Other psych0 social therapy

MR. JAYESH PATIDAR

www.drjayeshpatidar.blogspot.com

• Therapeutic community

• Millieu therapy

• Occupational therapy

• Play therapy

• Recreational therapy

• Attitude therapy

• Music therapy

• Dance therapy

4/24/2013 2JAYESH PATIDAR

THERAPEUTIC COMMUNITY


The concept of therapeutic community was first developed by Maxwell Jones in 1953 . He wrote a book entitled “Social Psychiatric” which was first published in England. Later on when it was published in the United States, its title was changed to “Therapeutic Community.”


Stuart & Sundeen defined therapeutic community as “a therapy in which patient‟s social environment would be used to provide a therapeutic experience for the patient by involving him as an active participant in his own care & the daily problems of his community.”


To use patient‟s social environment to provide a therapeutic experience for him.

To enable the patient to be an active participant in his own care & become involved in daily activities of his community.

To help patients to solve problems, plan activities & to develop the necessary rules & regulations for the community.

To increase their independence & gain control over many of their own personal activities.

To enable the patients become aware of how their behavior affects others.


Free communication

Shared responsibilities

Active participation

Involvement in decision making

Understanding of roles, responsibilities, limitations & authorities.


Responsibility for treatment belong to the staff & client.

Roles of staff & clients are equalized- may discuss either staff behavior or clients behavior.

Democratic environment is fostered.

Open communication is encouraged

Focus is on client assets.

Peer pressure is utilized to reinforce rules & regulations.

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Interpersonal interactions are utilized to improve communication skills.

Inappropriate behavior are dealt with as they occur.

Team approach is used.

Clients are involved in all phases of treatment

Community government is set up – Use meetings to teach standards, values & behavior, explore behavior, make decision, use problem solving.

Two main goals for clients – Learn to set limits, Learn psychosocial skills


1. Daily community Meetings

2. Patient Government or Ward Council

3. Staff Meeting or Review

4. Living & Learning Opportunities


These meetings are composed of 60-90 patients. All levels of unit staff are involved, including administrative personnel. Acute patients are involved in the meetings.

Meetings should be held regularly for 60 minutes.

Discussion should focus mainly on day-to-day life in the unit.

During discussion patients‟ feelings & behaviors are examined by other members.

Frank discussion are encouraged, these may take place with much outpouring of emotions & anger.


The purpose of patient government is to deal with practical unit details such as house-keeping functions, activity planning & privileges.

A group of 5-6 patient will have specific responsibilities, such as house keeping, physical exercise, personal hygiene, meal distribution, a group to observe suicidal patients, etc. staff members should be available always.

All decisions should be feedback to the community through the community meetings.


A staff meeting should be held following each community meeting (patient are excluded & only staff are present). In this meeting the staff would examine their own responses, expectations, & prejudices.

4. Living & Learning Opportunities:Learning opportunities are to be

provided within the social milieu, which should provide realistic learning experiences for the patients.


Schizophrenia

Substance abuse disorder

Antisocial disorder

Children‟s care taking environment


Free communication both within & between staff & patient group.

Communication are directed towards the modification of patient‟s attitude, behavior & role performance.

Atmosphere in the community will be democratic as opposed to hierarchical, rehabilitative rather than custodial, permissive instead of limited & controlled.

Nurses will be more communal with the patient instead of displaying all the time therapeutic role.


Environment will be essentially permissive & flexible.

Patient‟s activities are individualized & the role of patients are unspecified & their participation is completely voluntary.

A compulsory daily community meeting that all staff members have to attend & all patients are encouraged to attend.

The primary role of staff is to help the patients gain new insights & test new behavioral patterns.

Problems of the patients are discussed & the solutions are sought in the small group therapy session following each community meeting.


Patient government or ward council is to deal with practical unit details such as privileges & house keeping rosters. Staff member is available to the patient government, & all decisions are fed back to the community through the community meetings.

Staff meeting or review is essential to on-the-ward training. It gives opportunity for the staff members to examine their own responses, expectations & prejudices.

Feedback is one of the fundamental concepts in therapeutic community practice.


Patient develops harmonious relationship with other members of the community.

Gains self-confidence.

Develop leadership skills.

Learns to understand & solve problems of self & others.

Become socio-centric.


Learns to live & think collectively with the members of the community.

Lastly therapeutic community provides opportunities to participate in the formulation of hospital rules & regulations that affect patient‟s personal liberties like bedtime, meal time, weekend permission, control of radio or TV, social activities, late night privileges etc.


Role blurring between staff & patient.

Group responsibility can easily become nobody‟s responsibility.

Individual needs & concerns may not be met.

Patient may find the transition to community difficulty.


Providing & maintaining a safe & conflict free environment through role modeling & group leadership.

Sharing of responsibilities with patients.

Encouraging patient to participate in decision-making functions.

Assisting patients to assume leadership roles.

Giving feedback.

Carrying out supervisory functions.


MILLIEU THERAPY


„Milieu‟ is a French word meaning “Middle Place”.

In English language, milieu means “environment” or “setting”, as used in psychiatric mental health nursing, it refers to the people & all other social & physical factors in the environment with which the client interacts.


A therapeutic milieu is a 24 – hour environment designed to provide a secure retreat for individuals whose capacities for coping with reality have deteriorated.

The therapeutic milieu gives them opportunities to acquire adaptive coping skills. By offering secure, comfortable physical facilities for sleeping, dining, bathing & engaging in recreational, occupational, social, psychiatric & medical therapies, the therapeutic milieu does many advantages.


A therapeutic milieu is a “safe space,” a non-punitive atmosphere in which caring is a basic factor.

In this environment, confrontation may be a positive therapeutic tool that can be tolerated by the client.

Nurses & treatment team members should be aware of their own roles in this environment, maintaining stability & safety, but minimizing authoritarian behavior

Clients are expected to assume responsibility for themselves within the structure of the milieu as much as possible.

Feedback from other clients & the sharing of tasks or duties within the treatment program facilitate the client‟s growth.


Shelters clients physically from what they perceive as painful, terrifying stressors.

Protects clients physically from discharges of their own & other‟s maladaptive behaviors.

Supports the physiological existence of clients.

Provides pleasant, attractive, sensory stimulation of clients.

Educates clients & their families about adaptive, effective coping.


1. Maintaining Safe Environment

2. The Trust Relationship

3. Building Self-esteem

4. Limit-setting


The nursing staff should follow the facility‟s policies with regard to prevention of routine safety hazards & supplement these policies as necessary.

For Example;

Dispose of all needles safety & out of reach of client.

Restrict or monitor the use of matches & lighters.

Do not allow smoking.


Remove mouthwash, aftershave lotions & so forth, if substance abuse is suspected.

Keep sharp objects out of reach of client

Identify potential weapons & dangerous equipment.

Do not leave medicines unattended or unlocked.

Keep keys (to unit door, medicines) on your person at all times.

Search packages brought in by visitors, explain the reason for such rules briefly, & do not make any exceptions.


one of the keys to a therapeutic environment is the establishment of trust. Both the client & the nurse must trust that treatment is desirable & productive. Trust is the foundation of a therapeutic relationship, & limit-setting & consistency are its building blocks.


Strategies to help build or enhance self-esteem must be individualized & built on honesty & on the client‟s strengths.

Some general suggestions are:

Set & maintain limits.

Accept the client as a person.

Be non-judgmental at all times.

Structure the client‟s time & activities.


Have realistic expectations of the client & make them clear to the client.

Initially provide the client with tasks, responsibilities & activities that can be easily accomplished.

Never flatter the client.

Allow the client to make his own decisions whenever possible.


Setting & maintaining limits are integral to a trust relationship & to a therapeutic milieu. Before stating a limit explain the reason for limit-setting.

Some basic guidelines for effective using limits are:

State the expectations or the limit as clearly, directly & simply as possible.


The consequence that will follow the client‟s exceeding the limit also must be clearly stated at the outset.

The consequences should immediately follow the client‟s exceeding the limit & must be consistent, both over time (each time the limit is exceeded) & among staff (each staff member must enforce the limit).

Consequences are essential to setting & maintaining limits, they are not an opportunity to be punitive to a client.


In conclusion, the nurse works with other health professionals in an interdisciplinary team; The interdisciplinary team works within a milieu that is constructed as a therapeutic environment, with the aim of developing a holistic view of the client & providing effective treatment.


Use nursing process to provide comprehensive care.

Provide direct client care

Manages the day-to-day care of individual clients.

Assists the client for re-entry into the community.

Give indirect client care

Maintains on going communication with other mental health team members.

Enforces rules, policies & regulations of therapeutic milieu.

A schedule, assigns, manages, & evaluates clinical work


Administer medication & give medication teaching

Provide psychosocial care

Uses informal group interventions such as community meetings & structured or unstructured group therapy sessions to assist client with problems in their current life situations.

Conducts brief, “on-the-spot” counseling with clients & families.

Set limits to deal with behaviors destructive to the self, others, or the environment.

Helps the clients use their time productively for leisure & work.

Involves withdrawn clients in the milieu.


Encourages clients who have low self-esteem to value themselves.

Serves as a role model by demonstrating inter personal effectiveness in relating to clients & other mental health team members.

Conducts one-to-one therapy sessions daily with selective clients.

Conducts group therapy on a daily basis to help clients to gain self-awareness about how they behave in groups

Provide mental health teaching Psychotropic medications, methods of coping, inter

personal effectiveness (eg; assertiveness training, communication, problem-solving skills, parenting skills & so forth) stress management, relaxation & physical exercise etc.


Encourage clients to help & support each other individually & as a group.

Assist clients to understand each other‟s feelings & problems.

Conduct community meetings.

Participate freely in milieu activities (i.e, exercise, art, craft classes, social function)


OCCUPATIONAL

THERAPY


Occupational therapy is the application of goal-oriented, purposeful activity in the assessment & treatment of individuals with psychological, physical or developmental disabilities.


“Any activity, which engages a person‟s resources of time & energy & is composed of skills & values” (Reed & Sanderson, 1980).

“Any goal-directed activity meaningful to the individual & providing feedback to him about his worth & value as an individual & about his inter-relatedness to others”.


The aim of the occupational therapist‟s intervention is the alleviation of dysfunction & the development of maximum functional independence in all aspects of living. Specific aims of occupational therapy are:

I. Promotion of recovery

II. Mobilization of total assets of the patient

III. Prevention of hospitalization.

IV. Creation of good habits of work & leisure.

V. Rehabilitation with return of self-confidence.


The main goal is to enable the patient to achieve a healthy balance of occupations through the development of skills that will allow him to function at a level satisfactory to himself & others.


Occupational therapy is provided to children, adolescents, adults & elderly patients.

These programs are offered in psychiatric hospitals, nursing homes, rehabilitation centers, special schools, community group homes, community mental health centers, day care centers, halfway homes & addiction centers.


Helps to develop social skills & provide an outlet for self-expression.

Strengthens ego defenses.

Develops a more realistic view of the self in relation to other.


The client should be involved as much as possible in selecting the activity.

Select an activity that interests or has the potential to interest him.

The activity should utilize the client‟s strengths & abilities.

The activity should be of short duration to foster a feeling of accomplishment.

If possible, the selected activity should provide some new experience for the client.


It consists of six stages:

1. Initial evaluation of what patient can do & cannot do in a variety of situations over a period of time.

2. Development of immediate & long-term goals by the patient & therapist together. Goals should be concrete & measurable so that it is easy to see when they have been attained.

3. Development of therapy plan with planned intervention.


4. Implementation of the plan & monitoring the progress. The plan is followed until the first evaluation. If found satisfactory it is continued & altered, it not.

5. Review meetings with patient & all the staff involved in treatment.

6. Setting further goals when immediate goals have been achieved; modifying the treatment program as relevant.


1. Diversional activity: These activities are used to divert one‟s thoughts from life stresses or to fill time. For example, organized games.

2. Therapeutic activities: These activities are used to attain a specific care plan or goal. For example, basket making, carpentry etc.


Anxiety disorder: Simple concrete tasks with no more than 3 or 4 steps that can be learnt quickly. For example, kitchen tasks, washing, sweeping, mopping, mowing lawn & wedding gardens.

Depressive disorder: Simple concrete tasks which are achievable; it is important for the patient to experience success. Provide positive reinforcement after each achievement. For example, craft, mowing lawn, wedding gardens.


Manic disorder: Non-competitive activities that allow to use of energy & expression of feelings. Activities should be limited & changed frequently. Patient needs to work in an area away from distraction. For example, raking, grass, sweeping, etc.

Schizophrenia (paranoid): Non- competitive, solitary meaningful tasks that require some degree of concentration so that less time is available for focus on delusions. For example, puzzles, scrabble.


Schizophrenia (catatonic): Simple concrete tasks in which patient is actively involved. Patient needs continuous supervision & at first works best on a one-to-one basis. For example, metal work, molding clay, etc.

Antisocial personality: Activities that enhance self-esteem & are expressive & creative, but not too complicated. Patient needs supervision to makes sure each tasks is completed. For example, leather works, painting, etc.


Dementia: Group activities to increase feeling of belonging & self-worth. Provide those activities which promote familiar individual hobbies. Activities need to be structured requiring little time for completion & not much concentration. Explain & demonstrate each task, then have patient repeat the demonstration. For example, cover making, packing goods.

Substance abuse: Group activities in which patient uses his talent. For example, involving patient in planning social activities, encouraging interaction with others etc.


Childhood & Adolescent disorders:

Children: Playing, story telling, painting, poetry, music etc

Adolescent: Creative activities such as leather works, drawing, painting

Mental retardation: Repetitive work assignments are ideal; positive reinforcement after each achievement. For example, cover making, candle making packaging goods etc.


PLAY THERAPY


Play is a natural mode of growth & development in children. Through play a child learns to express his emotions & it serves as a tool in the development of the child.


It releases tension & pent-up emotions.

It allows compensation for loss & failures.

It improves emotional growth through his relationship with other children.

It provides an opportunity to the child to act out his fantasies & conflict, to get rid of aggression & to learn positive qualities from other children.


Play therapy gives the therapist a chance to explore family relationships of the child & discover what difficulties are contributing to the child‟s problem.

Play therapy allows studying hidden aspects of the child‟s problems.

It is possible to obtain a good ideas of the intelligence level of the child.

Through play inter-sibling relationships can be adequately studied.


Individual vs group play therapy: In individual therapy the child is allowed to play by himself & the therapist‟s attention is focused on this one child alone. In group play therapy other children are involved.

Free play vs controlled play therapy: In free play the child is given freedom in deciding with what toys he wants to play. In controlled play therapy, the child is introduced into a scene where the situation or setting is already established.


Structured vs unstructured play therapy: Structured play therapy involves organizing the situation in such a way so as to obtain more information. In unstructured play therapy no situation is set & no plans are followed.

Directive vs non-directive play therapy: In directive play therapy, the therapist totally sets the direction, whereas in non-directive play therapy, the child receives no direction. Play therapy is generally conducted in a playroom. The playroom should be suitably stocked with adequate play material, depending upon the problems of the child.


RECREATIONAL

THERAPY


Recreation is a form of activity therapy used in most psychiatric setting.

It is planned therapeutic activity that enables people with limitations to engage in recreational experiences.


To encourage social interaction.

To decrease withdrawal tendencies

To provide outlet for feelings.

To promote socially acceptable behavior

To develop skills, talents & abilities

To increase physical confidence & a feeling of self worth.


Provide a non-threatening & non-demanding environment.

Provide activities that are relaxing & without rigid guidelines & time-frames.

Provide activities that are enjoyable & self-satisfying.


Motor forms: These can be further divided into fundamental & accessory; among the fundamental forms are such games as hockey & football, while the accessory forms are exemplified by play activity & dancing.

Sensory forms: These can be either visual for example, looking at motion pictures, play, etc., or auditory such as listening to a concert.

Intellectual forms: These include reading, debating & so on.


Anxiety disorder: Aerobic activities like walking, jogging, etc.

Depressive disorder: Non-competitive sports, which provide outlet for anger, like jogging, walking , running, etc.

Manic disorder: One-to-one basis individual games like shuttle badminton, ball badminton, etc.

Schizophrenia (paranoid): Activities requiring concentration like chess, puzzles.


Schizophrenia (catatonic): Social activities to give patient contact with reality like dancing, athletics.

Dementia: Concrete, repetitious craft & projects that breed familiarization & comfort.

Childhood & adolescent disorders: It is better to work with the child on a one-to-one basis & give him a feeling of importance. Employ activities such as playing, story telling & painting. Adolescents fare better in groups; provide gross motor activities like sports & games to use up excess energy.

Mental Retardation: Activities should be according to the patient‟s level of functioning such as walking, dancing, swimming, ball playing. Etc.


ATTITUDE

THERAPY4/24/2013JAYESH PATIDAR 69

Attitude therapy is a form of milieu therapy in which all staff members assume a consistent, prescribed attitude designed to be therapeutic towards patients.


i. When the patient is in the hospital for a long time:

• The patient is interviewed to assess his emotional state & activity level.

• Family members are interviewed to acquaint them with the attitude therapy which will be used for the patient.

ii. After this, a staff meeting is held in which all the team members are present.


iii. A clinical diagnosis is made by the psychiatrist.

iv. A plan of attitude to be adopted for a particular patient is discussed with purpose.

v. One Principal Line of Approach at a time by all the team members.

The attitude therapy is basically meaning to change the attitude of the patient in specific situations. A general attitude which the nurse needs to adopt for psychiatric patients is kept in mind.


The patient starts feeling that an organized approach is being used for his/her treatment.

Guesswork & haphazard plans by individual members of the team are reduced.

The patient‟s problems or conflict are solved in less time.


This approach also provides an opportunity for the members to explore, test & change the therapeutic attitude which will bring best results in patient.

It brings members of the team together to plan, work & evaluate each other‟s efforts & to discover new ways of helping the patient.


MUSIC

THERAPY


Music therapy is the functional application of music towards the attainment of specific therapeutic goals.


Facilitates emotional expressions

Improves cognitive skills like learning, listening & attention span.

Social interaction is stimulated.


DANCE

THERAPY


It is a psychotherapeutic use of movement, which furthers the emotional & physical integration of the individual.


Helps to develop body awareness.

Facilitates expression of feelings.

Improves interaction & communication

Fosters integration of physical, emotional & social experiences that results in a sense of increased self-confidence & contentment.

Exercise through body movement maintains good circulation & muscle tone.



Other psych0 social therapy

Education

practical

unstructured

simple concrete

directive

controlled

group play

patients social

play therapy