TREATMENT MODALITIES

APPLICABLE TO THE
PSYCHIATRIC CLIENT

At the end of this unit,

students will be able to:
Describe each treatment modality.
Explain the rational for the various
treatment. modalities utilized in mental
health conditions.
Describe the preparation of the patient,
environment, and equipment (if required)
for each modality.
Describe expected outcomes, and
consequences (if any) of the application of
each modality.

NON-PHARMACOLOGICAL
TREATMENT
Counselling- individual and group
Psychotherapy individual, family ,
group
Milieu Therapy
Electro-convulsive
Cognitive behavioural therapy

Counselling versus
Psychotherapy
Counselling

Psychotherapy

Preventive and
remedial
Highly interpersonal
process (social
interaction; sharing of
feelings & perceptions)
Problem oriented;
often addressing
developmental crisis/
issues
Much emphasis on
feelings, needs and
behaviours of pts and
cognitive aspect

Focuses on remediation,
treatment and
personality
reconstruction (minor or
major)
Corrects emotional and
behavioural problems
that affect social
functioning
Addresses major
psychological problems
Involves conscious and
unconscious awareness;
present and past

Counselling versus
Psychotherapy
Counselling
Patient is basically
well adjusted
requiring minimal
personality
reconstruction
Growth oriented
focusing on selfawareness,
enhancement,
development
Takes multiple
sessions (weeksmonths)

Psychotherapy
Reeducates
Patient may be
severely emotionally
disturbed, psychotic or
socially deviant
Techniques applied to
make the unconscious,
conscious; to provide
catharsis
Takes multiple sessions
(may take years)

Breakout Group Session

Apply the various theories

to
counselling/psychotherapy

Group 1
A 25 year old female is feeling depressed as
she is currently unemployed with two young
babies to care for. Of note, her childrens father
is not supportive emotionally or financially.
Utilize the Theory of interpersonal relationship
(posited by Hildegard Peplau) to guide your
counselling session for this female.

1. Orientation
Orientation/Introduction
Establish trust and rapport
Identify purpose, roles and
responsibilities
Assess clients needs
Form contract

2. Identification
The nurse facilitates expression of feelings
Patient participates to identify problems
Patient responds and trusts the nurse
3. Exploitation
Promote patient insights & perception of reality
Overcome resistant behaviors
Patient tests alternate problem solving & coping
skills
Initiate action plan & new goals
from dependent to independent behavior
Increase skills in interpersonal relationships

4. Resolution/Termination
Summarize work & growth
accomplished
Review termination plan & actions to
deal with potential stressors
Referrals to community resources
Acknowledge feelings related to ending
relationship

 Group 2
A 45 year old male client has a recurrent
issue of abusing his spouse whenever
he becomes frustrated. He employs
various coping mechanism, at various
stages of his frustration, which at times
does not work. Assist the client in
addressing this issue using the Systems
model (as posited by Betty Neuman).

 Flexible line of defense

A protective accordion-like mechanism that surrounds and
protects the normal line of defense from invasion by stressors.
Normal line of defense
An adaptational level of health developed over time and
considered normal for a particular individual client or system; it
becomes a standard for wellness-deviance determination.
Lines of resistance
Protection factors activated when stressors have penetrated the
normal line of defense, causing a reaction synptomatology.
(Neuman, 1995)

Negentropy
A process of energy conservation that increases
organization and complexity, moving the system toward
stability or a higher degree of wellness.

The purpose of the nurse is to retain this

system's stability through the three levels of
prevention:
Primary prevention to protect the normal line
and strengthen the flexible line of defense.
Secondary prevention to strengthen internal
lines of resistance, reducing the reaction, and
increasing resistance factors.
Tertiary prevention to readapt and stabilize
and protect reconstitution or return to
wellness following treatment.

 Group 3
A female who was forced into
prostitution seeks your guidance in
coping with her recent diagnosis of
syphilis. She is particularly concerned
about her inability to make money
during this initial flare as well as her
possibilities of starting a family in the
future. Utilizing the Adaptation Model
(as posited by Sister Calista Roy),
assist this client meeting her request.

Roys Adaptation Model

 Group 4
A mentally ill client just throw a bucket
of urine on you. His relatives are
upset and are demanding to beat
him. Utilizing the Theory of Human
Caring ( as posited by Jean Watson),
conduct a group counselling session
with the angry relatives.

The Ten Carative Factors

The formation of a humanistic- altruistic system of
values.
The installation of faith-hope.
The cultivation of sensitivity to ones self and to others.
The development of a helping-trust relationship
The promotion and acceptance of the expression of
positive and negative feelings.
The systematic use of the scientific problem-solving
method for decision making
The promotion of interpersonal teaching-learning.
The provision for a supportive, protective and /or
corrective mental, physical, socio-cultural and spiritual
environment.
Assistance with the gratification of human needs.
The allowance for existential-phenomenological forces.

 Group 5
A 5 year serial paedophile has been sent to
you for psychoanalysis. He is known to
sexually abuse (oral, anal and vaginal) his
male and female victims. He states he was
abused by his uncle as a child hence
believes he has the authority to perform
similar acts with uncensenting minors.
Utilize the concepts of psychoanalysis to
guide your psychotherapy session.

 A persons development is determined

by events in early childhood.
A clients behaviour is strongly
influenced by a conflict between the ID
and SUPEREGO.
Attempts to bring the ID to the
conscious is usually blocked by
unconscious defence mechanisms.
Unresolved conflicts between the
conscious and unconscious may resolve
in mental disturbances.
A resolution of mental disturbances can
be achieved through the uncovering of
these conflicts. (interpretation via a
psychoanalyst).

 Group 6
A third year college student is struggling
with adjusting to a large group where
individuality is limited. She feels lost in
the system and does not wish to
continue her program, as she feels her
self esteem is constantly being bruised
by her colleagues. Apply the concepts of
the Client Centered Therapy (as posited
by Carl Rogers) to counsel this client.

 "It is that the individual has within himself

or herself vast resources for selfunderstanding, for altering his or her selfconcept, attitudes and self-directed
behaviour - and that these resources can be
tapped if only a definable climate of
facilitative psychological attitudes can be
provided."
The counsellor should display
Genuineness (congruence)
Unconditional Positive Regard
Empathy
Non-judgemental

 Group 7
A young male has been ostracised by his
family and community because of his
eccentric sexual orientation. He is
constantly relocating from town to town as
persons are intolerant to his beliefs and
sexual practices. He suffers frequent
palpitations and bowel movement since
the incident. He wonders if he has
developed a physiological condition during
this stressful period. Apply the theory of
stress adaptation to this clients situation.

 Group 8
Mrs T, one year from retirement has vowed to
significantly improve the nations health care
system before she retires. She has no time to
counsel her 15 year old daughter who is
struggling with her sexual feelings and
responsibilities. Her 21 year younger spouse
does not appreciate Mrs Ts extra hours spent
at work .Analyse this situation utilizing the
concepts of Psychosexual development (as
posited by Erik Erikson). Discuss the
implications of each stage involved in this
scenario.

 Group 9
Each time the schizophrenic client sees
a person in white, he becomes
defensive and starts shouting me no
whaa no injection todeh nurse!!!!
Explain this behaviour and how the
nurse can address it utilizing the
theory of Classical Conditioning (as
posited by Ivan Pavlov)

Neutral
Stimulus
(nurse in
white uniform)

Uncondition
ed stimulus
(injection)

Conditioned
response
(pain from
the
injection)

Conditioned
stimulus
(white
uniform)

Extinct
ion
Generaliza
tion

Unconditioned
response (pain
from the
injection)

Spontan
eous
recovery

Behavioural Therapy
Behavioural therapy is based on the
theory that behaviour is learned and
has consequences. Changing
abnormal or maladaptive behaviour
can occur without the need for
insight into the underlying cause of
the behaviour.

Fastest Matcher
Column A

Column B

1. ________Modelling

A)

2. ________Operant
Conditioning (negative
reinforcement)

B) The nurse can teach this to

3.

C) The nurse serve as

_________Aversion therapy

Occurs when a behaviour is

followed by the removal of an
unpleasant stimulus, thereby
increasing that behaviour's
frequency
a client with an escalating
temper.

A source of reference for the

client, who learns improved
behaviour by
imitation.
4. __________Diaphragmatic
Breathing.

D)

A nurse may use

unpleasant stimuli,
such mild electric shock, as

Cognitive Therapy
Cognitive therapy is based on the
cognitive model, which focuses on
individual thoughts and behaviours
to solve current problems.

 Priority restructuring assists clients to

identify what should be given priority, such
as devoting energy to pleasurable
activities.
Journal keeping helps clients write down
stressful thoughts and has a positive effect
on well-being
Assertiveness training teaches clients to
express feelings, and solve problems in a
nonaggressive manner.
Monitoring thoughts helps clients to be
aware of negative thinking.

Electro Convulsive Therapy

(ECT)
ECT delivers an electrical current that
produces a grand mal seizure.
The exact mechanism of ECT is still
unknown and controversial. One
theory suggests that ECT may
enhance the effects of
neurotransmitters (serotonin,
dopamine, and norepinephrine) in the
brain.

Indicators for ECT

Frequent episode of mania (rapid
cycling), precedes for lithium
therapy.
Types of schizophrenia less response
to neuroleptic therapy
Severe depression unresponsive to
anti depressants

 Any medications that affect the clients

seizure threshold must be decreased or
discontinued several days before the ECT
procedure.
Any cardiac conditions, such as
dysrhythmias, should be monitored and
treated before the procedure.
Thirty minutes prior to the beginning of
the procedure, an IM injection of atropine
sulfate is given to decrease secretions.

 NPO 8-12 hours before procedure.

Insert a bit guard to prevent injury during
the procedure
Anaesthesia and muscle relaxant is given.
The electrical stimulus is typically applied
for 0.2 to 0.8 seconds. Seizure activity is
monitored, and the duration of the
seizure, which is usually 25 to 60
seconds.

 Place client in recovery position post procedure.

During the recovery phase, the nurse needs to
orient the client frequently, because confusion
and short-term memory loss are common
during this time.
The clients baseline heart rate is expected to
increase by 25% during the procedure and early
recovery.
Blood pressure may initially fall and then rise
during the procedure. The elevated blood
pressure should resolve shortly after the
procedure.

 Headache, muscle soreness, and

nausea can occur during and
following the immediate recovery
period

Therapeutic Milieu
Milieu therapy creates an
environment that is supportive,
therapeutic and safe.
Milieu therapy began as an effort to
provide an environment conducive to
the treatment of children who were
mentally ill.

 Management of the milieu refers to

the management of the total
environment of the mental health
unit in order to provide the least
amount of stress, while promoting
the greatest benefit for all the
clients.

 The goal is that while the client is in

this therapeutic environment, he will
learn the tools necessary to cope
adaptively, interact more effectively
and appropriately, and strengthen
relationship skills. Hopefully, the
client will use these tools in all other
aspects of his life.

 The nurse, as manager of care, is

responsible for structuring and/or
implementing aspects of the
therapeutic milieu within the mental
health facility.
One structure of the therapeutic
milieu is regular community
meetings, which include both the
clients and the nursing staff.

Characteristics of the
Therapeutic Milieu
Physical Setting
Unit should be clean and orderly.
Colour scheme and overall design should
be appropriate for the clients age.
The setting should include comfortable
furniture placed so that it promotes
interaction, solitary spaces for reading
and thinking alone, comfortable places
conducive to meals, and quiet areas for
sleeping.

Characteristics of the
Therapeutic Milieu
Health Care Provider
Promote independence for self-care and
individual growth in clients.
Treat clients as individuals.
Allow choices for clients within the daily
routine and within individual treatment
plans.
Apply rules of fair treatment for all clients.
Model good social behaviour for clients,
such as respect for the rights of others.

Characteristics of the
Therapeutic Milieu
Health Care Provider
Work cooperatively as a team to provide
care.
Maintain boundaries with clients.
Maintain a professional appearance and
demeanour.
Promote safe and satisfying peer
interactions among the clients.
Practice open communication techniques
with health team members and clients.
Promote feelings of self-worth and hope for
the future.

Characteristics of the
Therapeutic Milieu
Emotional climate
Clients should feel safe from harm
(self-harm, as well as harm from
disruptive behaviours of other clients).
Clients should feel cared for and
accepted by the staff and others.

Physical Safety
The nurses station and other areas should
be placed to allow for easy observation of
clients by staff .
Set up the following provisions to prevent
client self-harm or harm by others:
No access to sharp or otherwise harmful
objects
Restriction of client access to restricted or
locked areas
Monitoring of visitors

 Restriction of alcohol and illegal drug access

or use
Restriction of sexual activity among clients
Rapid de-escalation of disruptive and
potentially violent behaviours through
planned interventions by trained staff
Seclusion rooms and restraints should be
set up for safety and used only after all less
restrictive measures have been exhausted.
When used, facility policies and procedures
must be followed.

The therapeutic milieu should facilitate

Community meetings
Individual therapy
Group therapy
Psycho-education
Recreational activities
Unstructured contact time with care
providers

Scouting for evidence

PHARMACOLOGICAL
THERAPY
Antipsychotics
atypical and typical

Mood Stabilizers
Lithium Carbonate
Anticonvulsants (valproate, Tegretol etc.)

Antidepressants

Tricyclic
MAOIs
SSRIs
SNRIs

Anti-anxiolytic agents
Benzodiazepines
Barbiturates

Anticholenergic-Antimuscarinics used in psychiatry

Artane
Cogentin