THERAPEUTIC MODALITIES IN MENTAL HEALTH.pptx

THERAPEUTIC MODALITIES
IN PSYCHIATRIC NURSING
Owondo Thomas
Bwindi Community Hospital
© 2017 Thomas Owondo. All rights reserved.

INTRODUCTION
• Mental health disorders can affect physical and
psychological behaviors.
• Therapeutic modalities can provide useful guidance for
the prevention and treatment of mental health disorders
and the care of the people.
• Therapeutic modalities in mental health refers to the
various ways of management of people with mental
illness.
© 2017 Thomas Owondo. All rights reserved. 2

TYPES OF THERAPEUTIC MODALITIES
1. Pharmacotherapy/ Drug therapy.
2. Psychotherapy/ Talk therapy.
3. Electroconvulsive therapy (ECT).
4. Occupational therapy.

PHARMACOTHERAPY/ DRUG THERAPY.
• This is the treatment of disease through the administration of drugs.
• Most medications are used by mental health specialists in much the same
way that medications are used to treat high blood pressure or diabetes.
• After completing thorough evaluations, mental health specialists can
prescribe medications to help treat mental disorders.
• Psychiatric medications can help correct imbalances in brain chemistry
that are thought to be involved in some mental disorders. Patients on
long-term medication treatment will need to meet with their mental health
specialist periodically to monitor the effectiveness of the medication and
any potential side effects.

PHARMACOTHERAPY/ DRUG THERAPY
• Class of Medications used in mental health include:
Antidepressants – used to treat depression, panic disorder,
PTSD, anxiety, obsessive-compulsive disorder, borderline
personality disorder and eating disorders.
Antipsychotic medications – used to treat psychotic symptoms
(delusions and hallucinations), schizophrenia, bipolar disorder.
Sedatives and anxiolytics – used to treat anxiety and insomnia.
Hypnotics – used to induce and maintain sleep.
Mood stabilizers – used to treat bipolar disorder.
Anticonvulsants- used to treat epilepsy and other seizure
disorders. © 2017 Thomas Owondo. All rights reserved. 5

PSYCHOTHERAPY/ TALK THERAPY
• If any single therapeutic modality can be said to be the mainstay of mental
health treatment, it is psychotherapy. The talking relationship between a
therapist and client or patient is the best known tool in mental health.
• Psychotherapy, sometimes called talk therapy, is a treatment that involves
a talking relationship between a therapist and patient.
• It can be used to treat a broad variety of mental disorders and emotional
difficulties.
• The goal of psychotherapy is to eliminate or control disabling or troubling
symptoms so the patient can function better.
• Depending on the extent of the problem, treatment may take just a few
sessions over a week or two or may take many sessions over a period of
years. Psychotherapy can be done individually, as a couple, with a family,
or in a group.

Psychotherapy/ Talk therapy
• There are many forms of psychotherapy. There are
psychotherapies that help patients change behaviors or thought
patterns, psychotherapies that help patients explore the effect of
past relationships and experiences on present behaviors, and
psychotherapies that are tailored to help solve other problems in
specific ways.
• There are more than fifty types of therapeutic approaches. Only a
few of them are common, though. There are also some that act as
broad categories and contain subtypes.ytt
Note: Remember, most therapists blend therapeutic approaches
and customize an integrated approach for each client.

• A theory of psychotherapy acts as a roadmap for
psychologists: It guides them through the process of
understanding clients and their problems and developing
solutions.
• Approaches to psychotherapy fall into five broad categories:
Psychoanalysis and psychodynamic therapies
Behavior therapy
Cognitive therapy
Humanistic therapy.
Integrative or holistic therapy

 Psychoanalysis and psychodynamic therapies. This approach focuses on
changing problematic behaviors, feelings, and thoughts by discovering their
unconscious meanings and motivations. Psychoanalytically oriented
therapies are characterized by a close working partnership between therapist
and patient. Patients learn about themselves by exploring their interactions in
the therapeutic relationship. While psychoanalysis is closely identified
with Sigmund Freud, it has been extended and modified since his early
formulations.
 Cognitive therapy. Cognitive therapy emphasizes what people think rather
than what they do.
• Cognitive therapists believe that it's dysfunctional thinking that leads to
dysfunctional emotions or behaviors. By changing their thoughts, people
can change how they feel and what they do.
• Major figures in cognitive therapy include Albert Ellis and Aaron Beck.

Behavior therapy. This approach focuses on learning's
role in developing both normal and abnormal behaviors.
• Ivan Pavlov made important contributions to behavior therapy by
discovering classical conditioning, or associative learning. Pavlov's
famous dogs, for example, began drooling when they heard their dinner
bell, because they associated the sound with food.
• "Desensitizing" is classical conditioning in action: A therapist might help a
client with a phobia through repeated exposure to whatever it is that
causes anxiety.
• Another important thinker was E.L. Thorndike, who discovered operant
conditioning. This type of learning relies on rewards and punishments to
shape people's behavior. BF Skinner is regarded as the father of Operant
Conditioning, but his work was based on Thorndike’s (1898) law of effect.

 Humanistic therapy. This approach emphasizes people's capacity to
make rational choices and develop to their maximum potential.
Concern and respect for others are also important themes.
• Humanistic philosophers like Jean-Paul Sartre, Martin Buber and Søren
Kierkegaard influenced this type of therapy.
• Three types of humanistic therapy are especially influential. Client-
centered therapy rejects the idea of therapists as authorities on their
clients' inner experiences. Instead, therapists help clients change by
emphasizing their concern, care and interest.
• Gestalt therapy emphasizes what it calls "organismic holism," the
importance of being aware of the here and now and accepting
responsibility for yourself.
• Existential therapy focuses on free will, self-determination and the
search for meaning. © 2017 Thomas Owondo. All rights reserved. 11

Integrative or holistic therapy. Many therapists don't tie
themselves to any one approach. Instead, they blend
elements from different approaches and tailor their
treatment according to each client's needs.

• Examples of psychotherapy include;
 Client-Centered Therapy [Person-Centered Therapy, PCT, CCT
or Rogerian Therapy] (Part of the Humanistic Category of
Therapy)
 Cognitive or Cognitive Behavioral Therapy [CBT] (part of the
behavioral category)
 Rational Emotive therapy
 Behavioural therapy

ELECTROCONVULSIVE
THERAPY (ECT)

ELECTROCONVULSIVE THERAPY (ECT)
• Electroconvulsive therapy (ECT) is a medical treatment most
commonly used in patients with severe major depression or
bipolar disorder that has not responded to other treatments.
• ECT involves a brief electrical stimulation of the brain while
the patient is under anesthesia. It is typically administered by
a team of trained medical professionals that includes a
psychiatrist, an anesthesiologist, and a nurse.
• During this therapy, electrical currents are sent through the
brain to induce a seizure. The procedure has been shown to
help 78 percent of people with clinical depression.

ELECTROCONVULSIVE THERAPY (ECT)
• ECT has a checkered past. When ECT was first introduced in
the 1930s, it was known as “electroshock therapy.” In its early
use, patients regularly suffered broken bones and related
injuries during therapy. Muscle relaxants weren’t available to
control the violent convulsions caused by ECT. Because of
this, it’s considered one of the most controversial treatments
in modern psychiatry.
• In modern ECT, electrical currents are administered more
carefully. Also, the patient is sedated to reduce the risk of
injury.

INDICATIONS OF ECT
• ECT is typically used when other treatments, including medications and
psychotherapy, haven’t worked.
• ECT is also used for people who require a rapid treatment response
because of the severity of their condition, such as being at risk for
suicide.
• Acute catatonia: characterized by lack of movement, fast or strange
movements, lack of speech, and other symptoms. It's associated with
schizophrenia and certain other psychiatric disorders. In some cases,
catatonia is caused by a medical illness.
• Severe depression
• Acute mania
• Mood disorders with psychotic features.

INDICATIONS OF ECT
• Although ECT can be very effective for many individuals
with serious mental illness, it is not a cure. To prevent a
return of the illness, most people treated with ECT need
to continue with some type of maintenance treatment.
This typically means psychotherapy and/or medication or,
in some circumstances, ongoing ECT treatments.

CONTRAINDICATIONS
• Contraindications to ECT include brain tumors, space-
occupying lesions, and other brain diseases that cause
increased intracranial pressure.

TYPES OF ECT
• There are two major types of ECT: unilateral and bilateral.
 In bilateral ECT, electrodes are placed on either side of your
head. The treatment affects your entire brain.
 In unilateral ECT, one electrode is placed on the top of your
head. The other is placed on your right temple. This treatment
affects only the right side of your brain.
• Some hospitals employ “ultra-brief” pulses during ECT. These
last less than half a millisecond, compared to the standard
one-millisecond pulse. The shorter pulses are believed to help
prevent memory loss.

EQUIPMENT FOR ECT
• Treatment devices and supplies, including electrode paste and gel, gauze
pads , saline, electro encephalogram electrodes and chart paper.
• Monitoring equipment including ECG and EEG electrodes
• BP cuffs, peripheral nerve stimulator and pulse oxymeter
• Stethoscope
• Reflex hammer
• Intravenous and venipuncture supplies
• Stretchers with firm mattress with side rails with the capacity of raising the
head and foot end
• Bite blocks

EQUIPMENT FOR ECT
• Suction device
• Ventilation equipment, including tubing , masks, Ambu bag,
oral airways , intubations equipment with an oxygen delivery
system capable of providing positive- pressure oxygen
• Emergency and other medications as recommended by the
anesthesia staff
• Miscellaneous medications not supplied by anesthesia staff
for medical management during ECT such as midazolam,
diazepam, thiopental sodium, glycopyrolate, succinyl choline
etc.

NURSING ROLES BEFORE AND AFTER
ELECTROCONVULSIVE THERAPY
• Electroconvulsive therapy is treated like a minor surgical procedure that
requires preoperative preparation and postoperative care.
• The nurse's multifaceted role in ECT is enacted by providing education
and support, performing pretreatment assessments, monitoring the
procedure, and observing and interpreting posttreatment patient
responses.
• There are four components of nursing care in ECT.
 Providing educational and emotional support.
 Pre-treatment planning and assessment.
 Preparing and monitoring the patient during the actual procedure.
 Post-treatment care and evaluation

Providing Educational and emotional support:
• Explain the procedure to the patient
• Obtain an informed consent from the patient and the
carer.
• Respond to patient’s concerns and feelings.
• Educate the patient concerning the procedure and explain
to the patient the necessary tasks associated with ECT.
• Initiate education interventions based on knowledge
deficits.

Pre-treatment Nursing care:
• Preparation of treatment suite for the ECT procedure.
• An adjustable height stretcher trolley
• Complete the pre-treatment check list.
• The patient’s identity is checked and the patient wears an identity bracelet.
• Ensure safekeeping of the patient’s valuables.
• The patient’s hair should be clean and dry to allow for electrode contact.
• Hairpins, bracelets, body piercing should be removed to avoid burns.
• The patient should be encouraged to pass urine before the treatment to avoid
incontinence during the procedure.
• Minimise anxiety through anxiety management techniques, ensuring short
waiting time and offering reassurance and support.

Nursing Care during ECT Procedure
• Transfer the patient on a trolley from the waiting room to the ECT room on a
well padded bed and placed in a comfortable dorsal position or supine
position. A small pillow is placed under the lumber curve.
• Apply ECG electrodes, BP cuff, and pulse oximetry sensor (not on same
extremity as BP cuff).
• Give a short acting anesthetic agent. Thiopental .25mg to .5 mg , IV and
secoline (succynyl choline) 30-50 mg. The dose of drug may vary from
patient to patient.
• Prepare EEG electrodes, per treatment specifications.
• Prepare scalp and stimulus ECT electrodes (unilateral vs. bilateral) and apply
paste to electrodes.

• Support the shoulder and arms of the patient. Restraint the thigh with
the help of a sheet.
• Hyperextension of the head with support to the chin.
• Administer oxygen.
• Apply jelly to the electrodes.
• Make the observations of the convulsions.
• The presence of initial tonic stage which lasts for 10-15 seconds
followed by clonic stage which lasts for 25-30 sec then there is a phase
of muscular relaxation with stertorus respiration i.e. flaccid stage.
• Do suction immediately
• Restore respiration by giving O2 if necessary. 27

Post-ECT Care
• Observe and record the vital parameters
• Place the patient on side lying position, clean the secretions
• Transfer the patient from recovery room . record vital signs every
15 min for 30 min and once in every 30 min till the patient recover
to the normal stage.
• Allow the patient to sleep for 30 min to one hour
• Reassure the client and reorient to the ward
• Allow the patient to have tea or any drinks
• Record the procedure

RISKS, SIDE EFFECTS AND
COMPLICATIONS OF ECT
• Although ECT is generally safe, risks and side effects associated with ECT
are uncommon and generally mild.
• Confusion. Immediately after treatment, you may experience confusion,
which can last from a few minutes to several hours. You may not know where
you are or why you're there. Rarely, confusion may last several days or
longer. Confusion is generally more noticeable in older adults.
• Memory loss. Some people have trouble remembering events that occurred
right before treatment or in the weeks or months before treatment or, rarely,
from previous years. This condition is called retrograde amnesia. You may
also have trouble recalling events that occurred during the weeks of your
treatment. For most people, these memory problems usually improve within a
couple of months after treatment ends.

RISKS, SIDE EFFECTS AND
COMPLICATIONS OF ECT
• Physical side effects. On the days of an ECT treatment, some people
experience nausea, headache, jaw pain or muscle ache. These generally
can be treated with medications.
• Medical complications. As with any type of medical procedure, especially
one that involves anesthesia, there are risks of medical complications. During
ECT, heart rate and blood pressure increase, and in rare cases, that can lead
to serious heart problems. If you have heart problems, ECT may be more
risky.
• Death is a rare but severe outcome of ECT treatment. It is a result of various
complications of ECT such as reactions to anesthesia, cardiovascular
complications, pulmonary complications, or stroke. Potential mitigating
factors include those proposed for each of these key risks.

OCCUPATIONAL THERAPY
(OT)

• Many people associate occupational therapy with
pediatric services or physical rehabilitation. They are
surprised to find occupational therapists also working in
mental health settings.
• Occupational therapy is a mode of treatment that uses
purposeful activities of self-care, work and play/leisure to
increase independence, enhance development and/or
prevent disability.

• Like social work, occupational therapy is a broad profession that works in
many areas. In general, occupational therapists work to help clients
participate in the things they want and need to do through the therapeutic use
of everyday activities, or “occupations.”
• The origins of occupational therapy are rooted in mental health, as the
creation of the profession dovetailed with the early 20th century's mental
hygiene movement. With the call for deinstitutionalization of individuals with
mental illness, which culminated in the 1963 Community Mental Health Act,
occupational therapists began working in community mental health.
• Today, occupational therapy practitioners provide services in community
settings including, but not limited to mental health clients.

Where do Occupational Therapists work?
• Hospitals
• Schools/Special
schools
• Mental Health
Facilities
• Armed forces
• Old Homes
• Private Clinics
• Rehabilitation
Centers
• Community Health
Centers
• Insurance
Companies
• Client Homes
• Client Work Places

Who do Occupational Therapists work with?
Children
Adolescents
Adults
Seniors

• In the past, there was an adherence to the medical model; now the focus is
on incorporating the recovery model. This model acknowledges that recovery
is a long-term process, with the ultimate goal being full participation in
community activities.
• These activities may include obtaining and maintaining employment, going to
school, and living independently.
• The philosophical base of the recovery model is a good fit with occupational
therapy because the purpose of occupational therapy in mental health is to
increase an individual's ability to live as independently as possible in the
community while engaging in meaningful and productive life roles. Because
occupational therapy facilitates participation and is client-centered, it plays an
important role in the success of those recovering in the community.

• Occupational therapy often is misunderstood in this process.
According to the American Occupational Therapy Association, the
primary goal of occupational therapy is to support and enable
each person’s “health and participation in life through engagement
in occupation.”
• “Occupation” does not solely mean work. Some examples of
occupations include time spent on personal hygiene, preparing a
meal, managing finances, painting a picture, attending a
community leisure course, and socializing with others.
Occupational therapists enhance people’s ability to live
meaningful and satisfying lives.

ROLES OF OTs IN MENTAL HEALTH
• Individuals of all ages who are diagnosed with a mental illness
can benefit from occupational therapy. Furthermore, friends and
family members can also benefit from these services to learn
ways to deal with the stress of caregiving and how to balance
their daily responsibilities to allow them to continue to lead
productive and meaningful lives.
• OTs help people to identify the things they want and need to do in
their lives, identify areas where skills development is needed and
assess how the environment helps or hinders people in achieving
their goals.

ROLES OF OTs IN MENTAL HEALTH
• Occupational therapists working in the mental health settings focus on
enabling individuals to re-engage in meaningful occupations through a
variety of skill sets such as skills development, establishing positive habits
and routines, setting therapy goals, using cognitive-behavioral techniques
(CBT), and understanding underlying physiological influences.
• Specifically, occupational therapy within the setting of child and adolescent
mental health focuses on those underlying physiological influences and
teaching patients to identify and utilize self-regulation strategies in order for
patients to get back to participating in meaningful occupations such as going
to school, being with friends, and participating within the family system.

APPROACHES OT’S USE WITH
CLIENTS/PATIENTS
• Providing education on coping skills and self-regulation skills to use in a variety of contexts
• Providing education on sensory exploration and implementation of sensory approaches for
self-regulation
• Incorporating yoga and movement interventions to provide sensory input and achieve self-
regulation
• Utilizing CBT approaches to facilitate participation in desired activities
• Identifying and implementing healthy, positive habits and structure into daily routines
• Providing education and implementation of skills related to social competence, such as
making and keeping friends, coping with anger, solving problems, learning about social
etiquette, and following school rules
• Evaluating factors interfering with success in school, home, community, etc.
• Modifying the environment to support improved attention, participation and decrease sensory
overload in the classroom

APPROACHES OT’S USE WITH
CLIENTS/PATIENTS
• Providing parents with education on behavioral and psychosocial
approaches to enhance the child’s daily functioning
• Reducing restraints and seclusions in the inpatient setting by
conducting comprehensive assessments to determine facilitators
and barriers to participation in life tasks, promoting the use of self-
awareness and skills development, collaborating with the client to
develop attainable goals, modifying the environment for optimal
fit, promoting use of self-regulation and sensory strategies, and
educating the interdisciplinary team on prevention techniques.

ASSESSMENTS A CLIENT FOR
• When working with someone with a mental health condition,
occupational therapists employ a variety of assessments. Once
the necessary information has been obtained, the therapist
creates a personalized occupational profile. This profile is used for
goal-setting and treatment planning.
• Common areas of assessment include: Activities of daily living
(e.g., bathing, dressing, eating), Instrumental activities of daily
living (e.g., driving, money management, shopping), Work (paid
and volunteer), Social participation, Mental and cognitive
processing skills, Communication and interaction skills, Leisure,
Habits, roles and routines etc.

ASSESSMENTS A CLIENT FOR
• For example, an occupational therapist may assess a client with
schizophrenia who is living in a residential hospital in order to help
to determine the best placement in the community.
• The assessment may include standardized evaluation tools,
individual interview, and observation to determine ability to
function and live alone safely, and identify important roles and
occupations.
• This information is then used to determine the skills, supports,
and environmental modifications the person may need to live as
independently as possible.

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