mental health

a state of emotional, psychological, and social wellness evidenced by: satisfying interpersonal relationships effective behavior and coping positive self-concept emotional stability

FACTORS INFLUENCING MENTAL HEALTH

1. 2. 3. 4. 5. 6. 7.

Autonomy and independence Maximization of ones potential Tolerance of lifes uncertainties Self Esteem Mastery of the environment Reality orientation Stress management

MENTAL ILLNESS

Mental illness
a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom

General criteria to diagnose mental disorders:

dissatisfaction with ones characteristics, abilities, and accomplishments ineffective or nonsatisfying relationships Dissatisfaction with ones place in the world ineffective coping with life events lack of personal growth In addition, the persons behavior must not be culturalyl expected or sanctioned nor does deviant behavior necessarily indicate a mental disorder (APA, 2000).

INDIVIDUAL, INTERPERSONAL, AND SOCIAL/ CULTURAL CATEGORIES.

Individual factors:
biologic Makeup anxiety, worries and fears, a sense of disharmony in life a loss of meaning in ones life (Seaward, 1997).

Interpersonal factors:
Ineffective communication excessive dependency or withdrawal from relationships loss of emotional control.

Social and Cultural Factors:

lack of resources, Violence Homelessness Poverty Discrimination such as racism, classism, ageism, and sexism.

HISTORICAL PERSPECTIVES and TRENDS

People of ancient times believed that any sickness indicated displeasure of the gods and in fact was punishment for sins and wrongdoing. Those with mental disorders were viewed as being either divine or demonic depending on their behavior.

 Individuals seen as divine were worshipped and adored; those seen as demonic were ostracized, punished, and sometimes burned at the stake.

Aristotle (382- 322 BC)

related mental disorders to physical disorders theorized that the amounts of blood, water, and yellow and black bile in the body controlled the emotions. These 4 substances were also called humors corresponded with happiness, calmness, anger, and sadness.

 Imbalances of the four humors were believed to cause mental disorders so treatment aimed at restoring balance through: 1. Bloodletting 2. starving 3. purging Such treatments persisted well into the 19th century (Baly, 1982).

early Christian times (11000 AD),

Primitive beliefs and superstitions were strong All diseases were again blamed on demons mentally ill were viewed as possessed. Priests performed exorcisms to rid evil spirits. When that failed, they used more severe measures such as incarceration in dungeons, flogging, starving, and other brutal treatments.

Renaissance (13001600)
people with mental illness were distinguished from criminals in England. Those considered harmless were allowed to wander the countryside or live in rural communities but the more dangerous lunatics were thrown in prison, chained, and starved (Rosenblatt, 1984).

 In 1547, the Hospital of St. Mary of Bethlehem was officially declared a hospital for the insane (the first of its kind) 1775, visitors at the institution were charged a fee for the privilege of viewing and ridiculing the inmates, who were seen as animals, less than human (McMillan, 1997). During this same period in the colonies (later the United States), the mentally ill were considered evil or possessed and were punished. Witch hunts were conducted, and offenders were burned at the stake.

Period of Enlightenment and Creation of Mental Institutions

 1790s, a period of enlightenment concerning persons with mental illness began. Phillippe Pinel in France and William Tukes in England formulated the concept of asylum as a safe refuge or haven offering: protection at institutions where people had been whipped, beaten, and starved just because they were mentally ill (Gollaher, 1995).

 Dorothea Dix (18021887) began a crusade to reform the treatment of mental illness after a visit to Tukes institution in England. was instrumental in opening 32 state hospitals that offered asylum to the suffering. HOWEVER: The period of enlightenment was short-lived. Within 100 years after establishment of the first asylum, state hospitals were in trouble. Attendants were accused of abusing the residents, the rural location of hospitals was viewed as isolating patients from family and their homes, and the phrase insane asylum took on a negative connotation.

SIGMUND FREUD AND TREATMENT OF MENTAL DISORDERS

 The period of scientific study and treatment of mental disorders began with Sigmund Freud (18561939) Emil Kraepelin (18561926) Eugene Bleuler (18571939).

 Freud challenged society to view human beings objectively. He studied the mind, its disorders, and their treatment as no one had before. Many other theorists built on Freuds pioneering work Kraepelin began classifying mental disorders according to their symptoms, Bleuler coined the term schizophrenia.

DEVELOPMENT OF PSYCHOPHARMACOLOGY

 A great leap in the treatment of mental illness began in about 1950 with the development of psychotropic drugs (drugs used to treat mental illness). Chlorpromazine (Thorazine), an antipsychotic drug, and lithium, an antimanic agent, were the first drugs to be developed.

 For the first time, drugs actually reduced agitation, psychotic thinking, and depression. Hospital stays were shortened, and many people were well enough to go home. The level of noise, chaos, and violence greatly diminished in the hospital setting (Trudeau, 1993).

MENTAL ILLNESS IN THE 21ST CENTURY

 The Department of Health and Human Services (2002) estimates that 56 million Americans have a diagnosable mental illness Four of the ten leading causes of disability in theUnited States and other developed countries are mental disorders: major depression, bipolar disorder, schizophrenia, and obsessive-compulsive disorder

revolving door effect

While people with severe and persistent mental illnesses have shorter hospital stays, they are admitted to hospitals more frequently. In some cities, emergency department visits for acutely disturbed persons have increased by 400% to 500%.

 Many providers believe todays clients to be more aggressive than those in the past. Four to eight percent of clients seen in psychiatric emergency rooms are armed (Ries, 1997)

OBJECTIVES FOR THE FUTURE

 Decrease rates of suicide and homelessness to increase employment among those with serious mental illness to provide more services for both juveniles and adults who are incarcerated and have mental health problems.

Community-Based Care
Developed to meet the needs of persons with mental illness outside the walls of an institution. focus on rehabilitation, vocational needs, education,and socialization as well as management of symptoms and medication. These services are funded by states (or counties) and some private agencies.

UNFORTUNATELY:
community-based system did not accurately anticipate the extent of the needs of people with severe and persistent mental illness. Many clients do not have the skills needed to live independently in the community nature of some mental illnesses makes learning these skills more difficult

 For example, a client who is hallucinating, or hearing voices, can have difficulty listening to or comprehending instructions. Other clients experience drastic shifts in mood, being unable to get out of bed one day, then unable to concentrate or pay attention a few days later.

Positive impact:
Clients can remain in their communities, maintain contact with family and friends, and enjoy personal freedom that is not possible in an institution. People in institutions often lose motivation and hope as well as functional daily living skills such as shopping and cooking. Therefore treatment in the community is a trend that will continue.

Cultural Considerations
The United States Census Bureau (2000) estimates that 62% of the population has European origins. This number is expected to continue to decrease as more U.S. residents trace their ancestry to Africa, Asia, or the Arab or Hispanic worlds in the future.

 Nurses must be prepared to care for this culturally diverse population, and that includes being aware of cultural differences that influence mental health and the treatment of mental illness Diversity is not limited to culture the structure of families in the United States has changed as well. With a divorce rate of 50% in the United States, single parents head many families, and many blended families are created when divorced persons remarry.

 Twenty-five percent of households consist of a single person (Wright, 1995) many people live together without being married. Gay men and lesbians form partnerships and sometimes adopt children. The face of the family in the United States is varied, providing a challenge to nurses to provide sensitive, competent care.

PSYCHIATRIC NURSING PRACTICE

In 1873, Linda Richards graduated from the New England Hospital for Women and Children in Boston. She went on to improve nursing care in psychiatric hospitals and organized educational programs in state mental hospitals in Illinois. Richards is called the first American psychiatric nurse

 she believed that the mentally sick should be at least as well cared for as the physically sick (Doona, 1984) The first training of nurses to work with personswith mental illness was in 1882 at McLean Hospitalin Waverly, Mass.

Care focused on:

nutrition, hygiene, and activity. Nurses adapted medical-surgical principles to the care of clients with psychiatric disorders and treated them with tolerance and kindness.

 The role of psychiatric nurses expanded as somatic therapies for the treatment of mental disorders were developed. Treatments such as insulin shock therapy (1935), psychosurgery (1936) electroconvulsive therapy (1937) required nurses to use their medical-surgical skills further.

Nursing Mental Diseases (Harriet Bailey)

first psychiatric nursing textbook published in 1920.

 In 1913, Johns Hopkins was the first school of nursing to include a course in psychiatric nursing in its curriculum. 1950 - National League for Nursing, which accredits nursing programs, required schools to include an experience in psychiatric nursing.

NURSING THEORISTS

Hildegard Peplau
published Interpersonal Relations in Nursing in 1952 Interpersonal Techniques: The Crux of Psychiatric Nursing in 1962. Described the therapeutic nurseclient relationship with its phases and tasks and wrote extensively about anxiety

June Mellow
Nursing Therapy (1968) described her approach of focusing on the clients psychosocial needs and strengths. Contends that the nurse as therapist is particularly suited to working with those with severe mental illness in the context of daily activities, focusing on the here-and now to meet each persons psychosocial needs (1986).

Standards of care
Developed by American Nurses Association Authoritative statements by professional organizations that describe the responsibilities for which nurses are accountable. not legally binding unless they are incorporated into the state nurse practice act or state board rules and regulations. used to determine what is safe and acceptable practice and to assess the quality of care when legal problems or lawsuits arise

 describe the 12 areas of concern that mental health nurses focus on when caring for clients The standards of care incorporate the phases of the nursing process, including specific types of interventions, for nurses in psychiatric settings outline standards for professional performance: quality of care, performance appraisal, education, collegiality, ethics, collaboration, research, and resource utilization

Phenomena of concern

STUDENT CONCERNS:

What if I say the wrong thing?

No one magic phrase can solve a clients problems; likewise, no single statement will significantly worsen them. Listening carefully, showing genuine interest, and caring about the client are extremely important. A nurse who possesses these elements but says something that sounds out of place can simply restate it by saying: That didnt come out right. What I meant was ..

What will I be doing?

The student must deal with his or her own anxiety about approaching a stranger to talk about very sensitive and personal issues. Development of the therapeutic nurseclient relationship and trust takes times and patience.

What if no one will talk to me?

Students sometimes fear that clients will reject them or refuse to have anything to do with student nurses Some clients may not want to talk or are reclusive, but they may show that same behavior with experienced staff students should not see such behavior as a personal insult or failure.

 Generally many people in emotional distress welcome the opportunity to have someone listen to them and show a genuine interest in their situation. Being available and willing to listen is often all it takes to begin a significant interaction with someone.

Am I prying when I ask personal questions?

questions involving personal matters should not be the first thing a student says to the client. These issues usually arise after some trust and rapport have been established.

How will I handle bizarre or inappropriate behavior?

It is important to monitor ones facial expressions and emotional responses so that clients do not feel rejected or ridiculed. Students should never feel as if they will have to handle situations alone.

What happens if a client asks me for a date or displays sexually aggressive or inappropriate behavior? Some clients have difficulty recognizing or maintaining interpersonal boundaries. When a client seeks contact of any type outside the nurseclient relationship, it is important for the student (with the assistance of theinstructor or staff) to clarify the boundaries of the professional relationship

 Likewise, setting limits and maintaining boundaries are needed when the client's behavior is sexually inappropriate. It is also important to protect the clients privacy and dignity when he or she cannot do so.

Is my physical safety in jeopardy?

clients hurt themselves more often than they harm others. Staff members usually monitor clients with potential for violence closely for clues of an impending outburst. When physical aggression does occur, staff members are specially trained to handle aggressive clients in a safe manner.

 When talking to or approaching clients who are potentially aggressive: the student should sit in an open area rather than a closed room, provide plenty of space for the client, or request that the instructor or a staff person be present..

What if I encounter someone I know being treated on the unit?

It is essential in mental health that the clients identity and treatment be kept confidential. If the student recognizes someone he or she knows, the student should notify the instructor, who can decide how to handle the situation. It is usually best for the student (and sometimes the instructor or staff) to talk with the client and reassure him or her about confidentiality.

INTERDISCIPLINARY TEAM

Multidisciplinary team approach

Members include: 1. Pharmacist 2. Psychiatrist 3. Psychologists 4. Psychiatric nurse 5. Psychiatric social worker 6. Occupational therapist 7. Recreation therapist 8. Vocational rehabilitation specialists

Core skill areas of an Effective team member:

Interpersonal skills Humanity such as warmth, acceptance, empathy, genuineness and non judgemental attitude Knowledge base about mental disorders Communication skills Personal qualities such as consistency, assertiveness and problem solving abilities Teamwork skills such as collaborating, sharing and integrating Risk assessment and risk management skills

SELF-AWARENESS ISSUES

Self-awareness
is the process by which the nurse gains recognition of his or her own feelings, beliefs, and attitudes. particularly important in mental health nursing. Everyone, including nurses and student nurses, has values, ideas, and beliefs that are unique and different from others.

Accomplished through:
reflection, spending time consciously focusing on how one feels and what one values or believes.

 The goal of self-awareness is to know oneself so that ones values, attitudes, and beliefs are not projected to the client, interfering with nursing care. Self-awareness does not mean having to change ones values or beliefs unless one desires to do so.

THE MENTAL HEALTH ILLNESS CONTINUUM

Refer to pdf (chapter 1 slide- 7)

II. MENTAL HEALTH-PSYCHIATRIC

NURSING PRACTICE

A. PERSONALITY THEORIES AND

DETERMINANTS OF PSYCHOPATHOLOGY: IMPLICATIONS FOR

MENTAL HEALTH-PSYCHIATRIC NURSING PRACTICE

PERSONALITY THEORIES

1. 2. 3. 4.

5.
6. 7. 8. 9. 10.

PSYCHOANALYTIC BEHAVIORAL INTERPERSONAL COGNITIVE HUMANISTIC PSYCHOBIOLOGIC COGNITIVE PSYCHOSOCIAL PSYCHOSPIRITUAL ECLECTIC

SIGMUND FREUD: THE FATHER OF PSYCHOANALYSIS

Psychoanalytic Theories

PSYCHOANALYTIC
Developed by sigmund freud (18561939) in the late 19th and early 20th century in vienna supports the notion that all human behavior is caused and can be explained (deterministic theory). Freud believed that repressed (driven from conscious awareness) sexual impulses and desires motivated much human behavior.

1. PERSONALITY COMPONENTS: ID, EGO, AND SUPEREGO.

id is the part of ones nature that reflects basic or innate desires such as pleasure-seeking behavior, aggression, and sexual impulses. The id seeks instant gratification; causes impulsive, unthinking behavior; and has no regard for rules or social convention.

SUPEREGO

is the part of a persons nature that reflects moral and ethical concepts, values, and parental and social expectations; therefore, it is in direct opposition to the id.

EGO is the balancing or mediating force between the id and the superego. The ego represents mature and adaptive behavior that allows a person to function successfully in the world. Freud believed that anxiety resulted from the egos attempts to balance the impulsive instincts of the id with the stringent rules of the superego.

2. BEHAVIOR MOTIVATED BY SUBCONSCIOUS THOUGHTS AND FEELINGS.

human personality functions at three levels of awareness: conscious, preconscious, and unconscious

CONSCIOUS

refers to the perceptions, thoughts, and emotions that exist in the persons awareness such as being aware of happy feelings or thinking about a loved one

PRECONSCIOUS

Preconscious thoughts and emotions are not currently in the persons awareness, but he or she can recall them with some effortfor example, an adult remembering what he or she did, thought, or felt as a child.

UNCONSCIOUS
is the realm of thoughts and feelings that motivate a person, even though he or she is totally unaware of them. This realm includes most defense mechanisms (see discussion below) and some instinctual drives or motivations. According to Freud's theories, the person represses into the unconscious the memory of traumatic events that are too painful to remember.

FREUDS DREAM ANALYSIS.

a persons dreams reflected his or her subconscious and had significant meaning, although sometimes the meaning was hidden or symbolic (Gabbard, 2000).

FREE ASSOCIATION

in which the therapist tries to uncover the clients true thoughts and feelings by saying a word and asking the client to respond quickly with the first thing that comes to mind. Freud believed that such quick responses would be likely to uncover subconscious or repressed thoughts or feelings.

FIVE STAGES OF PSYCHOSEXUAL DEVELOPMENT.

Refer to table 3.2 page 60 Oedipus complex (boys)- the boy fears retaliation from his father for desiring his mother and fantasizes that the father will cut of his penis (castration anxiety) Electra Complex(girls)- has no penis to fear of losing but believes that she has a penis at one time but was cut off and blames her mother

TRANSFERENCE AND COUNTERTRANSFERENCE.

Transference occurs when the client displaces onto the therapist attitudes and feelings that the client originally experienced in other relationships Countertransference occurs when the therapist displaces onto the client attitudes or feelings from his or her past.

BEHAVIORAL THEORIES
Behaviorism is a school of psychology that focuses on observable behaviors and what one can do externally to bring about behavior changes. It does not attempt to explain how the mind works. Behaviorists believe that behavior can be changed through a system of rewards and punishments

IVAN PAVLOV: CLASSICAL CONDITIONING

theory of classical conditioning: behavior can be changed through conditioning with external or environmental conditions or stimuli.

2. B. F. SKINNER: OPERANT CONDITIONING

developed the theory of operant conditioning, which says people learn their behavior from their history or past experiences, particularly those experiences that were repeatedly reinforced. PRINCIPLES: 1. All behavior is learned. 2. Consequences result from behaviorbroadly speaking, reward and punishment. 3. Behavior that is rewarded with rein forcers tends to recur.

4. Positive reinforcers that follow a behavior increase the likelihood that the behavior will recur. 5. Negative reinforcers that are removed after a behavior increase the likelihood that the behavior will recur. 6. Continuous reinforcement (a reward every time the behavior occurs) is the fastest way to increase that behavior, but the behavior will not last long after the reward ceases. 7. Random, intermittent reinforcement (an occasional reward for the desired behavior) is slower to produce an increase in behavior, but the behavior continues after the reward ceases.

Behavior modification is a method of attempting to strengthen a desired behavior or response by reinforcement, either positive or negative.

HARRY STACK SULLIVAN: INTERPERSONAL RELATIONSHIPS AND MILIEU THERAPY

Interpersonal Theories

INTERPERSONAL

Harry Stack Sullivan (18921949; Fig. 3-2) was an American psychiatrist. include the significance of interpersonal relationships. Sullivan believed that ones personality involved more than individual characteristics, particularly how one interacted with others. He thought that inadequate or non satisfying relationships produced anxiety, which he saw as the basis for all emotional problems The importance and significance of interpersonal relationships in ones life was probably Sullivans greatest contribution to the field of mental health. Life stages- table 3-4 page: 63

DEVELOPMENTAL COGNITIVE MODES OF EXPERIENCE

prototaxic mode, characteristic of infancy and childhood, involves brief unconnected experiences that have no relationship to one another. Adults with schizophrenia exhibit persistent prototaxic experiences.

parataxic mode begins in early childhood as the child begins to connect experiences in sequence. The child may not make logical sense of the experiences and may see them as coincidence or chance events. The child seeks to relieve anxiety by: repeating familiar experiences, although he or she may not understand what he or she is doing. Sullivan explained paranoid ideas and slips of the tongue as a person operating in the parataxic mode.

syntaxic mode, which begins to appear in schoolage children and becomes more predominant in preadolescence, the person begins to perceive himself or herself and the world within the context of the environment and can analyze experiences in a variety of settings. Maturity may be defined as predominance of the syntaxic mode (Sullivan, 1953).

JEAN PIAGET AND COGNITIVE STAGES OF DEVELOPMENT

COGNITIVE
Jean Piaget (18961980) explored how intelligence and cognitive functioning developed in children. He believed that human intelligence progresses through a series of stages based on age with the child at each successive stage demonstrating a higher level of functioning than at previous stages.

FOUR STAGES OF COGNITIVE DEVELOPMENT 1. Sensorimotorbirth to 2 years: The child develops a sense of self as separate from the environment and the concept of object permanence; that is, tangible objects dont cease to exist just because they are out of sight. He or she begins to form mental images.

2. Preoperational2 to 6 years: The child develops the ability to express self with language, understands the meaning of symbolic gestures, and begins to classify objects.

3. Concrete operations6 to 12 years: The child begins to apply logic to thinking, understands spatiality and reversibility, and is increasingly social and able to apply rules; however, thinking is still concrete.

4. Formal operations12 to 15 years and beyond The child learns to think and reason in abstract terms, further develops logical thinking and reasoning, and achieves cognitive maturity.

HUMANISTIC
Humanism focuses on a persons positive qualities, his or her capacity to change (human potential), and the promotion of self-esteem. Humanists do consider the person's past experiences, but they direct more attention toward the present and future.

PSYCHOBIOLOGIC

ERIK ERIKSON AND PSYCHOSOCIAL STAGES OF DEVELOPMENT

PSYCHOSOCIAL
1950, Erikson published Childhood and Society, in which he described eight psychosocial stages of development.(Vp61) In each stage, the person must complete a life task that is essential to his or her well-being and mental health. These tasks allow the person to achieve lifes virtues: hope, purpose, fidelity, love, caring, and wisdom. REFER TO TABLE 3.3 PAGE 61

PSYCHOSPIRITUAL

ECLECTIC

GENERAL ASSESSMENT CONSIDERATIONS

PRINCIPLES AND TECHNIQUES OF PSYCHIATRIC NURSING INTERVIEW

Refer to 142 videbeck 5th edition

ENVIRONMENT
comfortable, private, safe for both the client and the nurse fairly quiet with few distractions allows the client to give his or her full attention to the interview.) The nurse must ensure the safety of self and client even if that means another person is present during the assessment.

MENTAL STATUS EXAMINATION

purpose of the psychosocial assessment is to construct a picture of the clients current emotional state, mental capacity, and behavioral function. This assessment serves as the basis for developing a plan of care to meet the clients needs. The assessment is also a clinical baseline used to evaluate the effectiveness of treatment and interventions or a measure of the clients progress

CONTENT OF THE ASSESSMENT

History General appearance and motor behavior Mood and affect Thought process and content Sensorium and intellectual processes Judgment and insight Self-concept Roles and relationships Physiologic and self-care concerns

DIAGNOSTIC EXAMINATIONS SPECIFIC

TO PSYCHIATRIC PATIENTS

DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS-TEXT REVISION (DSM-IV-TR),

a taxonomy published by the APA. The DSM-IV-TR describes all mental disorders, outlining specific diagnostic criteria for each based on clinical experience and research. All mental health clinicians who diagnose psychiatric disorders use the DSM-IV-TR.

THREE PURPOSES:

To provide a standardized nomenclature and language for all mental health professionals To present defining characteristics or symptoms that differentiate specific diagnoses To assist in identifying the underlying causes of disorders

AXIS 1
is for identifying all major psychiatric disorders except mental retardation and personality disorders. Examples include depression, schizophrenia, Anxiety substance-related disorders.

AXIS II

is for reporting mental retardation and personality disorders as well as prominent maladaptive personality features and defense mechanisms.

AXIS III

is for reporting current medical conditions that are potentially relevant to understanding or managing the persons mental disorder as well as medical conditions that might contribute to understanding the person.

AXIS IV

is for reporting psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders. Included are problems with primary support group, social environment, education, occupation, housing, economics, access to health care, and legal system.

AXIS V

presents a Global Assessment of Functioning (GAF), which rates the persons overall psychological functioning on a scale of 0 to 100. This represents the clinicians functioning; the clinician also may give a score for prior functioning (for instance, highest GAF in past year or GAF 6 months ago)

BUILDING NURSE- CLIENT RELATIONSHIP

NURSE CLIENT INTERACTION VS. NURSE CLIENT RELATIONSHIP

Refer to table 5.3 and 5.2

THERAPEUTIC USE OF SELF

Refer to the book page 102

THERAPEUTIC COMMUNICATION
a. b.

Characteristics techniques

THERA COM
is an interpersonal interaction between the nurse and client during which the nurse focuses on the clients specific needs to promote an effective exchange of information. Skilled use of therapeutic communication techniques helps the nurse understand and empathize with the clients experience. All nurses need skills in therapeutic communication to effectively apply the nursing process and to meet standards of care for their clients.

THERACOM CHARACTERISTICS

THERACOM TECHNIQUES

Refer to table 6-1 page 116

PHASES IN THE DEVELOPMENT OF

NURSE CLIENT RELATIONSHIP
Refer to page 100 table 5-3

THERAPEUTIC MODALITIES
PSYCHOSOCIAL SKILLS AND THERAPEUTIC MODALITIES

BIOPHYSICAL/ SOMATIC INTERVENTIONS

ECT AND OTHER SOMATIC THERAPIES

PSYCHOPHARMACOLOGY

2. SUPPORTIVE PSYCHOTHERAPY
1.

2.
3.

nurse- patient relationship therapy Group therapy Family therapy

3. COUNSELLING

4. MENTAL HEALTH TEACHING/ CLIENT

EDUCATION

5. SELF ENHANCEMENT, GROWTH/

THERAPEUTIC GROUPS

6. ASSERTIVENESS TRAINING

7. STRESS MANAGEMENT

8. BEHAVIOR MODIFICATION

9. COGNITIVE RESTRUCTURING

10. MILLEU THERAPY

11. PLAY THERAPY

12. PSYCHOSOCIAL SUPPORT INTERVENTIONS