Transcript Psychosocial Theories and Therapy

Current Theories & Practice
Psychosocial Theories and Therapy
Learning Outcomes
• Describe the following psychosocial theories
and treatment modalities: psychoanalytic,
behavioral, existential, and somatic
• Identify the nurse’s role in applying treatment
modalities
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
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
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
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 selfintegrity
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
• Reaction formation
– 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.
Ego Defense Mechanisms
• Nursing interventions
– Recognize and understand use of maladaptive
defense mechanisms
– Teach patient adaptive coping skills
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Assertiveness
Problem solving
Positive self-talk
Conflict resolution
Communication skills
Stress/anger management
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)
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)
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
Behavior Therapy
• Used to treat:
– Addictions
– Anxiety disorders
– Sexual disorders
– Post traumatic stress disorder (PTSD)
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
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
Existential Theories
• Cognitive therapy used to treat:
– Changing the way they think & act
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Anxiety
Sexual disorders
Eating disorders
Personality disorders
Suicidal thoughts/ideation
Treatment Modalities
• Hospital (inpatient)
– Severely psychotic
– Severely depressed/suicidal
– Alcohol or drug withdrawal
– Exhibiting behaviors that require close supervision
in a safe supportive environment
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
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
Treatment Modalities
• Types of groups:
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Support
Family therapy
Family education
Activity
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Support- AA, MADD
Family- divorce
Family EdActivity
Self-help- WW, AA, Gambler’s Anonymous
- Education
- Self-help
- Psychotherapy
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
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
Treatment Modalities
GOOD
• Group member roles:
– Growth-producing
• Energizer (pep)
• Harmonizer (mediator ; Giving their opinions)
• Encourager
• Opinion seeker
• Information seeker/giver
Treatment Modalities
BAD
• Group member roles:
– Growth-inhibiting
• Critic
• Aggressor
• Dominator
• Monopolizer- someone who monopolizes the
means of producing or selling something
• Passive follower
• Recognition-seeker
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
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)
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
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
Herbs: St. John’s Wort
• Used to treat
– Depression
– Seasonal Affective Disorder
– Anxiety
– Sleep Disorders
– No FDA req’d
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
Acupuncture
• Complimentary
therapy for drug
addiction
• Research is showing
effective for
treatment of mild to
moderate depression
• Side effects
Other Therapy Examples
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Massage
Yoga
Chiropractic
Curanderismo- traditional folk healer
Meditation
Homeopathic
Rheiki/therapeutic touch
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
Electroconvulsive Therapy
• Emerged in 1930’s
• Seen as barbaric
• Written consent usually
not obtained
• Psych patients were
all given “Shocks”
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
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
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
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
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
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
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
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
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
Bright Light Therapy
• Used to treat seasonal affective disorder
• Exposure to intense artificial light
• May help bulimia, insomnia,
non-seasonal depression
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
References
• Yalom, I.D. (2005). The Theory and
Practice of Group Psychotherapy
(5th ed.). New York: Basic Books.