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

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 self-

integrity

Pg47, Table 3.1

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• 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• 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

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

pg57

Treatment Modalities• Types of groups:– Support - Education– Family therapy - Self-help– Family education - Psychotherapy– Activity

– Support- AA, MADD– Family- divorce– Family Ed-– Activity– Self-help- WW, AA, Gambler’s Anonymous

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 ModalitiesGOOD

• Group member roles:– Growth-producing • Energizer (pep)• Harmonizer (mediator ; Giving their opinions)• Encourager• Opinion seeker• Information seeker/giver

Treatment ModalitiesBAD

• 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 (Yalom, 2005)

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

• 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.