol [9]. Unstructured psychotherapy may be viewed as exploratory, often using free association methods whereby the clinician helps the client identify sometimes spontaneous and unconnected, conscious or unconscious themes in order to identify content that arises in the client’s mind [10]. Psychotherapies that fall under this category might include: psychoanalysis, psychodynamic therapy, internal family systems, polyvagal-informed therapy, acceptance and commitment therapy, brain spotting therapy, and compassion focused therapy [10]. Compassion focused therapy has been included into both structured and unstructured types of psychotherapy as it was born out of both forms and can naturally follow either a structured or unstructured approach [9].

Beyond the base of the Y and the core therapeutic skills that are often taught in college, undergraduate, and terminal degree programs, many introductory levels to psychotherapy modalities from either arm of the Y (structured and unstructured) are also introduced, but often without full training, supervision and clinical experience to be able to practice them fully and with a competent level of skill. Receiving training in one or more of the many types of psychotherapies that exist is important to give psychotherapists a theoretical framework to work from. Further, clinical supervision is critical as it allows for objective feedback while implementing the therapeutic intervention, and the opportunity for continual learning and growth as a therapist. Supervision must be continuous throughout the clinicians career as they are constantly treating new clients with different presentations, and gleaning new skills in various types of therapies. Supervision allows therapists the ability to challenge themselves and to continuously become better therapists for the clients they treat. Consultation, which differs from supervision, enables the therapist to ask questions about complex client presentations and can be an extremely valuable way to connect with peers and to seek advice from expert psychotherapists specializing in a particular modality. With further education and/or on the job training, one can gain a more specialized understanding of the theoretical principles underpinning the specific psychotherapeutic modalities [6] and ways to properly implement the intervention. These specific therapeutic approaches may become the focus of the new psychotherapist's career. As clinicians expand their skill and knowledge base they can move along the arms of the Y, in a specific therapy type, as they progress from novice to expert [11]. As a clinician becomes an expert in one type of therapy, they may begin as a novice in another or in multiple therapies at once.

Clinicians who are in supervision or consultation, and striving to move from novice to expert level in a chosen model of therapy, often question when they can pull or blend an intervention or approach from one therapy type when practicing in another. This question does not have a direct or simple answer. Rather, when a psychotherapist becomes an expert in more than one psychotherapy modality, perhaps one or multiple from each side of the structured and unstructured psychotherapy arms of the Y Model, they have an advanced understanding of which therapies and interventions can be blended and which cannot. They will also have an adaptive ability as an advanced therapist to be able to maneuver between theoretical foundations and interventions as they arise and as beneficial to the client(s). With this ability they will not only be able to blend and pull from multiple therapy types, but would also be able to answer this question about blending therapy interventions themselves, as the skill set would drive the flow of the therapy. See Figure 2 for this joining or blending of the two arms of the Y Model as an Expanded Y Model.

The Expanded Y Model depicts the coming together of therapy modalities and interventions through expert skill set and knowledge of the clinician. The ways of knowing a therapist develops is the art behind the science of therapeutic intervention. Similar to nurses’ ways of knowing [12] which recognizes that nursing knowledge goes beyond scientific knowledge and encompasses personal experiences, ethical considerations, and the art of nursing, is a similarity to the way that therapists build this knowledge and way of knowing into their way of intervention. This art combined with science and the way in which it is communicated between therapist and client is the skill set behind the interventions and the difference between computer based therapies and a human therapist. It is the ability to pinpoint the intricacies in the clients presentation, to make decisions regarding which type of therapy modality to utilize, and then, which intervention to implement. This occurs at the appropriate time and with the appropriate timing within the conceptual whereabouts of the clients’ self-awareness and the therapeutic alliance.

Emelia, a 33 year old female, recently sought therapy to work through symptoms of grief and Post-Traumatic Stress Disorder (PTSD) following the sudden and traumatic death of her husband from a car accident 2 years ago. Feeling that she was unable to “move through this grieving process” she began to think that something was wrong with her and was very critical of herself for not being able to “feel better” and start to “move on”. The therapist, trained and highly skilled in multiple modalities, assessed Emelia’s needs and symptoms and based on her presentation decided to begin by using cognitive behavioral therapy (CBT) and prolonged exposure (PE) therapy to target the symptoms of PTSD and grief. As therapy continued, parts of cognitive processing therapy (CPT) were added to identify and work through stuck points which helped to identify further emotions of guilt that were fueling the grief. Compassion focused therapy (CFT) was utilized, implementing chair work to give the emotions a voice and allowing the compassionate self to explore the feelings of guilt and the initial self-criticism of not being able to “move on”. Brain spotting therapy and parts of psychodynamic psychotherapy such as free association, were then blended, allowing the client’s unconscious and conscious to target any residual areas she was needing to process.

Throughout any psychotherapists’ practice, there should be an ongoing drive for additional learning through training, supervision, consultation and perhaps with this, the ability to blend psychotherapies as appropriate. Clinicians are continuously striving to move from novice to expert by increasing their knowledge and skills to improve the interventions best suited for their clients. The Expanded Y Model serves as a way for psychotherapists, regardless of their clinical discipline and perhaps by embracing transdisciplinary approaches in psychotherapy, to expand their knowledge base in many modalities, across disciplines, and in blending approaches to best support the clients they serve.

Ethan Lamothe, St. Catherines, ON, Canada for his contributions to this publication.