Therapeutic modalities

Therapeutic Modalities, Psychosocial Skills, and Nursing

1 BIOPHYSICAL/ SOMATIC INTERVENTIONS

a. 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)

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

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 0.5-2.0 seconds.and usually given
at 70 – 159 volts

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.
.

2. Pharmacotherapy
A. Minor tranquilizers / Anxiolytics

Common Indication: Anxiety Disorders

Example:

- Diazepam (Valium)

- Oxazepam (Serax)

- Chlordiazepoxide (Librium)

- Chlorazepate Dipotassium (Tranxene)

- Alprazolam (Xanax)

Keep in mind:

c – anti anxiety; muscle relaxant

H – decreased anxiety, adequate sleep

E – best take before meals, food in the stomach

C – delays absorption

K – avoid driving, intake of alcohol and caffeine containing foods, since it alters
the effect of the drug

B. Trycyclic Antidepressants
Indication : Depression

Examples:

- Imipramine (Tofranil)

- Amitripyline (Elavin)
Keep in mind:

C – Tricyclic; anti depressants

H – increased appetite; adequate sleep

E – best given after meals

C – therapeutic effects may become evident only 2-3 weeks of intake

K – check the BP, it causes hypotension; check the heart rate, it causes cardiac
arrythmias

c. Anti depressants – MAO inhibitors

Example:
- Tranylcypromide (Parnate)

- Pheneizine (Nardil)

- Isocarboxazid (Marplan)

Keep in mind:

• antidepressants (MAO inhibitors)

• increased appetite; adequate sleep

• best taken after meals

• report headache; it indicates hypertensive crisis

• avoid tyramine containing foods because toxic when taken with MAO inhibitors,
like avocado, banana, cheddar and aged cheese, soysauce and preserved foods.

• It takes 2-3 weeks before initial therapeutic effects become noticeable.

• Monitor the BP. There should be at least a two week interval when shifting from
one anti depressant to another.
D. Anti Manic Agent:
- cause augmentation of serotonin function in the CNS preventing increase nerve
impulse transmission.

Examples:

- Lithium Citrate (Cibalith)

- Lithium Carbonate (Eskalith, Lithane, Lithobid)

Keep in mind:

• anti manic, decreased hyperactivity

• best taken after meals

• increase fluid intake (3L / day) and sodium intake (3gm / day). Avoid activities
that increase perspiration.

• It takes 10-14 days before therapeutic effect becomes evident.

• Antipsychotic is administered during the first 2 weeks to manage the acute

symptoms of Mania until Lithium takes affect.

• Monitor serum level

• Nausea, anorexia, vomiting, diarrhea and abdominal cramps indicate lithium

toxicity.

• Mannitol is administered if toxicity occurs.

E. Major tranquilizers / Anti psychotics

Indication: Schizophrenia

Examples:

- Haloperidol (Haldol)
- Prochioperazine (Comazine)

- Fluphenazine (Prolixin)

- Chlorpromazine (Thorazine)

Keep in mind:

• anti psychotics

• decreased delusions, hallucinations and looseness of association.

• Best taken after meals

• Report elevated temperature and muscle rigidity (it indicates neuroleptic

malignant syndrome), a life-threatening idiosyncratic reaction to antipsychotic
drugs that begins with muscle rigidity followed by a fever within several hours of
onset and mental status changes that can range from mild drowsiness, agitation,
or confusion to a severe delirium or coma.

• Check the BP, the drug causes hypotension

• Assess for akathisia, a movement disorder characterized by a feeling of inner

restlessness and a compelling need to be in constant motion, as well as by actions
such as rocking while standing or sitting, lifting the feet as if marching on the spot,
and crossing and uncrossing the legs while sitting. People with akathisia are
unable to sit or keep still, complain of restlessness, fidget, rock from foot to foot,
and pace

• Assess Tardive Dyskinesia, cause involuntary movement of the eyes, face, and
hands, facial grimacing, rapid eye blinking, and piano playing-like finger
movement. initially manifested by tongue witching or lip smacking

• Check the CBC, drugs cause leucopenia

3.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.

SUPPORTIVE PSYCHOTERAPY
Psychotherapy - is also known as talk therapy because its basic rule is to
make client to talk about anything that enters his mind and not to hold back.
Freud said that the goal of therapy is simply to make the unconscious conscious.

1. Individual Psychotherapy ( Nurse-Patient Relationship Therapy)

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.

Reasons why people seek psychotherapy:

To understand themselves and their behaviour

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.
2. GROUP 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.

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.

3 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

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
 a. 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

b. 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)

Schedules of 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 behaviour - 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.

Exposure Models
a. 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. in the presence of the therapist, but can be practiced independently (as
homework) later in the process.
b. 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.

c. 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.

PSYCHOSOCIALINTERVENTIONS
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.