1. Therapeutic Modalities, Psychosocial Skills, and Nursing StrategiesPrepared by: Eric F. Pazziuagan, RN, MAN
2. BIOPHYSICAL/ SOMATIC INTERVENTIONS
3. ELECTROCONVULSIVE THERAPY (ECT) Introduced by Ugo Cerletti and Luciano Bini in 1938. Once commonly referred to as electroshock therapy (EST) or simply shock therapy. During ECT, an electric current is passed through the brain, causing a seizure.
4. Electric current is passed through the brain for 0.2 to 8.0 seconds. Induction of a seizure is necessary for therapeutic outcome. Seizure must be of sufficient quality to produce the best effect. Seizures are timed and subdivided: Motor convulsions (at least 20 seconds) Increased heart rate (for 30-50 seconds) Brain seizure monitored by EEG (for 30-150 seconds)
5. The patient is given an oximeter- monitored anesthetic to ensure optimal oxygenation.
6. Preparation for ECT: Pretreatment evaluation: physical examination, laboratory work (blood count, blood chemistry, urinalysis), and baseline memory abilities. Consent form; if profoundly depressed, signed by family members. Eliminate use of benzodiazepines or barbiturates for nighttime sedation because of their ability to raise seizure threshold. A trained electrotherapist and an anesthesiologist should be available.
7. Nursing Responsibilities before ECT NPO for 6-8 hours before ECT, except for cardiac, antihypertensive, and a few other medications. Administer Atropine at least an hour before treatment (to reduce secretions and counteract vagal stimulation). Ask client to urinate before the treatment. Remove hairpins, contact lenses, hearing aids and dentures.
8. Take VS. The nurse should be positive about the treatment and attempt to reduce the patient’s anxiety.
9. Procedures during ECT IV line is inserted. Electrodes are attached to the proper place on the head. Electrodes are typically held in place with a rubber strap. The bite block is inserted. Methohexital (Brevital)or another short- acting barbiturate is given IM (causing immediate anesthesia and preempting anxiety)
10. Succinylcholine (anectine), a neuromuscular agent, is given IV (causes paralysis but not sedation). This prevents the external manifestations of grand mal seizures, thus minimizing fractures or dislocations. The anesthesiologist mechanically ventilates the patient with 100% oxygen immediately before the treatment. The electrical impulse is given for 0.2-8.0 seconds.
11. The seizure should last a certain length of time to be of therapeutic value. If seizure lasts less than the expected time, the physician may stimulate another seizure. Seizures of more than 180 seconds is less favorable and can be terminated with diazepam or another benzodiazepine. Monitoring devices: heart rate and rhythm, BP, EEG. Ventilation and monitoring until patient recovers.
12. Nursing responsibilities after ECT The nurse or anesthesiologist mechanically ventilates the client with 100% oxygen until the patient can breathe unassisted. Monitor respiratory problems. Reorient patient to time, place and person as he emerges from groggy state. Give benzodiazepine as needed (if in agitated state).
13. Observe until client is oriented and study, particularly when the patient first attempts to stand. Document all aspects of treatment.
14. How does ECT work? No one knows for sure. Most promising theories: ECT alters the endocrine system in ways that promote an antidepressant effect. ECT alters neurotransmitter systems that contribute to mental disorders. ECT alters (raises) the seizure treshold, which in turn, causes an antidepressant effect. ECT alters (increases) the permeability of the blood-brain barrier.
15. Number of Treatments Two to three times a week, up to a total of 6-12 treatments (or until the patient improves or is obviously not going to improve). Many patients require continuation or maintenance of treatments to function at their best.
16. Indications for ECT: Major Depression Primarily indicated for schizophrenia, but soon shifted to patients who are severely depressed (85%-90%). Hierarchy of patients who should receive ECT: Those who require a rapid response (e.g., suicidal or catatonic patients) Those who cannot tolerate or be exposed to pharmacotherapy (e.g., pregnant women) Those who are depressed but have not responded to multiple and adequate trials of
17. Contraindications to ECT Very high risk Recent MI Recent CVA Intracranial mass Increased ICP
18. High risk Angina pectoris CHF Extremely loose teeth Severe pulmonary disease Severe osteoporosis Major bone fractures Glaucoma Retinal detachment Thromboplebitis High- risk pregnancy Use of MAOIs (severe HPN) Use of clozapine (seizures, delirium)
19. Advantages of ECT Fastest relief for depression. Safe procedure, More effective than antidepressants for certain groups of patients. Can be used safely and effectively in older patients, even in old-old patients, and in adolescents.
20. Disadvantages of ECT Provision of only temporary relief. Does not provide a permanent cure Might need another series of treatments May need maintenance or continuation treatment (6-12 months or longer) Memory loss Most frequent side effect: Memory impairment, both retrograde and anterograde There seems to be no substantial loss of mental function for most patients. Not clear whether this is related to ECT or depression.
21. Adverse physiologic effects Cardiac effects: HPN, arrhythmias, alterations of cardiac output, and changes in cerebrovascular dynamics. Hemodynamic changes + increased muscle tone= increased in oxygen consumption -> ischemia hyponatremia Migraine headaches Does not cause brain damage
22. PSYCHOSURGERY (LOBOTOMY) Destroys brain tissue for the purpose of relieving intractable mental disorders not amenable to other therapies. Indications: OCD or aggressiveness related to a mental disorder.
23. The MOST CONTROVERSIAL topic in psychiatry. Clinicians should eliminate all other options before using this drastic approach. Pioneered by Antonio Egas Monis, a Portuguese neurologist, in 1935. Popularized by Walter Freeman (with James Watt) in the US. Ethical concerns: to destroy the brain tissue constitutes an extreme and irreversible tactic; most clinicians believe that psychosurgery should be abandoned.
24. BRIGHT LIGHT THERAPY (BLT) Formerly called phototherapy. Exposes clients to intense light (5,000 lux- hours) each day. Rationale: environmental factors play a role in mood disorders. Therapeutic effect is believed to be mediated by the eyes, not the skin.
25. Indications: Seasonal affective disorder (SAD); morning administration is most beneficial. Bulimia Sleep maintenance insomnia Nonseasonal depression Contraindications: Nausea, eye irritation Adverse effects: Glaucoma, cataracts and use of photosynthesizing medications
26. REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION TMS or rTMS Produces a magnetic field over the brain, influencing brain activity.
27. Increases the release of neurotransmitters and/or regulates beta-adrenergic receptors, thus ameliorating depressive symptoms and possibly other disorders. An attractive alternative to ECT. Some studies have suggested that it is as effective as ECT in nonpsychotic patients. Patients with mental implants and increased ICP should be carefully evaluated before receiving treatment. Adverse effects: Seizures, headache, and transient hearing loss
28. INDIVIDUAL PSYCHOTHERAPY
29. Individual Psychotherapy A method of bringing about change in a person by exploring his or her feelings, attitudes, thinking, and behavior. Involves a one-to-one relationship between the therapist and the client. Stages: Introduction Working Termination
30. Reasons why people seek psychotherapy: To understand themselves and their behavior To make personal changes To improve interpersonal relationships To get relief from emotional pain or unhappiness The key to success is the therapist-client relationship. A therapist’s theoretical beliefs strongly influences his or her style of therapy.
31. GROUP THERAPY
32. Group Therapy Clients participate in sessions with a group of people. Members share a common purpose and are expected to contribute to the group to benefit others and receive benefit from others in return. Group rules are established, which all members must observe.
33. Being a member of the group allows the client to learn new ways of looking at a problem or ways of coping with or solving problems and also helps him or her to learn interpersonal skills. For example: by interacting with other members, clients often receive feedback on how others perceive and react to them and their behavior.
34. Therapeutic Results of Group Therapy Gaining new information, or learning. Gaining inspiration or hope. Interacting with others. Feeling of acceptance and belonging Becoming aware that one is not alone and that others share the same problems Gaining insight into one’s problems and behaviors and how they affect others Giving of oneself for the benefit of others (altruism)
35. Psychotherapy Groups Goal: for members to learn about their behavior and to make positive changes in their behavior by interacting and communicating with others as a member of a group. Can be organized around a specific medical diagnosis (e.g., depression) or a particular issue (e.g., improving interpersonal skills or managing anxiety).
36. Group techniques and processes are used to help group members learn about their behavior with other people and how it relates to core personality traits. Members can also learn they have responsibility to others and can help other members achieve their goals. Often formal in structure with one or two therapists as group leaders. Leaders establish rules that deal with confidentiality, punctuality, attendance, and social contact between members outside of group time.
37. Two Types: Open groups: ongoing and run indefinitely, allowing members to join or leave the group as they needed to. Closed groups: structured to keep the same members of the group for a specified number of sessions.
38. Family Therapy A form of group therapy in which the client and his or her family members participate. Goals: Understanding how family dynamics contribute to the client’s psychopathology Mobilizing the family’s inherent strengths and functional resources Restructuring maladaptive family behavioral styles Strengthening family problem- solving behaviors
39. Can be used both to assess and to treat various psychiatric disorders. Although one family member usually is identified initially as the one who has problems and needs help, it is evident through the therapeutic process that other family members also have emotional problems and difficulties.
40. Education Groups Goal: to provide information to members on a specific issue- for instance, stress management, medication management, or assertiveness training. Group leader has expertise: nurse, therapist, or a health professional Are scheduled for a specific number of sessions and retain the same members for the duration of the group.
41. The leader presents the information and then members can ask questions or practice new techniques. Example: medication administration group Leader discuss medication regimens and possible side effects Screen client for side effects May administer medications
42. Support Groups Are organized to help members who share a common problem to cope with it. Group leader explores members’ thoughts and feelings and creates an atmosphere of acceptance so that members feel comfortable expressing themselves. Often provide a safe place for group members to express their feelings of frustration, boredom, or unhappiness and also to discuss common problems and potential solutions.
43. Rules differ from psychotherapy: Members are encouraged to contact one another and socialize outside the sessions. Confidentiality may be a rule. Tend to be open groups. Examples: Cancer or stroke victims Persons with AIDS Family members of someone who have committed suicide Mothers Against Drunk Driving (MADD)
44. Self- Help Groups Members share a common experience, but not a formal or structured therapy group. Many are run by members and do not have a formally identified leader. Most have a rule of confidentiality May be locally or nationally organized Example: Alcoholics Anonymous, Gamblers Anonymous, Parents Without Partners, etc.
45. Group Number of persons who gather in a face- to-face setting to accomplish tasks that require cooperation, collaboration, or working together. Group content: what is said in the context of the group, including educational material, feelings and emotions, or discussions of the project to be completed.
46. Group process: the behavior of the group and its individual members, including seating arrangements, tone of voice, who speaks to whom, who is quiet, and so forth. Content and process occur continuously throughout the life of the group.
47. Stages of Group Development Initial stage: commences as soon as the group begins to meet. Members introduce themselves Leader is selected Purpose is discussed Rules and expectations for group participation are reviewed. Group members begins to “check out” one another.
48. Working stage: members begin to focus their attention on the purpose or the task the group is trying to accomplish. May happen relatively quickly; may take 2-3 sessions in a therapy group. Group characteristics that may be seen: Cohesiveness: degree to which members work together to accomplish the purpose. Cohesiveness is desirable. Evident if members value one another’s contributions, members think as “we”, and
49. Termination: final stage; occurs before the group disbands. Work is reviewed Focus is on group accomplishments or growth of group members, or both.
50. Group leadership Identified or formal leader: someone designated to lead the group. Formal leader in therapy and education groups: identified based on his education, qualifications, and experience. Informal leaders: members recognized by others as having the knowledge, experience, or characteristics that members admire and value. Effective group leaders focus on group process as well as on group content.
51. Tasks of a group leader: Giving feedback and suggestions Encourage participation from all members (eliciting response from quiet members and placing limits on members who may monopolize the group’s time) Clarifying thoughts, feelings, and ideas Summarizing progress and accomplishments Facilitating progress through the stages of group development.
52. Group roles Growth producing roles: Information seeker Opinion seeker Information giver Energizer Coordinator Harmonizer Encourager Elaborator
55. Some mental illnesses (e.g., schizophrenia and AD) result in an impairment that works against developing meaningful relationships; other mental illnesses have social withdrawal as a characteristic symptom.
56. Social Skills Groups Help psychiatric patients learn, practice, and develop skills for dealing with people in social situations. Might focus on appropriate dress, grooming, or table manners. More advance efforts address appropriate social and interpersonal verbal skills- e.g., meeting new people, initiating conversations, and interviewing for a job.
57. The opportunity to try out new skills and make mistakes in a safe environment is crucial to learning. Feedback helps patients assess their progress in improving or acquiring social skills.
58. ASSERTIVENESS TRAINING
59. Assertiveness Training Helps the person take more control over life situations. Techniques help the person negotiate interpersonal situations and foster self- assurance. Involve using “I” statements to identify feelings and communicate concerns or needs to others.
60. Examples: “I feel angry when you turn your back when I am talking.” “I want to have 5 minutes of your time for uninterrupted conversation about something important.” “I would like to have about 30 minutes in the evening to relax without interruption.”
61. THERAPEUTIC PLAY
62. Therapeutic play Play techniques are used to understand the child’s thoughts and feelings and to promote communication. Not to be confused with play therapy, a psychoanalytic technique used by psychiatrists.
63. Dramatic play: acting out an anxiety- producing situation such as allowing a child to be a doctor or use a stethoscope or other equipment to take care of a patient (a doll). Play techniques to release energy: pounding pegs, running, or working with modelling clay. Creative play techniques: help client to express themselves; drawing pictures of themselves, their family, and peers. Especially useful when children are unable or unwilling to express themselves verbally.
64. COGNITIVE THERAPY
65. Cognitive Therapy Focuses on immediate thought processing- how a person perceives or interprets his or her experience and determines how he or she feels and behaves. Example: If a person interprets a situation as dangerous, he or she experiences anxiety and tries to escape. Basic emotions of sadness, elation, and anger are reactions to perceptions of loss, gain, danger, and wrongdoing of others.
66. BEHAVIOR MODIFICATION
67. Behavior Modification Operant conditioning is the model used when patient’s behaviors are reinforced or maintained by consequences of the behavior. Include the patient in the process of behavioral contracting (written). Includes acceptable and unacceptable behaviors, as well as rewards and consequences. Contingencies that can be controlled by the therapist, patient, or family are altered to create a change in the problematic behaviors.
68. Increasing theprobability that abehavior will recur
69. Conditioning The strengthening of a response by reinforcement. Positive reinforcement: follows a behavior with a reinforcing stimulus that increases the probability that the behavior will recur. Negative reinforcement: the process of removing a stimulus from a situation immediately after a behavior occurs, which increases the probability of the behavior occurring.
70. The timing of reinforcement is important. When reinforcers are presented according to a timed schedule (rather than being contingent on a particular response). Any behavior immediately preceding the reinforcer is strengthened.
71. Premack Principle When a person is observed often enjoying a particular activity, the opportunity to engage in that activity can be used for other behaviors to occur (Premack, 1962)
72. Shaping A process of reinforcing successive approximations of responses to increase the probability of a behavior. The selective reinforcement of each behavior that more closely approximates the target response is called differential reinforcement.
73. Schedules ofReinforcement
74. Continuous Reinforcement The presentation of reinforcing stimuli following each occurrence of the selected response. Used primarily during the initial phases of conditioning or shaping a behavior and results in a high rate of behavior.
75. Intermittent Reinforcement The presentation of the reinforcer following the target response according to a selected number of responses (ratio scheduler). E.g., every fifth target response or according to a selected time period (interval schedule) of 10 minutes after every target response.
76. Decreasing the probabilitythat a behavior will recur
77. Differential reinforcement of other behavior A technique used to decrease the frequency of a behavior. When the goal of treatment is to decrease a behavior, another behavior, incompatible with the target behavior can be reinforced. Target behavior, if emitted, is not reinforced.
78. Extinction The gradual decrease in the rate of responses when the reinforcement is no longer available. The rate of responses might increase for a short time and then begin to decrease gradually. Emotional responses characteristically occur during extinction. Social extinction: withdrawal of attention from a patient when he acts inappropriately in the setting.
79. Negative consequence The presentation of an event immediately following a response that decreases the probability of that response recurring. Negative consequences usually result in the immediate suppression of that particular response. Used when other techniques are not effective in decreasing the frequency of a particular response.
80. Time-out A negative consequence technique in which a person is removed from a setting in which ongoing reinforcers are available.
81. Skills Training When behavioral responses are not appropriate for a person’s age and life situation, new behaviors are acquired through teaching anger management, social skills, and problem solving processes. Instruction, modelling, behavior rehearsal, corrective feedback, positive reinforcement, programmed practice, and flexibility exercises are used for this
82. Imitation and shaping are also used. Nurses often make individual assessments of the patients and form small groups to conduct training of skills that are appropriate for the patients but have not seen in the hospital situation.
83. Contingency Contracting The arrangement of conditions that enable patients to participate in setting target behaviors and selecting reinforcements. Therapist and patients jointly specify what, how, when , and where behavioral changes will occur. Criteria for the delivery of reinforcement are defined. Type, amount, and schedule of reinforcement are specified.
84. Self- Control Practical for outpatient settings. The development of self-control program with contingency contracting in which patients do the assessment, change their behaviors, provide their own reinforcement, and evaluate the results. Can be used with thought stopping, when patients have automatic negative thoughts. Say “STOP”, and to substitute with a positive thought.
85. Token Economy The use of operant principles in the management of behavior with groups of patients in inpatient, outpatient or outpatient partial hospital programs. Used more often with individual patient who, because of severity of illness, have trouble with daily functioning. Tokens (tangible conditioned reinforcements) are presented to patients when they exhibit target behaviors. Tokens can be exchange for positive reinforcers.
86. Respondent conditioning: helping clients cope with disturbing stimuli Used for particular stimuli situations such as those related to pain, phobias, and PTSD. Involves making changes in stimuli situations or in control of problematic behaviors.
87. Reciprocal Inhibition The process of strengthening alternative responses to fear or anxiety associated with a stimulus is called reciprocal inhibition or counterconditioning. Relaxation techniques, for instance, can be taught to highly anxious patients or those in pain. Techniques: positive and affirming self- thought, yoga, deep breathing, meditation, progressive muscle relaxation, and positive or pleasant imagery.
88. Exposure Models
89. Systematic Desensitization- In Vivo The planned progressive or graduated exposure to stimuli in real life (in vivo) that elicit fear or anxiety while the anxiety or fear response is suppressed with relaxation techniques. Biofeedback program might be used to reach and maintain a state of relaxation or pain control.
90. Used more often in combination with other therapies such as education, supportive therapy, cognitive-behavioral therapy, and skills training. Hierarchies of the fear-eliciting response are constructed through a detailed assessment. Hierarchies related to traumatic events could include conditioned external and internal cues: External: places, situations, smells, and sounds, associated with the trauma. Internal: emotions (fear and disgust), the physiological arousal during traumatic events, and conditions experienced during event (thoughts of dying or going crazy).
91. Patients need to be aware that exposure initially increases their emotional and physical distress, so that they are engage in the process. However, prolonged, repeated exposure,, along with relaxation, eventually decreases the pain and anxiety. Done in the presence of the therapist, but can be practiced independently (as homework) later in the process.
92. Systematic Desensitization- Imaginal The imagining of traumatic events, beginning with the least traumatic aspects of trauma. Patients might be asked to write about or write and then talk about each aspect with the therapist. Writing assignments and journaling might given as homework in between the sessions. Relaxation techniques are used.
93. Flooding or Implosion A process in which patients imagine or place themselves in the fearful situation; that is they immersed themselves in the feared stimuli. Normally done when accompanied by the therapist.
95. Psychosocial Interventions Nursing activities that enhance the client’s social and psychological functioning and improve social skills, interpersonal relationships, and communication. Nurses often use psychosocial interventions to help meet clients’ needs and achieve outcomes in all practice settings.
96. For example, a medical-surgical nurse might need to use interventions that incorporate behavioral principles such as setting limits with manipulative behavior or getting positive feedback. Example: A client with DM Patient: “I promise to have just one bite of cake. Please! It’s my grandson’s birthday cake.” Nurse: “I can’t give you permission to eat the cake. Your blood glucose level will go up if you do, and your insulin can’t be adjusted properly.”
97. COMPLEMENTARY ANDALTERNATIVE THERAPIES (CAM)
98. Complementary medicine: therapies used with conventional medicine practices. Alternative medicine: therapies used in place of conventional treatment. Integrative medicine: combines conventional medical therapy and CAM therapies that have scientific evidence supporting their safety and effectiveness.
99. Alternative Medical Systems Homeopathic medicine and naturopathic medicine in Western cultures, and traditional Chinese medicine, which includes herbal and nutritional therapy,
100. Mind-body Interventions Meditation, prayer, mental healing, and creative therapies that use art, music, or dance.
101. Biologically Based Therapies Use substances found in nature such as herb, food, vitamins. Include dietary supplements, herbal products, medicinal teas, aromatherapy, and a variety of diets.
102. Manipulative and Body- Based Therapies Based on manipulation or movement of one or more parts of the body, such as therapeutic massage and chiropractic or osteopathic stimulation.
103. Energy Therapies Biofield therapies: intended to affect energy fields that are believed to surround and penetrate the body, such as therapeutic touch, qi gong, and Reiki, and bioelectric- based therapies involving the use of electromagnetic fields, such as pulsed fields, magnetic fields, and AC or DC fields.
104. Qi gong: Chinese medicine that combines movement, meditation, and regulated breathing to enhance the flow of vital energy and promote healing. Reiki (which in Japanese means universal life energy): based on the belief that when spiritual energy is channeled through a Reiki practitioner, the patient’s spirit and body are healed.