TREATMENT MODALITIES APPLICABLE TO THE PSYCHIATRIC

CLIENT

At the end of this unit, students will be able to:

• Describe each treatment modality.• Explain the rational for the various treatment.

modalities utilized in mental health conditions.• Describe the preparation of the patient,

environment, and equipment (if required) for each modality.

• Describe expected outcomes, and consequences (if any) of the application of each modality.

NON-PHARMACOLOGICAL TREATMENT

• Counselling- individual and group• Psychotherapy – individual, family , group • Milieu Therapy• Electro-convulsive • Cognitive behavioural therapy

Counselling versus Psychotherapy Counselling• Preventive and remedial• Highly interpersonal

process (social interaction; sharing of feelings & perceptions)

• Problem oriented; often addressing developmental crisis/ issues

• Much emphasis on feelings, needs and behaviours of pts and cognitive aspect

Psychotherapy

• Focuses on remediation, treatment and personality reconstruction (minor or major)

• Corrects emotional and behavioural problems that affect social functioning

• Addresses major psychological problems

• Involves conscious and unconscious awareness; present and past

Counselling versus Psychotherapy

Counselling• Patient is basically well

adjusted requiring minimal personality reconstruction

• Growth oriented – focusing on self-awareness, enhancement, development

• Takes multiple sessions (weeks-months)

Psychotherapy

• Reeducates• Patient may be severely

emotionally disturbed, psychotic or socially deviant

• Techniques applied to make the unconscious, conscious; to provide catharsis

• Takes multiple sessions (may take years)

Breakout Group Session

Apply the various theories to counselling/psychotherapy

Group 1A 25 year old female is feeling depressed as she is currently unemployed with two young babies to care for. Of note, her children’s father is not supportive emotionally or financially.Utilize the Theory of interpersonal relationship (posited by Hildegard Peplau) to guide your counselling session for this female.

1. Orientation• Orientation/Introduction– Establish trust and rapport– Identify purpose, roles and responsibilities– Assess client’s needs– Form contract

2. Identification• The nurse facilitates expression of feelings• Patient participates to identify problems• Patient responds and trusts the nurse

3. Exploitation• Promote patient insights & perception of reality• Overcome resistant behaviors• Patient tests alternate problem solving & coping skills• Initiate action plan & new goals• from dependent to independent behavior

• Increase skills in interpersonal relationships

4. Resolution/Termination

• Summarize work & growth accomplished• Review termination plan & actions to deal with

potential stressors• Referrals to community resources• Acknowledge feelings related to ending

relationship

• Group 2A 45 year old male client has a recurrent issue of

abusing his spouse whenever he becomes frustrated. He employs various coping mechanism, at various stages of his frustration, which at times does not work. Assist the client in addressing this issue using the Systems model (as posited by Betty Neuman).

• Flexible line of defense

A protective accordion-like mechanism that surrounds and protects the normal line of defense from invasion by stressors.

Normal line of defense

An adaptational level of health developed over time and considered normal for a particular individual client or system; it becomes a standard for wellness-deviance determination.

Lines of resistance

Protection factors activated when stressors have penetrated the normal line of defense, causing a reaction synptomatology. (Neuman, 1995)

Negentropy

A process of energy conservation that increases organization and complexity, moving the system toward stability or a higher degree of wellness.

The purpose of the nurse is to retain this system's stability through the three levels of prevention:

•Primary prevention to protect the normal line and strengthen the flexible line of defense.• Secondary prevention to strengthen internal lines of resistance, reducing the reaction, and increasing resistance factors.•Tertiary prevention to readapt and stabilize and protect reconstitution or return to wellness following treatment.

• Group 3A female who was forced into prostitution seeks

your guidance in coping with her recent diagnosis of syphilis. She is particularly concerned about her inability to make money during this initial flare as well as her possibilities of starting a family in the future. Utilizing the Adaptation Model (as posited by Sister Calista Roy), assist this client meeting her request.

Roy’s Adaptation Model

• Group 4A mentally ill client just throw a bucket of urine

on you. His relatives are upset and are demanding to beat him. Utilizing the Theory of Human Caring ( as posited by Jean Watson), conduct a group counselling session with the angry relatives.

The Ten Carative Factors• The formation of a humanistic- altruistic system of values.• The installation of faith-hope.• The cultivation of sensitivity to one’s self and to others.• The development of a helping-trust relationship• The promotion and acceptance of the expression of

positive and negative feelings.• The systematic use of the scientific problem-solving

method for decision making• The promotion of interpersonal teaching-learning.• The provision for a supportive, protective and /or

corrective mental, physical, socio-cultural and spiritual environment.

• Assistance with the gratification of human needs.• The allowance for existential-phenomenological forces.

• Group 5A 5 year serial paedophile has been sent to you for

psychoanalysis. He is known to sexually abuse (oral, anal and vaginal) his male and female victims. He states he was abused by his uncle as a child hence believes he has the authority to perform similar acts with uncensenting minors. Utilize the concepts of psychoanalysis to guide your psychotherapy session.

A person’s development is determined by events in early childhood.

A client’s behaviour is strongly influenced by a conflict between the ID and SUPEREGO.

Attempts to bring the ID to the conscious is usually blocked by unconscious defence mechanisms.

Unresolved conflicts between the conscious and unconscious may resolve in mental disturbances.

A resolution of mental disturbances can be achieved through the uncovering of these conflicts. (interpretation via a psychoanalyst).

• Group 6A third year college student is struggling with

adjusting to a large group where individuality is limited. She feels lost in the system and does not wish to continue her program, as she feels her self esteem is constantly being bruised by her colleagues. Apply the concepts of the Client Centered Therapy (as posited by Carl Rogers) to counsel this client.

• "It is that the individual has within himself or herself vast resources for self-understanding, for altering his or her self-concept, attitudes and self-directed behaviour - and that these resources can be tapped if only a definable climate of facilitative psychological attitudes can be provided."

The counsellor should display…• Genuineness (congruence)• Unconditional Positive Regard • Empathy• Non-judgemental

• Group 7A young male has been ostracised by his family

and community because of his eccentric sexual orientation. He is constantly relocating from town to town as persons are intolerant to his beliefs and sexual practices. He suffers frequent palpitations and bowel movement since the incident. He wonders if he has developed a physiological condition during this stressful period. Apply the theory of stress adaptation to this client’s situation.

• Group 8Mrs T, one year from retirement has vowed to

significantly improve the nation’s health care system before she retires. She has no time to counsel her 15 year old daughter who is struggling with her sexual feelings and responsibilities. Her 21 year younger spouse does not appreciate Mrs T’s extra hours spent at work .Analyse this situation utilizing the concepts of Psychosexual development (as posited by Erik Erikson). Discuss the implications of each stage involved in this scenario.

• Group 9Each time the schizophrenic client sees a person

in white, he becomes defensive and starts shouting “me no whaa no injection todeh nurse!!!!” Explain this behaviour and how the nurse can address it utilizing the theory of Classical Conditioning (as posited by Ivan Pavlov)

Neutral Stimulus (nurse in white

uniform)

Unconditioned stimulus

(injection)

Unconditioned response (pain from

the injection)

Conditioned stimulus (white

uniform)

Conditioned response (pain

from the injection)

Generalization

Extinction

Spontaneous recovery

Behavioural Therapy

• Behavioural therapy is based on the theory that behaviour is learned and has consequences. Changing abnormal or maladaptive behaviour can occur without the need for insight into the underlying cause of the behaviour.

Fastest MatcherColumn A Column B

1. ________Modelling A) Occurs when a behaviour is followed by the removal of an unpleasant stimulus, thereby increasing that behaviour's frequency

2. ________OperantConditioning (negative reinforcement)

B) The nurse can teach this to a client with an escalating temper.

3. _________Aversion therapy C) The nurse serve asA source of reference for the client, who learns improved behaviour byimitation.

4. __________DiaphragmaticBreathing.

D) A nurse may use unpleasant stimuli,such mild electric shock, as punishment for behaviours such as smoking.

Cognitive Therapy

• Cognitive therapy is based on the cognitive model, which focuses on individual thoughts and behaviours to solve current problems.

• Priority restructuring – assists clients to identify what should be given priority, such as devoting energy to pleasurable activities.

• Journal keeping – helps clients write down stressful thoughts and has a positive effect on well-being

• Assertiveness training – teaches clients to express feelings, and solve problems in a nonaggressive manner.

• Monitoring thoughts – helps clients to be aware of negative thinking.

Electro Convulsive Therapy (ECT)

• ECT delivers an electrical current that produces a grand mal seizure.

• The exact mechanism of ECT is still unknown and controversial. One theory suggests that ECT may enhance the effects of neurotransmitters (serotonin, dopamine, and norepinephrine) in the brain.

Indicators for ECT

• Frequent episode of mania (rapid cycling), precedes for lithium therapy.

• Types of schizophrenia less response to neuroleptic therapy

• Severe depression unresponsive to anti depressants

• Any medications that affect the client’s seizure threshold must be decreased or discontinued several days before the ECT procedure.

• Any cardiac conditions, such as dysrhythmias, should be monitored and treated before the procedure.

• Thirty minutes prior to the beginning of the procedure, an IM injection of atropine sulfate is given to decrease secretions.

• NPO 8-12 hours before procedure.• Insert a bit guard to prevent injury during the

procedure• Anaesthesia and muscle relaxant is given.• The electrical stimulus is typically applied for

0.2 to 0.8 seconds. Seizure activity is monitored, and the duration of the seizure, which is usually 25 to 60 seconds.

• Place client in recovery position post procedure.• During the recovery phase, the nurse needs to orient

the client frequently, because confusion and short-term memory loss are common during this time.

• The client’s baseline heart rate is expected to increase by 25% during the procedure and early recovery.

• Blood pressure may initially fall and then rise during the procedure. The elevated blood pressure should resolve shortly after the procedure.

• Headache, muscle soreness, and nausea can occur during and following the immediate recovery period

Therapeutic Milieu

• Milieu therapy creates an environment that is supportive, therapeutic and safe.

• Milieu therapy began as an effort to provide an environment conducive to the treatment of children who were mentally ill.

• Management of the milieu refers to the management of the total environment of the mental health unit in order to provide the least amount of stress, while promoting the greatest benefit for all the clients.

• The goal is that while the client is in this therapeutic environment, he will learn the tools necessary to cope adaptively, interact more effectively and appropriately, and strengthen relationship skills. Hopefully, the client will use these tools in all other aspects of his life.

• The nurse, as manager of care, is responsible for structuring and/or implementing aspects of the therapeutic milieu within the mental health facility.

• One structure of the therapeutic milieu is regular community meetings, which include both the clients and the nursing staff.

Characteristics of the Therapeutic Milieu

Physical Setting•Unit should be clean and orderly.•Colour scheme and overall design should be appropriate for the client’s age.•The setting should include comfortable furniture placed so that it promotes interaction, solitary spaces for reading and thinking alone, comfortable places conducive to meals, and quiet areas for sleeping.

Characteristics of the Therapeutic Milieu

Health Care Provider•Promote independence for self-care and individual growth in clients.•Treat clients as individuals.•Allow choices for clients within the daily routine and within individual treatment plans.•Apply rules of fair treatment for all clients.•Model good social behaviour for clients, such as respect for the rights of others.

Characteristics of the Therapeutic Milieu

Health Care Provider•Work cooperatively as a team to provide care.•Maintain boundaries with clients.•Maintain a professional appearance and demeanour.•Promote safe and satisfying peer interactions among the clients.•Practice open communication techniques with health team members and clients.•Promote feelings of self-worth and hope for the future.

Characteristics of the Therapeutic Milieu

Emotional climate•Clients should feel safe from harm (self-harm, as well as harm from disruptive behaviours of other clients).•Clients should feel cared for and accepted by the staff and others.

Physical Safety•The nurses’ station and other areas should be placed to allow for easy observation of clients by staff .•Set up the following provisions to prevent client self-harm or harm by others:No access to sharp or otherwise harmful objectsRestriction of client access to restricted or locked areasMonitoring of visitors

Restriction of alcohol and illegal drug access or use

Restriction of sexual activity among clientsRapid de-escalation of disruptive and potentially

violent behaviours through planned interventions by trained staff

• Seclusion rooms and restraints should be set up for safety and used only after all less restrictive measures have been exhausted. When used, facility policies and procedures must be followed.

The therapeutic milieu should facilitate •Community meetings•Individual therapy•Group therapy•Psycho-education•Recreational activities•Unstructured contact time with care providers

Scouting for evidence

PHARMACOLOGICAL THERAPY• Antipsychotics

– atypical and typical• Mood Stabilizers

– Lithium Carbonate– Anticonvulsants (valproate, Tegretol etc.)

• Antidepressants– Tricyclic– MAOIs– SSRIs– SNRIs

• Anti-anxiolytic agents– Benzodiazepines– Barbiturates

• Anticholenergic-Antimuscarinics used in psychiatry– Artane– Cogentin