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Other psych0 social therapy


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  • 2. • Therapeutic community • Millieu therapy • Occupational therapy • Play therapy • Recreational therapy • Attitude therapy • Music therapy • Dance therapy 4/24/2013 2JAYESH PATIDAR
  • 4.  The concept of therapeutic community was first developed by Maxwell Jones in 1953 . He wrote a book entitled “Social Psychiatric” which was first published in England. Later on when it was published in the United States, its title was changed to “Therapeutic Community.” 4/24/2013 4JAYESH PATIDAR
  • 5.  Stuart & Sundeen defined therapeutic community as “a therapy in which patient‟s social environment would be used to provide a therapeutic experience for the patient by involving him as an active participant in his own care & the daily problems of his community.” 4/24/2013 5JAYESH PATIDAR
  • 6.  To use patient‟s social environment to provide a therapeutic experience for him.  To enable the patient to be an active participant in his own care & become involved in daily activities of his community.  To help patients to solve problems, plan activities & to develop the necessary rules & regulations for the community.  To increase their independence & gain control over many of their own personal activities.  To enable the patients become aware of how their behavior affects others. 4/24/2013 6JAYESH PATIDAR
  • 7.  Free communication  Shared responsibilities  Active participation  Involvement in decision making  Understanding of roles, responsibilities, limitations & authorities. 4/24/2013 7JAYESH PATIDAR
  • 8.  Responsibility for treatment belong to the staff & client.  Roles of staff & clients are equalized- may discuss either staff behavior or clients behavior.  Democratic environment is fostered.  Open communication is encouraged  Focus is on client assets.  Peer pressure is utilized to reinforce rules & regulations. 4/24/2013JAYESH PATIDAR 8
  • 9.  Interpersonal interactions are utilized to improve communication skills.  Inappropriate behavior are dealt with as they occur.  Team approach is used.  Clients are involved in all phases of treatment  Community government is set up – Use meetings to teach standards, values & behavior, explore behavior, make decision, use problem solving.  Two main goals for clients – Learn to set limits, Learn psychosocial skills 4/24/2013JAYESH PATIDAR 9
  • 10. 1. Daily community Meetings 2. Patient Government or Ward Council 3. Staff Meeting or Review 4. Living & Learning Opportunities 4/24/2013 10JAYESH PATIDAR
  • 11.  These meetings are composed of 60-90 patients. All levels of unit staff are involved, including administrative personnel. Acute patients are involved in the meetings.  Meetings should be held regularly for 60 minutes.  Discussion should focus mainly on day-to-day life in the unit.  During discussion patients‟ feelings & behaviors are examined by other members.  Frank discussion are encouraged, these may take place with much outpouring of emotions & anger. 4/24/2013 11JAYESH PATIDAR
  • 12.  The purpose of patient government is to deal with practical unit details such as house-keeping functions, activity planning & privileges.  A group of 5-6 patient will have specific responsibilities, such as house keeping, physical exercise, personal hygiene, meal distribution, a group to observe suicidal patients, etc. staff members should be available always.  All decisions should be feedback to the community through the community meetings. 4/24/2013 12JAYESH PATIDAR
  • 13.  A staff meeting should be held following each community meeting (patient are excluded & only staff are present). In this meeting the staff would examine their own responses, expectations, & prejudices. 4. Living & Learning Opportunities: Learning opportunities are to be provided within the social milieu, which should provide realistic learning experiences for the patients. 4/24/2013 13JAYESH PATIDAR
  • 14.  Schizophrenia  Substance abuse disorder  Antisocial disorder  Children‟s care taking environment 4/24/2013JAYESH PATIDAR 14
  • 15.  Free communication both within & between staff & patient group.  Communication are directed towards the modification of patient‟s attitude, behavior & role performance.  Atmosphere in the community will be democratic as opposed to hierarchical, rehabilitative rather than custodial, permissive instead of limited & controlled.  Nurses will be more communal with the patient instead of displaying all the time therapeutic role. 4/24/2013JAYESH PATIDAR 15
  • 16.  Environment will be essentially permissive & flexible.  Patient‟s activities are individualized & the role of patients are unspecified & their participation is completely voluntary.  A compulsory daily community meeting that all staff members have to attend & all patients are encouraged to attend.  The primary role of staff is to help the patients gain new insights & test new behavioral patterns.  Problems of the patients are discussed & the solutions are sought in the small group therapy session following each community meeting. 4/24/2013JAYESH PATIDAR 16
  • 17.  Patient government or ward council is to deal with practical unit details such as privileges & house keeping rosters. Staff member is available to the patient government, & all decisions are fed back to the community through the community meetings.  Staff meeting or review is essential to on-the- ward training. It gives opportunity for the staff members to examine their own responses, expectations & prejudices.  Feedback is one of the fundamental concepts in therapeutic community practice. 4/24/2013JAYESH PATIDAR 17
  • 18.  Patient develops harmonious relationship with other members of the community.  Gains self-confidence.  Develop leadership skills.  Learns to understand & solve problems of self & others.  Become socio-centric. 4/24/2013 18JAYESH PATIDAR
  • 19.  Learns to live & think collectively with the members of the community.  Lastly therapeutic community provides opportunities to participate in the formulation of hospital rules & regulations that affect patient‟s personal liberties like bedtime, meal time, weekend permission, control of radio or TV, social activities, late night privileges etc. 4/24/2013 19JAYESH PATIDAR
  • 20.  Role blurring between staff & patient.  Group responsibility can easily become nobody‟s responsibility.  Individual needs & concerns may not be met.  Patient may find the transition to community difficulty. 4/24/2013 20JAYESH PATIDAR
  • 21.  Providing & maintaining a safe & conflict free environment through role modeling & group leadership.  Sharing of responsibilities with patients.  Encouraging patient to participate in decision- making functions.  Assisting patients to assume leadership roles.  Giving feedback.  Carrying out supervisory functions. 4/24/2013 21JAYESH PATIDAR
  • 23.  „Milieu‟ is a French word meaning “Middle Place”.  In English language, milieu means “environment” or “setting”, as used in psychiatric mental health nursing, it refers to the people & all other social & physical factors in the environment with which the client interacts. 4/24/2013 23JAYESH PATIDAR
  • 24.  A therapeutic milieu is a 24 – hour environment designed to provide a secure retreat for individuals whose capacities for coping with reality have deteriorated.  The therapeutic milieu gives them opportunities to acquire adaptive coping skills. By offering secure, comfortable physical facilities for sleeping, dining, bathing & engaging in recreational, occupational, social, psychiatric & medical therapies, the therapeutic milieu does many advantages. 4/24/2013 24JAYESH PATIDAR
  • 25.  A therapeutic milieu is a “safe space,” a non-punitive atmosphere in which caring is a basic factor.  In this environment, confrontation may be a positive therapeutic tool that can be tolerated by the client.  Nurses & treatment team members should be aware of their own roles in this environment, maintaining stability & safety, but minimizing authoritarian behavior  Clients are expected to assume responsibility for themselves within the structure of the milieu as much as possible.  Feedback from other clients & the sharing of tasks or duties within the treatment program facilitate the client‟s growth. 4/24/2013 25JAYESH PATIDAR
  • 26.  Shelters clients physically from what they perceive as painful, terrifying stressors.  Protects clients physically from discharges of their own & other‟s maladaptive behaviors.  Supports the physiological existence of clients.  Provides pleasant, attractive, sensory stimulation of clients.  Educates clients & their families about adaptive, effective coping. 4/24/2013 26JAYESH PATIDAR
  • 27. 1. Maintaining Safe Environment 2. The Trust Relationship 3. Building Self-esteem 4. Limit-setting 4/24/2013 27JAYESH PATIDAR
  • 28. The nursing staff should follow the facility‟s policies with regard to prevention of routine safety hazards & supplement these policies as necessary. For Example;  Dispose of all needles safety & out of reach of client.  Restrict or monitor the use of matches & lighters.  Do not allow smoking. 4/24/2013 28JAYESH PATIDAR
  • 29.  Remove mouthwash, aftershave lotions & so forth, if substance abuse is suspected.  Keep sharp objects out of reach of client  Identify potential weapons & dangerous equipment.  Do not leave medicines unattended or unlocked.  Keep keys (to unit door, medicines) on your person at all times.  Search packages brought in by visitors, explain the reason for such rules briefly, & do not make any exceptions. 4/24/2013JAYESH PATIDAR 29
  • 30. one of the keys to a therapeutic environment is the establishment of trust. Both the client & the nurse must trust that treatment is desirable & productive. Trust is the foundation of a therapeutic relationship, & limit-setting & consistency are its building blocks. 4/24/2013JAYESH PATIDAR 30
  • 31. Strategies to help build or enhance self-esteem must be individualized & built on honesty & on the client‟s strengths. Some general suggestions are:  Set & maintain limits.  Accept the client as a person.  Be non-judgmental at all times.  Structure the client‟s time & activities. 4/24/2013JAYESH PATIDAR 31
  • 32.  Have realistic expectations of the client & make them clear to the client.  Initially provide the client with tasks, responsibilities & activities that can be easily accomplished.  Never flatter the client.  Allow the client to make his own decisions whenever possible. 4/24/2013JAYESH PATIDAR 32
  • 33.  Setting & maintaining limits are integral to a trust relationship & to a therapeutic milieu. Before stating a limit explain the reason for limit- setting.  Some basic guidelines for effective using limits are:  State the expectations or the limit as clearly, directly & simply as possible. 4/24/2013JAYESH PATIDAR 33
  • 34.  The consequence that will follow the client‟s exceeding the limit also must be clearly stated at the outset.  The consequences should immediately follow the client‟s exceeding the limit & must be consistent, both over time (each time the limit is exceeded) & among staff (each staff member must enforce the limit).  Consequences are essential to setting & maintaining limits, they are not an opportunity to be punitive to a client. 4/24/2013JAYESH PATIDAR 34
  • 35.  In conclusion, the nurse works with other health professionals in an interdisciplinary team; The interdisciplinary team works within a milieu that is constructed as a therapeutic environment, with the aim of developing a holistic view of the client & providing effective treatment. 4/24/2013JAYESH PATIDAR 35
  • 36.  Use nursing process to provide comprehensive care.  Provide direct client care  Manages the day-to-day care of individual clients.  Assists the client for re-entry into the community.  Give indirect client care  Maintains on going communication with other mental health team members.  Enforces rules, policies & regulations of therapeutic milieu.  A schedule, assigns, manages, & evaluates clinical work 4/24/2013JAYESH PATIDAR 36
  • 37.  Administer medication & give medication teaching  Provide psychosocial care  Uses informal group interventions such as community meetings & structured or unstructured group therapy sessions to assist client with problems in their current life situations.  Conducts brief, “on-the-spot” counseling with clients & families.  Set limits to deal with behaviors destructive to the self, others, or the environment.  Helps the clients use their time productively for leisure & work.  Involves withdrawn clients in the milieu. 4/24/2013JAYESH PATIDAR 37
  • 38.  Encourages clients who have low self-esteem to value themselves.  Serves as a role model by demonstrating inter personal effectiveness in relating to clients & other mental health team members.  Conducts one-to-one therapy sessions daily with selective clients.  Conducts group therapy on a daily basis to help clients to gain self-awareness about how they behave in groups  Provide mental health teaching  Psychotropic medications, methods of coping, inter personal effectiveness (eg; assertiveness training, communication, problem-solving skills, parenting skills & so forth) stress management, relaxation & physical exercise etc. 4/24/2013JAYESH PATIDAR 38
  • 39.  Encourage clients to help & support each other individually & as a group.  Assist clients to understand each other‟s feelings & problems.  Conduct community meetings.  Participate freely in milieu activities (i.e, exercise, art, craft classes, social function) 4/24/2013JAYESH PATIDAR 39
  • 41.  Occupational therapy is the application of goal-oriented, purposeful activity in the assessment & treatment of individuals with psychological, physical or developmental disabilities. 4/24/2013JAYESH PATIDAR 41
  • 42.  “Any activity, which engages a person‟s resources of time & energy & is composed of skills & values” (Reed & Sanderson, 1980).  “Any goal-directed activity meaningful to the individual & providing feedback to him about his worth & value as an individual & about his inter- relatedness to others”. 4/24/2013JAYESH PATIDAR 42
  • 43.  The aim of the occupational therapist‟s intervention is the alleviation of dysfunction & the development of maximum functional independence in all aspects of living. Specific aims of occupational therapy are: I. Promotion of recovery II. Mobilization of total assets of the patient III. Prevention of hospitalization. IV. Creation of good habits of work & leisure. V. Rehabilitation with return of self-confidence. 4/24/2013JAYESH PATIDAR 43
  • 44. The main goal is to enable the patient to achieve a healthy balance of occupations through the development of skills that will allow him to function at a level satisfactory to himself & others. 4/24/2013JAYESH PATIDAR 44
  • 45.  Occupational therapy is provided to children, adolescents, adults & elderly patients.  These programs are offered in psychiatric hospitals, nursing homes, rehabilitation centers, special schools, community group homes, community mental health centers, day care centers, halfway homes & addiction centers. 4/24/2013JAYESH PATIDAR 45
  • 46.  Helps to develop social skills & provide an outlet for self-expression.  Strengthens ego defenses.  Develops a more realistic view of the self in relation to other. 4/24/2013JAYESH PATIDAR 46
  • 47.  The client should be involved as much as possible in selecting the activity.  Select an activity that interests or has the potential to interest him.  The activity should utilize the client‟s strengths & abilities.  The activity should be of short duration to foster a feeling of accomplishment.  If possible, the selected activity should provide some new experience for the client. 4/24/2013JAYESH PATIDAR 47
  • 48. It consists of six stages: 1. Initial evaluation of what patient can do & cannot do in a variety of situations over a period of time. 2. Development of immediate & long-term goals by the patient & therapist together. Goals should be concrete & measurable so that it is easy to see when they have been attained. 3. Development of therapy plan with planned intervention. 4/24/2013JAYESH PATIDAR 48
  • 49. 4. Implementation of the plan & monitoring the progress. The plan is followed until the first evaluation. If found satisfactory it is continued & altered, it not. 5. Review meetings with patient & all the staff involved in treatment. 6. Setting further goals when immediate goals have been achieved; modifying the treatment program as relevant. 4/24/2013JAYESH PATIDAR 49
  • 50. 1. Diversional activity: These activities are used to divert one‟s thoughts from life stresses or to fill time. For example, organized games. 2. Therapeutic activities: These activities are used to attain a specific care plan or goal. For example, basket making, carpentry etc. 4/24/2013JAYESH PATIDAR 50
  • 51.  Anxiety disorder: Simple concrete tasks with no more than 3 or 4 steps that can be learnt quickly. For example, kitchen tasks, washing, sweeping, mopping, mowing lawn & wedding gardens.  Depressive disorder: Simple concrete tasks which are achievable; it is important for the patient to experience success. Provide positive reinforcement after each achievement. For example, craft, mowing lawn, wedding gardens. 4/24/2013JAYESH PATIDAR 51
  • 52.  Manic disorder: Non-competitive activities that allow to use of energy & expression of feelings. Activities should be limited & changed frequently. Patient needs to work in an area away from distraction. For example, raking, grass, sweeping, etc.  Schizophrenia (paranoid): Non- competitive, solitary meaningful tasks that require some degree of concentration so that less time is available for focus on delusions. For example, puzzles, scrabble. 4/24/2013JAYESH PATIDAR 52
  • 53.  Schizophrenia (catatonic): Simple concrete tasks in which patient is actively involved. Patient needs continuous supervision & at first works best on a one-to-one basis. For example, metal work, molding clay, etc.  Antisocial personality: Activities that enhance self-esteem & are expressive & creative, but not too complicated. Patient needs supervision to makes sure each tasks is completed. For example, leather works, painting, etc. 4/24/2013JAYESH PATIDAR 53
  • 54.  Dementia: Group activities to increase feeling of belonging & self-worth. Provide those activities which promote familiar individual hobbies. Activities need to be structured requiring little time for completion & not much concentration. Explain & demonstrate each task, then have patient repeat the demonstration. For example, cover making, packing goods.  Substance abuse: Group activities in which patient uses his talent. For example, involving patient in planning social activities, encouraging interaction with others etc. 4/24/2013JAYESH PATIDAR 54
  • 55.  Childhood & Adolescent disorders:  Children: Playing, story telling, painting, poetry, music etc  Adolescent: Creative activities such as leather works, drawing, painting  Mental retardation: Repetitive work assignments are ideal; positive reinforcement after each achievement. For example, cover making, candle making packaging goods etc. 4/24/2013JAYESH PATIDAR 55
  • 57.  Play is a natural mode of growth & development in children. Through play a child learns to express his emotions & it serves as a tool in the development of the child. 4/24/2013JAYESH PATIDAR 57
  • 58.  It releases tension & pent-up emotions.  It allows compensation for loss & failures.  It improves emotional growth through his relationship with other children.  It provides an opportunity to the child to act out his fantasies & conflict, to get rid of aggression & to learn positive qualities from other children. 4/24/2013JAYESH PATIDAR 58
  • 59.  Play therapy gives the therapist a chance to explore family relationships of the child & discover what difficulties are contributing to the child‟s problem.  Play therapy allows studying hidden aspects of the child‟s problems.  It is possible to obtain a good ideas of the intelligence level of the child.  Through play inter-sibling relationships can be adequately studied. 4/24/2013JAYESH PATIDAR 59
  • 60.  Individual vs group play therapy: In individual therapy the child is allowed to play by himself & the therapist‟s attention is focused on this one child alone. In group play therapy other children are involved.  Free play vs controlled play therapy: In free play the child is given freedom in deciding with what toys he wants to play. In controlled play therapy, the child is introduced into a scene where the situation or setting is already established. 4/24/2013JAYESH PATIDAR 60
  • 61.  Structured vs unstructured play therapy: Structured play therapy involves organizing the situation in such a way so as to obtain more information. In unstructured play therapy no situation is set & no plans are followed.  Directive vs non-directive play therapy: In directive play therapy, the therapist totally sets the direction, whereas in non-directive play therapy, the child receives no direction. Play therapy is generally conducted in a playroom. The playroom should be suitably stocked with adequate play material, depending upon the problems of the child. 4/24/2013JAYESH PATIDAR 61
  • 63.  Recreation is a form of activity therapy used in most psychiatric setting.  It is planned therapeutic activity that enables people with limitations to engage in recreational experiences. 4/24/2013JAYESH PATIDAR 63
  • 64.  To encourage social interaction.  To decrease withdrawal tendencies  To provide outlet for feelings.  To promote socially acceptable behavior  To develop skills, talents & abilities  To increase physical confidence & a feeling of self worth. 4/24/2013JAYESH PATIDAR 64
  • 65.  Provide a non-threatening & non- demanding environment.  Provide activities that are relaxing & without rigid guidelines & time- frames.  Provide activities that are enjoyable & self-satisfying. 4/24/2013JAYESH PATIDAR 65
  • 66.  Motor forms: These can be further divided into fundamental & accessory; among the fundamental forms are such games as hockey & football, while the accessory forms are exemplified by play activity & dancing.  Sensory forms: These can be either visual for example, looking at motion pictures, play, etc., or auditory such as listening to a concert.  Intellectual forms: These include reading, debating & so on. 4/24/2013JAYESH PATIDAR 66
  • 67.  Anxiety disorder: Aerobic activities like walking, jogging, etc.  Depressive disorder: Non-competitive sports, which provide outlet for anger, like jogging, walking , running, etc.  Manic disorder: One-to-one basis individual games like shuttle badminton, ball badminton, etc.  Schizophrenia (paranoid): Activities requiring concentration like chess, puzzles. 4/24/2013JAYESH PATIDAR 67
  • 68.  Schizophrenia (catatonic): Social activities to give patient contact with reality like dancing, athletics.  Dementia: Concrete, repetitious craft & projects that breed familiarization & comfort.  Childhood & adolescent disorders: It is better to work with the child on a one-to-one basis & give him a feeling of importance. Employ activities such as playing, story telling & painting. Adolescents fare better in groups; provide gross motor activities like sports & games to use up excess energy.  Mental Retardation: Activities should be according to the patient‟s level of functioning such as walking, dancing, swimming, ball playing. Etc. 4/24/2013JAYESH PATIDAR 68
  • 70. Attitude therapy is a form of milieu therapy in which all staff members assume a consistent, prescribed attitude designed to be therapeutic towards patients. 4/24/2013JAYESH PATIDAR 70
  • 71. i. When the patient is in the hospital for a long time: • The patient is interviewed to assess his emotional state & activity level. • Family members are interviewed to acquaint them with the attitude therapy which will be used for the patient. ii. After this, a staff meeting is held in which all the team members are present. 4/24/2013JAYESH PATIDAR 71
  • 72. iii. A clinical diagnosis is made by the psychiatrist. iv. A plan of attitude to be adopted for a particular patient is discussed with purpose. v. One Principal Line of Approach at a time by all the team members. The attitude therapy is basically meaning to change the attitude of the patient in specific situations. A general attitude which the nurse needs to adopt for psychiatric patients is kept in mind. 4/24/2013JAYESH PATIDAR 72
  • 73.  The patient starts feeling that an organized approach is being used for his/her treatment.  Guesswork & haphazard plans by individual members of the team are reduced.  The patient‟s problems or conflict are solved in less time. 4/24/2013JAYESH PATIDAR 73
  • 74.  This approach also provides an opportunity for the members to explore, test & change the therapeutic attitude which will bring best results in patient.  It brings members of the team together to plan, work & evaluate each other‟s efforts & to discover new ways of helping the patient. 4/24/2013JAYESH PATIDAR 74
  • 76.  Music therapy is the functional application of music towards the attainment of specific therapeutic goals. 4/24/2013JAYESH PATIDAR 76
  • 77.  Facilitates emotional expressions  Improves cognitive skills like learning, listening & attention span.  Social interaction is stimulated. 4/24/2013JAYESH PATIDAR 77
  • 79.  It is a psychotherapeutic use of movement, which furthers the emotional & physical integration of the individual. 4/24/2013JAYESH PATIDAR 79
  • 80.  Helps to develop body awareness.  Facilitates expression of feelings.  Improves interaction & communication  Fosters integration of physical, emotional & social experiences that results in a sense of increased self-confidence & contentment.  Exercise through body movement maintains good circulation & muscle tone. 4/24/2013JAYESH PATIDAR 80
  • 81. 4/24/2013JAYESH PATIDAR 81