1、1Roles of the nurse in different treatment modalities&settings Chia-Ling Mao2Individual 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 them
2、selves;empowerment with self-esteem&self worth Transference Managed care-how why Practical problem:insurers will not cover the costs3Types of individual therapies Classic psychoanalysis unconsciousness,R Cognitive therapy how;irrational thinking Behavioral therapy-reshaping Cognitive-behavioral ther
3、apy thought&action Rational emotive therapy situation,irrational belief-behavior Choice therapy doing feeling;self-responsibility&self-discipline Brief,solution-focused therapy4Outcome of psychoanalysis Insight into repressed conflicts Restructuring of the personality based on integration of repress
4、ed conflicts.5Cognitive Therapy Theorist Aaron Beck(1979)Cognitive Triad the interaction of the clients negative view of self,the world,&the future How to perceive an event the event itself Cognition=the clients construction of his world Roles of the nurse trust relationships,goals,review feelings,n
5、ote accomplishments Using voicing doubt in dealing with clients cognitive distortion6Techniques of cognitive therapy Look for idiosyncratic meaning Question the evidence Reattribute De-catastrophize,Fantasize consequences Examine options and alternatives Weight advantages&disadvantages Turn adversit
6、y to advantage Using thought stopping Use distraction7Outcome of cognitive therapy Recognition of irrational thinking patterns Enhancement of functional responses8Behavioral Therapy The concepts of behavior therapy stimulus,response,&reinforcement Behaviors are measurable,observable,Classical condit
7、ioning S-R Operant conditioning Discriminative stimulus,response,reinforcing stimulus Learning,extinction Identify techniques for increasing/decreasing a behavior9Behavior modification Conditioning Shaping Extinction Negative consequence Time out Reinforcement Modeling Token economy10Nursing process
8、&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),11Focus&outcome of behavior
9、al therapy Promotion of desirable behaviors with alternations of undesirable behaviors Reshaping of behavior with elimination of negative behaviors12Cognitive-Behavioral Therapy Focus on making changes in current ways of thinking and behavior Nursing intervention:self-responsibility&self-discipline;
10、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”13Outcome of cognitive-behavioral TH Participatory relationship between client and the therapist R
11、esults oriented Client learning new skills 14Rational-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:belie
12、f about A C:emotional reaction Irrational belief-negative emotions15Roles 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 f
13、ocus on positive statements and behaviors and skill development Role-playing&modeling 16Outcome of RET Client control of behavior and thinking Assumption of responsibility and blame for irrational beliefs17Group Therapy Definition&evolution Leadership Types:autocratic,democratic,Laissez-faire power
14、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,18Group dynamics Group content Group process Pre-interaction phase sele
15、cting 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 separation19Therapeutic factors of group th
16、erapy 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 factors20Leadership sty
17、le Democratic Autocratic Laissez-fairs21Roles of the group member Group maintenance role Individual roles Blocker Dominator Follower Gatekeeper22Family Therapy Background and evolution Family burden Iatrogenic burden from the MH system/professionals Objective burden practical problems Subjective bur
18、den grief,fear,guilt,anger23Roles of the healthy family Responding to family members needs Coping actively with lifes problems and stressed Accomplishing family tasks with equal distribution of power Encouraging interaction among family members and the community Promoting positive personal health pr
19、actices24Conceptual 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 Cal
20、gary Family Assessment Model-25Concepts in Bowens theory Differentiation Triangulation Nuclear family emotion system Family projection process Emotional cutoff Mutigenerational transmission process Sibling position26Family Assessment Calgary Family Assessment Model Family structure genogram,ecomap F
21、amily 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 considera
22、tion27Nursing 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 care28Conclusion on Family Therapy Family
23、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 Materialism29Forensic Nursing Background overlap between the criminal justice&me
24、ntal health systems;criminalization&deinstitutionalization Clients victims,perpetrators,and their families Related issues legal,ethical,political,administrative,&professional30Characteristics of the forensic setting Physical setting Client population Authoritarian interpersonal environment31Characte
25、ristics 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,Decrease
26、d social skills or physical strength Criminalized lifestyle32Crisis Intervention Characters of crisis a threat to homeostasis -anxiety,confusion,loss of problem solving ability Crisis=danger+opportunity Short:4-6 weeks33Phases of a crisis Increased anxiety-coping Coping failed-further increased anxi
27、ety Escalated anxiety-reach out for help Active state of crisis34Balancing factors Realistic perception of the events Coping skills Support systems35Nursing diagnoses Ineffective coping Anxiety Disturbed thought processes Situational low self-esteem Social isolation Impaired social interaction36Type
28、s 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 37Somatic Therapy38Electroconvulsive Therapy Historic background 1938 Mechanism unknown
29、 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 bladder39Nursing care During ECT typical grand mal seizure with tonic and clonic pha
30、ses After ECT Respiratory problems apnea,oxygen Confusion&disorientation Memory impairment Recording40Issues related to ECT Advantages-$,safety,effect,Disadvantages memory impairmentCommunity CareObjectives Review revolution of community mental health Define“community support system”Identify the lev
31、els of prevention on MI Describe roles of the nurse in community mental health careLandmarks in community mental health 1946-Natl M H Act;1949-NIMN 1955 MH Study Act 60s-Community Mental Health Centers Act;Deinstitutionalization 70s-Community Support Program case managers 80s Mental Health Systems A
32、ct 90s American Disabilities Act pts rights 2000 Healthy people 2010;NAMI;NAMP National health goal;advocacyHealthy 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
33、.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.Healthy People 2010(contd)18-6.(Developmental)Increase the number of persons seen in prim
34、ary 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 problem
35、s.Healthy People 2010(contd)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-munity-based jail diversion programs for adults with
36、serious mental illness(SMI).18-12.track consumers satisfaction with the mental health services they receive.Healthy People 2010(contd)18-13.operational mental health plan that addresses cultural competence.18-14.operational mental health plan that addresses mental health crisis interventions,ongoing
37、 screening,and treatment services for elderly persons.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.Goals of communi
38、ty 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 Primary prevention Health promotion continued well-being Disease prevention no potential threat S
39、econdary prevention Screening,referral,crisis intervention Tertiary prevention Rehabilitation social skill training,self-help groups,Levels of PreventionComponents of a Community Support System Availability adequate resources Accessibility outreach,24 hours services Integration collaboration&sharing
40、 Continuity inpt-rehab.Community involvement community resources,grass root work,empowerment,advocacy,Elements of Case Management Psychiatric rehabilitation Resource linkage,Consultation/liaison Advocacy Crisis intervention Home care-improved functional ability TherapiesRange of Community-based Care
41、 Home care-homebound clients Outreach services-for homeless clients Residential services-Group homes-temp./permanent housing Halfway house-chemical dependency Apartment living programs Foster care and boarding homes Self-help groupsNumbers r/t Community Mentally ill In the U.S.20%of adults=MI 12%of
42、children=mental or emotional pro.1/3 of homeless have serious MI;1/2 have a substance abuse problem 7%of inmates have a serious MI;12.4%require psy attention 25%of those who have MI receive Tx.Many HIV infection or AIDS cases need psy Tx.Issues r/t community care Concepts about MI ie rehabilitation
43、Stalled resources ie funding and planning Poverty ie.SSI Reinstitutionalization hosp&jail Special education for disabled children Stigma employment,housing,self-esteem Reforms Application of Nursing Process Assessment Aggregates and problems bureau of census,vital statistics,survey,local news Indivi
44、duals-Severity of individuals illness;Amount of supervision required by the individual Diagnosis community orientedNursing Process(contd)Planning Multidisciplinary team includes key people and agencies Short-and long-term goals Implementation Primary,secondary,&tertiary preventions Evaluation On goi
45、ng processHome care Def-Part of a comprehensive health and mental healthcare system that aims to provide an array of health-related services to clients and families in their places of residence.Residence private home,residential care facilities,group homes,Characteristics of home care natural settin
46、g;not an alternative to institutional care reduce or prevent hospitalization cost-effective rapidly growing and changing fields in health care,even though it is one of the oldest forms of ambulatory healthcare crisis intervention&emergency responseGoals of home care Teaching problem-solving,stress-r
47、eduction,and coping skills to the clients/family members/caregivers Providing respite and community resources Educating about MI/MH,medications,relapse prevention,and IPR&communication skills Coordinating medical,social,spiritual,community based servicesCare for the homeless with MI 5%of the people
48、with MI are homeless Co-morbidity ie DM,Respiratory infections,asthma,malnutrition,dental caries,STD,thyroid problems,foot problemsRoles of nurse in caring for the homeless Knowledge no standard protocols Perform an assessment physical,mental status,violence,hopelessness,spiritual,substance abuse,IP
49、R&communication Immediate needs of the client Community resourcesChallenges Use traditional knowledge/skill in new setting;Overlapping of professional and personal boundaries;Short,crisis oriented inpatient stay;Intensive outpatient services;Wider range of treatment modalities;Multidisciplinary coll
50、aborationSpirituality&religion Spirituality A persons experience of,or a belief in,a power apart from his/her own existence;an individual search for meaning The concept of ones relationship with a transcendent reality Religion Outward practice of a spiritual system of beliefs,values,codes of conduct
