C urrent Theories & Practice Psychosocial Theories and Therapy

1. Current Theories & PracticePsychosocial Theories and Therapy

2. Learning Outcomes • Describe the following psychosocial theories and treatment modalities: psychoanalytic, behavioral, existential, and somatic • Identify the nurse’s role in applying treatment modalities

3. Psychoanalytic Theories • Behavior motivated by subconscious thoughts and feelings • Transference and countertransference • Ego defense mechanisms • (Remember chart in book) • Trans- unconscious assignment to others of feelings and attitudes • Counter- When a therapist begins to transfer their own unconscious feelings onto their patient. Sigmund Freud

4. Psychoanalytic Theories • Psychotherapy used today • Therapeutic interaction between a qualified provider and patient or group designed to benefit persons experiencing emotional distress, impairment, or illness Very Expensive

5. Pg47, Table 3.1 Ego Defense Mechanisms • Ego: usually copes with anxiety or anxiety producing situations • If anxiety is too painful, the person may cope using defense mechanisms • Protects the ego and lowers anxiety • Defense mechanisms used too frequently: problems not solved; individual has problems with their reality

6. Pg47, Table 3.1 Ego Defense Mechanisms • Defense mechanisms are maladaptive when they: • Distort reality • Interfere with interpersonal relationships • Limit one’s ability to work productively • Promote ego disintegration instead of self-integrity

7. Ego Defense Mechanisms*Term definitions: Table 3.1 • Denial-as long as I can’t see it, there’s nothing wrong. • Smoker says “I’m coughing b/c of a cold that’s going around.” • Displacement • Punished child is sent to room, where he kicks and breaks apart a toy. • Intellectualization • Projection • Conversion-mind over matter • Dissociation-taking yourself out of the situation • Reactionformation • Woman who just lost election exclaims “She’s a sweet person! I like her!” • Sublimation • Husband is angry at wife, so he goes outside and energetically begins to cut up firewood.

8. Ego Defense Mechanisms • Nursing interventions • Recognize and understand use of maladaptive defense mechanisms • Teach patient adaptive coping skills • Assertiveness • Problem solving • Positive self-talk • Conflict resolution • Communication skills • Stress/anger management

9. Behavioral Theories • Ivan Pavlov • Classical conditioning • B.F. Skinner • Behaviorism focuses on behaviors and behavior changes, rather than explaining how the mind works • Behavior is learned, has consequences • Stimulus: an event immediately preceding or following behavior (client sees cocaine and gets the urge)

10. Behavioral Theories • Positive reinforcement increases the frequency of behavior • Removal of negative reinforcers increases the frequency of behavior • Continuous reinforcement is fastest way to change behavior (Training a dog: do a trick = give em a treat every time) • Random intermittent reinforcement is slower; has longer lasting effect (Training a dog: do a trick = give em a treat every other time)

11. Behavior Therapy • Behavior therapy- a therapeutic approach to help modify behavior by changing or modifying old patterns • Treatment modalities based on behaviorism: behavior modification, token economy, systematic desensitization • Premack principle- using an activity (or something you enjoy) as a reinforcer so behaviors occur less frequently

12. Behavior Therapy • Used to treat: • Addictions • Anxiety disorders • Sexual disorders • Post traumatic stress disorder (PTSD)

13. Existential Theories • Cognitive therapy • Based on the premise that the way a person perceives an event, rather than the event itself, determines its relevance and emotional response • Ex: PTSD- important to have intervention before it gets too bad to change into a new way of thinking. • Helps patient understand the construction of their world and experience with new ways to respond to situations

14. Existential Theories • Treatment approach to cognitive therapy: • Build trust • Active listening/empathy • Decide a problem list • Focus each session on a problem • Work on dysfunctional or new skill desired

15. Existential Theories • Cognitive therapy used to treat: • Changing the way they think & act • Anxiety • Sexual disorders • Eating disorders • Personality disorders • Suicidal thoughts/ideation

16. Treatment Modalities • Hospital (inpatient) • Severely psychotic • Severely depressed/suicidal • Alcohol or drug withdrawal • Exhibiting behaviors that require close supervision in a safe supportive environment

17. Treatment Modalities • Community (outpatient) • Can continue to work and stay connected with family, friends, and other supports • Personality or behavior patterns gradually develop over the course of a lifetime and cannot be changed in a short inpatient course of treatment

18. pg57 Treatment Modalities • Group therapy- involves a therapist or leader and a group of patients sharing a common purpose; members contribute to the group and expect to benefit from it

19. Treatment Modalities • Types of groups: • Support - Education • Family therapy - Self-help • Family education - Psychotherapy • Activity • Support- AA, MADD • Family- divorce • Family Ed- • Activity • Self-help- WW, AA, Gambler’s Anonymous

20. Treatment Modalities • Group leadership • Therapy groups and education groups have a formal leader • Support groups and self-help groups do not have a formal leader

21. Treatment Modalities • Stages of group development • Pre-group stage- gathering, forming, organizing • Initial stage- when group leader is selected • Working stage- set group rules, process • Termination stage- ending

22. Treatment ModalitiesGOOD • Group member roles: • Growth-producing • Energizer (pep) • Harmonizer (mediator ; Giving their opinions) • Encourager • Opinion seeker • Information seeker/giver

23. Treatment ModalitiesBAD • Group member roles: • Growth-inhibiting • Critic • Aggressor • Dominator • Monopolizer-someone who monopolizes the means of producing or selling something • Passive follower • Recognition-seeker

24. Treatment Modalities • Yalom’s therapeutic results of group therapy: • Altruism- (BEST) feel useful/helpful to others • Members begin to acknowledge others and take the focus off of themselves • Catharsis-let out the feelings • Universality- others like me • Cohesiveness- bonding • Imitative behavior - Instillation of hope - Existential factors- learning there’s a limit to what they can/can’t control (Yalom, 2005)

25. Treatment Modalities • Yalom therapeutic results (cont’d): - Interpersonal learning - Imparting of information • Development of socialization techniques • Corrective recapitulation of primary family group • View dysfunctional family patterns and learn to change it (Yalom, 2005)

26. Complementary and Alternative Therapies • Most of it is out of pocket, self medicated, self education • 1 in 3 people are using alternative therapies, many do not tell their physician • Several herbal compounds interact with medications

27. Terms • Alternative –not generally accepted as treatment in society • Broad range of healing philosophies • Not commonly used in Western society • Complimentary – same as alternative, yet • Used in conjunction with traditional medicine • Not a replacement for conventional therapy

28. Herbs: St. John’s Wort • Used to treat • Depression • Seasonal Affective Disorder • Anxiety • Sleep Disorders • No FDA req’d

29. Contraindications:St. John’s Wort • Just be careful w/ pts that’re on herbals, it may have neg affect w/ other meds. • May interact with Zyprexa “antipsychotic” • Avoid taking with SSRIs “Selective serotonin reuptake inhibitors” to treat depression • Other side effects: dizziness, insomnia, restlessness, constipation, abdominal cramps, photosensitivity • May reduce efficacy of oral contraceptives

30. Acupuncture • Complimentary therapy for drug addiction • Research is showing effective for treatment of mild to moderate depression • Side effects

31. Other Therapy Examples • Massage • Yoga • Chiropractic • Curanderismo- traditional folk healer • Meditation • Homeopathic • Rheiki/therapeutic touch

32. Somatic Therapies • Therapeutic approach including physiologic or physical interventions to effect behavioral changes • Electroconvulsive Therapy (ECT) • Mainly for severe depression (See slide 41) • Modern psychosurgery • Bright light therapy • Repetitive Transcranial Magnetic Stimulation

33. Electroconvulsive Therapy • Emerged in 1930’s • Seen as barbaric • Written consent usually not obtained • Psych patients were all given “Shocks”

34. Electroconvulsive Therapy • ECT is not a cure, but is now a viable treatment approach • Theory is the seizure changes brain chemistry and alleviates symptoms • Electric current is passed through the brain and causes the patient to have a seizure

35. Modern ECT • Electric current is a low dose joule • Seizure activity is timed • Patient is monitored as if in PACU setting • Anesthesiologist or electrotherapist present

36. Workup for ECT • Pre-treatment evaluation: physical exam, baseline memory assessment, level of functioning • Informed consent obtained • Discontinue any bedtime sedatives • Cause it’ll raise the seizure threshold • Labs drawn as baseline

37. ECT Preparation • Patient is NPO 6-8 hours before • Dose of Atropine or Robinul • To reduce secretions  to prevent aspirations • Have patient urinate before procedure • Remove any hairpins, dentures, contact lens, hearing aide • Take vital signs • Be positive, allay “to calm” patient’s anxiety

38. Procedures during ECT • Insert IV • Electrodes are placed • Brevital (methohexital) “a barbiturate derivative; sedative”; then Anectine (succinylcholine) “anesthesia med to paralyze” given IV • Bite block inserted, ventilations- 100% O2 • Electrical impulse administered • Seizure induced, should last 30-150 seconds • Continuous monitoring of heart rate, blood pressure, O2 sats, EEG

39. Post ECT • Evaluate for agitation upon awakening, administer PRN benzodiazepine “sedative” if needed • Monitor vital signs • Assess for return of gag reflux • Monitor for post-ECT confusion

40. ECT Therapy • Physician may order 6-15 treatments scheduled 3x a week • Maintenance ECT • State requirements for reporting • Risks: memory impairment, confusion, migraines, possible cardiac affects

41. Indications for ECT • Severe depression • Severe mania • Nonresponsive postpartum psychosis • Catatonic schizophrenia (or nonresponsive to meds) • Movement disorders – Parkinson’s, Neuroleptic Malignant Syndrome, Myasthenia Gravis

42. Elder Considerations for ECT • Suicide and depression is increased so ECT gets most rapid response • Not able to tolerate doses of antidepressants high enough to treat the depression

43. Bright Light Therapy • Used to treat seasonal affective disorder • Exposure to intense artificial light • May help bulimia, insomnia, non-seasonal depression

44. Self-Awareness Issues • No one theory or treatment approach is effective for all patients • Using a variety of psychosocial approaches increases nurse effectiveness • Patient’s feelings and perceptions are most influential in determining their response

45. References • Yalom, I.D. (2005). The Theory and Practice of Group Psychotherapy (5th ed.). New York: Basic Books.