STRATEGIES USED IN DEALING WITH PSYCHIATRIC CLIENTS

Kenn S. Nuyda, RNAquinas University

MAN 2008

2

1) WORKING WITH THE AGGRESSIVE PATIENT

2) WORKING WITH GROUPS OF CLIENTS

3) WORKING WITH THE FAMILY

3

WORKING WITH THE AGGRESSIVE PATIENT

ANGER– Is it normal?– Does it result to problem solving and change?– Is it destructive and life threatening?

4

ANGER

What is ANGER?– Normal human emotion crucial for growth

– When handled properly, it is a + force that leads to px solving and change

– When handled aggressively it is destructive and life threatening – assault, battery and violence

– PHYSICAL AGGRESSION

– PASSIVE AGGRESSION

5

HOW IS ANGER MANIFESTED?

AGGRESSION– Aggressive person: verbal expression (assault),

may carry out the verbal threat (battery)– Recipient: fear. Frustration and avoidance of

that person, helplessness, defensive, guilty or angry, may retaliate, revenge or hold grudge towards the person

6

Questions:

1) What if two competent clients are heard arguing by the nurse, would you intervene? Why?

2) What if the other one is less competent, as a nurse would you act stopping the argument? Why?

7

VERBAL AGGRESSION– Serves as warning signs of assault or

impending battery– May provoke counteractions = fighting /

violence

8

VERBAL AGGRESSION

Passive-aggressive = expression of anger in subtle and evasive ways, denies its source > coz afraid of punishment and rejection> inefficient to accomplish task

Passive – inward manifestations of anger> may damage, destroy or avoid relationship and intimacy > may lead to low self-esteem, depression, substance abuse, somatoform, suicide attempts

9

ASSERTIVENESS– Accepted: HEALTHY ASSERTIVENESS

• Respecting the rights of others and the self while expressing emotions

10

EXPRESSIONS OF ANGER

TURNED OUTWARD OVERT ANGER PASSIVE AGGRESSION

TURNED INWARD SUBJECTIVE OBJECTIVE

11

OUTWARD EXPRESSION

OVERT ANGER PASSIVE AGGRESSION

Verbalization of angerPacing with agitation

HostilityContempt

Clenching of fistsInsulting remarks

Provoking behaviorsSadistic acts

Temper tantrumsScreamingDeviance

RageDamage to property

Threats: words and weaponsRape, assault, homicide

ImpatiencePouting

Tensed facial expressionAnnoyancePessimism

ComplainingStubbornness

SarcasmManipulation

NoncomplianceResistanceBitterness

ProcrastinationUnfair teasing

domination

12

INWARD EXPRESSION

SUBJECTIVE OBJECTIVE

Feeling upsetTension

UnhappinessFeeling hurt

GuiltDisappointmentLow self-esteem

EnvyPowerlessnessSomatization

InferiorityDepression

HopelessnessDesperationHumiliation

CryingSelf-destructive behaviors

Self-mutilationSubstance abuse

Suicide

13

THE DEVELOPMENT OF AGGRESSION BY AGE

Infancy: Uncontrollable crying and screaming, profuse perspuration, DOB, flailing of arms and legs

Toddlerhood: temper tantrums SAC: hitting one another Preadolescents: hitting each other competitive

sports, “tsimis”, practical/sarcastic jokes, fighting is controlled and purposeful, gangs

14

22 – 45 y/o: aggression and fightingAfter 45 y/o: stopped fighting70 y/o: diminished impulse control and

cognitive impairment decreased expression of anger

15

16

INDIVIDUAL MODELS

Violence – quality of being human and use biologically based expressions of aggression– Neuroanatomy

• Limbic system, frontal and temporal lobe

– Neurophysiology• Neurotransmitters (sero, GABA, dopa)

17

Common Problems r/t aggression

Bifrontal injuries Damage to limbic system

AD Inc. dopamine

Dec. serotonin, GABA, Ach

Alcohol/drug abuse / withdrawal

Imbalance hormones Nutritional deficiencies

18

Social – Psychological – interaction with the environment and

the frustrations met

Socio – Cultural– Social structures, norms, values

19

STRESS MODEL (GAS)

Hans SelyeStress – wear and tearStressors - + / - stimuli that

requires a response

20

STAGES (A, R, E)

ALARM RESISTANCE EXHAUSTION

F or F responseAlertness to focus immediately with the px+1 to +2 anxiety

Coping / defense mechanisms initiatedPsychosomatic begins+2 to +3 anxiety

Stress that lasts too long leading to inability to cope

>+ 3

2121

2222

Smith’s Stress ModelSmith’s Stress Model

According to Smith, According to Smith, patients who are patients who are repeatedly assaultive repeatedly assaultive exhibit behavior exhibit behavior patterns that are:patterns that are: RitualisticRitualistic StereotypicalStereotypical AutomaticAutomatic

As the acuity of the As the acuity of the aggressive response aggressive response increases:increases:

Dec. px solving Dec. px solving abilities, creativity, abilities, creativity, spontaneity and spontaneity and behavioral optionsbehavioral options

2323

1)1) TRIGERRING PHASETRIGERRING PHASE- Stress- producing eventsStress- producing events

2)2) ESCALATION PHASEESCALATION PHASE- Escalating behaviors leading to loss of controlEscalating behaviors leading to loss of control

3)3) CRISIS PHASECRISIS PHASE- Emotional and physical crisis, loss of controlEmotional and physical crisis, loss of control

4)4) RECOVERY PHASERECOVERY PHASE- Cooling down, slowing down and return to normal Cooling down, slowing down and return to normal

responsesresponses

5)5) POST CRISIS DEPRESSION PHASEPOST CRISIS DEPRESSION PHASE- - Attempts to be reconciled with othersAttempts to be reconciled with others

2424

The Assault CycleThe Assault Cycle

2525

WHAT WILL THE NURSE FEEL WHAT WILL THE NURSE FEEL IF PTS. BECOME IF PTS. BECOME

AGGRESSIVE TO THEM?AGGRESSIVE TO THEM?

FRUSTATIONFRUSTATION PROFESSIONAL INADEQUACYPROFESSIONAL INADEQUACY SENSE OF FAILURESENSE OF FAILURE STIMULATE POWER STRUGGLES W/ STIMULATE POWER STRUGGLES W/

PTSPTS

26

HOW WILL THE NURSE CONTROL PATIENT’S AGGRESSION?

N must be know the factors that may contribute to the escalation of aggression of the pt.

1) Env’t that HAS EXCESSIVE STIMULI2) Env’t that is OVERCROWDED3) Facility that has NO OUTLET FOR ENERGY –

DRAINING4) Pt’s perceived lack of CONTROL OF LIFE

AND FREEDOM5) BOREDOM d/t lack of STRUCTURED

ACTIVITIES

27

Staffing must be sufficientStaff must have fair philosophies and

policies – Over-controlled env’t : aggression and

rebellion– Reasonable, flexible: reduce risk for power

– ESTABLISH THERAPEUTIC MILIEU

28

Nurses must be able to recognize when the patient would most likely become

aggressive or assaultive:

ADMISSION CHANGE OF

SHIFTS MEALTIMES VISITING HOURS

EVENING ELEVATORS DURING

TRANSPORTATION PERIODS OF

CHANGE

29

Hospitalization is a stress-producing situation.

NURSES' ROLES:

1) Explain rules and policies - the searches, the removal/restriction of personal items, physical examinations

2) Introduce unfamiliar professionals and other patients

3) Integrate pt slowly to the unit

4) Decrease the stimuli if possible

30

5) Explain all medications/treatments in advance

6) Assess history – family violence/abuse, previous history of assault, destruction of property

7) Render documentation

NURSING INTERVENTIONS NURSING INTERVENTIONS in ANGER AND in ANGER AND NONVIOLENT NONVIOLENT AGGRESSIONAGGRESSION

3232

FACTORS TO CONSIDER IN FACTORS TO CONSIDER IN INTERVENING WITH ANGER AND INTERVENING WITH ANGER AND

NONVIOLENT AGGRESSIONNONVIOLENT AGGRESSION

• SOURCE SOURCE – manifests inwardly– manifests inwardly• TARGETTARGET – may aim at no one in – may aim at no one in

particularparticular• LIKELIHOOD OF ESCALATIONLIKELIHOOD OF ESCALATION – –

may be defused if dealt may be defused if dealt appropriatelyappropriately

3333

• Assess at safe Assess at safe distancedistance

• Warmth and Warmth and empathy, but be empathy, but be firm in setting firm in setting limitslimits

• If patient is less If patient is less verbal, take an verbal, take an active, supportive active, supportive and directive roleand directive role

• Ask pts to Ask pts to ventilate their ventilate their feelings, feelings, thoughts, thoughts, situationssituations

3434

Forget these things Forget these things not!!!not!!!

• CHOOSE THE LEAST RESTRICTIVE CHOOSE THE LEAST RESTRICTIVE MEASURES BEFORE MEASURES BEFORE RESTRAINTS/SECLUSIONRESTRAINTS/SECLUSION

• DOCUMENT PT’S RESPONSESDOCUMENT PT’S RESPONSES• APPROACH THE PT IN CALM, APPROACH THE PT IN CALM,

POSITIVE MANNERPOSITIVE MANNER

3535

NI BASED ON THE NI BASED ON THE ASSAULT CYCLE … ASSAULT CYCLE …

TRIGGERING PHASETRIGGERING PHASEBEHAVIORSBEHAVIORS NINI

Muscle tension, changes in Muscle tension, changes in voice quality, readiness to voice quality, readiness to

retaliate, tapping of fingers, retaliate, tapping of fingers, pacing, repeated pacing, repeated

verbalization, noncompliance, verbalization, noncompliance, restlessness, irritability, restlessness, irritability, anxiety, suspiciousness, anxiety, suspiciousness,

perspiration, tremors, glaring, perspiration, tremors, glaring, changes in breathingchanges in breathing

1)1) EMPHATIC, EMPHATIC, NONDIRECTIVE, NONDIRECTIVE, CONCERNED TECHNIQUECONCERNED TECHNIQUE

2)2) ENCOURAGE VENTILATIONENCOURAGE VENTILATION

3)3) PROVIDE QUIETER PROVIDE QUIETER ENVIRONMENTENVIRONMENT

4)4) USE RELAXATION USE RELAXATION TECHNIQUESTECHNIQUES

5)5) FACILITATE PROBLEM FACILITATE PROBLEM SOLVING BY DISCUSSING SOLVING BY DISCUSSING ALTERNATIVE SOLUTIONSALTERNATIVE SOLUTIONS

6)6) PRN ORAL MEDSPRN ORAL MEDS

7)7) EMPIRICAL SUPPORTEMPIRICAL SUPPORT

3636

NI BASED ON THE NI BASED ON THE ASSAULT CYCLE … ASSAULT CYCLE …

ESCALATION PHASEESCALATION PHASEBEHAVIORSBEHAVIORS NINI

Pallor, screaming, anger, Pallor, screaming, anger, agitation, hypersensitivity, agitation, hypersensitivity, threats, demands, loss of threats, demands, loss of

reasoning ability, provocative reasoning ability, provocative behaviors, clenched fistsbehaviors, clenched fists

1)1) TAKE CHARGE WITH TAKE CHARGE WITH CALM, FIRM DIRECTIONS, CALM, FIRM DIRECTIONS, DON’T PUNISH/THREATEN, DON’T PUNISH/THREATEN, AVOID LOUD SOUNDSAVOID LOUD SOUNDS

2)2) DIRECT CLIENT TO A DIRECT CLIENT TO A QUIET ROOM FOR A “TIME QUIET ROOM FOR A “TIME OUT”OUT”

3)3) ASK ANOTHER STAFF TO ASK ANOTHER STAFF TO BE ON STANDBY AT A BE ON STANDBY AT A DISTANCEDISTANCE

4)4) PRN MEDSPRN MEDS

5)5) PREPARE FOR A “SHOW PREPARE FOR A “SHOW OFF DETERMINATION” – 4-6 OFF DETERMINATION” – 4-6 STAFF WITHIN THE SIGHT STAFF WITHIN THE SIGHT OF CT.OF CT.

3737

NI BASED ON THE NI BASED ON THE ASSAULT CYCLE … ASSAULT CYCLE … CRISIS CRISIS

PHASEPHASEBEHAVIORSBEHAVIORS NINI

Loss of self control, fighting, Loss of self control, fighting, hitting, rage, kicking, hitting, rage, kicking,

scratching, throwing thingsscratching, throwing things

1)1) INVOLUNTARY INVOLUNTARY SECLUSION, SECLUSION, RESTRAINTSRESTRAINTS

2)2) IM MEDSIM MEDS

3838

NI BASED ON THE NI BASED ON THE ASSAULT CYCLE … ASSAULT CYCLE … RECOVERY PHASERECOVERY PHASE

BEHAVIORSBEHAVIORS NINIAccusations, lowering of Accusations, lowering of

voice, decreased body voice, decreased body tension, change in tension, change in

conversational content, more conversational content, more normal responses, relaxationnormal responses, relaxation

1)1) CONTINUE NURSING CARE, CONTINUE NURSING CARE, ALLOW CLIENT TO RELAX ALLOW CLIENT TO RELAX AND SLEEP AND SLEEP

2)2) PROCESS THE INCIDENT PROCESS THE INCIDENT WITH THE STAFF AND WITH THE STAFF AND OTHER PATIENTSOTHER PATIENTS

3)3) ASSESS PATIENT, STAFFASSESS PATIENT, STAFF

4)4) EVALUATE PT’S PROGRESS EVALUATE PT’S PROGRESS TOWARD SELF-CONTROLTOWARD SELF-CONTROL

4040

NICE TO KNOW!!!NICE TO KNOW!!!

4141

SECLUSIONSECLUSION

• Principle of containmentPrinciple of containment• Placing of ct alone in a lockable room Placing of ct alone in a lockable room

designed with window and cameradesigned with window and camera• Minimize violence of aggressive Minimize violence of aggressive

client to himself, othersclient to himself, others• To reduce stimuliTo reduce stimuli• To increase nursing care to To increase nursing care to

agitated/violent/aggressive ptagitated/violent/aggressive pt

4242

Reasons for SeclusionsReasons for Seclusions

• AgitationAgitation

• Disruptive behaviorDisruptive behavior

• Inappropriate sexual behaviorsInappropriate sexual behaviors

• To avoid aggressive assaults and To avoid aggressive assaults and have a responsive actionhave a responsive action

4343

• ““TIME OUT”TIME OUT”

• BED, MATTRESS, WINDOW, SECURITY BED, MATTRESS, WINDOW, SECURITY CAMERACAMERA

• REMOVE DANGEROUS ARTICLES REMOVE DANGEROUS ARTICLES FROM THE PT.FROM THE PT.

4444

RESTRAINTRESTRAINT

• Protective devices used to limit the Protective devices used to limit the physical activity of a ct or to physical activity of a ct or to immobilize a ct. or an extremityimmobilize a ct. or an extremity

• To safely control the ct and assure To safely control the ct and assure that there’ll be no injuries to himself, that there’ll be no injuries to himself, other cts and the staffother cts and the staff

4545

INDICATIONSINDICATIONS

• Falling out of a bed/chairFalling out of a bed/chair

• Pulling out IV lines, NGT, catheterPulling out IV lines, NGT, catheter

• Breaking open suturesBreaking open sutures

• Unsafe ambulationUnsafe ambulation

• Wandering and entering an unsafe Wandering and entering an unsafe placeplace

• Causing harm to others, self, staffCausing harm to others, self, staff

4646

TYPES OF RESTRAINTTYPES OF RESTRAINT

1.1. PHYSICAL PHYSICAL

2.2. CHEMICAL CHEMICAL

4747

CHOOSING THE RESTRAINTCHOOSING THE RESTRAINT

• It restricts the ct's mov’t as little as It restricts the ct's mov’t as little as possiblepossible

• It is the least obvious to othersIt is the least obvious to others

• Does not interfere with the ct's tx Does not interfere with the ct's tx and health pxand health px

• It is readily changeableIt is readily changeable

• It is safe for a particular ctIt is safe for a particular ct

4848

Is there any alternative before Is there any alternative before the use of restraint?the use of restraint?• Orient ct and family to surroundingsOrient ct and family to surroundings• Explain all procedures and tx Explain all procedures and tx • Encourage family and friends to stay with the clientEncourage family and friends to stay with the client• Assign confused cts and disoriented ct's to rooms near Assign confused cts and disoriented ct's to rooms near

the nurses' stationthe nurses' station• Visual and auditory stimuli - clocks, calendarsVisual and auditory stimuli - clocks, calendars• Place familiar items - pictures near client's bedsidePlace familiar items - pictures near client's bedside• Maintain toileting routinesMaintain toileting routines• Eliminate bothersome tx - tube feedings ASAP Eliminate bothersome tx - tube feedings ASAP • Evaluate all medications that the ct is receivingEvaluate all medications that the ct is receiving• Relaxation techniquesRelaxation techniques• Ambulation and exercise schedule as the client's Ambulation and exercise schedule as the client's

condition allowscondition allows

4949

WHAT EVERY NURSE SHOULD KNOW IN WHAT EVERY NURSE SHOULD KNOW IN THE IMPLEMENTATION OF THE IMPLEMENTATION OF

RESTRAINT?RESTRAINT?

5050

• Never be used as a a punishment or for the Never be used as a a punishment or for the convenience of the staffconvenience of the staff

• The least restrictive means of restraint for the The least restrictive means of restraint for the shortest duration should be usedshortest duration should be used

• Used when physically harmful to the client or Used when physically harmful to the client or to othersto others

• Used when disruptive behavior presents a Used when disruptive behavior presents a danger to the facilitydanger to the facility

• Used when alternative or less restrictive Used when alternative or less restrictive measures are insufficient in protecting the ct measures are insufficient in protecting the ct or others from harmor others from harm

• Used when the ct anticipates that a controlled Used when the ct anticipates that a controlled env’t would be helpful and requests seclusionenv’t would be helpful and requests seclusion

• Requires a written order, reviewed, renewed q Requires a written order, reviewed, renewed q 24hrs, specify type of restraint24hrs, specify type of restraint

5151

• In an emergency, the charge nurse may In an emergency, the charge nurse may place a ct in restraint/seclusion and obtain a place a ct in restraint/seclusion and obtain a written or verbal order ASAP thereafterwritten or verbal order ASAP thereafter

• Laws require the of the ct unless an Laws require the of the ct unless an emergency situation exists and can be emergency situation exists and can be documenteddocumented

• The ct must be removed from restraint or The ct must be removed from restraint or seclusion when safer and quieter behavior is seclusion when safer and quieter behavior is observedobserved

• While in restraint/seclusion, the client must While in restraint/seclusion, the client must be protected from all sources of harmbe protected from all sources of harm

• Documentation - behavior, time, releaseDocumentation - behavior, time, release• Assessment q 15-30 min for physical needs, Assessment q 15-30 min for physical needs,

safety comfort = documentsafety comfort = document

5252

~End~ ~End~

WORKING WITH GROUPS OF PATIENTS

Kenn S. Nuyda, RN

WORKING WITH GROUPS OF PATIENTS

Kenn S. Nuyda, RN

55

NURSING CARE in Psych Cts

24/7 responsibilityManpower to provide therapeutic

interventionConcern with how our clients solve their

problems, conflicts and interpersonal relationships in order for them to learn and cope

56

TYPES OF GROUPS

1. INPATIENT- Open membership – adding and losing

members- 3 – 5 x a week- Short term

2. OUTPATIENT- Longer duration- Once a week- Closed membership

57

SIGNIFICANCE OF GROUPS

Deals with “here and now” Provides awareness and knowledge about the

ct’s behavior Teaches ct to be aware of the alternatives in

decision making and making choices Teaches the ct/family about their mental illness

and make them cope up with it

Considered as MILIEU therapy

58

BENEFITS OF THE GROUP

Ct gains knowledge about how to relate and how to relate and communicate w/ otherscommunicate w/ others

Ct gains acceptance, reassurance and support from peers and group leader

Ct gains feelings of hopefulness, sense of power Ct tests out new behaviors Ct shares feelings, problems, concerns and ideas w/

others Ct’s self- esteem is enhanced and affirmed and

developed Ct feels sense of importance and worthiness

59

11 THERAPEUTIC FACTORS- Dr. Irvin Yalom -

INSTILLATION OF HOPE Observe others in the group

UNIVERSALITY Unique individual and not alone having that problem

IMPARTING OF INFORMATION Gaining info r/t their needs

ALTRUISM Helpful to others

CORRECTIVE RECAPITULATION Review of previous dysfunctional family patterns and learning how to change them

SOCIALIZATION

IMITATIVE BEHAVIOR

CATHARSIS Expression of feelings appropriately

EXISTENTIAL FACTORS Acceptance of ultimate concerns – death, isolation

COHESIVENESS Sense of being values and accepted in a group

INTERPERSONAL LEARNING Learning of how their behavior affects others, and try out new ways of relating to others

60

61

1. SUPPORT GROUP

2. ACTIVITY GROUP

3. EDUCATION OR PROBLEM SOLVING GROUPS

4. THERAPY GROUPS

62

SUPPORT GROUPS

Nursing is supporting To support = to accept, emphatize, show

concern while cts talk Nurse’s presence, interest and

encouragement = ct’s ease of expressing his/her feelings and concerns

Support groups enable the ct to cope w/ feelings and situations

Reinforces or maintains the existing strengths/behaviors of cts

63

a) REALITY – ORIENTATION GRP- deals with psychopathology, confusion and short attention span

NI: > safe env’t> reality testing> orientation to time, place, person> setting limits

64

ACTIVITY GROUPS

Facilitate communication and interaction

- INDICATIONS - For withdrawn, depressed, regressed patients To increase self – esteem, provide openness

and expression of feelings to decrease isolation

Used to facilitate self – expression and patient interaction

65

EXAMPLES

TYPE PURPOSE/RN’S ROLE EXAMPLES

Recreation Fun, relief of tensionCt experiences sense of participation, acceptance and accomplishment

Indoor/outdoor sports, field trips, exercise groups and games

Creative Expression

Expression of feelings, a form of communication with others and socializationAllow for creativity, self-expression and praise for accomplishments

Arts and crafts, ADL, poetry, music, dance and pet therapy

66

EDUCATION / PROBLEM SOLVING GROUPS

Teaches ct and family about:Medication Dynamics and management of illnessProblem solving Stress managementSocial skills Interpersonal skills Relapse prevention

67

The nurse’s expertise, empathy and support help the ct to learn = ct cares for themselves/illness

Benefits to family: improved relationships with family members

68

EXAMPLESTYPE PURPOSE/RN’S ROLE EXAMPLES

Psychoeducation Dynamics of illness, mgt of illness, crises

Addiction processes, coping with sx, mood mgt, relapse prevention, community resources

Medication Dispensing of med, s/sx of SE, purpose of med, dosage, and therapeutic effects, support to prevent relapse

Problem Solving Identify and describe current px, develop solutions, its alternatives

Conflict resolutions, job concerns, relationship issues

Stress Mgt Teach and facilitate coping behaviors

Lifestyle balance and mgt, relaxation training, tension-reducing strategies, anger mgt

Social Skills Teach, develop and practice skills, focus on realistic day-to-day needs

Social interactions

69

THERAPY GROUPS

Develops insight, understanding of feelings, behaviors and roles in relationships in ct

Changes behaviors and healthier responses to other people

Motivates members : exposed to other members who share the same feeling

70

EXAMPLESTYPE PURPOSE/RN’S ROLE EXAMPLES

Insight – oriented

Understanding how individuals affect and be affected by othersDeals with healthier ways on how to handle feelings to others

self-esteem groups

Psychodrama Intense emotional release are achieved through intrapersonal and interpersonal conflictsImprove their roles using a script

Psychodrama

Sociodrama Focus insights on role communication, roles are reenacted/role played

> Psychodrama

71

CHARACTERISTICS THAT THE NURSE MUST POSSESS IN LEADING

A GROUP

72

Group Leadership Model as a leader Communication skills - reinforcement Must be aware of the environment that affects the

clinical setting Assessment skills of the mental status of the ct Must be able to gain the trust of his patient Confidentiality Must be able to document

73

Coleadership Useful when the primary nurse is on “off” or “on

leave” They are the ones who collaborate/share

responsibility for the group Teaches ct how to relate to others with respect

Active Structured/goal-directed Empathetic

74

PHYSICAL SETTING

Adequate space / private room

Adequate lighting, comfortable temp, seating and equipment

CIRCLE, SEMICIRCLE

MEMBERS: 7 – 10 more members will

make the group subdivide, create acting out behaviors

Audio Video, handouts

75

FORMAL GROUPS… guidelines

N must be goal directed and focus on the here and now in each inpatient and outpatient group session

N assesses the needs of the pt and formulates plans Timeframe: one hour (lower functioning), 1 ½ (higher

functioning) Participants are expected to arrive ON TIME NO SMOKING/REFRESHMENT will be served One person speaks at a time May be allowed to pace/leave if pt has inability to sit

still No hitting or throwing is allowed “What you see, what you here leave it here”

76

At the start, the N states the purpose of the group

Then working phaseThen before the end of the session,

summarize and close the session for 5-10 mins.

77

GROUP MEMBER ROLES accdg TO FUNCTION

ENCOURAGER – praises others, agrees and accepts ideas of others

HARMONIZER – mediates and reconciles intragroup differences

COMPROMISER –resolve conflicts

INITIATOR – offers new ideas, suggestions

78

ELABORATOR – gives examples

EVALUATOR – relates the group standards to any problem

COORDINATOR – clarifies relationships among ideas and activities of the group

79

ANNOYING MEMBERS

AGGRESSOR – acts negatively with hostility toward others, jokes aggressively, attacks the group/members

RECOGNITION SEEKER – calls attention to own activities, boasts achievements

HELP SEEKER / CONFESSOR – uses the group to gain sympathy, expresses insecurity and self – depreciation

DOMINATOR – asserts authority and manipulates individuals and the group as a whole

80

EXCLUSION FROM JOINING THE GROUP

MANICDISORIENTEDTOO PSYCHOTICHOSTILEVERBALLY THREATENING

81

STAGES… KELTNER

1. INITIAL

2. WORKING

3. TERMINATION

82

INITIAL WORKING TERMINATIONInvolves superficial rather than open and trusting communicationMember acquainted w/ each other, searching for similarities b/w themselvesMember still unclear about the purpose of goals of the groupNorms, roles and responsibilities takes place

Members are familiar w/ each other, the group leader and the group roles and they feel free to approach their problems and to attempt to solve their problemsConflict and cooperation surface

Group evaluates the experience and explores member's feelings about it and the impending separationProvides an opportunity for members who have difficulty w/ termination to learn to deal more realistically and comfortably with this normal part of human experience

83

STAGES OF GROUP DEV’T… MOSBY

1. PREGROUP

2. INITIAL

3. WORKING

4. TERMINATION

84

PREGROUP

Forming of the groupTime period before people knew each

other in the group setting

Select group membersDecide length of meetingDecide composition of members

HomogenousHeterogenous

85

Leader Responsibilities

Establish purpose Secures physical

space Selects members Screens

interviewees

Determine member motivation

Describes norms Educates about the

group Secures commitment

of the group Begins

leader/member rel.

86

INITIAL STAGE

Group members have anxiety about being accepted

TASKS:Setting of normsCasting of roles

87

Member Behaviors

Concerned with acceptanceFear of rejectionFear of self-disclosureDependent on leader – look to leader for

structure, approval, acceptance

88

Leader Behaviors

DirectiveActiveGroup contract dev’tEncourages interaction b/w membersFacilitates approach/avoidanceSuggests how members might be helpful

to one another

89

CONFLICT STAGE within INITIAL STAGE… member

Members concerned with status in groupDependency conflictIndependent members attempt to make

leader’s rolesSubgroups formHostility toward leader or other members

90

CONFLICT STAGE within INITIAL STAGE… leader

Allows expression of - / + feelingsHelps group understandPrevents scapegoatingDirects expression of hostility

91

COHESIVE STAGE within INITIAL STAGE… member

Form attachment to group+ feelings toward the group/membersSelf-disclosureSuppress hostilityLimited problem solving

92

COHESIVE STAGE within INITIAL STAGE… leader

Encourages problem solvingDemonstrates that differing opinions are

acceptable

93

WORKING STAGE

Group becomes team, complete tasks, shares responsibilities, group is stable

Anxiety is decreased

94

Member Behaviors: Explore goals and tasks Serious work occurs Explore feelings Explore new coping

mechanisms

Group Behaviors: Decreases activity Serves as consultant Fosters cohesion Maintains boundaries Encourages work on

tasks Solving the problem/s of

the group

95

TERMINATION STAGE

Types:

1. whole group ends

2. Individual member leaves

Involves grieving and sense of loss

96

Member Behaviors

Anger Regression

Dependency, competition Avoidance

Do not come to the group, do not talk about the termination

Devalue group Discuss other feelings (separations, death,

aging) Sense of resolution

97

Leader Behaviors

Reminisces about the group’s activities Evaluates group goals Discusses the member’s contribution to each

other Encourages full discussion of termination for

several sessions Shares own experience and feelings r/t the

group Discourages premature termination of

individual group members

98

COMMUNICATION SKILLS THAT THE NURSE MUST POSSESS IN

LEADING A GROUP

99

Giving informationSeeking clarification Encouraging description and explorationPresenting realitySeeking consensual validationFocusingEncouraging comparisonMaking observationsGiving recognition/acknowledgementAccepting Encouraging evaluationSummarizing

INTERVENTIONSINTERVENTIONSINTERVENTIONSINTERVENTIONS

101

DOMINANT CLIENTDOMINANT CLIENT

• Monopolizes the group discussion, other members feel that they do not have the opportunity to participate

• “Mr. Antonio, you are doing well today in our session, but I would like to hear what others are thinking about at this time.”

• Don’t put down the feelings of the pt

• Monopolizes the group discussion, other members feel that they do not have the opportunity to participate

• “Mr. Antonio, you are doing well today in our session, but I would like to hear what others are thinking about at this time.”

• Don’t put down the feelings of the pt

102

UNINVOLVED CLIENTUNINVOLVED CLIENT

• Tend to be quiet d/t anxiety or fear• Should be comfortable to the group

• “It is hard to talk about ourselves in group, but I know that everyone here has something to share that can help someone else.”

• The N recognizes that ct is mistrustful and anxious about initiating the group sharing.

• Respect, recognition

• Tend to be quiet d/t anxiety or fear• Should be comfortable to the group

• “It is hard to talk about ourselves in group, but I know that everyone here has something to share that can help someone else.”

• The N recognizes that ct is mistrustful and anxious about initiating the group sharing.

• Respect, recognition

103

HOSTILE CLIENTHOSTILE CLIENT

• Masks patient’s fear, self-anger and unresolved anger toward others

• “Mr. Antonio, tila galit ka ata ngayon. Ano ba nangyari? Gusto mo bang i-share iyan sa grupo?”

• N is confrontational in a sense that he is still supportive in dealing with the client’s feelings

• Masks patient’s fear, self-anger and unresolved anger toward others

• “Mr. Antonio, tila galit ka ata ngayon. Ano ba nangyari? Gusto mo bang i-share iyan sa grupo?”

• N is confrontational in a sense that he is still supportive in dealing with the client’s feelings

104

• N should not allow hostility in any manner – verbal, nonverbal because it endangers the group

• Members would feel:– Uneasy– Uncomfortable– Impairs group work– Would feel that anger of one ct is directed

to them

• N should not allow hostility in any manner – verbal, nonverbal because it endangers the group

• Members would feel:– Uneasy– Uncomfortable– Impairs group work– Would feel that anger of one ct is directed

to them

105

• But, NURSES should be:– Empathic– Understanding– Respectful for each ct

• To increase their sense of worth

• But, NURSES should be:– Empathic– Understanding– Respectful for each ct

• To increase their sense of worth

106

EXAMPLES OF GROUPSEXAMPLES OF GROUPS

• PYSCHODRAMA GROUP– explore truth through dramatic methods– individual produces a topic to be explored– therapists directs individual through role

playing– audience experiences the feelings and

identifies with the action on the stage– change occurs

• PYSCHODRAMA GROUP– explore truth through dramatic methods– individual produces a topic to be explored– therapists directs individual through role

playing– audience experiences the feelings and

identifies with the action on the stage– change occurs

107

COMMUNITY SUPPORT GROUPSCOMMUNITY SUPPORT GROUPS

• promote identification, clarification, understanding, role modeling, feelings of togetherness and group cohesion

• prevent the individual member from feelings lonely and isolated

• help members decrease levels of stress and increase levels of self-acceptance

• members are able to deal with the problems that they brought to the group

• dev’t of new or more effective patterns of behavior• some groups evolve into educational models that enhance

communication, self-image, body language, px-solving, decision making and growth processes

• promote identification, clarification, understanding, role modeling, feelings of togetherness and group cohesion

• prevent the individual member from feelings lonely and isolated

• help members decrease levels of stress and increase levels of self-acceptance

• members are able to deal with the problems that they brought to the group

• dev’t of new or more effective patterns of behavior• some groups evolve into educational models that enhance

communication, self-image, body language, px-solving, decision making and growth processes

108

Ex: Alcoholics anonymousEx: Alcoholics anonymous

• Alcoholics Anonymous is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism.

• The only requirement for membership is a desire to stop drinking.

• There are no dues or fees for AA membership

• Alcoholics Anonymous is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism.

• The only requirement for membership is a desire to stop drinking.

• There are no dues or fees for AA membership

109

• Fellowship of relatives and friends of alcoholics who share their experience, strength, and hope in order to solve their common problems

• Believe alcoholism is a family illness and that changed attitudes can aid recovery

• Fellowship of relatives and friends of alcoholics who share their experience, strength, and hope in order to solve their common problems

• Believe alcoholism is a family illness and that changed attitudes can aid recovery

110

NARCONONNARCONON

• Means “no drug”

• Drug-free rehab program in RP

• Uses nutrition, assists, objective exercises, and training routines

• Means “no drug”

• Drug-free rehab program in RP

• Uses nutrition, assists, objective exercises, and training routines

111

Other ExamplesOther Examples

• Overeater’s Anonymous

• Women’s Groups

• Men’s Groups

• Overeater’s Anonymous

• Women’s Groups

• Men’s Groups

112

GESTALT THERAPY GROUPGESTALT THERAPY GROUP

• "here and now"• emphasizes self-expression, self-

exploration and self-awareness in the present

• everyday problems and try to solve them• individual becomes aware of the total self

and the surrounding env’t, renders the ct. capable of change

ROLE: help the members express their feelings and grow from their experiences

• "here and now"• emphasizes self-expression, self-

exploration and self-awareness in the present

• everyday problems and try to solve them• individual becomes aware of the total self

and the surrounding env’t, renders the ct. capable of change

ROLE: help the members express their feelings and grow from their experiences

113

FAMILY THERAPYFAMILY THERAPY

• therapist works to assist the family members to identify and express their thoughts and feelings, define family roles and rules, try new, more productive styles of relating and restore strength to the family

• therapist works to assist the family members to identify and express their thoughts and feelings, define family roles and rules, try new, more productive styles of relating and restore strength to the family

114

INTERPERSONAL GROUP THERAPY

INTERPERSONAL GROUP THERAPY

• Promotes the individual’s comfort with others in the group, which then transfers to other relationships

• Promotes the individual’s comfort with others in the group, which then transfers to other relationships

115

~ END ~~ END ~

SALAMAT!SALAMAT!