Keltner: Psychiatric Nursing, 5th Edition

Chapter 2: Psychotherapeutic Management in the Continuum of Care

Chapter Focus
Psychotherapeutic management is proposed as a model to answer the question, What do
psychiatric nurses do that is different from other mental health professionals? This
model acknowledges the interdependence of mental health professionals and emphasizes
the unique strengths of psychiatric nurses. Emphasis is placed on the balance of three
components of psychiatric treatmentthe therapeutic nurse-patient relationship (words),
psychopharmacology (drugs), and milieu management (environment)all of which must
be supported by a sound understanding of psychopathology. Neglect of any component
compromises the therapeutic benefits of nursing intervention. The domain of the
psychiatric nurse includes the art of being therapeutic (as opposed to the practice of
therapy), management of the prescribed medication regimen (dispensing, monitoring,
evaluating, and decision making), and modulation of environmental elements to produce
therapeutic benefits (safety, structure, norms, limit setting, balance, and unit
modification).

Key Terms
behavior therapy
continuum of care
milieu
psychopathology
psychotherapeutic management
psychotropic drugs
therapeutic
therapy

Learning Objectives
After reading this chapter, you should be able to:
1. Describe the components of psychotherapeutic management.
2. Explain the way in which the balancing of psychotherapeutic management
components combines to form a powerful therapeutic model of care.
3. Recognize the relationship between the continuum of care and the psychotherapeutic
management model.
Chapter Outline

Teaching Strategies

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Instructor's Manual
Psychotherapeutic
Management

Application of
Psychotherapeutic
Management Interventions

Continuum of Care

Therapeutic Nurse-Patient
Relationship

Psychopharmacology

Milieu Management

2-2
A model proposed to clarify and distinguish the role of the
psychiatric nurse.
The three distinct dimensions are:
Therapeutic nurse-patient relationship (use of
self/words)
Psychopharmacology (use of drugs)
Milieu management (use of environment)
Extend beyond inpatient settings into a variety of settings
for example, outpatient programs, residential services, and
home care.
Maximal benefit to patients occurs when all components are
applied; however, one component can take precedence at a
given point in time.
Structured to provide services based on the changing needs
of the individual
Services include:
Health promotion
Prevention
Treatment
Rehabilitation
Initial contact of patient with system should provide
assessment and referral to services that are:
Least restrictive
Most effective
Most cost-conscious
Risk assessment phase: refers to decisions formerly made at
discharge to provide ongoing guidance to an appropriate
level of care
Providing therapy versus being therapeutic:
All nurses can be therapeutic.
Providing formal therapy is the domain of the advanced
practice psychiatric nurse.
All nurses should understand basic principles of
therapeutic communication and use same in nurse-patient
interactions.
Nurses use nursing process to:
Assess patient responses to medication.
Plan responses to side effects.
Implement plans.
Evaluate for desired results.
Additionally, nurses:
Administer medications.
Make decisions regarding use of prn medications.
Proactive approach to care that provides therapeutic

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Instructor's Manual

Psychopathology

Special Therapies

2-3
benefits from the environment of the care setting.
Six environmental elements considered:
Safety
Structure
Norms
Limit setting
Balance
Environmental modification
Nurses:
Are consistent forces in the milieu.
Provide guidance to other staff members toward being
therapeutic.
This is the study of the processes, mechanisms, and biology
associated with specific behavior.
Knowledge of psychopathology serves as a foundation for
the three components of psychotherapeutic management.
Refers to therapies that are effective treatments, but that do
not have the universal clinical applications of other
categories of psychiatric treatment emphasized in the text:
Behavior therapy
Somatic therapies (electroconvulsive therapy)
Alternative and complementary therapies

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.