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Revista Portuguesa de Enfermagem de Saúde Mental

versão impressa ISSN 1647-2160

Revista Portuguesa de Enfermagem de Saúde Mental  no.13 Porto jun. 2015




European Mental Health Nursing and Psychotherapy


Martin F. Ward*

*Diploma in Nursing; Registered Mental Health Nurse; Certificate in Education; Registered Nurse Teacher; NEBSS Diploma; MPhil; PhD; President of Horatio: European Psychiatric Nurses; Head of the University of Malta – Department of Mental Health, Msida MSD 2080
 Malta. E-mail:


Few issues cause as many heated discussions amongst mental health care professionals as that of who can, and who cannot, become a psychotherapist. In Europe confusion exists mainly because different countries offer a variety of qualification programmes but interpret the guidelines of the European Association of Psychotherapy (EAP) according to their own national needs and professional agendas. So, for example, a nurse wishing to undertake a postgraduate course in psychotherapy in some cantons of Switzerland may be refused entry, whereas another with the same qualifications in Belgium or Finland will be accepted. Yet, these countries are regulated by the same Association. Universally, psychologists and psychiatrists are seen as having the ‘correct’ entry qualifications yet one could argue that their professional background does not necessarily prepare them any better for the rigours of psychotherapeutic activities than mental health nurses, occupational therapists or social workers. So, why is there so much confusion?

As the Horatio: European Psychiatric Nurses position paper on psychotherapy and mental health nurses (2012) points out this debate is dominated by several factors: 1. historical and cultural issues – i.e. the development of psychiatric services and the role of nurses within them including their academic preparation; 2. the type and modality of psychotherapy to be offered – e.g. brief therapies as opposed to long term psychoanalytical, 3. national legislation as a local interpretation of EAP guidance and 4. the dominance of one mental health profession over others - based on a combination of issues from the other three factors. Each of these factors is complicated simply because the variables differ across borders, 27 in the EU and many more across a wider Europe. Yet this is despite the fact that the underlying principles for preparation and qualification are clearly laid down by the EAP, in items 4 and 5 of the Strasburg Declaration on Psychotherapy (EAP 2009) in turn supported by the World Council of Psychotherapy (WCP). Simply put, the base line requirements are a graduate level professional qualification in the humanities or social sciences and a graduation course of theory and supervised practice (3,200 hours). The whole lasts a total of seven years, the degree being the first three, the remaining four following a specific psychotherapeutic approach. Perhaps the omission of the word ‘nurse’ in the Declaration has lead to some local organisations stipulating that it is not one of the entry criterion but such a position suggests political lobbying by other professions in an attempt to protect interdisciplinary boundaries. It could also be speculated that authorities are concerned about standards of therapy care, though this is questionable given that all trainees must undergo the same preparation to register as a psychotherapist and some countries do not even maintain a register of specialist practitioners. Regardless of the reasons this situation has created a psychotherapy map of Europe that is as patchy as a hand made bed quilt!


Why Would a Nurse Decide to Become a Psychotherapist?

The question that should be asked, and one not addressed in the Horatio document, is, given the confusion and difficulties that exist why would a psychiatric/mental health nurse want to become a psychotherapist in the first place? After all, whether or not the individual has undertaken postgraduate courses to work in mental health or has a first degree in the subject, a considerable amount of years have been invested in becoming a mental health nursing practitioner. In addition, choosing nursing as a career option, particularly in mental health, is not a decision taken likely given the poor professional status they endure in some European countries and the stigma and suspicion associated with mental illness generally. Based on the evidence from Horatio a part of this question can be answered by comparing the profile of individuals who choose to work as therapists.

In the main European nurses tend to choose psychotherapeutic programmes which allow them to deliver brief therapies such as cognitive behavioural therapies, (UK, Turkey and the Czech Rep.) and very often focus on specific diagnoses such as alcohol related disorders (Finland), re-hospitalised patients suffering from schizophrenia (Germany) and patients suffering depressive disorders (Portugal). Where the term ’Nurse Therapist’ is permitted by law or through national regulatory bodies, nurses with the appropriate training deliver what are often termed, supportive or modified therapies. This is therapy at a lower level but complying with the fundamentals of a specific psychotherapeutic approach. In both the Czech Rep. and Turkey nurses ‘therapists’ from a mental health background carry out this work almost entirely. However, in both countries ‘professional psychotherapy’ is provided by psychiatrists and/or psychologists trained as psychotherapists. Whilst in the Czech Rep. there are moves to allow nurses holding a Master’s degree to enter these training programmes the absence of these programmes themselves hinder the chance of such a thing happening very soon. So, nurses can be restricted to undertaking what might be considered lower level therapy not because of their ability or potential skills but because of their academic background.

Conversely in places such as The Netherlands, Iceland, Belgium, Finland, UK and Ireland things are different either because of the lack of any legislation or because nursing qualifications are more readily accepted as being appropriate for entry into psychotherapy. Again we see the same pattern developing in these more permissive professional organisations as those in the ‘support’ area of practice. Namely, they tend to specialise in specific conditions and using brief therapies. Gournay, Dentford and Newell (2000) undertook a 25-year follow up of nurses working in behavioural psychotherapy in the UK using a sample (n=237) of trained nurse-therapists. They showed that these nurses had made a considerable contribution to mental health service provision, specifically in primary health care, using brief and short-term therapies. In a third group, those where only psychiatrists and psychologists can train and register as psychotherapists (Germany, Lithuania, Italy, Russia) nurses still focus on specific disorders but use nursing theorists to shape their interventions, such as Peplau and Barker, rather than psychotherapeutic theory. In a final group, represented here by Slovakia, there simply are not enough mental health nurses to justify further ‘micro-specialisation’. So, for many years to come and/or until there are more mental health nurses, psychotherapy will be delivered by other professional groups.

What this tells us is that many nurses working with the mentally ill in Europe are dissatisfied with their existing level of training and skills and wish to develop them further to become more effective as practitioners. If this were not the case why else would they subject themselves to intensive training courses and specialise in areas where they had a particular interest? It would not, as could be cynically speculated, be seen as way of ‘leaving’ nursing and becoming a therapist instead. What it may tell us is that many nurses see the process of becoming a nurse therapist or specialist therapist as a natural progression in their professional careers. In countries that have Advanced Nurse Practitioners (ANP) such as The Netherlands, Switzerland and Sweden, moving on to become a nurse therapist in a special area or with a specific disorder might also be seen as a positive career option.

But, this is at best mere speculation because no research has ever been published to try to discover why nurses choose to become psychotherapists. All that it provides us with is food for thought. When one considers the nature of mental health nursing what is strikingly obvious is the amount of time that nursing spends in the direct company of patients as opposed to that of other professional mental health disciplines. By choosing to become psychotherapists, or indeed any form of specially trained therapist, they are opting to intensify the nature of the relationships they develop with those patients. The implication of such a move suggests a desire to be better equipped to offer help and to use more dynamic processes to achieve it. Of course, there may well be another motive though this is more tenuous than the above.

We know that there is dissatisfaction with the growing influence of psychotropic medication, seen by many as the ‘medicalization of mental health care (Moncrieff 2003). Research tells us that there simply are not enough alternatives to medicating those with mental health challenges (Gournay, 2000 specifically highlighted the fact that there were not enough nurse behaviour therapists to meet demand). It may well be that mental health nurses, confronted with the frustration of medication management regimes, see entering into the ‘talking therapies’, much akin to the own training as a mental health nurse, as a far better use of their natural talents and far more likely to meet patient needs. Exposing nurses to the failings of a care system and allowing them the opportunity to progress to something they see as more valuable and in keeping with their own skills base, would seem to be a definite reason why they might see psychotherapy as a viable career option.


In Conclusion

However, there is one final point to be made concerning mental health nursing and the shift to psychotherapy. The European Council of the Liberal Professions (CEPLIS) states that professional codes of practice must show that individual practitioners maintain their professional development throughout their professional careers (CEPLIS, 2007). It might be argued that becoming a qualified psychiatric/mental health nurse was the start of a helping career, not the end point. As such, universities and training authorities throughout Europe ought to be considering the development of nurse therapy, psychotherapy and therapy driven practice programmes targeted specifically at nurses seeking to improve their practice as well as increasing the therapeutic options available to patients.



European Association of Psychotherapy (2009). The Strasbourg Declaration on Psychotherapy. Vienna: European Association of Psychotherapy.         [ Links ]

European Council of the Liberal Professions (2007). Common values of the liberal professions in the European Union. Brussels: European Commission.         [ Links ]

Gournay, K., Dentford, L., & Newell, R. (2000). British nurses in behavioural psychotherapy: A 25-year follow up. Journal of Advanced Nursing, 32 (2), 343-351.         [ Links ]

Horatio: European Psychiatric Nurses (2012). Horatio position paper on psychotherapy and mental health nurses. Retrieved from        [ Links ]

Moncreiff, J. (2003). An examination of the influence of the pharmaceutical industry on academic and practical psychiatry. London: Institute of Psychiatry.         [ Links ]

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