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Therapeutic Communication, Anxiety and Defense Mechanism

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wilsontom.blogspot.com

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MENTAL HEALTH CONCEPTSAssessment• Appearance, behaviour or mood

Well groomed, relaxedSelf-confident, self accepting

• Speech, thought content and thought processClear, coherentReality based

• SensoriumOrientedGood memoryAbility to abstract

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•Insight and judgment•Family relationships and work habits

Satisfying interpersonal relationships and work habits

Ability to trustAbility to copy effectively with stress

•Level of growth and development

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AnalysisPotential support system or stressors

Church or community supportFamilySocioeconomic resourcesEducation cultural norms

•Potential risk factorsFamily H/O mental illnessMedical history

•Satisfaction of basic human needs

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Potential nursing diagnosis

• Social interaction impaired• Anxiety• Ineffective individual coping• Self esteem disturbance

ImplementationTherapeutic communication

Listening to and understanding client while promoting clarification and insight

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MASLOW’S HIERRARCHY OF NEEDS

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Goals• To understand clients message verbal and non verbal• To facilitate verbalization of feelings• To communicate understanding and acceptance• To identify problems, goals and objectives

Guidelines• Nonverbal communication constitutes 2/3 of all the

communication• It gives most accurate reflection of attitude• Key points : say nothing and listen• Observe physical appearance, body movement, posture,

gesture and facial expression• Maintain eye contact, physical distance• Use therapeutic touch• Person’s feelings and what is said may be incongruent

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Therapeutic responses

Using silence• Use general leads or broad openings: what

would u like to talk about. go on….• Clarification : Give me one example, tell me

more…• Reflecting : it sounds like u r feeling angry,

are you saying…

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Avoid

•Close ended questions, yes or no: how many children u have

•advice giving : why don’t u ….•Responding to questions that r related to client in an embarrassed or concrete way : nurses r not allowed to go with their patients

•Arguing or responding in a hostile manner•“why” questions : why u did not take ur medication

•Being judgmental : u were wrong to do that

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Treatment modalities for mental illness

Biological• Emotional problem is an illness• Cause may be inherited or chemical in origin• Medications and ECT

Psychoanalytical• Anxiety results when there is conflict between id

and ego• Defense mechanisms form to ward off anxiety• Therapist helps the patient to become aware of

unconscious thoughts and feelings• he helps him to understand anxiety and defenses

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Milieu therapy• Providing a therapeutic environment will help

increase patients awareness of feelings, increase sense of responsibility and help him to return to community

• Client plans social and group interactions

Group therapy• Relationship is recreated among group members• Members meet regularly with a leader to form a

stable group• Members learn new ways to cope with stress and

develop insight into their behaviors with others

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Family therapy• Problem is a family problem not an individual

one• Therapist treats the whole family• Help members to develop their own sense of

identity

Activity therapy• Important group interactions occur when group

members work on a task together• Organized group activities r created to promote

socialization and increase self esteem

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Play therapy• Children express themselves more easily in play than in verbal communication• Choice of colors, toys, interaction with toys reflects child’s situation in family• Provide materials and toys to facilitate interaction with child, observe play, and

child to resolve problems through play

Behavior therapy and behavior modification

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Psychological problems r result of learning

Deficiencies can be corrected through learning

Operant conditioning: use of rewards to reinforce positive behavior

Desensitization used to treat phobias. Patient slowly adjusts to threatening objects

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ANXIETYFeeling of dread or fear in the absence of an externalthreat or disproportionate to the nature of threat

AssessmentCardiovascularIncreased pulse, BP, respirationPalpitations, chest discomfort or painPerspiration, flushing and heat sensationsCold hands and feetheadache

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GastrointestinalNausea, Vomiting, DiarrheaBelching, heart burns, cramps

MusculoskeletalIncreased muscle tension and tendon reflexesIncreased generalized fatigueTremors jerking of limbsUnsteady voice

IntellectualPoor comprehension, poor concentration, selective attentionImpaired problem solvingUnable to communicate : distorted, disconnected thought and impaired logic Rapid high pitched speech

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Social and emotional

• Feelings of helplessness and hopelessness• Feelings of increased threat, dread, horror,

anger and rage• Use of defense mechanisms and more

primitive coping behaviors such as shouting, arguing, hitting , kicking crying, rocking, curling up and withdrawal

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Analysis

DefinitionFeeling of dread or fear in the absence of an external

threat or disproportionate to the nature of threat

Predisposing conditions• Prolonged unmet needs of dependency, security, love

and attention• Stress threatening security or self esteem• Unacceptable thoughts or feelings surfacing to

consciousness eg rage, erotic impulses, flashbacks

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Levels of anxiety

Mild: high degree of alertness, mild uneasiness

Moderate: heart pounds, skin cold and clammy, poor comprehension

Severe: hallucinations and delusions

Panic: inability to see and hear, inability to function

Assess level of anxiety

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Look at body language, speech patterns, facial expressions, defense mechanism and behavior used

Distinguish levels of anxiety

Nursing interventions in anxiety

Keep environmental stresses low when anxiety is high

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Pleasant, attractive uncluttered environmentProvide privacy if presence of other patients is stimulatingProvide physical care when necessaryAvoid offering several alternatives or decisions when anxiety is highIntervene if anxiety is severe or panicProvide brief orientation to unit or proceduresProvide written information to read when anxiety is lower

Assist client to cope with anxiety more effectively

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Acknowledge anxious behavior: reflect and clarifyAlways remain with clientAssist client to clarify own thoughts and feelingsEncourage measures to reduce anxiety eg exercise, activities, talking with friends, hobbiesAssist client to recognize his strengths and capabilities realisticallyProvide therapy to develop more effective coping and interpersonal skills eg individual or groupMay need to administer antianxiety medications

Maintain accepting and helpful attitude towards client

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Use an unhurried approachAcknowledge client’s distress and concerns about problemEncourage clarifications of feelings and thoughtsEvaluate and manage own anxiety when working with the clientRecognize the value of defense mechanisms and realize that client is attempting to make the anxiety tolerable in the best possible wayAcknowledge defense but provide realityDo not attempt to remove a defense mechanism at any time

Anxiety disordersType Assessments Nursing Mx

PHOBIA

Apprehension, anxiety, helplessness when confronted with phobic situation•Acrophobia – heights•Claustrophobia –closed spaces•Agoraphobia- open spaces

•Avoid confrontation and humiliation•Do not focus on getting patient to stop being afraid•Systematic desensitization•Relaxation techniques•antidepressants24

Type Assessments Nursing Mx

OCD Obsession- repetitive,

uncontrollable thoughts

Compulsion- repetitive uncontrollable acts e.g.

rituals

• Accept ritualistic behavior

• Structure environment

• Provide for physical needs

• Offer alternative activities esp ones using hands

• Guide decisions, minimize choices

• Encourage socialization

• Group therapy

• Clomipramine (anafranil)

• Stimulus -response prevention

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Type Assessments Nursing Mx

Conversion hysteria

Physical symptoms with no organic basis-

blindness, paralysis,

Convulsions without loss of consciousness

“La belle indifference”

Stocking and glove anesthesia

• Diagnostic evaluation

• Discuss feelings rather than symptoms

• Promote therapeutic relationship

• Avoid secondary gain 26

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Defense mechanisms

Denial: an alcoholic says he does have an alcoholic problem

Displacement: yelling at dog when angry with boss

Projection: blaming others

Undoing: apologizing excessively

Compensation: small person excel in sports

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Substitution: marrying someone who looks like previous significant other

Introjection: blaming oneself when angry with others

Repression: inability to remember a traumatic event (unconsciously)

Reaction formation: being good to someone u don’t like

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Regression: bedwetting, babytalk

Dissociation: detachment of painful emotional conflict from consciousness

Suppression: deciding not to deal with something unpleasant until next day

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CRISIS INTERVENTIONAssessment  

Stages of crisisa. Denialb. Increased tension, anxietyc. Disorganization, inability to functiond. Attempts to reorganizee. Attempts to escape the problem pretends

problem doesn’t exist, blames othersf. General reorganization 

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Precipitating factors

   Development1) Birth, adolescence2) Midlife, retirement

   Situational1) Natural disasters2) Financial loss

Threats of self- concept1) Loss of job2) Failure at school3) Onset of serious illness

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Analysis 

Characteristicsa. Temporary state of disequilibrium precipitated by an eventb. Self-limiting – usually 4-6 weeksc. Crisis can promote growth and new behaviors

Potential diagnosesa. Individual coping ineffectiveb. Powerlessnessc. Grieving, dysfunctional

Plan/Implementationsa. Goal-directed, focus on the here and nowb. Focus on client’s immediate problems

 

 

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Explore nurse’s and client’s understating of the problem

 a. Define the event (client may truly not know what has precipitated the crisis)b. Confirm nurse’s perception by reviewing with clientc. Identify the factors that are affecting problem-solvingd. Evaluate how realistically client sees the problems or concerns 

Help client become aware of feelings and validate them a. Acknowledge feelingsb. Avoid blaming clientc. Encourage ventilationd. Tell client he will feel better but it will take 1 or 2 months 

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Develop a planEncourage client to make as many arrangements as possible, avoid dependenceWrite out information as comprehension is impairedMaximize clients situational supports

Find new coping skills and manage feelingsFocus on strengths and present coping skillsEncourage client to form new social outletsFacilitate future planningAsk client “what would u like to do?”, “where would u like to go from here?”Give referrals family and vocational counseling

Situational crisesGrieving patient Dying patient

Rape trauma

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S

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E

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M

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Stages of grief

• Shock and disbelief

• Awareness of the pain of loss

• Restitution

Actual grief period- 4 to 8 weeks

Usual resolution within 1 year

Long term resolution over time

Stages of dying

DABDA

Stages of crisesAcute reaction lasts 3-4 weeks

Reorganization is long term

Common responses to rape•Self blame, embarrassment

•Anxiety, insomnia

•Phobia fear of violence

wish to escape, move, relocate

•Psychosomatic disturbances

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Grieving patient Dying patient Rape trauma

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N

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L

Y

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I

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Potential Problems

Family

guilt, anger, anxiety

Patient

anger, withdrawal, guilt, anxiety, loss of role

•Avoidance behavior

•Inability to express feelings when in denial

•Feelings of guilt

•Withdrawal, lonely, frightened

•Anxiety of patient and family

•Fears, panic reactions, generalized anxiety

•Guilt, inability to cope

•Current crises may reactivate old unresolved trauma

•Follow emergency protocol

•Be alert for internal injuries

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Nursing interventions

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Grieving patient• Apply crises theory• Focus on here and now• Provide support to family• Provide family privacy• Encourage verbalization of feelings• Facilitate expression of anger and rage• Emphasize strengths increase ability to cope• Support adjustments to illness loss of body part

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Dying patient

• Keep communication open

• Let patient know he is not alone

• Provide comforting environment

• Provide privacy

• Physical care

• Give sense of control and dignity

• Respect patient’s wishes

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Rape trauma

• Write out Tx and appointments for client

• Record all information in chart

• Refer for legal assistance, support psychotherapy

• Follow up regularly until client is improved

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POST TRAUMATIC STRESS SYNDROME

Assessment• Exposure to traumatic event : rape, murder, fire• Response to trauma causes intense fear• Recurrent or distressing recollection of event• Distressing dreams or nightmares• Acting or feeling like the trauma is recurring

(flashbacks)• Hyper vigilance and exaggerated startle response• Irritable or outbursts of anger• Avoidance or numbing

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Analysis

• Duration of symptoms is atleast one month• Syndrome can emerge months to years after

traumatizing event• Biological changes due to impact of stressor

and excessive arousal of sympathetic nervous system

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Planning

1. Help client integrate the traumatic experience

Encourage client to talk about painful stored memories

• have client recall images of traumatic event with as much detail as possible: flooding

• use empathetic responses to the expressed distress

• remain nonjudgmental

• allow client to grieve over losses

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Assist client to challenge existing ideas about event and substitute more realistic thoughts and expectations

• Point out irrational thinking to the client

• Help client recognize the limits of his control over the stressful event

2. Assist client with emotional regulations

Help client label his feelings and find ways to express them safely

Teach stress management techniques

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Involve client in anger Mx program

• Recognize anger as normal feeling• Teach time out or other ways of walking

away from problematic situations involving anger

• Teach nonintrusive communication techniques

speak in first personMove away from object of angerCognitive restructuring eg using thoughts like this person cannot make me lose control

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Develop a schedule of regular physical activity with client: walking, running

Use empowering strategies such as keeping a journal of disturbed thoughts and feelings in response to flashbacks or other problems

Teach methods to reduce sleep disturbances1. regular bedtime2. Use bed for sleeping and lovemaking

exclusively. No TV or reading3. Do not lie in bed sleepless for more than half

an hour: get up and move around and then come back to bed

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3. Enhance the clients support systems• Refer to self help group• Include family and friends in

psychoeducational activities• Explore opportunities for socialisation

4. Educate client regarding the recovery process• Assess for and treat substance abuse• Administer antidepressants

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