Therapeutic communication, anxiety and defense mechanism

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Social interaction impaired, Anxiety, Ineffective, individual coping, Self esteem disturbance


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Therapeutic communication, anxiety and defense mechanism

  1. 1. Therapeutic Communication, Anxiety and Defense Mechanism Submitted By : wilsontom.blogspot.com
  2. 2. <ul><ul><ul><li>MENTAL HEALTH CONCEPTS </li></ul></ul></ul><ul><li>Assessment </li></ul><ul><li>Appearance, behaviour or mood </li></ul><ul><ul><li>Well groomed, relaxed </li></ul></ul><ul><ul><li>Self-confident, self accepting </li></ul></ul><ul><li>Speech, thought content and thought process </li></ul><ul><ul><li>Clear, coherent </li></ul></ul><ul><ul><li>Reality based </li></ul></ul><ul><li>Sensorium </li></ul><ul><ul><li>Oriented </li></ul></ul><ul><ul><li>Good memory </li></ul></ul><ul><ul><li>Ability to abstract </li></ul></ul>
  3. 3. <ul><li>Insight and judgment </li></ul><ul><li>Family relationships and work habits </li></ul><ul><ul><li>Satisfying interpersonal relationships and work habits </li></ul></ul><ul><ul><li>Ability to trust </li></ul></ul><ul><ul><li>Ability to copy effectively with stress </li></ul></ul><ul><li>Level of growth and development </li></ul>
  4. 4. <ul><li>Analysis </li></ul><ul><li>Potential support system or stressors </li></ul><ul><ul><li>Church or community support </li></ul></ul><ul><ul><li>Family </li></ul></ul><ul><ul><li>Socioeconomic resources </li></ul></ul><ul><ul><li>Education cultural norms </li></ul></ul><ul><li>Potential risk factors </li></ul><ul><ul><li>Family H/O mental illness </li></ul></ul><ul><ul><li>Medical history </li></ul></ul><ul><li>Satisfaction of basic human needs </li></ul>
  5. 5. <ul><li>Potential nursing diagnosis </li></ul><ul><li>Social interaction impaired </li></ul><ul><li>Anxiety </li></ul><ul><li>Ineffective individual coping </li></ul><ul><li>Self esteem disturbance </li></ul><ul><li>Implementation </li></ul><ul><li>Therapeutic communication </li></ul><ul><ul><li>Listening to and understanding client while promoting clarification and insight </li></ul></ul>
  6. 6. MASLOW’S HIERRARCHY OF NEEDS
  7. 7. <ul><li>Goals </li></ul><ul><li>To understand clients message verbal and non verbal </li></ul><ul><li>To facilitate verbalization of feelings </li></ul><ul><li>To communicate understanding and acceptance </li></ul><ul><li>To identify problems, goals and objectives </li></ul><ul><li>Guidelines </li></ul><ul><li>Nonverbal communication constitutes 2/3 of all the communication </li></ul><ul><li>It gives most accurate reflection of attitude </li></ul><ul><li>Key points : say nothing and listen </li></ul><ul><li>Observe physical appearance, body movement, posture, gesture and facial expression </li></ul><ul><li>Maintain eye contact, physical distance </li></ul><ul><li>Use therapeutic touch </li></ul><ul><li>Person’s feelings and what is said may be incongruent </li></ul>
  8. 8. <ul><li>Therapeutic responses </li></ul><ul><li>Using silence </li></ul><ul><li>Use general leads or broad openings : what would u like to talk about. go on…. </li></ul><ul><li>Clarification : Give me one example, tell me more… </li></ul><ul><li>Reflecting : it sounds like u r feeling angry, are you saying… </li></ul>
  9. 9. <ul><li>Avoid </li></ul><ul><li>Close ended questions, yes or no : how many children u have </li></ul><ul><li>advice giving : why don’t u …. </li></ul><ul><li>Responding to questions that r related to client in an embarrassed or concrete way : nurses r not allowed to go with their patients </li></ul><ul><li>Arguing or responding in a hostile manner </li></ul><ul><li>“ why” questions : why u did not take ur medication </li></ul><ul><li>Being judgmental : u were wrong to do that </li></ul>
  10. 10. <ul><li>Treatment modalities for mental illness </li></ul><ul><li>Biological </li></ul><ul><li>Emotional problem is an illness </li></ul><ul><li>Cause may be inherited or chemical in origin </li></ul><ul><li>Medications and ECT </li></ul><ul><li>Psychoanalytical </li></ul><ul><li>Anxiety results when there is conflict between id and ego </li></ul><ul><li>Defense mechanisms form to ward off anxiety </li></ul><ul><li>Therapist helps the patient to become aware of unconscious thoughts and feelings </li></ul><ul><li>he helps him to understand anxiety and defenses </li></ul>
  11. 11. <ul><li>Milieu therapy </li></ul><ul><li>Providing a therapeutic environment will help increase patients awareness of feelings, increase sense of responsibility and help him to return to community </li></ul><ul><li>Client plans social and group interactions </li></ul><ul><li>Group therapy </li></ul><ul><li>Relationship is recreated among group members </li></ul><ul><li>Members meet regularly with a leader to form a stable group </li></ul><ul><li>Members learn new ways to cope with stress and develop insight into their behaviors with others </li></ul>
  12. 12. <ul><li>Family therapy </li></ul><ul><li>Problem is a family problem not an individual one </li></ul><ul><li>Therapist treats the whole family </li></ul><ul><li>Help members to develop their own sense of identity </li></ul><ul><li>Activity therapy </li></ul><ul><li>Important group interactions occur when group members work on a task together </li></ul><ul><li>Organized group activities r created to promote socialization and increase self esteem </li></ul>
  13. 13. <ul><li>Play therapy </li></ul><ul><li>Children express themselves more easily in play than in verbal communication </li></ul><ul><li>Choice of colors, toys, interaction with toys reflects child’s situation in family </li></ul><ul><li>Provide materials and toys to facilitate interaction with child, observe play, and child to resolve problems through play </li></ul>
  14. 14. Behavior therapy and behavior modification <ul><li>Psychological problems r result of learning </li></ul><ul><li>Deficiencies can be corrected through learning </li></ul><ul><li>Operant conditioning : use of rewards to reinforce positive behavior </li></ul><ul><li>Desensitization used to treat phobias. Patient slowly adjusts to threatening objects </li></ul>
  15. 15. <ul><ul><ul><ul><ul><li>ANXIETY </li></ul></ul></ul></ul></ul><ul><li>Feeling of dread or fear in the absence of an external </li></ul><ul><li>threat or disproportionate to the nature of threat </li></ul><ul><li>Assessment </li></ul><ul><li>Cardiovascular </li></ul><ul><li>Increased pulse, BP, respiration </li></ul><ul><li>Palpitations, chest discomfort or pain </li></ul><ul><li>Perspiration, flushing and heat sensations </li></ul><ul><li>Cold hands and feet </li></ul><ul><li>headache </li></ul>
  16. 16. <ul><li>Gastrointestinal </li></ul><ul><li>Nausea, Vomiting, Diarrhea </li></ul><ul><li>Belching, heart burns, cramps </li></ul><ul><li>Musculoskeletal </li></ul><ul><li>Increased muscle tension and tendon reflexes </li></ul><ul><li>Increased generalized fatigue </li></ul><ul><li>Tremors jerking of limbs </li></ul><ul><li>Unsteady voice </li></ul><ul><li>Intellectual </li></ul><ul><li>Poor comprehension, poor concentration, selective attention </li></ul><ul><li>Impaired problem solving </li></ul><ul><li>Unable to communicate : distorted, disconnected thought and impaired logic </li></ul><ul><li>Rapid high pitched speech </li></ul>
  17. 17. <ul><li>Social and emotional </li></ul><ul><li>Feelings of helplessness and hopelessness </li></ul><ul><li>Feelings of increased threat, dread, horror, anger and rage </li></ul><ul><li>Use of defense mechanisms and more primitive coping behaviors such as </li></ul><ul><ul><li>shouting, arguing, hitting , kicking </li></ul></ul><ul><ul><li>crying, rocking, curling up and withdrawal </li></ul></ul>
  18. 18. <ul><li>Analysis </li></ul><ul><li>Definition </li></ul><ul><li>Feeling of dread or fear in the absence of an external threat or disproportionate to the nature of threat </li></ul><ul><li>Predisposing conditions </li></ul><ul><li>Prolonged unmet needs of dependency, security, love and attention </li></ul><ul><li>Stress threatening security or self esteem </li></ul><ul><li>Unacceptable thoughts or feelings surfacing to consciousness eg rage, erotic impulses, flashbacks </li></ul>
  19. 19. Levels of anxiety Mild : high degree of alertness, mild uneasiness Moderate : heart pounds, skin cold and clammy, poor comprehension Severe : hallucinations and delusions Panic : inability to see and hear, inability to function
  20. 20. Assess level of anxiety <ul><li>Look at body language, speech patterns, facial expressions, defense mechanism and behavior used </li></ul><ul><li>Distinguish levels of anxiety </li></ul>Nursing interventions in anxiety
  21. 21. Keep environmental stresses low when anxiety is high <ul><li>Pleasant, attractive uncluttered environment </li></ul><ul><li>Provide privacy if presence of other patients is stimulating </li></ul><ul><li>Provide physical care when necessary </li></ul><ul><li>Avoid offering several alternatives or decisions when anxiety is high </li></ul><ul><li>Intervene if anxiety is severe or panic </li></ul><ul><li>Provide brief orientation to unit or procedures </li></ul><ul><li>Provide written information to read when anxiety is lower </li></ul>
  22. 22. Assist client to cope with anxiety more effectively <ul><li>Acknowledge anxious behavior: reflect and clarify </li></ul><ul><li>Always remain with client </li></ul><ul><li>Assist client to clarify own thoughts and feelings </li></ul><ul><li>Encourage measures to reduce anxiety eg exercise, activities, talking with friends, hobbies </li></ul><ul><li>Assist client to recognize his strengths and capabilities realistically </li></ul><ul><li>Provide therapy to develop more effective coping and interpersonal skills eg individual or group </li></ul><ul><li>May need to administer antianxiety medications </li></ul>
  23. 23. Maintain accepting and helpful attitude towards client <ul><li>Use an unhurried approach </li></ul><ul><li>Acknowledge client’s distress and concerns about problem </li></ul><ul><li>Encourage clarifications of feelings and thoughts </li></ul><ul><li>Evaluate and manage own anxiety when working with the client </li></ul><ul><li>Recognize the value of defense mechanisms and realize that client is attempting to make the anxiety tolerable in the best possible way </li></ul><ul><li>Acknowledge defense but provide reality </li></ul><ul><li>Do not attempt to remove a defense mechanism at any time </li></ul>
  24. 24. Anxiety disorders Type Assessments Nursing Mx PHOBIA <ul><li>Apprehension, anxiety, helplessness when confronted with phobic situation </li></ul><ul><li>Acrophobia – heights </li></ul><ul><li>Claustrophobia –closed spaces </li></ul><ul><li>Agoraphobia - open spaces </li></ul><ul><li>Avoid confrontation and humiliation </li></ul><ul><li>Do not focus on getting patient to stop being afraid </li></ul><ul><li>Systematic desensitization </li></ul><ul><li>Relaxation techniques </li></ul><ul><li>antidepressants </li></ul>
  25. 25. Type Assessments Nursing Mx OCD Obsession- repetitive, uncontrollable thoughts Compulsion - repetitive uncontrollable acts e.g. rituals <ul><li>Accept ritualistic behavior </li></ul><ul><li>Structure environment </li></ul><ul><li>Provide for physical needs </li></ul><ul><li>Offer alternative activities esp ones using hands </li></ul><ul><li>Guide decisions, minimize choices </li></ul><ul><li>Encourage socialization </li></ul><ul><li>Group therapy </li></ul><ul><li>Clomipramine (anafranil) </li></ul><ul><li>Stimulus -response prevention </li></ul>
  26. 26. Type Assessments Nursing Mx Conversion hysteria Physical symptoms with no organic basis- blindness, paralysis, Convulsions without loss of consciousness “ La belle indifference” Stocking and glove anesthesia <ul><li>Diagnostic evaluation </li></ul><ul><li>Discuss feelings rather than symptoms </li></ul><ul><li>Promote therapeutic relationship </li></ul><ul><li>Avoid secondary gain </li></ul>
  27. 27. <ul><ul><ul><ul><li>Defense mechanisms </li></ul></ul></ul></ul><ul><li>Denial : an alcoholic says he does have an alcoholic problem </li></ul><ul><li>Displacement : yelling at dog when angry with boss </li></ul><ul><li>Projection: blaming others </li></ul><ul><li>Undoing : apologizing excessively </li></ul><ul><li>Compensation : small person excel in sports </li></ul>
  28. 28. Substitution : marrying someone who looks like previous significant other Introjection : blaming oneself when angry with others Repression : inability to remember a traumatic event (unconsciously) Reaction formation : being good to someone u don’t like
  29. 29. Regression : bedwetting, babytalk Dissociation : detachment of painful emotional conflict from consciousness Suppression : deciding not to deal with something unpleasant until next day
  30. 30. <ul><ul><li>CRISIS INTERVENTION </li></ul></ul><ul><li>Assessment </li></ul><ul><li>  </li></ul><ul><li>Stages of crisis </li></ul><ul><li>Denial </li></ul><ul><li>Increased tension, anxiety </li></ul><ul><li>Disorganization, inability to function </li></ul><ul><li>Attempts to reorganize </li></ul><ul><li>Attempts to escape the problem pretends problem doesn’t exist, blames others </li></ul><ul><li>General reorganization </li></ul><ul><li>  </li></ul>
  31. 31. <ul><ul><ul><ul><li>Precipitating factors </li></ul></ul></ul></ul><ul><li>     Development </li></ul><ul><li>1) Birth, adolescence </li></ul><ul><li>2) Midlife, retirement </li></ul><ul><li>    Situational </li></ul><ul><li>1) Natural disasters </li></ul><ul><li>2) Financial loss </li></ul><ul><li>Threats of self- concept </li></ul><ul><li>1) Loss of job </li></ul><ul><li>2) Failure at school </li></ul><ul><li>3) Onset of serious illness </li></ul>
  32. 32. <ul><li>Analysis </li></ul><ul><li>  </li></ul><ul><li>Characteristics </li></ul><ul><li>Temporary state of disequilibrium precipitated by an event </li></ul><ul><li>Self-limiting – usually 4-6 weeks </li></ul><ul><li>Crisis can promote growth and new behaviors </li></ul><ul><li>Potential diagnoses </li></ul><ul><li>Individual coping ineffective </li></ul><ul><li>Powerlessness </li></ul><ul><li>Grieving, dysfunctional </li></ul><ul><li>Plan/Implementations </li></ul><ul><li>Goal-directed, focus on the here and now </li></ul><ul><li>Focus on client’s immediate problems </li></ul><ul><li>  </li></ul><ul><li>  </li></ul>
  33. 33. <ul><li>Explore nurse’s and client’s understating of the problem </li></ul><ul><li>  </li></ul><ul><li>Define the event (client may truly not know what has precipitated the crisis) </li></ul><ul><li>Confirm nurse’s perception by reviewing with client </li></ul><ul><li>Identify the factors that are affecting problem-solving </li></ul><ul><li>Evaluate how realistically client sees the problems or concerns </li></ul><ul><li>  </li></ul><ul><li>Help client become aware of feelings and validate them </li></ul><ul><li>  </li></ul><ul><li>Acknowledge feelings </li></ul><ul><li>Avoid blaming client </li></ul><ul><li>Encourage ventilation </li></ul><ul><li>Tell client he will feel better but it will take 1 or 2 months </li></ul><ul><li>  </li></ul>
  34. 34. <ul><li>Develop a plan </li></ul><ul><li>Encourage client to make as many arrangements as possible, avoid dependence </li></ul><ul><li>Write out information as comprehension is impaired </li></ul><ul><li>Maximize clients situational supports </li></ul><ul><li>Find new coping skills and manage feelings </li></ul><ul><li>Focus on strengths and present coping skills </li></ul><ul><li>Encourage client to form new social outlets </li></ul><ul><li>Facilitate future planning </li></ul><ul><li>Ask client “what would u like to do?”, “where would u like to go from here?” </li></ul><ul><li>Give referrals family and vocational counseling </li></ul>
  35. 35. Situational crises Grieving patient Dying patient Rape trauma A S S E S S M E N T <ul><li>Stages of grief </li></ul><ul><li>Shock and disbelief </li></ul><ul><li>Awareness of the pain of loss </li></ul><ul><li>Restitution </li></ul><ul><li>Actual grief period- 4 to 8 weeks </li></ul><ul><li>Usual resolution within 1 year </li></ul><ul><li>Long term resolution over time </li></ul>Stages of dying DABDA <ul><li>Stages of crises </li></ul><ul><li>Acute reaction lasts 3-4 weeks </li></ul><ul><li>Reorganization is long term </li></ul><ul><li>Common responses to rape </li></ul><ul><li>Self blame, embarrassment </li></ul><ul><li>Anxiety, insomnia </li></ul><ul><li>Phobia fear of violence </li></ul><ul><li>wish to escape, move, relocate </li></ul><ul><li>Psychosomatic disturbances </li></ul>
  36. 36. Grieving patient Dying patient Rape trauma A N A L Y S I S Potential Problems Family guilt, anger, anxiety Patient anger, withdrawal, guilt, anxiety, loss of role <ul><li>Avoidance behavior </li></ul><ul><li>Inability to express feelings when in denial </li></ul><ul><li>Feelings of guilt </li></ul><ul><li>Withdrawal, lonely, frightened </li></ul><ul><li>Anxiety of patient and family </li></ul><ul><li>Fears, panic reactions, generalized anxiety </li></ul><ul><li>Guilt, inability to cope </li></ul><ul><li>Current crises may reactivate old unresolved trauma </li></ul><ul><li>Follow emergency protocol </li></ul><ul><li>Be alert for internal injuries </li></ul>
  37. 37. Nursing interventions <ul><li>Grieving patient </li></ul><ul><li>Apply crises theory </li></ul><ul><li>Focus on here and now </li></ul><ul><li>Provide support to family </li></ul><ul><li>Provide family privacy </li></ul><ul><li>Encourage verbalization of feelings </li></ul><ul><li>Facilitate expression of anger and rage </li></ul><ul><li>Emphasize strengths increase ability to cope </li></ul><ul><li>Support adjustments to illness loss of body part </li></ul>
  38. 38. <ul><li>Dying patient </li></ul><ul><li>Keep communication open </li></ul><ul><li>Let patient know he is not alone </li></ul><ul><li>Provide comforting environment </li></ul><ul><li>Provide privacy </li></ul><ul><li>Physical care </li></ul><ul><li>Give sense of control and dignity </li></ul><ul><li>Respect patient’s wishes </li></ul>
  39. 39. <ul><li>Rape trauma </li></ul><ul><li>Write out Tx and appointments for client </li></ul><ul><li>Record all information in chart </li></ul><ul><li>Refer for legal assistance, support psychotherapy </li></ul><ul><li>Follow up regularly until client is improved </li></ul>
  40. 40. <ul><li>POST TRAUMATIC STRESS SYNDROME </li></ul><ul><li>Assessment </li></ul><ul><li>Exposure to traumatic event : rape, murder, fire </li></ul><ul><li>Response to trauma causes intense fear </li></ul><ul><li>Recurrent or distressing recollection of event </li></ul><ul><li>Distressing dreams or nightmares </li></ul><ul><li>Acting or feeling like the trauma is recurring (flashbacks) </li></ul><ul><li>Hyper vigilance and exaggerated startle response </li></ul><ul><li>Irritable or outbursts of anger </li></ul><ul><li>Avoidance or numbing </li></ul>
  41. 41. <ul><li>Analysis </li></ul><ul><li>Duration of symptoms is atleast one month </li></ul><ul><li>Syndrome can emerge months to years after traumatizing event </li></ul><ul><li>Biological changes due to impact of stressor and excessive arousal of sympathetic nervous system </li></ul>
  42. 42. <ul><li>Planning </li></ul><ul><li>1. Help client integrate the traumatic experience </li></ul><ul><li>Encourage client to talk about painful stored memories </li></ul><ul><li>have client recall images of traumatic event with as much detail as possible: flooding </li></ul><ul><li>use empathetic responses to the expressed distress </li></ul><ul><li>remain nonjudgmental </li></ul><ul><li>allow client to grieve over losses </li></ul>
  43. 43. <ul><li>Assist client to challenge existing ideas about event and substitute more realistic thoughts and expectations </li></ul><ul><li>Point out irrational thinking to the client </li></ul><ul><li>Help client recognize the limits of his control over the stressful event </li></ul><ul><li>2. Assist client with emotional regulations </li></ul><ul><li>Help client label his feelings and find ways to express them safely </li></ul><ul><li>Teach stress management techniques </li></ul>
  44. 44. <ul><ul><li>Involve client in anger Mx program </li></ul></ul><ul><li>Recognize anger as normal feeling </li></ul><ul><li>Teach time out or other ways of walking away from problematic situations involving anger </li></ul><ul><li>Teach nonintrusive communication techniques </li></ul><ul><ul><ul><li>speak in first person </li></ul></ul></ul><ul><ul><ul><li>Move away from object of anger </li></ul></ul></ul><ul><ul><ul><li>Cognitive restructuring eg using thoughts like this person cannot make me lose control </li></ul></ul></ul>
  45. 45. <ul><li>Develop a schedule of regular physical activity with client: walking, running </li></ul><ul><li>Use empowering strategies such as keeping a journal of disturbed thoughts and feelings in response to flashbacks or other problems </li></ul><ul><li>Teach methods to reduce sleep disturbances </li></ul><ul><li>regular bedtime </li></ul><ul><li>Use bed for sleeping and lovemaking exclusively. No TV or reading </li></ul><ul><li>Do not lie in bed sleepless for more than half an hour: get up and move around and then come back to bed </li></ul>
  46. 46. <ul><li>3. Enhance the clients support systems </li></ul><ul><li>Refer to self help group </li></ul><ul><li>Include family and friends in psychoeducational activities </li></ul><ul><li>Explore opportunities for socialisation </li></ul><ul><li>4. Educate client regarding the recovery process </li></ul><ul><li>Assess for and treat substance abuse </li></ul><ul><li>Administer antidepressants </li></ul>
  47. 47. Thanks wilsontom.blogspot.com

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