1. ELEMENTS OF THERAPEUTIC
RELATIONSHIP
GOAL- helping the client for the growth and learning,
directed and purposeful, there is boundary
ROLE and RESPONSIBILITY- must be clearly
defined
CONFIDENTIALITY- appraise the patient with all the
information gathered
THERAPEUTIC BEHAVIOR- aware of thoughts and
feelings, values clarification
STAGES
• Pre-orientation
• Orientation
• Working
• Termination
THERAPEUTIC COMMUNICATION
Therapeutic Communication
Interpersonal interaction between the nurse and client
during which the nurse focuses on the client’s needs to
promote an effective exchange of info
Process in which the nurse consciously uses the verbal
and non-verbal in the goal of helping the client
Non verbal
Non verbal- gestures, facial expression
KINETICS- body movement, facial expression
PROXEMICS- distance or space between
Four Distance Zones
1. Intimate distance (0-18 inches between people)
• Close distance that individuals will allow
between themselves and others
• Close conversation with friends and colleagues,
parents with young children, people who
mutually desire body contact
2. Social distance (about 4-12 ft away from body)
• Conversation with strangers
• The distance is acceptable for communication in
social, work and business settings
3. Personal distance (18-36 inches)
• This distance is comfortable between family and
friends who are talking
4. Public distance (12-25 ft)
• This is acceptable distance between a speaker and
an audience, small groups and other informal
functions
Touch
• Very powerful communication tool
• Can either be positive or negative reaction
depends upon the people who’s rendering
5 types of Touch
1. Functional-Professional – used in exams or
procedures
2. Social-Polite – used in greeting (handshake, air
kisses some women use to greet acquaintances,
gentle hand guides someone in the correct
direction)
3. Friendship-Warmth – hug in greeting, arm
thrown around the shoulder of a good friend, back
slapping some men use to greet friends and
relatives
4. Love-intimacy – tight hug and kisses between
lovers or close relatives
5. Sexual-Arousal – used by lovers
ACTIVE LISTENING
• Means refraining from other internal mental
activities and concentrating exclusively on what
client says
ACTIVE OBSERVATION
• Means watching the speaker’s non verbal actions
as he/ she communicates
2. SOCIAL and THERAPEUTIC Relationship
Differentiation SOCIAL
INTERACTION
THERAPEUTIC
RELATIONSHIP
Characteristics Personal and
intimate
Personal but NOT
intimate
Goal Doing favor for
mutual benifit
Promoting
functional use of
one’s latent inner
resources
Termination Not defined Defined in the
beginning
Identification
of needs
May not occur By the client with
the help of the
nurse
Resource used Variety during
interaction
Specialized
professional skills
for intervention
THERAPEUTIC COMMUNICATION
Therapeutic Communication Techniques
Technique
Accepting – indicating reception “Yes”; “I follow what
you said”
Broad openings – allowing the client to take the initiative
in introducing the topic. “Is there something you’d like to
talk about?” “Where would you like to begin?”
Consensual validation- searching for mutual
understanding, for accord in the meaning of the word.
“Tell me whether my understanding of it agrees with
yours.”
Encouraging comparison- asking that similarities &
differences be noted. “Was it something like…?”” Have
you had similar experiences?”
Encouraging description of perceptions- asking the
client to verbalize what he or she perceives. “Tell me
when you feel anxious” ”What is happening?”
Encouraging expression- asking the client to appraise
the quality of his or her experiences “What are your
feelings in regard to…?” “Does this contribute to your
distress?”
Exploring- delving further into a subject. “Tell me more
about that”
Focusing- concentrating on a single point. “This point
seems worth looking at more closely”
Formulating a plan of action- asking the client to
consider kinds of behavior likely to be appropriate in
future situations. “What could you do to let your anger out
harmlessly?”
General leads- giving encouragement to continue “Go
on” “And then?”
Giving information- making available the facts that the
client needs. “My name is…” “Visiting hour are…”
Giving recognition- acknowledging, indicating
awareness. “Good morning, Mr. …”
Making observations- verbalizing what the nurse
perceives. “You appear tense”
Offering self- making oneself available “I’ll sit with you
awhile”
Placing event in time or sequence- clarifying the
relationship of events in time. “What seemed to lead up
to…?
Presenting reality- offering for consideration that which
is real. “I see no one else in the room”
Reflecting- directing client actions, thoughts and feelings
back to client
Client: Do you think I should tell the doctor?
Nurse: Do you think you should?
Restating- repeating the main idea expressed. Client: I
can’t sleep Nurse: You have difficulty sleeping
Seeking information- seeking to make clear that which
is not meaningful or that which is vague. “I’m not sure
that I follow”
Silence- absence of verbal communication, which
provides time for the client to put thoughts or feelings into
words
Nurse says nothing but continues to maintain eye contact
and conveys interest
3. Suggesting collaboration- offering to share, to strive, to
work with the client for his or her benefit. “Perhaps you
and I can discuss and discover the triggers for your
anxiety”
Summarizing- organizing & summing up that which has
gone before “Have I got this straight?”
Translating into feelings- seeking to verbalize client’s
feelings that he or she expressed only indirectly.
Client: I’m dead
Nurse: Are you suggesting that you feel lifeless?
Verbalizing the implied- voicing what the client has
suggested.
Client: I can’t talk to you or anyone. It waste my time
Nurse: Do you feel that no one understands?
Voicing doubts- expressing uncertainty about the reality
of the client’s perceptions
“Isn’t that unusual?”
Non therapeutic Comm.
Advising- telling the client what to do. “I think you
should…”
Agreeing- indicating accord with the client. “That’s
right..”
Belittling feelings expressed- misjudging the degree of
the client’s discomfort.
Client: I have nothing to live for… I wish I was dead”
Nurse: Everybody gets down in the dumps”
Challenging- demanding proof from the client
“But how can you be president of the United States?”
Defending- attempting to protect someone or something
from verbal attacks. “This hospital has a fine reputation”
Disagreeing- opposing the client’s ideas. “That’s wrong”
Disapproving- denouncing the client’s behavior or ideas.
“That’s bad”
Giving approval- sanctioning the client’s behavior or
ideas. “That’s good”
Giving literal responses- responding to a figurative
comment as though it were a statement of fact.
Client: They’re looking in my head with a television
camera
Nurse: Try not to watch TV
Indicating the existence of an external source-
attributing the source of thoughts, feelings, and behavior
to others or to outside influences
“What makes you say that?”
Interpreting- asking to make conscious that which is
unconscious. “What you really mean is…?
Introducing an unrelated topic- changing the subject.
Client: I’d like to die
Nurse: Did you have visitors last evening?
Making stereotyped comments- offering meaningless
clichés. “Its for your own good”
Probing- persistent questioning of the client. Now tell me
about this problem. You know I have to find out”
Reassuring- indicating there is no reason for anxiety. “I
wouldn’t worry about that”
Rejecting- refusing to show contempt for the client’s
ideas. “Let’ s not discuss…”
Requesting an explanation- asking the client to provide
reasons for thoughts, feelings, behaviors, events. “Why
do you think that?”
Testing- appraising the client’s degree of insight. “Do you
know what kind of hospital this is?
Using denial- refusing to admit a problem exists
Client: I’ m nothing
Nurse: Of course your something- everybody’ s
something
4. Defense Mechanisms
Anna Freud
Defense mechanisms are methods or coping strategies of
attempting to alleviate anxiety, to protect the self with the
basic drives or emotionally painful thoughts, feelings or
events.
Anna Freud - defense mechanism evolve during
specified developmental stage and are more likely to
result in maladaptive behaviors when are used too early
and too long
5. GENERALASSESSMENT
Assessment
A. Systematic Data Collection
1. Effective Interviewing
• Nursing history is an essential tool in developing
the assessment data base.
• It is from this information that the care plan is
developed.
• Basic nursing history tool in mental health
nursing includes functional health patterns and
socio cultural needs.
2. Observations of objective and subjective behaviors
• Mental health nurse uses observation, interview,
the nurse-client relationship, therapeutic
communication techniques, mental health status
examination, other tests and the medical
diagnosis to assist in formulating nursing
diagnosis.
B. Recording Data
C. Data review of documents available in the practice
setting (chart, medical history, laboratory results etc.)
Nursing Diagnosis
A. Standard Nursing Diagnosis
• Marjory Gordon’s definition of nursing diagnosis
– derived from database obtained by nursing
history and other tools available.
• Defining characteristics are observed as data are
collected and assist the mental health nurse to
specify the etiology underlying diagnosis
• DSM IV – TR alerts the nurse to potential
defining characteristics within specific mental
disorder categories.
B. Comparison of standard nursing diagnoses to
diagnostic classification of mental disorders
C. Recognition of actual or potential health problems
D. Opportunities for validation of diagnosis of peers
in the practice setting
Diagnostic and Statistical Manual of Mental
Disorders (DSM–5)
DSM–5 is the standard classification of mental
disorders used by mental health professionals
DSM-5-TR will be published in March 2022
Planning
• once nursing diagnosis are identified, it is important
to establish priorities. Maslow’s hierarchy of needs is
a good way of establishing care priorities.
• goals are established to guide the planning phase.
Include the client and establish mutually acceptable
goals are important to nursing care outcomes.
• objectives or expected outcomes are necessary to
spell out the behaviors the nurse will observe the in
the client to indicate that goals have been achieved.
A. Development of nursing care plan
1. Specific client goals based on client needs
2. Interventions unique to client needs
B. Guide to therapeutic interventions
C. Collaboration with others
Interventions
Basic types:
1. Dependent
2. Independent
3. Interdependent
Primary independent: THERAPEUTIC
RELATIONSHIP between the nurse and client.
Phases: introductory, working and termination
Nursing Actions
✓ to promote, maintain or restore physical and
mental
✓ To prevent illness
✓ To effect rehabilitation
✓ Interventions validated by client and peers
✓ Psychotherapeutic interventions
✓ Health-teaching interventions
✓ Activities of daily living interventions
depending on each other
6. ✓ Somatic therapy interventions
✓ Therapeutic environment interventions
Evaluation
• Purpose: to determine the client’s progress,
effectiveness of NCP, interventions,
determination of goal attainment and provision
of a new data base for changes in the plan of care.
Criteria for evaluation: Formative – on going;
Summative- terminal
• Self-evaluation – is an essential art of mental
health nursing because of the nature of the use of
self in independent nursing interventions.
A. Recording, communicating and revising
B. Evaluate client responses to nursing interventions
1. Revise the data
2. revise nursing diagnosis
3. revise care plan
C. Pursue validation, suggestions and new information
D. Documents results of evaluation
E. Evaluate self-performance on therapeutic
interventions
Principles and Techniques of Mental Health –
Psychiatric Nursing Interview
1. Assume an open posture. Sit facing the client with
both feet on the floor, knees parallel, hands at the sides of
the body, legs not crossed or crossed only at the ankle.
(this posture demonstrates unconditional positive regard,
trusting, caring and acceptance)
2.Explain the purpose of the interview, why the
information is necessary and help him recognize the
benefits of dealing with problems openly.
3.Sit beside or cross from the client(can put the client at
ease instead of sitting behind a desk which can decrease
the client’s willingness to open up and communicate
freely)
4.Keep chairs to be used by the nurse and patients of
approximately equal in height so that neither person looks
down on the other
5.If the client has difficulty maintaining boundaries, the
nurse may use a more formal setting.
6.Ensure the patient’s privacy, including asking the
client who should be present during the interview.
7. Choose a quiet, calm, private setting (interruptions
and distractions threaten confidentiality and may interfere
effective listening). Remove objects in the room that may
distract the patient.
8.Reassure the patient that he’s safe (if necessary).
9.Show support and sensitivity.
10.Use reliable information sources.
11.Check hospital records from previous admissions, if
possible, when comparing the patient’s past behavior with
the current situation.
12.Listen carefully and objectively to make the patient
feel comfortable enough to discuss his problems and
responding with sensitivity.
13.Avoid taking extensive notes during the interview
(can cut down on the nurse’s ability to listen)
14.Use open ended questions to start the assessment
(allows the client to begin as he feels comfortable and also
gives the nurse an idea about the client’s perception about
the situation)
15. If client cannot organize his thoughts or has
difficulty answering open-ended questions, use questions
that are more direct, clear, simple, focused on one
specific, behavior or symptom to obtain information.
16. Use non-judgmental language and matter- of- fact
tone particularly when asking about sensitive information
17. Validate non-verbal cues of the client rather than
assume what the client is thinking or feeling.
18. Maintaining good eye contact is important but the
nurse must not stare at the client.
19. Allow the client to respond even if it seems like a
long time.
20. When meeting the patient for the first time, introduce
self and explain the purpose of the interview. Then ask the
patient how he would like to be addressed.
21. Initial interview generally lasts for 30-60 minutes.
Keep interviews with psychotic patients brief because
they are easily stressed.
22. Find out the patient’s cultural beliefs.
7. 23. When possible, note specific details to fully explore
the patient’s chief complaints.
24. If the patient is capable of holding an in-depth
conversation, obtain a detailed personality profile.
25. Explore previous psychiatric or psychological
disturbances the patient may have had and previous
treatment he may have received.
26. Obtain a detailed psychosocial history
27. Obtained a detailed family history
28. Review the patient’s medical history.
MENTAL STATUS EXAMINATION
History
• Background assessment include the client’s
history
• Chronologic and developmental age
• Developmental stage
• Cultural considerations- many cultures have
beliefs and values about a person’s role in the
society or acceptable social or personal behavior
that may differ from those of the nurse
Spiritual beliefs
Previous history – has the client experienced similar
difficulties in the past
➢ PRIMARY PURPOSE: to help the examiner
gather more objective data to be used in
determining etiology, diagnosis, prognosis and
treatment and to deal immediately with any risk
for violence or harm.
Also: identifies the person’s present mental status
Sensorium and intellect are particularly important
in determining the existence of delirium, dementia,
amnestic and other cognitive disorders.
Categories of information in MSE
1. General behavior, appearance and attitude
2. Characteristic of talk
3. Emotional state
4. Content of thought
5. Orientation
6. Memory
7. General intellectual level
8. Abstract thinking
9. Insight evaluation
10. Summary
Nursing Responsibilities
• Inform the patient or accompanying family members
that the test usually takes 30-90 minutes. It may take
longer if more extensive tests are to be performed. Ex.
Welchsler Adult Intelligence
• Scale takes several hours to complete
• If the test includes assessment of behavioral
problems, the examiner will try to reveal the patient’s
feelings a emotions
• It is important to build rapport with the patient to gain
trust and cooperation during the test
• The nurse should take note of any physical disabilities
that the patient has that could interfere with Body
stiffness and rigidity because limbs are drawn up
tightly against his body (fetal position). If you
attempt to touch the body, tension is increased leading
to the test to be given.
A. General behavior, appearance and attitude
Complete and accurate description of client’s physical
characteristics, apparent age, manner of dress, use of
cosmetics, personal hygiene and responses to the
examiner
• Includes posture, gait, facial expression and
mannerisms
• Client’s general activity level
❑ Automatisms – repeated purposeless behaviors
often indicative of anxiety (drumming of fingers,
twisting locks of hair, tapping the foot)
8. ❑ Psychomotor retardation- overall slowed
movements
❑ Waxy flexibility – also called cerea flexibilitas
• maintenance of posture or position overtime
when in awkward or uncomfortable;
extremities maybe molded into any position,
in paused posture in prolonged period for 12
hour
• patient feels insensitive to fatigue,
exhaustion, distress or discomfort
• common among catatonic schizophrenic
stupor state
❑ Pathologic limb rigidity – in catatonic
schizophrenic stupor stage.
• body stiffness and rigidity because limbs are
drawn up tightly against his body (fetal),
when you attempt to touch the body, there
will be increase in tension and there will be
resistance.
• It signifies negativistic response or regression
to infantile level of need, communication or
disease
• May symbolize withdrawal from emotionally
painful reality with an associated need for
communication
❑ Echopraxia – involuntary imitation another
person’s gestures, body movement, repeated or
duplicated movement of others as if compelled to
do so; different from “mimic” bec. there’s no
humor; common in schizophrenia
• Maybe a security achieving operation
which is stronger than one’s conscious
control
❑ Compulsions - repetitive acts performed through
some inner need or drive and supposedly against
the client’s wishes yet not performing them
results in tension and anxiety
• motivated by unconscious isolations of
earlier emotional traumatic experiences
❑ Impulsiveness - sudden outburst of physical
activity without forethought or conscious
judgment
• unpredictable, unexpected; outcome of
long period of mental unrest
❑ Ticks and spasms - uncontrollable jerking and
twitching of some part of the body usually in the
head, face and neck
• psychogenic related to unconscious
conflict; appears to be organic in etiology
but maybe of psychic in origin
• occur in front of unfamiliar person
because of increased consciousness;
anxiety is displaced through actions such
as eye blinking
B. Characteristics of Talk
✓ The form rather than the content of client’s
speech, how the client can deliver his/her thought
✓ The SPEECH is described in terms of loudness,
flow, speed, quantity, level of coherence and logic
✓ The goal is to describe the quality and quantity of
speech to discern difficulties in thought process
❑ Circumstantiality - cumbersome, convoluted
and unnecessary detail in response to the
interviewer’s questions.
• caused by beating around the bush (pt.
with severe anxiety)
❑ Perseveration - a pattern of repeating the same
words or movements despite apparent efforts to
make a new response
❑ Mutism - no verbal response despite indications
that the client is aware of the examiner’s
questions
❑ Flight of ideas – rapid, overly productive
responses to questions that seem related only by
chance associated between one sentence
fragment and another. Associated with flight of
ideas might be rhyming, clang associations,
punning and evidence of distractibility (bipolar)
• excessive amount and rate of speech
composed of fragmented or unrelated
ideas.
❑ Clang association – words with similar sounds
that are linked by patients; used by manic patients
to conceal communication impairment.
9. ❑ Punning – injection by patient of witty or clever
remarks into conversation to gain attention,
recognition, feeling of acceptance and increase
self-esteem; used by manic patients
❑ Rhyming – rhyming of phrases or whole
sentences in lyrical or poetic which is used in
conversation.
❑ Echolalia – repetition of immediate speech of
another as if experiencing a compulsion to
respond. It maybe a security operation or the
pathological suppression of data which is painful
to verbalize.
❑ Blocking – a pattern of sudden silence in the
stream of conversation for no obvious reason but
often thought to be associated with intrusion of
delusional thoughts or hallucinations.
❑ Word salad – flow of unconnected words that
convey no meaning to the listener
❑ Neologisms – new words coined by patient
C. Emotional State or Mood
✓ refers to the person’s pervasive or dominant
mood or affective reaction both subjective
and objective.
Affect – the outward expression of the client’s emotional
state.
✓ Subjective data are obtained through the use
of non-leading questions (how are you
feeling?). If the client replies with general
terms the interviewer should ask the client to
describe what he feels.
✓ Observe objective signs such as facial
expression, motor behavior, presence of
tears, flushing, sweating, tachycardia
tremors, respiratory irregularities, state of
excitement, fear and depression
✓ The attitude of the client towards the examiner,
such as hostility, suspiciousness or
flirtatiousness, a desire for bodily contact or
outspoken criticisms, sometimes offers valuable
clues.
o Record verbatim the replies to questions
concerning the client’s mood.
o The relationship between mood and the
content of thought is particularly
significant
o Clients who are trying to cover up a deep
depression may show cheerfulness and
good spirits
There may be a wide divergence between what
the clients say or do and their emotional state as expressed
by attitudes or facial expressions.
• Shallowness or flattening of affect – an
insufficiently intense emotional display in
association with ideas or situations that ordinarily
would call for a stronger response; showing no
facial expression
• Inappropriate affect- displaying a facial
expression that is incongruent with mood or
situation; often silly or giddy regardless of
circumstances
• Blunted affect – showing little or slow to
respond facial expression; a flattening of affect or
loss of capacity to experience and express
emotional at normal intensity. It may progress to
loss of feeling of sympathy toward a relative and
to loss of such primitive emotions of fear, rage
and sexual drive
• Apathy – a reduction or dulling of emotional
response to stimuli so that one reacts with less
interest, attention and feeling than normally.
Emotionless
• Restricted affect – displaying one type of
expression, usually somber or serious
• Broad affect – displaying a full range of
emotional expressions
• Labile – when client exhibits unpredictable and
rapid mood swings from depressed and crying to
euphoria with no apparent stimuli
• Ambivalence – the coexistence of two opposing
drives, desires, feelings or emotions
10. D. Content of thought: special preoccupations
Thought process - refers to how the client thinks
Thought content – what the client actually says
✓ The nurse can elicit these data by asking
questions such as, “do you have any difficulties?”
“Have you been troubled or ill lately?”
✓ When the nurse encounters clients with marked
difficulties in thought process and content, ask
focused questions requiring short answers.
❑ Delusions – false belief that is defended intensely
despite its being illogical or unrealistic; a fixed
false idea not based on reality
❖ Types:
1. Nihilistic- more or less completely denies reality and
existence
2. Delusion of self-deprecation – client describes feeling
of unworthy, sinful, ugly or foul smelling
3. Delusion of grandeur – associated with elated states
such as great wealth, strength, power, sexual potency or
identifications with famous persons or even God.
4. Delusion of persecution – belief that is being
persecuted
5. Somatic delusion- feelings that their body is affected
with cancer, leprosy, obstructed bowel or some horrible
disease.
❑ Thought broadcasting – a delusional belief that
others can hear or know what the client is
thinking
❑ Thought insertion – delusional belief that others
are putting ideas or thoughts into the client’s
head- that is, the ideas are not those of the client.
❑ Thought withdrawal – delusional belief that
others are taking the client’s thoughts away and
the client is powerless to stop it.
❑ Hallucinations- false sensory impressions with
no external basis in fact; special senses
manifested, produced by internal or subjective
experience or sensory perception that does not
result from real external stimulus.
❖ Types:
1. Visual
2. Auditory
3.gustatory
4. Olfactory
5. Tactile
❑ Illusions – misinterpretation of an external
sensory stimulus usually visual or auditory
❑ Ideas of reference – client’s inaccurate
interpretation that general events are personally
directed to him, such as hearing a speech on the
news and believing they had personal meaning
❑ Loose associations – disorganized thinking that
jumps from one idea to another with little or no
evident relationship between thoughts.
❑ Obsessions – insistent thoughts recognized as
arising from the self
• Involuntary preoccupation with a
thought or idea that seems irrational
• Client usually regards them as absurd
and relatively meaningless, yet they
persist despite endeavors to get rid of
them.
❑ Fantasies and daydreams – preoccupations that
are often difficult to elicit from the client because
often people are ashamed to talk about them
because of their content
❑ Tangential thinking (tangentiality) –
wandering off the topic and never providing the
information requested
11. E. Sensorium and Intellectual process
Orientation – refers to client’s recognition of person,
place and time that is knowing who and when.
• also, in terms of time, place and self to determine
the presence of confusion or clouding of
consciousness;
• many clinicians begin MSE with questions to test
this.
• Ex. What day is today?
F. Memory
✓ the person’s attention span and ability to retain or
recall past experiences in both the recent and the
most remote past
✓ if memory loss exists, determine whether it is
constant or variable and whether the loss is
limited to a certain period of time.
✓ recall of remote past experiences – ask review
of important events in the client’s life
✓ recall of recent past experiences – events
leading to the present seeking of treatment
✓ retention and recall of immediate impressions
– ask the client to repeat a name, an address or a
set of objects immediately and again after 3-5
minutes; repeat 3-digit number or a complicated
sentence
✓ general grasp or recall - ask the client to read a
story and then repeat the gist with as many details
as possible
❑ Confabulation - invented memories to take place
of those the client cannot recall
G. General Intellectual level – non standardized
evaluation of intelligence
✓ nurse looks for the person’s ability to use factual
knowledge in a comprehensive way
General grasp of information – ask who the
present president of the Phil., the last 4 presidents.
Ability to calculate – test of simple
multiplication and addition
Reasoning and judgement – ask the client what he will
do with a gift of $ 1000
Judgement- refers to the ability to interpret one’s
environment, situation correctly and to adapts one’s
behavior and decisions accordingly
H. Abstract thinking
✓ ask the client to interpret simple simple proverbs
/ fables “don’t cry over spilled milk”
I. Insight Evaluation
Insight – ability to understand the true nature of one’s
situation and accept some personal responsibility for the
situation
• ask the client to describe realistically the strength
and weaknesses of his behavior
• ask if the client recognize the significance of the
present situation, whether they feel the need for
treatment and how they explain the treatment.
• ask client for suggestions for their own treatment
J. Summary
K. Self- Concept – the way one views one-self in terms
of personal worth and dignity
• ask the client to describe himself and what
characteristics he likes and what he would change
L. Roles and Relationships
• assess the roles that the client occupies, client’s
satisfaction with those roles and if the client
believes he is fulfilling the roles adequately
M. Physiologic and self-care considerations
• emotional problems can greatly affect eating and
sleeping patterns. Determine how these patterns
have changed
• ask any major or chronic health problems and if
he takes prescribed or illicit medications
N. Biologic assessment - the nurse must consider the
possibility that the client’s symptoms may have biologic,
particularly neurologic basis.
• brain imaging techniques (can detect seizure
activity, evaluate sleep disorder, examine blood
flowing to the brain, identify cerebral atrophy
etc.)
12. PSYCHOTHERAPIES
Psychotherapy
• is a general term for treating mental health
problems by talking with a psychiatrist,
psychologist or other mental health provider.
Psychoanalysis
• by Sigmund Freud
• the exploration of the unconscious, chiefly thru
free association
3 stages:
a. Free association
• the psychoanalyst encourages the patient to
discuss anything and everything that comes into
his mind during these sessions
b. Second stage
• when the patient realizes that he must do
something about his problems, he leans towards
the analyst for guidance, love and help
• the analyst constantly reviews the patient who
attempts to show that patient to reach emotional
maturity under the guidance of the analyst
C. Third stage
• slow weaning of the patient from the analyst
• the patient attempts to achieve independence and
solve his conflicts an a natural level
Hypnotherapy
• A technique where in the psychiatrist induces a
marked state of relaxation in the patient
• When the patient is completely relaxed and in a
sleep-like state, the psychiatrist begins to carry on
conversation with him
• He may get the patient to talk about things he
could not say during direct interview, or he may
strongly suggest the disappearance of symptoms,
such as pain or paralysis
Milieu Therapy
Definition -Management of the client’s environment to
promote a positive living experience and facilitate
recovery
Narcotherapy
• Is the production of a drowsy, yet not an actual
sleep-like sate by means of a sedative drug
• During this period, the psychiatrist interviews the
client about his/her problems
• He attempts to uncover and analyze emotional
conflicts buried in the unconscious mind and not
accessible to him when the patient converses on
the conscious level
Play Therapy
• Used in the treatment of children with
maladjustment or behavior disorders
• The child is given toys and while at play, the
psychiatrists observe him and tries to discover the
causes of child’s conflicts
• At play, the child often imitates their parents,
sisters, brothers, teacher, friends etc.
• Children reconstruct past experiences in their
play and carry out action which they would like
to express in real life but may be fearful because
of the possibility of punishment
Family therapy
• Is a technique in which the therapist focuses on
the behavior with problems
• In family therapy, the therapist is direct, personal
and actively involves himself with the family
• He begins by observing and picking of cues from
the interaction as soon as the family enters the
room
13. Therapeutic Community
A simple type of milieu therapy by which the total social
structure of the treatment unit is involved in the helping
process.
Goal and Objectives
• To help the patient develop a sense of self-esteem
and self-respect
• To help him learn to trust others.
• To improve his ability to relate to others and with
authority.
• To return him to the community, better prepared
to resume his role in living and working.
Elements
1. People
2. Organized Activities
3. Environment
Characteristics of Therapeutic Community
✓ Emphasis on social and group interaction
✓ Focusing Communication
✓ Sharing responsibilities with patient
✓ Living and learning abilities
Therapeutic Activities:
✓ Music appreciation thru arts
✓ Craft and occupation therapy
✓ Newspaper discussion
✓ Biblio-therapy
✓ Activities of daily living
✓ Calisthenics
✓ Indoor/Outdoor games
✓ Play therapy
Therapeutic Meetings:
Circle meeting- highlights of the 24 hours
Small group- personal problems of patient
Community meeting- problems of patient encountered in
the ward of general interest
Treatment Planning- treatment regimen of a patient
Discharge Planning Conference- discharge plan for
patient
Patient Government Meeting- officers of the patients
discuss issue related to their welfare
Staff’s Shift-to-Shift Meeting- endorsement
Advisory Board Meeting- discussion of the demotion
and promotion of patient status
Attitude Therapy - Prescribed ways on how to handle
mentally ill patients according to the behavior symptoms
they manifest.
Type of Attitude Therapy
1. Active Friendliness- withdrawn patient
2. Passive Friendliness- paranoid patient
3. Kind-firmness- depressed client
4. Matter-of-Fact- manipulative/demanding
client/elated
5. No demand- furious/ in rage
Characteristics of Attitude Therapy
• Consistency- must be used for the patient to
reach the maximum therapeutic value.
• All persons who come in contact with the patient
should have a uniform attitude.
• Should be prescribed by the physician and should
be individualized depending on the individual
needs.
Therapeutic Activities
1. ACTIVITIES OF DAILY LIVING
❖ An activity done by an individual which is
necessary for the promotion of good personal
hygiene which can be done with or without
assistance/ supervision to an individual.
Objectives
✓ To promote and improve personal hygiene and
grooming.
✓ To promote self-independence.
✓ To encourage participation
✓ Evaluation through return demonstration.
✓ To develop awareness on home management and
community development.
✓ To develop interpersonal relationship
14. 2. PLAY THERAPY
❖ A technique that makes it possible for a patient to
express himself freely.
❖ Free play enables the individual a unique
opportunity to discharge strong motion in a
secure atmosphere.
❖ It is also a form of psychotherapy for regressed
psychotics to an extent of making it impossible to
communicate with the through verbal channels.
❖ A form of therapy that brings fun and a form of
exercise, socialization with others, cooperation,
diverting patient’s attention, promote
sportsmanship and express feeling and thoughts.
Objectives:
✓ To help patient interact with other patients in a
slightly competitive but thoroughly enjoyable
level, manner.
✓ The client will be able to express themselves
through acceptance and enjoyable means.
✓ To promote diversion from usual routinary
experienced by the client in favor of a more
dynamic activities
✓ To promote cooperation and sportsmanship
✓ Allow free expression of feelings and thoughts
3. MUSIC AND ART THERAPY
❖ Music therapy is the opportunity for socialization
and self-expression and sometimes realization
affected by certain musical activities
❖ Art therapy is the process of letting the patient
express his feelings and thoughts through various
artistic means particularly sketching and drawing
❖ One type of therapy with purposeful use music
and art as a participative or listening experienced
in the treatment of the patient to improve and
motive their mental and emotional state
❖ Designed to increase patient perception,
concentration, memory retention, conceptual
development, rhythmic behavior, verbal retention
and auditory discrimination .
❖ Used to stimulate thoughts and feelings
❖ Designed to increase patient perception,
concentration, memory retention, conceptual
development, rhythmic behavior, verbal retention
and auditory discrimination .
❖ Used to stimulate thoughts and feelings
Objectives
✓ To serve as diagnostic tools
✓ To uncover emotional traumatic experience
✓ To provide a medium for stimulation of inner
feelings through music and art
4. BIBLIO-THERAPY
❖ Used of literature, film, or feature on creative
writing with group discussion to promote self-
acknowledgement and interaction of thoughts
and feelings
❖ A therapy that enhances patients awareness
regarding an article or material as well as it
increases their level of understanding with the
information and content of such reading materials
❖ It stimulates the inner self by expressing their
feelings regarding the given story
Objectives:
✓ To stimulate the psychological, sociological and
aesthetic values form books into human
character, personality and behavior
✓ To provide stimulus for the memory to compare
events with their own interpersonal and
intrapsychic experience
✓ To increase level of understanding with the
information from the reading materials
5. OCCUPATIONAL THERAPY
❖ Any activity mental or physical and guided to an
individual to recover from a handicap
❖ There is an increasing awareness that process,
and not the product of the process, is the greatest
importance
❖ Manual, recreational and creative technique to
facilitate personal experiences and increase social
responses and self-esteem
Objectives:
✓ To improve general performance
✓ To obtain essential skills of living
✓ To increase the sense of accomplishment,
satisfaction and control over one’s owns life
✓ To increase social responses
✓ To increase self esteem
15. 6. REMOTIVATION TECHNIQUE
Definition:
❖ Is a technique of every simple group therapy of
an objective nature used to reach the unwounded
areas of the patient's personality and get them
moving in the direction of reality
Indication:
❖ Can be used in any ward situation, regardless of
the length of time the patient has been
hospitalized, his age, or the reason of his illness,
and sex
❖ Highly indicated for chronic, regressed, long term
hospitalized client
Objectives:
✓ To stimulate patients to think about something
and talk about himself
✓ To develop ability to communicate and share idea
and experience with others
✓ To develop feeling of acceptance and recognition
Values to patient:
✓ Stimulate the patients to follow and explore the
real world
✓ Gives him reason to value himself and increase
his self respect
✓ Makes him part of the group
✓ Physical Set-up/Arrangement
✓ Patients maybe seated in circle or u-shape
✓ Requires 10-15 patients take about 45 minutes -1
hour
Subjects to be covered:
✓ Geography
✓ History
✓ Nature
✓ Hobbies
✓ Literature
✓ Industry
✓ Sports
✓ science
Subjects/ Topics Not to be Covered
1. Religion
2. Politics
3. Love
4. Family problem
5. Sex
Steps
1. Climate of Acceptance (5 minutes)
− leader stays at the center, greets each
patient and introduces self.
− if first session, ask patients to introduce
themselves one by one.
− makes the patients feel relax or
comfortable by commenting about the
weather, and or complementing patients
appearance.
− ask about the day and or date to make
them oriented.
2. Bridge to Reality (15 minutes)
− ask questions leading to the topic to be
discussed.
− ask anybody to recite a poem related to
the topic.
− ask questions that are generalized to
specific in nature.
− read a poem to the group and then ask the
patient to read it back to the group.
− show the visual aids.
3. Sharing the World We Live In (15 minutes)
− ask stimulating questions regarding the topic,
leader should try to explore the topic.
− let the group share or talk one at a time about
the topic.
16. 4. Appreciation of the Work of the World (15 minutes)
− make sure that you relate that patient with the
topic so he may be able to relate it with himself
and/or with his job.
− this step is blended with 3 step.
5. Climate of Appreciation (5 minutes)
− ask for a summary about the topic.
− express appreciation to the patients for coming to
the session.
− inform them what topic to be discussed next
session or ask their suggestion.
Electro Convulsive Therapy (ECT)
❖ A treatment in which a grand mal seizure is
artificially induced by passing an electrical
current through electrode applied to one or both
temples. The number of treatments given in a
series varies according to the patient’s initial
problem and therapeutic response as assessed
during the course of treatment. The most common
range for affective disorders is from 6-12
treatments, whereas as many as 30 may given for
schizophrenia. ECT is usually given three times a
week on alternative days, although it can be given
more or less frequently
Indications for use are:
✓ Major depressive illness that has not responded to
antidepressant medication or in-patients unable to
tale medication
✓ Bipolar disorder in which the patient has not
responded to medication
✓ Acutely suicidal patients who have not received
medication long enough to achieve a therapeutic
effect
Preparation for ECT
A. Before the day of ECT
✓ The patient must complete a thorough physical,
neurological and laboratory examination
✓ Informed consent is obtained
✓ NPO after midnight
B. On the day of ECT
✓ Ask the patient to remove jewelry, hairpins,
eyeglasses, and hearing aids, dentures
✓ Dress the patient in loose, comfortable clothing
✓ Have the patient empty bladder, administer pre-
treatment medications
Procedures for ECT
✓ Make patient lie simply, with the back resting on
a pillow to promote hypertension of the spine to
prevent fracture of vertebrae or dislocation
✓ Let the patient bite mouth gag
✓ Apply electrode jelly on the temple to ensure
complete contact
✓ Terminal plugs are inserted into electrodes
✓ Two assistant support shoulders and wrist joints
and another one to support the knee
✓ Treatment switch is pressed after adjusting the
dosage and the patient goes into ground mal
seizure. The electrical is given with up to 150
volts for 0.5 to 2 seconds
✓ When the convulsion subsides and breathing is
resumed, turn the patient on his side to prevent
swallowing of saliva
✓ Ventilation and monitoring continue until the
patient is recovered
DURING TREATMENT
− patient suffer grand mal seizure/ tonic-clonic =
usually begins with bilateral jerks of the
extremities/ focal seizure activity.
Tonic – picture of body rigidity at the start of seizure last
for 10 seconds.
Clonic – muscular twitching of the entire body and
storturous breathing froths at the mouth may become
cyanotic and incontinent - last for 1 minute.
AFTER TREATMENT
- upon awakening patient doesn’t remember the period of
treatment.
help administer a few breaths of oxygen following
treatment.
− patient sleeps for 5 - 10 minutes.
− close observation by the nurse is essential until
the patient is fully oriented, steady on his feet and
− able to be out of bed.
17. Nursing Interventions after ECT
✓ Let patient feel comfortable in bed and let him go
to sleep
✓ Monitor respiratory problem
✓ Inspect for any bleeding of gums or bitten lips
✓ Avoid draft and exposure
✓ Re-orient the patient when he wakes up
✓ Documents all treatments
✓ After the patient is oriented and has rested, let
him have a shower and start his usual activities
POINTS TO BE RECORDED DURING ECT
1. Types of seizure.
2. Time of occurrence.
3. Duration and description of reaction.
4. Behavior, general reactions, attitude and remark
before and after therapy or treatment.
EFFECTS OF ECT
1. Sedative effect for the manic.
2. Stimulating effect for depressed.
3. Produce spasm on the brain.
4. Produce amnesia.
COMPLICATION OF ECT
1. Apnea
2. Fracture
3. Temporary amnesia
