Therapeutic modalities

Therapeutic Modalities,
Psychosocial Skills, and
Nursing Strategies
Prepared by: Eric F. Pazziuagan, RN,
MAN

BIOPHYSICAL/ SOMATIC
INTERVENTIONS

ELECTROCONVULSIVE THERAPY
(ECT)

 Introduced by Ugo Cerletti and Luciano
Bini in 1938.
 Once commonly referred to as
electroshock therapy (EST) or simply
shock therapy.
 During ECT, an electric current is passed
through the brain, causing a seizure.

 Electric current is passed through the
brain for 0.2 to 8.0 seconds.
 Induction of a seizure is necessary for
therapeutic outcome.
 Seizure must be of sufficient quality to
produce the best effect.
 Seizures are timed and subdivided:
 Motor convulsions (at least 20 seconds)
 Increased heart rate (for 30-50 seconds)
 Brain seizure monitored by EEG (for 30-150
seconds)

 The patient is given an oximeter-
monitored anesthetic to ensure
optimal oxygenation.

Preparation for ECT:
 Pretreatment evaluation: physical
examination, laboratory work (blood
count, blood chemistry, urinalysis), and
baseline memory abilities.
 Consent form; if profoundly
depressed, signed by family members.
 Eliminate use of benzodiazepines or
barbiturates for nighttime sedation because
of their ability to raise seizure threshold.
 A trained electrotherapist and an
anesthesiologist should be available.

Nursing Responsibilities before ECT
 NPO for 6-8 hours before ECT, except for
cardiac, antihypertensive, and a few other
medications.
 Administer Atropine at least an hour before
treatment (to reduce secretions and
counteract vagal stimulation).
 Ask client to urinate before the treatment.
 Remove hairpins, contact lenses, hearing
aids and dentures.

 Take VS.
 The nurse should be positive about the
treatment and attempt to reduce the
patient’s anxiety.

Procedures during ECT
 IV line is inserted.
 Electrodes are attached to the proper
place on the head. Electrodes are typically
held in place with a rubber strap.
 The bite block is inserted.
 Methohexital (Brevital)or another short-
acting barbiturate is given IM (causing
immediate anesthesia and preempting
anxiety)

 Succinylcholine (anectine), a
neuromuscular agent, is given IV (causes
paralysis but not sedation). This prevents
the external manifestations of grand mal
seizures, thus minimizing fractures or
dislocations.
 The anesthesiologist mechanically
ventilates the patient with 100% oxygen
immediately before the treatment.
 The electrical impulse is given for 0.2-8.0
seconds.

 The seizure should last a certain length of
time to be of therapeutic value. If seizure
lasts less than the expected time, the
physician may stimulate another seizure.
Seizures of more than 180 seconds is less
favorable and can be terminated with
diazepam or another benzodiazepine.
 Monitoring devices: heart rate and rhythm,
BP, EEG.
 Ventilation and monitoring until patient
recovers.

Nursing responsibilities after ECT
 The nurse or anesthesiologist
mechanically ventilates the client with
100% oxygen until the patient can breathe
unassisted.
 Monitor respiratory problems.
 Reorient patient to time, place and person
as he emerges from groggy state.
 Give benzodiazepine as needed (if in
agitated state).

 Observe until client is oriented and study,
particularly when the patient first attempts
to stand.
 Document all aspects of treatment.

How does ECT work?
 No one knows for sure.
 Most promising theories:
 ECT alters the endocrine system in ways that
promote an antidepressant effect.
 ECT alters neurotransmitter systems that
contribute to mental disorders.
 ECT alters (raises) the seizure treshold, which
in turn, causes an antidepressant effect.
 ECT alters (increases) the permeability of the
blood-brain barrier.

Number of Treatments
 Two to three times a week, up to a
total of 6-12 treatments (or until the
patient improves or is obviously not
going to improve).
 Many patients require continuation or
maintenance of treatments to function
at their best.

Indications for ECT: Major
Depression
 Primarily indicated for schizophrenia, but
soon shifted to patients who are severely
depressed (85%-90%).
 Hierarchy of patients who should receive
ECT:
 Those who require a rapid response
(e.g., suicidal or catatonic patients)
 Those who cannot tolerate or be exposed to
pharmacotherapy (e.g., pregnant women)
 Those who are depressed but have not
responded to multiple and adequate trials of

Contraindications to ECT

 Very high risk
 Recent MI
 Recent CVA

 Intracranial

mass
 Increased ICP

 High risk
 Angina pectoris
 CHF
 Extremely loose teeth
 Severe pulmonary disease
 Severe osteoporosis
 Major bone fractures
 Glaucoma
 Retinal detachment
 Thromboplebitis
 High- risk pregnancy
 Use of MAOIs (severe HPN)
 Use of clozapine (seizures, delirium)

Advantages of ECT
 Fastest relief for depression.
 Safe procedure,
 More effective than antidepressants
for certain groups of patients.
 Can be used safely and effectively in
older patients, even in old-old
patients, and in adolescents.

Disadvantages of ECT
 Provision of only temporary relief.
 Does not provide a permanent cure
 Might need another series of treatments
 May need maintenance or continuation treatment
(6-12 months or longer)
 Memory loss
 Most frequent side effect: Memory impairment,
both retrograde and anterograde
 There seems to be no substantial loss of mental
function for most patients.
 Not clear whether this is related to ECT or
depression.

 Adverse physiologic effects
 Cardiac effects: HPN, arrhythmias,
alterations of cardiac output, and
changes in cerebrovascular dynamics.
 Hemodynamic changes + increased

muscle tone= increased in oxygen
consumption -> ischemia
 hyponatremia

 Migraine headaches

 Does not cause brain damage

PSYCHOSURGERY (LOBOTOMY)

 Destroys brain tissue for the purpose of
relieving intractable mental disorders not
amenable to other therapies.
 Indications: OCD or aggressiveness
related to a mental disorder.

 The MOST CONTROVERSIAL topic in
psychiatry.
 Clinicians should eliminate all other options
before using this drastic approach.
 Pioneered by Antonio Egas Monis, a
Portuguese neurologist, in 1935.
 Popularized by Walter Freeman (with James
Watt) in the US.
 Ethical concerns: to destroy the brain tissue
constitutes an extreme and irreversible tactic;
most clinicians believe that psychosurgery
should be abandoned.

BRIGHT LIGHT THERAPY (BLT)

 Formerly called phototherapy.
 Exposes clients to intense light (5,000 lux-
hours) each day.
 Rationale: environmental factors play a role
in mood disorders.
 Therapeutic effect is believed to be mediated
by the eyes, not the skin.

 Indications:
 Seasonal affective disorder (SAD); morning
administration is most beneficial.
 Bulimia
 Sleep maintenance insomnia
 Nonseasonal depression
 Contraindications:
 Nausea, eye irritation
 Adverse effects:
 Glaucoma, cataracts and use of
photosynthesizing medications

REPETITIVE TRANSCRANIAL
MAGNETIC STIMULATION

 TMS or rTMS
 Produces a magnetic field over the
brain, influencing brain activity.

 Increases the release of neurotransmitters
and/or regulates beta-adrenergic receptors,
thus ameliorating depressive symptoms and
possibly other disorders.
 An attractive alternative to ECT.
 Some studies have suggested that it is as
effective as ECT in nonpsychotic patients.
 Patients with mental implants and increased
ICP should be carefully evaluated before
receiving treatment.
 Adverse effects:
 Seizures, headache, and transient hearing loss

Individual Psychotherapy
 A method of bringing about change in a
person by exploring his or her feelings,
attitudes, thinking, and behavior.
 Involves a one-to-one relationship between
the therapist and the client.
 Stages:
 Introduction
 Working
 Termination

 Reasons why people seek psychotherapy:
 To understand themselves and their behavior
 To make personal changes
 To improve interpersonal relationships
 To get relief from emotional pain or
unhappiness
 The key to success is the therapist-client
relationship.
 A therapist’s theoretical beliefs strongly
influences his or her style of therapy.

Group Therapy
 Clients participate in sessions with a
group of people.
 Members share a common purpose
and are expected to contribute to the
group to benefit others and receive
benefit from others in return.
 Group rules are established, which all
members must observe.

 Being a member of the group allows
the client to learn new ways of looking
at a problem or ways of coping with or
solving problems and also helps him
or her to learn interpersonal skills.
 For example: by interacting with other
members, clients often receive feedback
on how others perceive and react to
them and their behavior.

Therapeutic Results of Group
Therapy
 Gaining new information, or learning.
 Gaining inspiration or hope.
 Interacting with others.
 Feeling of acceptance and belonging
 Becoming aware that one is not alone and
that others share the same problems
 Gaining insight into one’s problems and
behaviors and how they affect others
 Giving of oneself for the benefit of others
(altruism)

Psychotherapy Groups
 Goal: for members to learn about their
behavior and to make positive changes in
their behavior by interacting and
communicating with others as a member
of a group.
 Can be organized around a specific
medical diagnosis (e.g., depression) or a
particular issue (e.g., improving
interpersonal skills or managing anxiety).

 Group techniques and processes are used to
help group members learn about their
behavior with other people and how it relates
to core personality traits.
 Members can also learn they have
responsibility to others and can help other
members achieve their goals.
 Often formal in structure with one or two
therapists as group leaders.
 Leaders establish rules that deal with
confidentiality, punctuality, attendance, and social
contact between members outside of group time.

 Two Types:
 Open groups: ongoing and run
indefinitely, allowing members to join or
leave the group as they needed to.
 Closed groups: structured to keep the

same members of the group for a
specified number of sessions.

Family Therapy
 A form of group therapy in which the client
and his or her family members participate.
 Goals:
 Understanding how family dynamics contribute
to the client’s psychopathology
 Mobilizing the family’s inherent strengths and
functional resources
 Restructuring maladaptive family behavioral
styles
 Strengthening family problem- solving
behaviors

 Can be used both to assess and to treat
various psychiatric disorders.
 Although one family member usually is
identified initially as the one who has
problems and needs help, it is evident
through the therapeutic process that other
family members also have emotional
problems and difficulties.

Education Groups
 Goal: to provide information to members
on a specific issue- for instance, stress
management, medication management, or
assertiveness training.
 Group leader has expertise:
nurse, therapist, or a health professional
 Are scheduled for a specific number of
sessions and retain the same members for
the duration of the group.

 The leader presents the information and
then members can ask questions or
practice new techniques.
 Example: medication administration group
 Leader discuss medication regimens and
possible side effects
 Screen client for side effects
 May administer medications

Support Groups
 Are organized to help members who share a
common problem to cope with it.
 Group leader explores members’ thoughts
and feelings and creates an atmosphere of
acceptance so that members feel comfortable
expressing themselves.
 Often provide a safe place for group
members to express their feelings of
frustration, boredom, or unhappiness and
also to discuss common problems and
potential solutions.

 Rules differ from psychotherapy: Members
are encouraged to contact one another
and socialize outside the sessions.
 Confidentiality may be a rule.
 Tend to be open groups.
 Examples:
 Cancer or stroke victims
 Persons with AIDS
 Family members of someone who have
committed suicide
 Mothers Against Drunk Driving (MADD)

Self- Help Groups
 Members share a common experience,
but not a formal or structured therapy
group.
 Many are run by members and do not
have a formally identified leader.
 Most have a rule of confidentiality
 May be locally or nationally organized
 Example:
 Alcoholics Anonymous, Gamblers
Anonymous, Parents Without Partners, etc.

Group
 Number of persons who gather in a face-
to-face setting to accomplish tasks that
require cooperation, collaboration, or
working together.
 Group content: what is said in the context
of the group, including educational
material, feelings and emotions, or
discussions of the project to be completed.

 Group process: the behavior of the group
and its individual members, including
seating arrangements, tone of voice, who
speaks to whom, who is quiet, and so
forth.
 Content and process occur continuously
throughout the life of the group.

Stages of Group
Development
 Initial stage: commences as soon as the
group begins to meet.
 Members introduce themselves
 Leader is selected
 Purpose is discussed
 Rules and expectations for group participation
are reviewed.
 Group members begins to “check out” one
another.

 Working stage: members begin to
focus their attention on the purpose or
the task the group is trying to
accomplish.
 May happen relatively quickly; may take
2-3 sessions in a therapy group.
 Group characteristics that may be seen:

 Cohesiveness: degree to which members
work together to accomplish the purpose.
 Cohesiveness is desirable.

 Evident if members value one another’s

contributions, members think as “we”, and

 Termination: final stage; occurs before the
group disbands.
 Work is reviewed
 Focus is on group accomplishments or growth
of group members, or both.

Group leadership
 Identified or formal leader: someone
designated to lead the group.
 Formal leader in therapy and education
groups: identified based on his education,
qualifications, and experience.
 Informal leaders: members recognized by
others as having the knowledge, experience,
or characteristics that members admire and
value.
 Effective group leaders focus on group
process as well as on group content.

 Tasks of a group leader:
 Giving feedback and suggestions
 Encourage participation from all

members (eliciting response from quiet
members and placing limits on members
who may monopolize the group’s time)
 Clarifying thoughts, feelings, and ideas

 Summarizing progress and

accomplishments
 Facilitating progress through the stages

of group development.

Group roles
 Growth producing roles:
 Information seeker
 Opinion seeker
 Information giver
 Energizer
 Coordinator
 Harmonizer
 Encourager
 Elaborator

 Growth-inhibiting roles:
 Monopolizer
 Aggressor

 Dominator

 Critic

 Recognition seeker

 Passive follower

THERAPEUTIC GROUPS
RELATED TO LIVING SKILLS

 Some mental illnesses
(e.g., schizophrenia and AD) result in
an impairment that works against
developing meaningful relationships;
other mental illnesses have social
withdrawal as a characteristic
symptom.

Social Skills Groups
 Help psychiatric patients learn, practice,
and develop skills for dealing with people
in social situations.
 Might focus on appropriate dress,
grooming, or table manners.
 More advance efforts address appropriate
social and interpersonal verbal skills- e.g.,
meeting new people, initiating
conversations, and interviewing for a job.

 The opportunity to try out new skills and
make mistakes in a safe environment is
crucial to learning.
 Feedback helps patients assess their
progress in improving or acquiring social
skills.

Assertiveness Training
 Helps the person take more control over
life situations.
 Techniques help the person negotiate
interpersonal situations and foster self-
assurance.
 Involve using “I” statements to identify
feelings and communicate concerns or
needs to others.

 Examples:
 “I feel angry when you turn your back
when I am talking.”
 “I want to have 5 minutes of your time

for uninterrupted conversation about
something important.”
 “I would like to have about 30 minutes in

the evening to relax without
interruption.”

Therapeutic play
 Play techniques are used to
understand the child’s thoughts
and feelings and to promote
communication.
 Not to be confused with play

therapy, a psychoanalytic
technique used by psychiatrists.

 Dramatic play: acting out an anxiety-
producing situation such as allowing a
child to be a doctor or use a stethoscope
or other equipment to take care of a
patient (a doll).
 Play techniques to release energy:
pounding pegs, running, or working with
modelling clay.
 Creative play techniques: help client to
express themselves; drawing pictures of
themselves, their family, and peers.
 Especially useful when children are unable
or unwilling to express themselves
verbally.

Cognitive Therapy
 Focuses on immediate thought
processing- how a person perceives or
interprets his or her experience and
determines how he or she feels and
behaves.
 Example: If a person interprets a situation
as dangerous, he or she experiences
anxiety and tries to escape.
 Basic emotions of sadness, elation, and
anger are reactions to perceptions of loss,
gain, danger, and wrongdoing of others.

Behavior Modification
 Operant conditioning is the model used when
patient’s behaviors are reinforced or
maintained by consequences of the behavior.
 Include the patient in the process of
behavioral contracting (written).
 Includes acceptable and unacceptable behaviors,
as well as rewards and consequences.
 Contingencies that can be controlled by the
therapist, patient, or family are altered to
create a change in the problematic behaviors.

Increasing the
probability that a
behavior will recur

Conditioning
 The strengthening of a response by
reinforcement.
 Positive reinforcement: follows a behavior
with a reinforcing stimulus that increases
the probability that the behavior will recur.
 Negative reinforcement: the process of
removing a stimulus from a situation
immediately after a behavior occurs, which
increases the probability of the behavior
occurring.

 The timing of reinforcement is important.
 When reinforcers are presented according
to a timed schedule (rather than being
contingent on a particular response). Any
behavior immediately preceding the
reinforcer is strengthened.

Premack Principle

 When a person is observed
often enjoying a particular
activity, the opportunity to
engage in that activity can be
used for other behaviors to
occur (Premack, 1962)

Shaping
 A process of reinforcing successive
approximations of responses to
increase the probability of a behavior.
 The selective reinforcement of each
behavior that more closely
approximates the target response is
called differential reinforcement.

Continuous Reinforcement
 The presentation of reinforcing stimuli
following each occurrence of the
selected response.
 Used primarily during the initial
phases of conditioning or shaping a
behavior and results in a high rate of
behavior.

Intermittent Reinforcement
 The presentation of the reinforcer
following the target response
according to a selected number of
responses (ratio scheduler).
 E.g., every fifth target response or
according to a selected time period
(interval schedule) of 10 minutes after
every target response.

Decreasing the probability
that a behavior will recur

Differential reinforcement of other
behavior
 A technique used to decrease the
frequency of a behavior.
 When the goal of treatment is to decrease
a behavior, another behavior, incompatible
with the target behavior can be reinforced.
 Target behavior, if emitted, is not
reinforced.

Extinction
 The gradual decrease in the rate of responses
when the reinforcement is no longer available.
 The rate of responses might increase for a
short time and then begin to decrease
gradually.
 Emotional responses characteristically occur
during extinction.
 Social extinction: withdrawal of attention from
a patient when he acts inappropriately in the
setting.

Negative consequence
 The presentation of an event immediately
following a response that decreases the
probability of that response recurring.
 Negative consequences usually result in
the immediate suppression of that
particular response.
 Used when other techniques are not
effective in decreasing the frequency of a
particular response.

Time-out
 A negative consequence technique in
which a person is removed from a
setting in which ongoing reinforcers
are available.

Skills Training
 When behavioral responses are not
appropriate for a person’s age and life
situation, new behaviors are acquired
through teaching anger management,
social skills, and problem solving
processes.
 Instruction, modelling, behavior rehearsal,
corrective feedback, positive
reinforcement, programmed practice, and
flexibility exercises are used for this

 Imitation and shaping are also used.
 Nurses often make individual
assessments of the patients and form
small groups to conduct training of skills
that are appropriate for the patients but
have not seen in the hospital situation.

Contingency Contracting
 The arrangement of conditions that enable
patients to participate in setting target
behaviors and selecting reinforcements.
 Therapist and patients jointly specify
what, how, when , and where behavioral
changes will occur.
 Criteria for the delivery of reinforcement are
defined.
 Type, amount, and schedule of
reinforcement are specified.

Self- Control
 Practical for outpatient settings.
 The development of self-control program
with contingency contracting in which
patients do the assessment, change their
behaviors, provide their own
reinforcement, and evaluate the results.
 Can be used with thought stopping, when
patients have automatic negative
thoughts.
 Say “STOP”, and to substitute with a
positive thought.

Token Economy
 The use of operant principles in the
management of behavior with groups of
patients in inpatient, outpatient or outpatient
partial hospital programs.
 Used more often with individual patient who,
because of severity of illness, have trouble with
daily functioning.
 Tokens (tangible conditioned reinforcements)
are presented to patients when they exhibit
target behaviors.
 Tokens can be exchange for positive
reinforcers.

Respondent conditioning:
helping clients cope with
disturbing stimuli
 Used for particular stimuli situations such
as those related to pain, phobias, and
PTSD.
 Involves making changes in stimuli
situations or in control of problematic
behaviors.

Reciprocal Inhibition
 The process of strengthening alternative
responses to fear or anxiety associated with a
stimulus is called reciprocal inhibition or
counterconditioning.
 Relaxation techniques, for instance, can be
taught to highly anxious patients or those in
pain.
 Techniques: positive and affirming self-
thought, yoga, deep
breathing, meditation, progressive muscle
relaxation, and positive or pleasant imagery.

Systematic Desensitization- In
Vivo
 The planned progressive or
graduated exposure to stimuli in real
life (in vivo) that elicit fear or anxiety
while the anxiety or fear response is
suppressed with relaxation
techniques.
 Biofeedback program might be used
to reach and maintain a state of
relaxation or pain control.

 Used more often in combination with other
therapies such as education, supportive
therapy, cognitive-behavioral therapy, and
skills training.
 Hierarchies of the fear-eliciting response are
constructed through a detailed assessment.
 Hierarchies related to traumatic events could
include conditioned external and internal cues:
 External: places, situations, smells, and sounds,
associated with the trauma.
 Internal: emotions (fear and disgust), the
physiological arousal during traumatic events, and
conditions experienced during event (thoughts of
dying or going crazy).

 Patients need to be aware that exposure
initially increases their emotional and
physical distress, so that they are engage in
the process.
 However, prolonged, repeated
exposure,, along with relaxation, eventually
decreases the pain and anxiety.
 Done in the presence of the therapist, but
can be practiced independently (as
homework) later in the process.

Systematic Desensitization- Imaginal
 The imagining of traumatic events,
beginning with the least traumatic aspects
of trauma.
 Patients might be asked to write about or
write and then talk about each aspect with
the therapist.
 Writing assignments and journaling might
given as homework in between the
sessions.
 Relaxation techniques are used.

Flooding or Implosion
 A process in which patients imagine or
place themselves in the fearful situation;
that is they immersed themselves in the
feared stimuli.
 Normally done when accompanied by the
therapist.

Psychosocial Interventions

 Nursing activities that enhance the client’s
social and psychological functioning and
improve social skills, interpersonal
relationships, and communication.
 Nurses often use psychosocial
interventions to help meet clients’ needs
and achieve outcomes in all practice
settings.

 For example, a medical-surgical nurse
might need to use interventions that
incorporate behavioral principles such as
setting limits with manipulative behavior or
getting positive feedback.
 Example: A client with DM
 Patient: “I promise to have just one bite of
cake. Please! It’s my grandson’s birthday
cake.”
 Nurse: “I can’t give you permission to eat the
cake. Your blood glucose level will go up if you
do, and your insulin can’t be adjusted
properly.”

COMPLEMENTARY AND
ALTERNATIVE THERAPIES (CAM)

 Complementary medicine:
therapies used with conventional
medicine practices.
 Alternative medicine: therapies
used in place of conventional
treatment.
 Integrative medicine: combines
conventional medical therapy and
CAM therapies that have scientific
evidence supporting their safety
and effectiveness.

Alternative Medical Systems

 Homeopathic medicine and naturopathic
medicine in Western cultures, and
traditional Chinese medicine, which
includes herbal and nutritional therapy,

Mind-body Interventions

 Meditation, prayer, mental healing, and
creative therapies that use art, music, or
dance.

Biologically Based Therapies

 Use substances found in nature such as
herb, food, vitamins.
 Include dietary supplements, herbal
products, medicinal
teas, aromatherapy, and a variety of diets.

Manipulative and Body- Based
Therapies

 Based on manipulation or movement of
one or more parts of the body, such as
therapeutic massage and chiropractic or
osteopathic stimulation.

Energy Therapies

 Biofield therapies: intended to affect energy
fields that are believed to surround and
penetrate the body, such as therapeutic
touch, qi gong, and Reiki, and bioelectric-
based therapies involving the use of
electromagnetic fields, such as pulsed fields,
magnetic fields, and AC or DC fields.

 Qi gong: Chinese medicine that
combines movement, meditation, and
regulated breathing to enhance the flow
of vital energy and promote healing.
 Reiki (which in Japanese means
universal life energy): based on the
belief that when spiritual energy is
channeled through a Reiki
practitioner, the patient’s spirit and body
are healed.

Therapeutic modalities

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