Other psych0 social therapy

MR. JAYESH PATIDAR
www.drjayeshpatidar.blogspot.com

• Therapeutic community
• Millieu therapy
• Occupational therapy
• Play therapy
• Recreational therapy
• Attitude therapy
• Music therapy
• Dance therapy

JAYESH PATIDAR 4/24/2013 2

THERAPEUTIC
COMMUNITY


 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.”


 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.”


 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.


 Free communication
 Shared responsibilities
 Active participation
 Involvement in decision making
 Understanding of roles,
responsibilities, limitations &
authorities.


 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.


 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


1. Daily community Meetings
2. Patient Government or Ward Council
3. Staff Meeting or Review
4. Living & Learning Opportunities


 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.

 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.


 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.


 Schizophrenia
 Substance abuse disorder
 Antisocial disorder
 Children‟s care taking
environment


 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.

 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.


 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.


 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.


 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.


 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.


 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.


MILLIEU
THERAPY

 „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.


 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.


 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.

 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.


1. Maintaining Safe Environment
2. The Trust Relationship
3. Building Self-esteem
4. Limit-setting


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.


 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.


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.


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.


 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.


 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.

 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.


 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.


 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

 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.


 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.

 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)


OCCUPATIONAL
THERAPY


 Occupational therapy is the
application of goal-oriented,
purposeful activity in the assessment
& treatment of individuals with
psychological, physical or
developmental disabilities.


 “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”.


 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.


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.


 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.


 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.


 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.


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. 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.

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.


 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.

 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.


 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.


 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.

 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.


PLAY
THERAPY

 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.


 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.


 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.


 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.


 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.

RECREATIONAL
THERAPY


 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.


 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.


 Provide a non-threatening & non-
demanding environment.
 Provide activities that are relaxing &
without rigid guidelines & time-
frames.
 Provide activities that are enjoyable &
self-satisfying.


 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.


 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.


 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.
68
JAYESH PATIDAR 4/24/2013

ATTITUDE
THERAPY

Attitude therapy is a form of milieu
therapy in which all staff members
assume a consistent, prescribed
attitude designed to be therapeutic
towards patients.


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.


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.


 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.


 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.


MUSIC
THERAPY

 Music therapy is the functional
application of music towards the
attainment of specific therapeutic
goals.


 Facilitates emotional expressions
 Improves cognitive skills like learning,
listening & attention span.
 Social interaction is stimulated.


DANCE
THERAPY

 It is a psychotherapeutic use of
movement, which furthers the
emotional & physical integration of
the individual.


 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.

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