A.

ELECTROCONVULSIVE AND OTHER SOMATIC THERAPIES

Electroconvulsive therapy (ECT)
Electroconvulsive therapy, also known as ECT and electroshock therapy, was
developed in the 1930s when various observations led physicians to conclude that
epileptic seizures might prevent or relieve the symptoms of schizophrenia. After
experiments with insulin and other potentially seizure-inducing drugs, Italian physicians
pioneered the use of an electric current to create seizures in schizophrenic patients.
ECT was routinely used to treat schizophrenia, depression, and, in some
cases, mania. It eventually became a source of controversy due to misuse and negative
side effects. ECT was used indiscriminately and was often prescribed for treating
disorders on which it had no real effect, such as alcohol dependence, and was used for
punitive reasons. Patients typically experienced confusion and loss of memory after
treatments, and even those whose condition improved eventually relapsed. Other side
effects of ECT include speech defects, physical injury from the force of the convulsions,
and cardiac arrest. Use of electroconvulsive therapy declined after 1960 with the
introduction of antidepressant and antipsychotic drugs.
ECT is still used today but with less frequency and with modifications that have
made the procedure safer and less unpleasant. Anaesthetics and muscle relaxants are
usually administered to prevent bone fractures or other injuries from muscle spasms.
Patients receive approximately 4 to 10 treatments administered over a period of about
two weeks. Confusion and memory loss are minimized by the common practice of
applying the current only to the non-dominant brain hemisphere, usually the right-brain
hemisphere. Nevertheless, some memory loss still occurs; anterograde memory
(the ability to learn new material) returns relatively rapidly following treatment, but
retrograde memory (the ability to remember past events) is more strongly affected.
There is a marked memory deficit one week after treatment which gradually improves
over the next six or seven months. In many cases, however, subtle memory losses
persist even beyond this point, and can be serious and debilitating for some patients.

ECT can only be administered with the informed consent of the patient and is
used primarily for severely depressed patients who have not responded to
antidepressant medications or whose suicidal impulses make it dangerous to wait until
such medications can take effect. ECT is also administered to patients with bipolar
disorder. Contrary to the theories of those who first pioneered its use, ECT is not an
effective treatment for schizophrenia unless the patient is also suffering from
depression. The rate of relapse after administration of ECT can be greatly diminished
when it is accompanied by other forms of treatment.
Researchers are still not sure exactly how electro-convulsive therapy works,
although it is known that the seizures rather than the electric current itself are the basis
for the treatment's effects, and that seizures can affect the functioning of
neurotransmitters in the brain, including nor epinephrine and serotonin, which are
associated with depression. They also increase the release of pituitary hormones.
Because of its possible side effects, as well as the public's level of discomfort with both
electrical shock and the idea of inducing seizures, ECT remains a controversial
treatment method. In 1982, the city of Berkeley, California, passed a referendum making
the administration of ECT a misdemeanor punishable by fines of up to $500 and six
months in prison, but the law was later overturned.
In the 1940s there were few treatments available for mental illnesses. One
regimen, called shock therapy, involved the use of drugs or electricity to treat severe
mental disorders by inducing coma or convulsions. Early shock treatments used such
chemicals as insulin, camphor, or metrazol. Injections of increasing levels of insulin
deoxygenated the blood and induced a deep coma. Metrazol was used to produce
convulsions. The therapeutic benefit of the drug shock therapies seemed to be greatest
with schizophrenics. In 1938 Ugo Cerletti of Italy first developed an electric shock
therapy technique. It proved to be less dangerous, more controlled, and less expensive
than the drug treatments. It rapidly became the primary medical treatment for the
mentally ill, since there was little else available. At a meeting of the New York Academy
of

Medicine

in

February

1944,

physicians

concluded

that

the

benefits

of

electroconvulsive therapy far outweighed the dangers involved. Physicians considered

electric-shock therapy especially beneficial in cases of severe depression or

"melancholia," as an alternative to months or years in a mental hospital. In these cases
treatments were used about three times a week for two to eight weeks or more. In
cases of extreme psychosis psychiatrists gave as many as three treatments a day over
a period of several weeks.
Definition
Electroconvulsive therapy (ECT) is a medical treatment for severe mental illness
in which a small, carefully controlled amount of electricity is introduced into the brain.
This electrical stimulation, used in conjunction with anesthesia and muscle relaxant
medications, produces a mild generalized seizure or convulsion. While used to treat a
variety of psychiatric disorders, it is most effective in the treatment of severe
depression, and provides the most rapid relief currently available for this illness.
Purpose
The purpose of electroconvulsive therapy is to provide relief from the signs and
symptoms of mental illnesses such as severe depression, mania, and schizophrenia.
ECT is indicated when patients need rapid improvement because they are suicidal, selfinjurious, refuse to eat or drink, cannot or will not take medication as prescribed, or
present some other danger to themselves. Antidepressant medications, while effective
in many cases, may take two-six weeks to produce a therapeutic effect. Antipsychotic
medications used to treat mania and schizophrenia has many uncomfortable and
sometimes dangerous side effects, limiting their use. In addition, some patients
develop allergies and therefore are unable to take their medicine.
Precautions
The most common risks associated with ECT are disturbances in heart rhythm.
Broken or dislocated bones occur very rarely.
Preparation
Patients and their relatives are prepared for ECT by viewing a videotape that
explains both the procedure and the risks involved. The physician then answers any
questions these individuals might have, and the patient is asked to sign an informed

consent form. This form gives the doctor and the hospital legal permission to administer
the treatment.
After the form has been signed, the doctor performs a complete physical
examination and orders a number of tests that can help identify any potential problem.
These tests may include a chest x ray; an electrocardiogram (EKG); a CT scan; a
urinalysis; a spinal x ray; a brain wave tracing (EEG); and a complete blood count
(CBC).
Some medications, such as lithium and a class of antidepressants known as
monoamine oxidase inhibitors (MAOIs), should be discontinued for some time before
ECT administration. Patients are instructed not to eat or drink for at least eight hours
prior to the procedure in order to reduce the possibility of vomiting and choking. During
the procedure itself, the members of the health care team closely monitor the patient's
vital signs, including blood pressure, heart rate and oxygen content.
Aftercare
The patient is moved to a recovery area after an ECT treatment. Vital signs are
recorded every five minutes until the patient is fully awake, which may take 1530
minutes. The patient may experience some initial confusion, but this feeling usually
disappears in a matter of minutes. The patient may complain of headache, muscle pain,
or back pain, which can be quickly relieved by aspirin or another mild medication.
Following successful ECT treatments, patients with bipolar disorder may be given
maintenance doses of lithium. Similarly, patients with depression may be given
antidepressant drugs. These medications are intended to reduce the chance of relapse
or the recurrence of symptoms. Some studies have estimated that approximately onethird to one-half of patients treated with ECT relapse within 12 months of treatment.
After three years, this figure may increase to two-thirds. Follow-up care with
medications for bipolar disorder or depression can reduce the relapse rate in the year
following ECT treatment from 50% to 20%. Some patients might relapse because they
do not respond well to the medications they take after their ECT sessions are
completed. In some cases, patients who relapse may suffer from severe forms of
depression that are especially difficult to treat by any method.

Risks
Recent advances in medical technology have substantially reduced the
complications associated with ECT. These include memory loss and confusion. Persons
at high risk of having complications following ECT include those with a recent heart
attack, uncontrolled high blood pressure, brain tumors, and previous spinal injuries.
One of the most common side effects of electroconvulsive therapy is memory loss.
Patients may be unable to recall events that occurred before and after treatment.
Elderly patients, for example, may become increasingly confused and forgetful as the
treatments continue. In a minority of individuals, memory loss may last for months. For
the majority of patients, however, recent memories return in a few days or weeks.
Elderly patients receiving ECT may experience disturbances in heart rhythm; slow
heartbeat (bradycardia); or rapid heartbeat (tachycardia); and an increased number of
falls. As many as one-third of elderly patients may experience such complications
following the procedure.
Normal results
ECT often produces dramatic improvement in the signs and symptoms of major
depression, especially in elderly patients. Sometimes the benefits are evident even
during the first week of treatment.
A remarkable 90% of patients who receive ECT for depression respond
positively. By contrast, only 70% respond as well when treated with antidepressant
medications alone. While it is estimated that as many as 50% of successfully treated
patients will have future episodes of depression, the prognosis for each episode of
illness is good. Mania also often responds well to treatment with ECT. The picture is not
as bright for schizophrenia, which is more difficult to treat and is characterized by
frequent relapses.
Post-treatment confusion and forgetfulness are common, though disturbing,
symptoms associated with ECT. Doctors and nurses must be patient and supportive by
providing patients and their families with factual information about the nature and
timeframe of the patient's recovery.

A few patients are placed on maintenance ECT. This term means that they must
return to the hospital every one to two months as needed for an additional treatment.
These persons are thus able to keep their illness under control and lead normal and
productive lives.
Abnormal results
If an ECT-induced seizure lasts too long (more than two minutes) during the
procedure, physicians will control it with an intravenous infusion of an anticonvulsant
drug, usually diazepam (Valium).
Overall, ECT is a very safe procedure. The complications encountered are no different
from those that may occur with the administration of anesthesia without ECT. There is
no convincing evidence of long-term harmful effects from ECT. Researchers are
continuing to explore its potential in treating other disorders.
SOMATIC THERAPIES
Somatic psychology is an interdisciplinary field involving the study of the body,
somatic

experience,

and

the

embodied

self,

including

therapeutic

and holistic approaches to body. The word somatic comes from the ancient Greek root
- somat- (body).

The

word psychology comes

from

the

ancient

Greek psyche (breath, soul hence mind) and -logia (study). Psychotherapies a general
branch of this subject, whilst Somatherapy, Eco-somatics and Dance therapy, for
example, are specific branches of the subject. Somatic psychology is a field of study
that bridges the Mind-body dichotomy.
Whilst Pierre Janet can perhaps be considered the first Somatic Psychologist
due to his extensive psychotherapeutic studies and writings with significant reference to
the body (some of which pre-date Freud), it was actually Wilhelm Reich who was the
first person to bring body awareness systematically into psychoanalysis, and also the
first psychotherapist to touch clients physically, working with their bodies. [1] Reich was a
significant influence in the founding of Body Psychotherapy (or Somatic Psychology as
it is often known in the USA & Australia) - though he called his early work "Character
Analysis"[2] and "Character-Analytic Vegetotherapy"). Several types of body-oriented
psychotherapies trace their origins back to Reich, though there have been many

subsequent developments and other influences (ref: entry on Body Psychotherapy and
Somatic Psychology is of particular interest in trauma work.
There is increasing use of body-oriented therapeutic techniques within
mainstream psychology (like EMDR and Mindfulness practice) and psychoanalysis has
recognized the use of somatic resonance, embodied trauma, and similar concepts, for
many years.
Historically,

there

are

early

practitioners,

for

example,

the

Persian

physician Avicenna (980 to 1037 CE) who performed psychotherapy only by observing
the movement of the patient's pulse as he listened to their anguish. This is reminiscent
of both traditional Tibetan medicine and current energy therapies that employ tapping
points on a meridian. As a contrast to the Western separation of body/mind, some
writers describe the "body as a slow mind" and this re-examination of the
fundamental mind-body

dichotomy has

coincided

with

research

into neuroscience, embodiment and consciousness, and an unconscious mind that

'speaks' through the language of body.
Dance therapy or (Dance Movement Psychotherapy) also reflect something of
this approach and are considered a study and practice within the field of somatic
psychology.
B. PSYCHOPHARMACOLOGY
Medical management is a crucial issue that greatly influences the outcomes of
treatment for many clients with mental disorder. The following sections discuss several
categories of drugs used to treat mental disorders (psychotropic drugs): antipsychotics,
antidepressants, mood stabilizers, anxiolytics and stimulants. Nurses should understand
why these drugs works; their side effects, contraindications and interactions; and the
nursing interventions required helping clients manage medication regimens.
Several terms used in discussion of drugs and drug therapy are important for
nurses to know. Efficacy refers to the maximal therapeutic effect that a drug can
achieve. Potency describes the amount of the drug needed to achieve the maximum
effect; low-potency drugs require higher dosages to achieve efficacy, whereas high-

potency drugs achieve efficacy at lower dosages. Half life is the time it takes for a half of
the drug to be removed from the bloodstream. Blood with a shorter half-life may need to
be given 3 or 4 times a day, but drugs with a longer half-life may be given once a day.
The time that the drugs need to leave the body completely after it has been
discontinued is about 5 times its half life.
Principles that Guide Pharmacologic Treatment
The following are several principles that guide the use of medications to treat psychiatric
disorder:
A medication is selected based on its effect on the clients target symptoms such
as delusional thinking, panic attacks, or hallucinations. The medications
effectiveness is evaluated largely by its ability to diminish or eliminate the target
symptoms.
Many psychotropic drugs must be given in adequate dosages for some time
before their full effect is realized. For example, tricyclic antidepressants can
require 4 to 6 weeks before the client experiences optimal therapeutic benefit.
The dosage of medication often is adjusted to the lowest effective dosage for the
client. Sometimes client may need higher dosages to stabilize his or her target
symptoms, whereas lower dosages can be used to sustain those effects
overtime.
As a rule, older adults require lower dosages of medications than do younger
clients to experience therapeutic effects. It also may take longer for a drug to
achieve its full therapeutic effect in older adults.
Psychotropic medications often are decreased gradually (tapering) rather than
abruptly. This is because of potential problem with rebound (temporary return of
symptoms), recurrence of the original symptoms, or withdrawal (new symptoms
resulting from discontinuation of the drug).
Follow up care is essential to ensure compliance with the medication regimen, to
make needed adjustments in dosage, and no mange side effects.
Compliance with the medication regimen often is enhanced when the regimen is
as simple as possible in terms of both the number of medications prescribed and
the number of daily doses.

Lists of medications such as:

Antipsychotic Drugs
Antidepressant Drugs
Antianxiety Drugs (Anxiolytics)
Disulfiram (Antabuse)

SUPPORTIVE PSYCHOTHERAPY
-Is a psychotherapeutic approach that integrates psychodynamic, cognitivebehavioral, and interpersonal conceptual models and techniques.
-Is used primarily to reinforce a patients ability to cope with stressors through a
number of key activities, including attentively listening and encouraging
expression of thoughts and feelings; assisting the individual to gain a greater
understanding of their situation and alternatives; helping to buttress the
individuals self-esteem and resilience; and working to instill a sense of hope.
-Is a type of psychological therapy that aims to help the client to function better
by providing personal support
-In general, the therapist does not ask the client to change; rather they act as a
support person, allowing the client to reflect on their life situation in an
environment where they are accepted.
-It is a common form of therapy that may be provided over the short or long term,
depending on the individual and the specific set of circumstances.
-The objective of the therapist is to reinforce the patient's healthy and adaptive
patterns of thought behaviors in order to reduce the intrapsychic conflicts that
produce symptoms of mental disorders.
-Unlike in psychoanalysis, in which the analyst works to maintain a neutral
demeanor as a "blank canvas" for transference, in supportive therapy the

therapist engages in a fully emotional, encouraging, and supportive relationship

with the patient as a method of furthering healthy defense mechanisms,
especially in the context of interpersonal relationships.
-This therapy has been used for patients suffering from severe cases of addiction
as well as Bulimia Nervosa, stress and other mental illnesses. Trust is very
important between patients and the doctors to help patients get better treatment
effect.
-In this form of therapy, a trusting relationship between the patient and the
therapist is integral to the patients healing or progress. It is important that the
individual has confidence that the therapist can understand their feelings of
despair or anger, yet still maintain a belief in their ability to recover. They must
also help the patient to understand the difference between recovering and
gaining back what has been lost. In many cases, re-establishing the past or prior
patterns of life is not possible, and the patient will need to come to terms with the
changes that need to be made.
A. NURSE-PATIENT RELATIONSHIP THERAPY
Hildegard Peplau: Therapeutic nurse- patient Relationship
Peplau studied and wrote about the interpersonal processes and the phases of
the nurse- client relationship for 35 years. Her work provides the nursing profession with
a model that can be use to understand and document progress with interpersonal
interactions. Peplaus model has three phases: orientation, working, and resolution
phase or termination.
Orientation phase- begins when the nurse and client meet and ends when the client
begins to identify problems to examine.
Working Phase- of the nurse client relationship is usually divided into two sub phases:
During problem identification, the client identifies the issues or concerns causing
problems. During exploitation, the nurse guides the client to examine feelings and
responses and to develop better coping skills and a more positive self image

Termination or resolution phase- is the final stage in the nurse client relationship. It
begins when the problems are resolved and it ends when the relationship is ended
Definition of Groups

is a number of persons who gather in a face to face setting to accomplish tasks

that require cooperation, collaboration, or working together.

Is a collection of individuals whose association is founded on commonalties of
interest, norms and values?

Group Context

Refers to what is said in the context of the group, including educational material,
feelings and emotions, or discussions of the project to be completed.

Group Process

Refers to the behavior of the group and its individual members, including seating
arrangement, tone voice, who speaks to who, who is quiet, and so forth.

Stages of Group Development

Pregroup Stages
Members are selected, the purpose or work of the group is identified, and group
structure is addressed.
Initial/beginning Stages
Members introduce themselves, a leader can be selected, group purpose is
discussed, and rules and expectation for group participation are reviewed.
Working Stages
Begins as members begin to focus their attention on the purpose or task the
group is trying to accomplish.
Phase in which several group characteristics maybe seen like cohesiveness and
competition or rivalry.

Final/Termination Stage
Occur before the group disbands.
Work of the group is reviewed with the focus on group accomplishments or
growth of the group members or both depending on the purpose of the group.
GROUP LEADERSHIP
Groups often have an identified or formal leader- someone designated to lead
the group. In therapy and education groups, a formal leader is usually identified based
on his/her education, qualifications, and experience. Support and self groups usually do
not have identified formal leaders; all members are seen as equal. Effective group,
leaders focus on group process as well as on group content. His/her tasks include
giving feedback and suggestions; encouraging participation from all members; clarifying
thoughts, feelings, and ideas; summarizing progress and accomplishments;

and

facilitating progress through the stages of group development.

GROUP ROLES
Roles are the parts that members play within the group. Some roles facilitate the
work of the group, whereas others can negatively affect the process or outcome of the
group. Growth-producing roles include the information seeker, opinion seeker,
information giver, energizer, coordinator, harmonizer, encourager, and elaborator.
Growth-Inhibiting roles include monopolize, aggressor, dominator, critic, recognition
seeker, and passive follower.
B.GROUP THERAPY

Clients participate in sessions with a group of people.

A type of psychiatric care in which several patients meet one or more
therapists at the same time. The group therapy model is particularly
appropriate for psychiatric illnesses that are support-intensive, such as
anxiety disorders, but is not well suited for treatment of some other
psychiatric disorders.

Is a form of psychosocial treatment where a small group of patients meet

regularly to talk, interact, and discuss problems with each other and the
group leader (therapist).

The therapeutic results of group therapy includes gaining new information, or

learning; gaining inspiration or hope, interacting with others; feeling of
acceptance and belonging; becoming aware that one is not alone and that others
share the same problems; gaining insight into one`s problems and behaviors and
how they affect others; giving of oneself for the benefit of others(altruism).
PSYCHOTERAPHY GROUPS
The goal of psychotherapy group is for members to learn about their behavior
and to make positive changes in their behavior by interacting and communicating with
others as a member of a group. Psychotherapy groups are often formal in structure with
one or two therapists as the group leader or the entire group is to establish the rules for
the group.
There are two types of groups: open groups and closed groups. Open groups
are ongoing and run indefinitely, allowing members to join or leave the group as they
need to while the Closed groups are structured to keep the same members in the
group for a specified number of sessions.
C.FAMILY THERAPY
Family Therapy is a form of group therapy in which the client and his or her
family members participate. The goals include understanding how family dynamics
contribute to the clients psychopathology, mobilizing the family`s inherent strengths and
functional

resources,

restructuring

maladaptive

family

behavioral

styles,

and

strengthening family-problem solving behaviors. It can be used both to asses and to

treat various psychiatric disorders.

EDUCATION GROUPS
The goal of the group is to provide information to members to a specific issue-for
instance, stress management, medication management, or assertive training. It is
usually scheduled for a specific number of sessions and retains the same members for
the duration of the group.
SUPPORT GROUPS
It is organized to help members who share a common problem to cope with it.
Support groups often provide a safe place for group members to express their feelings
of frustration, boredom, or unhappiness and also to discuss common problems and
potential solutions.
COUNSELLING
-One of the Roles or Function of a Nurse
- is the process of helping a client to recognize and cope with stressful psycologic
and stressful problems, to develop improved interpersonal relationships, and to promote
personal growth. It involves providing emotional, intellectual and psychological support.
-The nurse counsel primarily healthy individuals with normal adjustment
difficulties and focuses on helping the person develop new attitudes, feeling and
behaviour by encouraging the client to look at alternative behaviours, recognize
choices, and develop sense of control.
Virginia Satir- explained how important the clients participation is to finding effective
and meaningful solutions to the problem.
MENTAL HEALTH TEACHING/ CLIENT EDUCATION
-Teaching- coaching is one of the standards of care for the Psychiatric-Mental
Health Nurse. According to this standard, the PMH nurse attempts to understand the
life experience of the client and uses this understanding to support and promote
learning related to health and personal development.

-Based on principles of teaching, health teaching involves collaborating with the

client to determine learning needs and transmitting new information, while considering
the context of the clients life experiences:
The nurse considers:
1. Readiness- Readiness may include readiness for change, readiness to
engage in a specific program or with a specific helper and readiness to
continue the ongoing process of rehabilitation.
2. Culture- When approaching someone outside your own culture or community
to discuss their mental health, be aware:
a. In some communities, for example, eye contact is considered as staring,
and may make the person feel as though they are being judged.
b. Ask for the persons permission before asking about sensitive topics, but
suggest that they may feel better once they have spoken about their
problems. Be careful not to falsely imply that by talking about mental
illness the persons problems will go away. Instead, just reassure the
person that you care and want to help.
c. Allow for periods of silence while the person considers what you have said
and allow them plenty of time to tell their story.
3. Literacy- the capacity to obtain, process and understand basic health
information and services needed to make appropriate health decisions.
4. Language- What is a respectful way to communicate with the person
(including body language, seating position and use of certain words) may
differ from community to community and region to region, especially between
rural and remote areas. When discussing your concerns, use simple and
clear language.
5. Preferred learning style- Learners with mental health difficulties, like all
learners, is more likely to learn when they: are encouraged and supported,
feel confident and competent, and are interested.
Canadian Standards of Psychiatric-Mental Health Nursing- according to them all
interactions between the nurse and patient are potentially teaching/learning
situations.
SELF-ENHANCEMENT

-is a type of motivation that works to make people feel good about themselves
and to maintain self-esteem. This motive becomes especially prominent in situations of
threat, failure or blows to one's self-esteem
Levels of Self-Enhancement:
Observed Effect- Self-enhancement at the level of an observed effect describes
the product of the motive. For example, self-enhancement can produce inflated
self-ratings (positive illusions). Such ratings would be self-enhancement
manifested as an observed effect. It is an observable instance of the motive.
Ongoing Process- Self-enhancement at the level of an ongoing process
describes the actual operation of the motive. For example, self-enhancement can
result in attributing favorable outcomes to the self and unfavorable outcomes to
others (self-serving attribution bias). The actual act of attributing such ratings
would be self-enhancement manifested as an ongoing process. It is the motive in
operation.
Personality Trait- Self-enhancement at the level of a personality trait describes
habitual or inadvertent self-enhancement. For example, self-enhancement can
cause situations to be created to ease the pain of failure (self-handicapping). The
fabrication of such situations or excuses frequently and without awareness would
be self-enhancement manifested as a personality trait. It is the repetitive
inclination to demonstrate the motive.
Underlying Motive- Self-enhancement at the level of an underlying motive
describes the conscious desire to self-enhance. For example, self-enhancement
can cause the comparison of the self to a worse other, making the self seem
greater in comparison (strategic social comparisons). The act of comparing
intentionally to achieve superiority would be self-enhancement manifested as an
underlying motive. It is the genuine desire to see the self as superior. (The four
levels of self-enhancement manifestation as defined by Sedikides & Gregg
(2008)
Dimensions:

 Self-Advancement vs. Self-Protection- Self-enhancement can occur by either

self-advancing or self-protecting that is either by enhancing the positivity of one's
self-concept, or by reducing the negativity of one's self-concept. Self-protection
appears to be the stronger of the two motives, given that avoiding negativity is of
greater importance than encouraging positivity.
Public vs. Private- Selfenhancement can occur in private or in public. Public
self-enhancement is obvious positive self-presentation,

whereas private self

enhancement is unnoticeable except to the individual

Central vs. Peripheral- Potential areas of self-enhancement differ in terms how
important, or central, they are to a person. Self-enhancement tends to occur
more in the domains that are the most important to a person, and less in more
peripheral, less important domains.
Candid vs. Tactical- Self-enhancement can occur either candidly or tactically.
Candid self-enhancement serves the purpose of immediate gratification whereas
tactical self-enhancement can result in potentially larger benefits from delayed
gratification. Tactical self-enhancement is often preferred over candid selfenhancement as overt self-enhancement is socially displeasing for those around
it.
Types:
Self-serving attribution bias- People have a tendency to exhibit a self-serving
attribution bias, that is to attribute positive outcomes to one's internal disposition
but negative outcomes to factors beyond one's control e.g. others, chance or
circumstance.
Selective memory- People sometimes self-enhance by selectively remembering
their strengths rather than weaknesses. This pattern of selective forgetting has
been described as mnemic neglect. Mnemic neglect may reflect biases in the
processing of information at encoding, retrieval or retention.
Selective acceptance & refutation- Selective acceptance involves taking as fact
self-flattering or ego-enhancing information with little regard for its validity.
Selective refutation involves searching for plausible theories that enable criticism
to be discredited.

 Strategic Social Comparisons- The social nature of the world we live in means
that self-evaluation cannot take place in an absolute nature - comparison to other
social beings is inevitable. Many social comparisons occur automatically as a
consequence of circumstance, for example within an exam sitting social
comparisons of intellect may occur to those sitting the same exam.
Upward Social Comparisons- involves comparing oneself to an individual

perceived to be superior to or better than one.

Downward Social Comparisons- involve comparing oneself to an
individual perceived to be inferior to or less skilled than the self.
Downwards social comparisons serve as a form of ego-defense whereby
the ego is inflated due to the sense of superiority gained from such

downwards social comparisons.

Lateral Social Comparisons- comparisons against those perceived as
equal to the self can also be self-enhancing.

ASSERTIVE TRAINING
-it helps the person take control over life situations
- Form of behaviour therapy designed to help people stand up for themselvesto
empower themselves, in more contemporary terms.
-it works best when the speaker is calm, specific, factual statements and focuses
on I statements.
Purpose
- To teach persons appropriate strategies for identifying and acting on their
desires, needs, and opinions while remaining respectful of others
- Useful in variety of situations, such as resolving conflicts, solving problems and
expressing feelings or thoughts
Four types of responses
1. Aggressive - a style in which individuals express their feelings and opinions and
advocate for their needs in a way that violates the rights of others. Thus,
aggressive communicators are verbally and/or physically abusive. Aggressive
communication is born of low self-esteem (often caused by past physical and/or
emotional abuse), unhealed emotional wounds, and feelings of powerlessness.

2. Passive-aggressive - a style in which individuals appear passive on the surface

but are really acting out anger in a subtle, indirect, or behind-the-scenes way.
Prisoners of War (POWs) often act in passive-aggressive ways to deal with an
overwhelming lack of power.
3. Passive -a style in which individuals have developed a pattern of avoiding
expressing their opinions or feelings, protecting their rights, and identifying and
meeting their needs. Passive communication is usually born of low self-esteem.
These individuals believe: Im not worth taking care of.
4. Assertive - a style in which individuals clearly state their opinions and feelings,
and firmly advocate for their rights and needs without violating the rights of
others. Assertive communication is born of high self-esteem. Individuals value
themselves, their time, and their emotional, spiritual, and physical needs and are
strong advocates for them while being very respectful of the rights of others.
*broken record technique instead of responding to additional information, the speaker
simply repeats the response without justifying or explaining the response. In time, the
person can become quite comfortable refusing a request without feeling guilty or
compelled to explain the refusal.
STRESS MANAGEMENT
Too often anxiety is viewed negatively as something to avoid at all costs. Actually
for many people anxiety is a warning that they are not dealing with stress effectively.
Learning to heed this warning and to make needed changes is a healthy way to deal
with the stress of daily events.
Stress and resulting anxiety are not associated exclusively with life problems.
Events that are positive or desired such as going away to college, getting a first job,,
getting married, and having children are stressful and cause anxiety. Managing the
effects of stress and anxiety in ones life is important to being healthy. Tips for managing
stress include the following:

Keep a positive attitude and believe in yourself.

Accept that there are events you cannot control.
Communicate assertively with others.
Learn to relax.
Exercise regularly.

Eat well-balanced meals.

Limit intake of caffeine and alcohol.
Get enough rest and sleep.
Set realistic goals and expectations.
Learn stress management techniques such as relaxation, guided imagery,
and meditation; practice them as part of your daily routine.

BEHAVIOR MODIFICATION
Behavior Modification is a therapeutic technique based on the work ofB.F.
Skinner, a famous psychologist who is known as the "Father of Behaviorism." Skinner
developed a theory of operant conditioning, which states that all behavior is governed
by reinforcing and punishing stimuli. Behavior modification uses a scheduled approach
that rewards desired behavior and "punishes" undesirable behavior. This technique
continues to be used in therapy and issued in many psychological settings.
Behavior modification is a term used in behavioural therapies to denote methods
for conditioning behavior. It has its roots in classical conditioning, which involves the
pairing of a behavior with reinforcement. The main idea is to reward the person if they
implement a desired behavior or if they stop undesired behavior. Behavior modification
can also involve incurring an unpleasant consequence for undesired behavior. Behavior
modification is used in a variety of situations, ranging from the behaviors of a child in the
classroom and at home to the behavior of adult prison inmates. This conditioning may
be implemented by an authority figure, or it may be used in self-help exercises.
Behavior Modification is a method of attempting to strengthen a desired behavior
or response by reinforcement, either positive. For example, if the desired behavior is
assertiveness, wherever the client uses assertiveness skills in a communication group,
the group POSITIVE REINFORCEMENT is by giving the client attention and positive
feedback. NEGATIVE REINFORCEMENT involves removing a stimulus immediately
after a behavior occurs so that the behavior is more likely to occur again. For example,
if a client becomes anxious when waiting to talk in a group, he or she may volunteer to
speak first to avoid anxiety.
The Purpose of Behavior modification is used to treat a variety of problems in
both adults and children. Behavior modification has been successfully used to treat

Obsessive-CompulsiveDisorder (OCD), Attention-Deficit/Hyperactivity Disorder (ADHD),

Phobias and Enuresis (bed-wetting).
COGNITIVE RESTRUCTURING
Learning how to think differently to change faulty thinking to a more
realistic, rational, positive thinking.
Also referred to as cognitive reframing which is a behavior technique
associated with cognitive therapy.
Being able to recognize when thoughts are irrational and learn to replace
them with rational thoughts.
Cognitive restructuring is most beneficial for those who suffer from anxiety,
depression, social phobia, eating disorders, etc
Allows people to face their daily lives with confidence because they have
learned to control their thinking and change irrational thoughts into rational
thoughts.
Cognitive-behavioral Therapy (CBT)
It focuses on immediate thought processing how a person
perceives or interprets his/her experience and determines how
he/she feels and behaves.
It involves learning how to think differently, to change fundamental
faulty thinking, and replace it with more rational, realistic, and
perhaps positive thinking.

It focuses on helping its users understand the negative thought

processes that can cause problems, and on restructuring these so
that they are fair and balanced.

Dr. Aaron T. Beck

Pioneered CBT in the 1960s while he was a psychiatrist at the University of
Pennsylvania
Dr. Beck designed and carried out experiments to test psychoanalytic concepts
of depression

 He found that depressed patients experienced streams of negative thoughts and

named these cognitions automatic thoughts

Automatic thoughts
Critical thoughts that frequently think and say to yourself.
Thoughts which sabotage success & happiness
Thoughts which makes feel sad or anxious
Can occur consciously or without any awareness that youre
thinking them.

1. Rational Emotive Therapy (RET)

A cognitive therapy using confrontation of irrational beliefs that
prevent the individual from accepting responsibility for self and
behavior.
It emphasizes that thoughts affect human emotion as well as
behavior and irrational beliefs are mainly responsible for a wide
range of disorders.
Uses ABC technique to help people identify these automatic
thoughts.
A: Activating Agent/ Adversity
B: Believe
C: Consequences
Example:
A:Your employer falsely accuses you of taking money from
her purse and threatens to fire you.
B:You believe, She has no right to accuse me. Shes a
bitch!
C:You feel angry.
If you had held a different belief, the emotional
response would have been different.
A:Your employer falsely accuses you of taking money from
her purse and threatens to fire you.

B:You believe, I must not lose my job. That would be

unbearable.
C:You feel anxious.
ABC model shows that A does not cause C. It is B
that causes C.
Albert Ellis

Albert Ellis founded Rational Emotive Therapy (RET).

He identified irrational beliefs that people use to make their selves unhappy.

He believes that people have automatic thoughts that cause them unhappiness
in certain situations.
2. Logotherapy

It means 'therapy through meaning'.

A therapy designed to help individuals assume personal

responsibility (the search for meaning in life is a central theme)

Third Viennese School of Psychology, following Freud and Adler

According to Logotherapy, we can discover our meaning in life

in three different ways:
1. by creating a work or doing a deed
2. by experiencing something (goodness, truth, beauty,
nature and culture) or encountering someone
experiencing

another

human

being

in

his

(by
very

uniqueness; by loving him)

3. by the attitude we take toward unavoidable suffering.
Viktor Emil Frankl

He is a Professor of Neurology and Psychiatry

Founder of Logotherapy and Existential Analysis

Authored the book Mans Search for Meaning- belongs to "the ten most
influential books in America."
3. Gestalt Therapy

 A therapy focusing on the identification of feelings in the here and

now, which leads to self-acceptance.
It is used to increase clients self-awareness by having them write
and read letters, keep journals, and perform other activities
designed to put the past to rest and focus on the present.
Frederick S. Perls
- He believed that self-awareness leads to self-acceptance and
responsibility for ones own thoughts and feelings.
4. Reality Therapy
Therapeutic focus is need for identity through responsible behavior.

Individuals are challenged to examine ways in which their behavior

thwarts their attempts to achieve life goals.

William Glasser

Devised an approach called Reality Therapy.

He developed this approach while working with persons with delinquent behavior,
unsuccessful school performance, and emotional problems.

He believed that persons who were unsuccessful often blamed their problems on
other people, the system, or the society.

He believed they needed to find their own identities through responsible

behavior.

MILIEU THERAPY
Milieu therapy involves clients interaction with one another, that is, practicing
interpersonal relationship skills, giving one another feedback about behavior and
working cooperatively as a group to solve day-to-day problems. Sullivan coined the term
Participant Observer for the therapist role, meaning that the therapist both participates

and observes the progress of the relationship. In the concept of therapeutic community
or milieu, the interaction among the client is seen as beneficial and treatment
emphasizes the role of the client-to-client interaction. It was believe that the interaction
between the client and the psychiatrist was the one essential component to the clients
treatment.
Objectives of Milieu Therapy
To promote a fundamental respect for individuals (both clients and staff).
To use opportunities for communication between client and staff for maximum
therapeutic benefit.
To encourage clients to act at a level equal to their ability and to enhance their
self esteem( autonomy is reinforced)
Provide safety and protection for all clients and promote social interaction
Positive Peer pressure is utilized to reinforce rules and regulations.
Advantages:
1. Milieu therapy creates a different type of attitude and behaviour in the patient
because the environment is like home.
2. The patient learns to make decisions which improve his self confidence.
3. A therapeutic milieu is a safe space, a non punitive atmosphere, which minimize
the environmental stress and provides a chance for rest and nurturance of self, a
time to focus on the developments of strengths, and an opportunity to learn to
identify alternatives or solutions to problems.
4. Patient develops harmonious relationships with other members of the community.
Disadvantages:
1. Role blurring between staff and patient.
2. Milieu therapy is limited to only hospitalized patients.

3. Conflict resolution is needed as part of the staffs skills.

4. Low client- to- staff ratio.
5. Requires continuous open communication among all staff and clients.
PLAY THERAPY
-is also known as THERAPEUTIC PLAY, play techniques are used to understand
the childs thoughts and feelings and to promote communication. It is used by
Psychiatrists.
DRAMATIC PLAY
- Is acting out an anxiety- producing situation such as allowing the child to be a
doctor or use a stethoscope or other equipment to take care of a patient (a doll). Play
techniques to release energy could include pounding pegs, running, or working with
modeling clay.
CREATIVE PLAY
- It is a technique that can help children to express themselves, for example, by

drawing pictures of themselves, their family and peers. These techniques are especially
useful when children are unable or unwilling to express themselves verbally.
PSYCHOSOCIAL SUPPORT INTERVENTIONS
Psychosocial Interventions- Nursing activities that enhance the clients social and
psychological functioning and improve social skills, interpersonal relationships, and
communication. Nurses often use psychosocial interventions to help meet clients needs
and achieve outcomes in all practice settings.
For example, a medical-surgical nurse might need to use interventions that incorporate
behavioral principles such as setting limits with manipulative behavior or getting positive
feedback. Example: A client with DM Patient: I promise to have just one bite of cake.
Please! Its my grandsons birthday cake. Nurse: I cant give you permission to eat the

cake. Your blood glucose level will go up if you do, and your insulin cant be adjusted
properly.
PSYCHO SPIRITUAL INTERVENTIONS
Psychotherapy can help patients with religious and spiritual problems to shape
their experience into a coherent narrative, to see the "message" contained in their
experiences, and to create a life-affirming personal mythology that integrates their
spiritual problem. Psycho-spiritual interventions can be essential to facilitating recovery
and change. At times these could include:
-Educating the patient about the spiritual emergence process that is part of a
spiritual journey with a potentially positive outcome.
-Encouraging the patient's involvement with a spiritual path or religious
community that is consistent with their experiences and values.
-Encouraging the patient to seek support and guidance from a credible and
appropriate religious or spiritual leader.
-Encouraging the patient to engage in religious and spiritual practices consistent
with their beliefs (e.g., prayer, meditation, reading spiritual books, acts of worship, ritual,
forgiveness and service)
-Modeling his/her own spirituality (when appropriate), including a sense of
spiritual purpose and meaning, hope, and faith in something transcendent
COMPLEMENTARY AND ALTERNATIVE THERAPIES
National Center for Complementary and Alternative Medicine (NCCAM)
The National Center for Complementary and Alternative Medicine (NCCAM) is a
federal government agency for scientific research on complementary and alternative
medicine (CAM). This agency is a part of National Institutes of health in the Department
of Health and Human Services. This United States government agency is formerly
known as Office of Alternative Medicine (OAM) that investigates in different healing
practices in the context of rigorous science, in training complementary and alternative
medicine researchers, and in disseminating authoritative information to the public and
professionals.
NCCAM's programs and organization incorporate 3 long-range goals:

Advance the science and practice of symptom management.

Develop effective, practical, personalized strategies for promoting health and

well-being.
Enable better evidence-based decision making regarding CAM use and its
integration into health care and health promotion.

Five major objectives serve the goals:

Advance research on mind and body interventions, practices, and disciplines.

Advance research on CAM natural products.
Increase understanding of "real world" patterns and outcomes of CAM use and

its integration into health care and health promotion.

Improve the capacity of the field to carry out rigorous research.
Develop and disseminate objective, evidence-based information on CAM
interventions.

Complementary Medicine includes therapies used with conventional medicine

practices (the medical model).Conventional Medicine Practices are treatments
prescribed by the Medical Doctors (M.D.); this is the regular and standard medicine.
Conducting research on the use of chiropratic massage and antidepressant medications
to treat depression is an example of complementary medicine research.
Alternative Medicine includes therapies used in place of conventional treatment.
NCCAM conducts clinical research to help determine the safety and efficacy of these
practices. Studying the use of St. Johns worth to treat depression (instead of using
antidepressant medication) would be an example of researching alternative medicine.
Conducting research on the use of chiropratic massage and antidepressant medications
to treat depression is an example of complementary medicine research.
Integrative Medicine combines conventional medical therapy and CAM therapies that
have scientific evidence supporting their safety and effectiveness.
NCCAM studies a wide variety of complementary and alternative therapies:

Alternative medical systems include homeopathic medicine and naturopathic

medicine in Western cultures, and traditional Chinese medicine, which include
herbal and nutritional therapy, restorative physical exercises (yoga and Tai chi),

meditation, acupuncture, and remedial massage.

Mind-body interventions include meditation, prayer, mental healing, and creative
therapies that use art, music or dance.

Biologically based therapies use substances found in nature such as herbs, food
and vitamins. Dietary supplements, herbal products, herbal teas, aromatherapy,

and a variety of diets are included.

Manipulative and body-based therapies are based on manipulation or movement
of one or more parts of the body, such as therapeutic massage and chiropathic or

osteopathic manipulation.
Energy therapies include two types of therapy: biofield therapies, intended to
affect energy fields that are believed to surround and penetrate the body such as
therapeutic touch, qi gong, and Reiki, and bioelectrical-based therapies
involving the unconventional use of electromagnetic fields, such as pulsed fields,
magnetic fields, and AC or DC fields. Qi gong is a part of Chinese medicine that
combines movement, meditation, and regulated breathing to enhance the flow of
vital energy and promote healing. Reiki (which in Japanese means universal life
energy) is based on the belief that when spiritual energy is channelled through a
Reiki practitioner, the patients spirit and body are healed.

Client may be reluctant to tell the psychiatrist or primary care provider about the use of
CAM. Therefore, it is important that the nurse ask clients specifically about use of herbs,
vitamins, or other health practices in a non-judgemental way.