Pharmacology and Alternative Therapies

PVN123 – Mental Health Nursing - Presentation #4

Objectives

Identify common medications used to treat mental disorders (ATI Tutorial 2011B) Identify expected pharmacological actions Identify therapeutic uses Identify side/adverse effects Identify contraindications and precautions Identify food and medication interactions Identify patient teaching strategies

Identify Traditional Non-pharmacological Therapies for the treatment of mental health disorders

Psychopharmacological Therapies

How to Access the ATI Pharmacology Tutorial (2011B) -(Quiz #2)

Click on the link below for a video message from your instructor.

http://www.screencast.com/t/72WMOeLbNzP

Complete the Tutorial! (due beginning of Day 3)

ATI Tutorial (Course Quiz #2)

Pharmacology Made Easy 2.0 ID = TU1532398 Password = 15F7U Module = The Neurological System (Part

2)Here’s a Link to the ATI Website!

https://www.atitesting.com

Alternative Therapies

• Psychoanalysis / Psychotherapy / Behavioral Therapies

• Group and Family Therapy

• Stress Management

• Electroconvulsive Therapy

Psychoanalysis PsychotherapyBehavioral Therapies

Psychoanalysis / Psychotherapy / Behavioral Therapies

Approaches to addressing mental health issues using various methods and theoretical bases

Nurses should be familiar with methods employed!

Psychoanalysis

Assessing unconscious thoughts and feelings

Resolving conflict through talking to psychoanalyst Many sessions over months to

years

Not usually sole therapy of choice Lengthy duration and insurance

constraints

First developed by Sigmund Freud

Past relationships are common focus

Therapeutic Tools Used:• Free Association

• Spontaneous/uncensored verbalization of whatever comes to mind

• Dream Analysis• Transference

• Feelings that client has developed toward therapist related to someone else from early childhood

• Use of defense mechanisms

Psychotherapy

More verbal therapist/client interaction than traditional psychoanalysis

Trusting relationship between client and therapist

Includes: Psychodynamic Psychotherapy Interpersonal Psychotherapy (IPT) Cognitive Therapy Behavioral Therapy Cognitive Behavioral Therapy

Psychotherapy

Psychodynamic Psychotherapy Same tools as Psychoanalysis But!.... Oriented more to client’s present state than early life

Interpersonal Psychotherapy (IPT) Used for clients with specific problems Can improve interpersonal relationships / communication / role-relationship / bereavement

Cognitive Therapy Based on cognitive model – focuses on individual thoughts/ behaviors to solve current

problems.▪ Used to treat depression / anxiety / eating disorders / other issues that require changing attitude toward life

experiences

Behavioral Therapy Focuses on changing behavior Based on theory that behavior is learned and has consequences Abnormal behavior is result of avoiding painful feelings Teaches clients to decrease anxiety or avoidant behavior Used successfully to treat phobias / addictions

Cognitive Behavioral Therapy Uses both cognitive and behavioral approach Used in anxiety management

Cognitive Therapy

Anxiety decreased by changing cognitive distortions Cognitive Reframing

identify negative thoughts that produce anxiety▪ Examine the cause▪ Develop supportive ideas

Priority Restructuring ▪ identifying priorities

Journal Keeping ▪ writing down stressful thoughts

Assertiveness Training▪ expressing feelings and solving problems in nonaggressive manner

Monitoring Thoughts▪ becoming aware of negative thinking

Behavioral TherapyType Definition Use in MH Nursing

Modeling Therapist serves as role model for client

Improving interpersonal skills Therapist demonstrates behavior in

stressful situation Goal is for client to imitate the behavior

Operant Conditioning Positive rewards for positive behavior

Ex: tokens given for good behavior which can be exchanged for a privilege or other items

Systematic Desensitization

Planned, progressive, or graduated exposure to anxiety provoking situations and stimulio Real life situations or

imagining events Anxiety response is

suppressed through relaxation techniques

Client masters relaxation techniques Client exposed to increasing levels of

anxiety-producing stimulus Relaxation used to overcome anxiety Client then able to tolerate greater and

greater level of stimulus

Aversion Therapy Maladaptive behavior paired with a punishment or unpleasant stimuli

Therapist uses unpleasant stimuli as punishment for undesirable behaviorso Bitter taste/mild electric shock

Medication / guided imagery/ diaphragmatic breathing / muscle relaxation / biofeedback

Techniques used to control pain / tension / anxiety

Ex: Reinforced teaching about diaphragmatic breathing for client having a panic attack.

Behavioral Therapy

Other techniques Flooding▪ Exposing (in presence of therapist) to a great deal of an

undesirable stimulus ▪ Attempt to “turn off” anxiety response

Response Prevention▪ Prevent client from performing compulsive behavior▪ Intent is that anxiety will be diminished

Thought Stopping▪ Teaching client to shout the word “STOP” when negative

thoughts or compulsive behaviors arise▪ Over time the client will use the command silently

Quick Quiz!

A client states that he is depressed because he has had to deal with role reversal with his spouse after the loss of his job due to a disability. Which of the following therapies would the nurse expect to help implement for the client?

A. Operant conditioning B. Systematic desensitization Psychodynamic psychotherapy Interpersonal psychotherapy

Quick Quiz!Answer      

  Psychoanalysis A A client who has had heated disputes with other clients on the unit learns to solve problems by sitting down and talking calmly and reasonably with other clients.

  Cognitive Technique B The client discusses his dreams with the therapist.

  Assertiveness Training C The client is encouraged to stop sucking his thumb by having a bitter liquid applied to his thumb.

  Aversion Therapy D A client who feels awkward in group social situations watches a video showing some positive ways to interact in groups.

  Modeling E A client who displayed violent behavior in the past and felt negative about herself, learns to think and speak about herself in more positive terms.

Group and Family Therapy

Group and Family Therapy Open therapeutic communication

Participants willing to be involved

Part of treatment plan for clients in mental health setting

Guided by leaders

Leadership styles include: Democratic▪ Supports group interaction and decision making to solve problems

Laissez-faire▪ Group progresses with no attempt by the leader to control the direction

of the group Autocratic▪ Leader completely controls the direction and structure of the group▪ No group interaction or decision-making to solve problems

Group Therapy

Watch a Video

Group Therapy Isn’t…

http://www.youtube.com/watch?v=cEFAHOzc8no

Group Therapy

Verbal and nonverbal communication occurring within group sessions

Group Norm The way the group behaves during sessions Provides structure for the group

Hidden Agenda Some group members (or leader) have goals different from the stated group

goals▪ May disrupt group progress

Subgroup Small number of people within a larger group

▪ Function separately from the group

Groups may be open or closed Open groups – new members added as old members leave Closed groups – no new members added after the group is formed

Group Therapy

Homogenous group All members share a certain characteristic▪ Ex: diagnosis or gender

Therapy sessions include Use of open and clear communication Cohesiveness and guidelines Direction toward a goal Opportunity for development of:▪ Interpersonal skills▪ Resolution of personal / family issues▪ Relationship development

Communication regarding respect among members Support and education regarding community support resources

Group Therapy

Group Therapy Goals: Sharing of common feelings / concerns Sharing of stories / experiences Diminishing feelings of isolation Creating a community of healing and restoration Providing more cost-effective environment than individual

counseling

Group therapy may be used for varying age groups: Children ▪ play while talking about a common experience

Adolescents▪ Especially valuable due to strong peer relationships

Older Adult▪ Helps with socialization and sharing memories

Group Therapy Roles

Maintenance Roles Members maintain the purpose and process of the group▪ Ex: harmonizer▪ Attempts to prevent conflict within the group

Task Roles Members take on various tasks within the group process▪ Ex: recorder▪ Takes notes or records of what occurs

Individual Roles Individuals take roles to promote their own agenda Prevents teamwork Ex: dominator▪ Tries to control other members

Family Therapy

Family Therapy

Family defined as a group with reciprocal relationships

Members are committed to each other

Family Therapy Focus is on the family as a system rather than members

as individuals Family assessments include focused interviews and use of

various family assessment tools Nurses work with families to:▪ Provide teaching▪ Mobilize family resources▪ Improve communication▪ Strengthen ability to cope with illness of one member

Characteristics of FamiliesArea of Functioning Healthy Families Dysfunctional Families

Communication Clear understandable messages between family members

Each member encouraged to express individual feelings and thoughts

One or more members use unhealthy patternso Blamingo Manipulatingo Placatingo Distracting

Management Adults of family agree on important issues Rule-making Finances Plans for the future

Management may be chaotico Child making management decisions at

times

Boundaries Distinguishable boundaries between family roles

Clear boundaries defined for each member Boundaries understood by all Each member can function appropriately

Enmeshed boundarieso Thoughts/roles/feelings are so blended

that individual roles are unclear Rigid boundaries

o Rules and roles are inflexibleo Family tends to have isolated members

Socialization All members interact / plan / adopt healthy ways of coping

Children learn to function as family and society members

Members can change as the family grows and matures

Children do not learn health socialization skills within the family

Have difficulty adapting to socialization roles in society

Emotional/Supportive Emotional needs of family and members are met most of the time

Members are concerned about each other Conflict and anger do not dominate

Negative emotions predominate most of the time Members are isolated and afraid

o Do not show concern for each other

Concepts Related to Family Dysfunction Scapegoating

A member of the family has little power Blamed for problems in the family

Triangulation Third party is drawn into the relationship with two

members whose relationship is unstable

Multigenerational Issues Emotional issues within the family that continue for at

least three generations▪ Addiction patterns when family under stress▪ Dysfunctional grief patters▪ Triangulation patterns▪ Divorce

Focus and GoalsIndividual / Family / Group Therapies

Therapy Focus Goals

Individual Client needs and problems

The therapeutic relationship

Make more positive individual decisions

Make productive life decisions

Develop a strong sense of self

Family Family needs and problems

Improving family relationships

Learn effective ways for dealing with mental illness within the family

Improve understanding among family members

Maximize positive interaction among family members

Group Help individuals develop functional and satisfying relations within a group setting

Goals depend on type of group

Clients generally:o Discover that members

share common feelings / experiences / thoughts

o Experience positive behavior changes as result of group interaction and feedback

Watch a Video

Structural family therapy example

http://www.youtube.com/watch?v=bOrnOcHWXgA

Quick Quiz!

A nurse leading a stress management group demonstrates that he supports group interaction and the decision-making required to solve problems. The group proceeds with all members feeling that they have input into the group’s decisions. Which leadership style does this illustrate?

A. Democratic B. Laissez-faire C. Autocratic D. Authoritative

Quick Quiz!

A nurse is conducting a family therapy session. The teenage son tells the nurse that his parents will punish him harshly if he discloses anything in the session about the family’s arguments at home. The parents have never made any such threats to him. This is an example of which of the following?

A. placation B. manipulation C. blaming D. distraction

Stress Management

Stress

Body’s nonspecific response to any demand made upon it

Stressors Physical Psychological Produces a biological response in the body Some stressors are needed to provide interest and purpose Too much stress or too many stressors can cause distress Anxiety and anger are damaging stressors that cause distress

General Adaptation Syndrome (GAS) Body’s response to an increased demand First stage = “Fight or Flight” mechanism▪ If prolonged, maladaptive responses may occur

Stress Management

The person’s ability to experience appropriate emotions and cope with stress

Healthy management of stress Flexible Uses a variety of coping techniques and mechanisms

Responses to stress/anxiety affected by: Age Gender Culture Life experiences Lifestyle

Effects of stressors are cumulative

Protective Factors

Things that increase ability to resist the effects of stress Physical health Strong sense of self Religious/spiritual beliefs Optimism Hobbies and other outside interests Satisfying interpersonal relationships Strong social support systems Humor

Subjective and Objective Data

Acute Stress “Fight or Flight”

Prolonged Stress (maladaptive responses)

Apprehension Chronic anxiety or panic attacks

Unhappiness / sorrow Depression / chronic pain / sleep disturbances

Decreased appetite Weight gain or loss

Increased respiratory rate / heart rate / cardiac output / BP

Increased risk for myocardial infarction / stroke

Increased metabolism and glucose use

Poor diabetes control / hypertension / fatigue / irritability / decreased ability to concentrate

Depressed immune system Increased risk for infection

Standardized Screening Tools

Life-Changing Events Questionnaires Holmes Rahe Stress Scale (see handout) Lazarus’s Cognitive Appraisal

Nursing Care

Reinforce teaching of stress reduction strategies Cognitive Retraining▪ Help clients look at irrational thoughts in a more realistic light

and restructure thoughts in a more positive way. Behavioral Techniques▪ Relaxation techniques▪ Meditation▪ Guided imagery▪ Breathing Exercises▪ Progressive Music Relaxation (PMR)▪ Physical Exercise

Journal Writing Priority Restructuring Biofeedback Assertiveness Training

Client Outcomes• Client will verbalize

stressors and ways to decrease exposure

• Client will demonstrate appropriate relaxation techniques

• Client will demonstrate assertive communication

Quick Quiz!

Scenario:

A client speaking to a nurse in a general medical clinic, describes herself as feeling anxious, apprehensive, and tired all the time. She says she cannot understand why, since she is very happy. She recently moved to the area to start a new job for a large corporation. She purchased a new and much larger home for herself and her three children (ages 5, 8, and 12). The children transitioned to their new schools successfully and are making friends. The client’s family and friends are all back in the previous city where she lived, but she has been so busy with work that she has not had time to telephone or write to them. The client states she has not been able to sleep and has lost weight in the 2 months since the move.

1. List the stressors that affect this client.

2. Which of the client’s manifestations of increased stress reflects acute Stress rather than prolonged stress?

a. Weight lossb. Apprehensionc. Fatigued. Insomnia

Electroconvulsive Therapy

Watch a Video

Electroconvulsive Therapy

http://www.youtube.com/watch?v=zYl13Relzbs

Electroconvulsive Therapy (ECT) Alternative somatic treatment for mental health

disorders

Delivers an electrical current that produces a grand mal seizure

The exact mechanism of ECT is still unknown and controversial May enhance the effects of neurotransmitters in the

brain▪ Serotonin▪ Dopamine▪ norepinephrine

Indications for ECT

Severe depression Symptoms not responsive to pharmacological treatment If risks of other treatments outweigh those of ECT▪ First trimester of pregnancy

Actively suicidal▪ Need for rapid therapeutic response

Some types of Schizophrenia If less responsive to neuroleptic medications▪ Catatonic schizophrenia▪ Schizoaffective disorder

Acute manic episodes For bipolar clients with rapid cycling and very destructive behavior▪ Four or more episodes of acute mania within 1 year▪ Both features usually do not respond well to Lithium therapy

Contraindications for ECT No absolute contraindications if deemed necessary to

save / improve a client’s life

Medical conditions for high risk with ECT Recent myocardial infarction History of cerebrovascular accident Cerebrovascular malformation Intracranial mass lesion

Medical conditions for which ECT is useful: Developmental disabilities Chemical dependence Personality disorders Situational depression

Nursing Actions

Prepare the client Typical course of treatment is 3 x /week for 6 – 12 treatments

Use therapeutic communication

Physician will discuss the procedure and obtain informed consent Risks and benefits Guardian gives consent if client incompetent Sometimes separate informed consent for anesthesia History and physical examination▪ Neuro exam▪ Electrocardiogram (ECG)▪ Lab tests

Nursing ActionsMedication Management Medication management

Meds that affect client’s seizure threshold are decreased or discontinued several days before ECT procedure.

MAOIs and lithium should be DC’d 2 weeks before the procedure

Severe hypertension is controlled Short period of hypertension post procedure

▪ Monitor vital signs▪ Monitor mental status

Ask client and family about understand and knowledge of the procedure Redirect to MD for clarification as needed

IV inserted and maintained until full recovery

IM injection of atropine sulfate or glycopyrrolate (Robinul) is given 30 minutes prior to procedure to decrease secretions and counteract vagal stimulation.

Nursing Actions – During Procedure ECT administered in early morning

After 8 – 12 hours of fasting

Client uses bite guard to prevent oral cavity trauma

Electrodes are applied to the scalp

The client is mechanically ventilated and receives 100% oxygen

Ongoing cardiac monitoring provided BP / heart rate and rhythm / oxygen saturation

Short acting anesthetic (Brevital) is provided IV bolus

Muscle relaxant (Anectine) is administered

Cuff placed on one leg or arm Blocks muscle relaxant so seizure activity can be monitored and documented Duration of seizure is usually 25 to 60 seconds

After seizure activity is ceased, anesthetic is discontinued

Client is extubated and assed to breathe voluntarily

Nursing Actions – Post Procedure

Client is transferred to recovery area Assess:▪ LOC▪ Cardiac status▪ Vital signs▪ Oxygen saturation

Position client on side to facilitate drainage and prevent aspiration

Client is usually awake are ready for transfer back to the mental health unit within 30 to 60 minutes after the procedure

Orient client frequently Confusion and short-term memory loss are common

Continue to monitor vital signs and mental status for memory loss

Complications of ECT

Memory loss and confusion Short term memory loss

▪ May persist for several weeks▪ If ECT causes permanent memory loss is controversial

Confusion Disorientation Explain to clients and families that memory loss is typically short term Assist client with memory

▪ Clock in the room▪ Label client’s room location

Headache / muscle soreness / nausea Observe degree of discomfort Administer antiemetic and analgesic medication as needed Explain the reason for clinical manifestations Encourage clients to contact nurse regarding these symptoms

Summary

Identified common medications used to treat mental disorders (ATI Tutorial 2011B) Identified expected pharmacological actions Identified therapeutic uses Identified side/adverse effects Identified contraindications and precautions Identified food and medication interactions Identified patient teaching strategies

Identified Traditional Non-pharmacological Therapies for the treatment of mental health disorders

Assignment

See Schedule for assignments due for next class

Next Class

ATI Tutorial (Quiz #2) due!

Mid Term Evaluations

Q&A Special Populations and Mental Health Issues (Ppoint Presentation and Study Guide #5)

Nursing Process and Care Plan Development for Mental Health

ATI Practice Test #2 Be sure to practice before test!! Grade on practice will be averaged with your graded test

We’re halfway there!Keep up the great job!!!