Roles of the nurse in different treatment modalities & settings

1. Roles of the nurse in different treatment modalities & settings Chia-Ling Mao

2. Individual Psychotherapy • Foundation – trusting relationship • Goal – changes in behaviors, self-perceptions, emotional comfort, insight • Conceptual framework – multiple including CBT • Basic – trust; empathy; helping the clients to help themselves; empowerment with self-esteem & self worth • Transference • Managed care ->how > why • Practical problem: insurers will not cover the costs

3. Types of individual therapies • Classic psychoanalysis – unconsciousness, R • Cognitive therapy – how; irrational thinking • Behavioral therapy - reshaping • Cognitive - behavioral therapy –thought & action • Rational emotive therapy – situation, irrational belief -> behavior • Choice therapy – doing > feeling; self-responsibility & self-discipline • Brief, solution-focused therapy

4. Outcome of psychoanalysis • Insight into repressed conflicts • Restructuring of the personality based on integration of repressed conflicts.

5. Cognitive Therapy • Theorist – Aaron Beck (1979) • Cognitive Triad – the interaction of the client’s negative view of self, the world, & the future • How to perceive an event > the event itself • Cognition = the client’s construction of his world • Roles of the nurse – trust relationships, goals, review feelings, note accomplishments • Using voicing doubt in dealing with client’s cognitive distortion

6. Techniques of cognitive therapy • Look for idiosyncratic meaning • Question the evidence • Reattribute • De-catastrophize, Fantasize consequences • Examine options and alternatives • Weight advantages & disadvantages • Turn adversity to advantage • Using thought stopping • Use distraction

7. Outcome of cognitive therapy • Recognition of irrational thinking patterns • Enhancement of functional responses

8. Behavioral Therapy • The concepts of behavior therapy – stimulus, response, & reinforcement • Behaviors are measurable, observable, • Classical conditioning – S -> R • Operant conditioning • Discriminative stimulus, response, reinforcing stimulus • Learning, extinction • Identify techniques for increasing/ decreasing a behavior

9. Behavior modification • Conditioning • Shaping • Extinction • Negative consequence • Time out • Reinforcement • Modeling • Token economy

10. Nursing process & behavior therapy • Assessment – appropriate/inappropriate behaviors, time, frequency, duration… • Dx – expected changes • Plan – target response, decreasing or increasing, new skills • Intervention – reinforcement; (+) & (-) • Evaluation – outcomes (as planned) & maintaining, additional change (if needed),

11. Focus & outcome of behavioral therapy • Promotion of desirable behaviors with alternations of undesirable behaviors • Reshaping of behavior with elimination of negative behaviors

12. Cognitive-Behavioral Therapy • Focus on making changes in current ways of thinking and behavior • Nursing intervention: self-responsibility & self-discipline; • Nurse acting as a coach, teacher in identifying of situations involving undesirable thoughts and actions • Example – • Pt: “My wife makes me so angry” • N: ” What is self-defeating about the statement you just made”

13. Outcome of cognitive-behavioral TH • Participatory relationship between client and the therapist • Results oriented • Client learning new skills

14. Rational-emotive therapy (RET) • Theorist – Albert Ellis (1973) • Present perceptions, thoughts, assumptions, beliefs, values, attitudes, and philosophies as needing modification or change. • Should, ought, must …. • ABC theory – Intervention is aimed at B • A : activating event • B : belief about A • C : emotional reaction • Irrational belief -> negative emotions

15. Roles of the nurse in RET • Acceptance – do not allow the pt to condemn themselves • Challenge/confront the irrational thinking • Present centered • Help the pt learn to take responsibility for their ideas and behaviors. • Homework assignments focus on positive statements and behaviors and skill development • Role-playing & modeling

16. Outcome of RET • Client control of behavior and thinking • Assumption of responsibility and blame for irrational beliefs

17. Group Therapy • Definition & evolution • Leadership • Types: autocratic, democratic, Laissez-faire • power • Group roles • Group task roles: initiator, information seeker, information giver, coordinator, recorder … • Group building & maintenance roles: encourager, harmonizer, gatekeeper … • Individual roles: aggressor, blocker, recognition seeker, play person,

18. Group dynamics • Group content • Group process • Pre-interaction phase – selecting members, contract… • Orientation phase – searching for similarity, building norms, politeness, … • Working phase – attempt to solve the problems, conflict, cooperation • Termination phase – evaluates the experience and explores members’ feelings about it and the impending separation

19. Therapeutic factors of group therapy • Instillation of hope • Universality • Imparting of information • Altruism • Corrective recapitulation of the primary family group • Development of socializing techniques • Imitative behavior • Interpersonal learning • Group cohesiveness • Catharsis – expression of deep emotions • Existential factors

20. Leadership style • Democratic • Autocratic • Laissez-fairs

21. Roles of the group member • Group maintenance role • Individual roles • Blocker • Dominator • Follower • Gatekeeper

22. Family Therapy • Background and evolution • Family burden • Iatrogenic burden – from the MH system/professionals • Objective burden – practical problems • Subjective burden – grief, fear, guilt, anger

23. Roles of the healthy family • Responding to family members’ needs • Coping actively with life’s problems and stressed • Accomplishing family tasks with equal distribution of power • Encouraging interaction among family members and the community • Promoting positive personal health practices

24. Conceptual framework of family therapy • Structural family therapy – Minuchin • Boundary, role, sub-system; conflicts are resolved in a rational manner • Communication theory – Satir • Identified patient • Communication style • Distractor, placator, blamer, … • Pseudomutuality, pseudohostility • System theory – Bowen • Calgary Family Assessment Model -

25. Concepts in Bowen’s theory • Differentiation • Triangulation • Nuclear family emotion system • Family projection process • Emotional cutoff • Mutigenerational transmission process • Sibling position

26. Family Assessment – Calgary Family Assessment Model • Family structure – genogram, ecomap • Family development/life cycle – associated tasks • Beginning families • Early childbearing families • Families with preschool children • Families with school children • Families with teenagers • Launching center families • Families of middle years • Families in retirement and old age • Family function • Cultural consideration

27. Nursing Diagnoses (FT) • Altered family processes • Ineffective family coping • Impaired home maintenance management • Related issues • Concept of resilience • Major concerns of the care giver? • Resources – NAMI • Confidentiality – can be a barrier to including families in care

28. Conclusion on Family Therapy • Family as a system • Changes involve whole system • Application of change theory (Prochaska, 1992) • Precontemplation, contemplation, preparation, action, maintenance • Family myths • Family harmony • Parental determinism • Breakdown of the family • Materialism

29. Forensic Nursing • Background – overlap between the criminal justice & mental health systems; criminalization & deinstitutionalization • Clients – victims, perpetrators, and their families • Related issues – legal, ethical, political, administrative, & professional

30. Characteristics of the forensic setting • Physical setting • Client population • Authoritarian interpersonal environment

31. Characteristics of the forensic population • Poor judgment, limited reasoning abilities, history of not learning form past mistakes, • High level of substance abuse • Depression, suicidal ideation, aggressiveness, irritability, violence • Personality disorder; chr mental illnesses, mental retardation, brain injuries, … • Decreased social skills or physical strength • Criminalized lifestyle

32. Crisis Intervention • Characters of crisis • a threat to homeostasis -> anxiety, confusion, loss of problem solving ability • Crisis = danger + opportunity • Short : 4-6 weeks

33. Phases of a crisis • Increased anxiety -> coping • Coping failed -> further increased anxiety • Escalated anxiety -> reach out for help • Active state of crisis

34. Balancing factors • Realistic perception of the events • Coping skills • Support systems

35. Nursing diagnoses • Ineffective coping • Anxiety • Disturbed thought processes • Situational low self-esteem • Social isolation • Impaired social interaction

36. Types of crises • Maturational or developmental crisis – various task in different states • Situational crisis - sudden traumatic event ie job loss • Adventitious crisis – precipitated by an unexpected event ie, natural disasters

37. Somatic Therapy

38. Electroconvulsive Therapy • Historic background – 1938 • Mechanism – unknown • Modern ECT • Nursing care – before ECT – like before surgery • Explanation – fear, stigma, fear, anxiety… • Physical exam - vital signs, lab data, spinal X-ray • Consent form & preparation • NPO for 8 hours, moveable accessory, • Atropine • Empty bladder

39. Nursing care • During ECT – typical grand mal seizure with tonic and clonic phases • After ECT • Respiratory problems – apnea, oxygen • Confusion & disorientation • Memory impairment • Recording

40. Issues related to ECT • Advantages - $, safety, effect, • Disadvantages – memory impairment

41. Community Care

42. Objectives • Review revolution of community mental health • Define “community support system” • Identify the levels of prevention on MI • Describe roles of the nurse in community mental health care

43. Landmarks in community mental health • 1946 - Natl M H Act; 1949- NIMN • 1955 – MH Study Act • 60’s - Community Mental Health Centers Act; • Deinstitutionalization • 70’s - Community Support Program • case managers • 80’s – Mental Health Systems Act • 90’s – American Disabilities Act – pt’s rights • 2000 – Healthy people 2010; NAMI; NAMP • National health goal; advocacy

44. Healthy People 2010 • 18-1. Reduce the suicide rate. • 18-2. Reduce the rate of suicide attempts by adolescents • 18-3. Reduce the proportion of homeless adults who have serious mental illness (SMI). • 18-4. Increase the proportion of persons with serious mental illness (SMI) who are employed. • 18-5. (Developmental) Reduce the relapse rates for persons with eating disorders, including anorexia nervosa and bulimia nervosa.

45. Healthy People 2010 (cont’d) • 18-6. (Developmental) Increase the number of persons seen in primary health care who receive mental health screening and assessment. • 18-7. (Developmental) Increase the proportion of children with mental health problems who receive treatment. • 18-8. (Developmental) Increase the proportion of juvenile justice facilities that screen new admissions for mental health problems.

46. Healthy People 2010 (cont’d) • 18-9. Increase the proportion of adults with mental disorders ( serious mental illness, depression, schizophrenia, generalized anxiety disorder) who receive treatment. • 18-10. co-occurring substance abuse and mental disorders • 18-11. community-based jail diversion programs for adults with serious mental illness (SMI). • 18-12. track consumers’ satisfaction with the mental health services they receive.

47. Healthy People 2010 (cont’d) • 18-13. operational mental health plan that addresses cultural competence. • 18-14. operational mental health plan that addresses mental health crisis interventions, ongoing screening, and treatment services for elderly persons.

48. Community Support System • A network of caring and responsible people committed to assisting a vulnerable population to meet its needs and develop its potential without becoming unnecessarily isolated or excluded from the community.

49. Goals of community support system • Improve the competence of the client • Alleviate the symptoms • Use various therapeutic constructs • Improve outcomes • Install hope • Active participation in the rehab. • Develop individual skills

50. Levels of Prevention • Primary prevention – • Health promotion – continued well-being • Disease prevention – no potential threat • Secondary prevention – • Screening, referral, crisis intervention • Tertiary prevention – • Rehabilitation – social skill training, self-help groups,