Psychosocial Therapies

Psychosocial Therapies

PSYCHOTHERAPY

As human beings most people experience various kinds of emotional difficulties at some time or the other in their lives. These emotional problems are frequently related to several kinds of undesirable life experiences. Problems related to family, work, education, finance, health, marriage, and relationships with other people and the like are experienced by us from time to time. At times these problems may become so severe and so unbearable that unpleasant symp­toms of anxiety and depression may result, interfering with normal functioning. Treatment methods most effective in these situations involve the principles of psychotherapy and counseling.

Definition

Briefly it can be defined as "the treatment of emotional and/or related bodily problems by psychological means". The term 'psychological means' is meant to cover a number of techniques, which are mediated by verbal interaction.

Wolberg defined psychotherapy as, "the treatment by psychological means, of problems of an emotional nature, in which a trained person (therapist) deliberately establishes a professional relationship with the patient to,

(i) Remove, modify or retard existing symptoms,

(ii) Mediate disturbed patterns of behaviour, and/or

(iii) Promote positive personality growth and development".

Common Factors of Psychotherapy

In all the forms of psychotherapy, the therapist tries to help the patient to overcome emo­tional problems by a combination of listening and talking.

Restoration of Morale is an important part of psychotherapy because most of the patients who are treated have experienced repeated failures and become demoralized, losing the convic­tion that they can help themselves.

Release of Emotion is helpful in the early stage of treatment. Abreaction is a type of psy­chotherapy and it refers to a procedure in which particularly intense and rapid release of feelings are encouraged.

All forms of psychotherapy include a rationale that makes the patient's disorder more intel­ligible. This rationale may be described in detail by the therapist in behaviour therapy or short-term psychotherapy, or the patient may have to piece it together from partial explanations and interpretations as in psycho-analytically oriented psychotherapy. Rationale has the effect of mak­ing problems more understandable and therefore gives the patient more confidence that he can solve his problems.

All psychotherapy contains an element of suggestion. In hypnosis this is deliberately culti­vated as the main agent of change.

Types of Psychotherapy

Psychotherapies are classified according to:

(a) Depth of probing in the unconscious mind

(i) Superficial or short-term, (also known as supportive psychotherapy).

(ii) Deep or long-term (also known as analytic psychotherapy).

(iii) Educative (also known as counseling).

(b) Number of patients treated in any therapeutic session.

(i) Individual psychotherapy

(ii) Group psychotherapy

 (iii)Family psychotherapy

(c) According to the purpose for which psychotherapy is given and the theoretical formulations used in psychotherapy

i) Supportive psychotherapy: It provides support, guidance, advice and reassurance.

ii) Re-educative psychotherapy: It attempts to teach the individual new patterns of behav­iour and social functioning.

iii) Reconstructive psychotherapy: It aims to dismantle and rebuild a new personality. 

Commonly Applied Psychotherapeutic Techniques:

(i) Ventilation

Emotional problems and minor psychiatric disorders like neurosis are frequently related to several psychological and social factors. These could be in the form of various external pressures (stress factors), internal pressures (conflicts), or because of faulty learning. Often these experi­ences involve the subject's very personal aspects of life. As a consequence emotions get bottled up and result in a variety of symptoms. In such situations, the very process of facilitating the individual to talk about his suppressed experiences will bring down the distress. As the proverb goes 'Joy shared is doubled, sorrow shared is halved'. This process of allowing the release of bottled up emotion is called ventilation.

(ii) Abreaction

This is a process similar to ventilation. The only difference is that the degree of emotional release is much greater here. The patient might burst out sobbing while recounting his experi­ences. In such circumstances, the therapist allows the person to abreact without interrupting him. (iii) Reassurance

Often we come across patients who have marked anxiety over their symptoms. For example, a person experiencing chest pain may fear that it is indicative of a serious physical illness. Simi­larly, many other patients express doubts as to whether they would get well at all. In such situa­tions it is necessary to alleviate the person's anxiety with reassuring statements like, "you do not have a serious problem. I am confident that you will get well".

(iv) Explanation

Patients and family members may often have an inadequate understanding of the nature and cause of the illness resulting in anxiety about the illness. Explanations should be provided to remove misconceptions and to provide a proper understanding of the problem.

v)   Suggestion

Suggestion is a process by which symptoms relief is achieved through positive statements made with a degree of firmness and authority. Suggestion often works well when the subject displays a high degree of faith in the therapist. Examples of suggestive statements are:

"You will feel confident henceforth" "You will not experience headache any more" Sugges­tion is always beneficial in neurotics and psychosomatic conditions.

However, suggestion must be employed along with other techniques. For example, sugges­tion might help the removal of a hysterical symptom. But further exploration may be necessary to understand the cause of the hysterical symptom. Based on the cause of the problem, more specific treatment needs to be instituted.

(vi) Persuasion

Persuasion is a procedure by which the therapist urges the patient repeatedly to change his behaviour or to try new methods of dealing with his problem.

(vii) Reinforcement

Reinforcements or rewards are potent methods to enhance the desired, behaviour. They can be verbal or material in nature. Verbal reinforcers include statements like "you have done well", "excellent", "I am happy that you have begun to work", etc. Such statements should be associated with the appropriate gestures. Material reinforcers are often used in children. For example, edibles or play materials can be given immediately after the child shows desirable behaviour.

(viii)Recreation

Recreation helps to break monotony of work. It is especially required for subjects who have developed emotional problems as a result of having to perform monotonous and hard work. The therapist suggests such activities as listening to radio, going for a movie/drama, playing indoor games, attending bhajans, playing with children or going out for a refreshing walk.

(ix) Work as Therapy

Work is an important form of therapy for many types of emotional problems. When a person engages in work, his preoccupations with his problems get lessened. It enhances his self-esteem since he is not dependent on others. Sometimes work can even be a healthy way of resolving conflict.

(x)  Relaxation

Relaxation is a technique especially useful for anxious individuals. When a person is tense, his muscles are in a state of contraction, and this produces muscular pains. By voluntary effort, the individual can learn to relax his muscles and experience relief from tension pains. Relaxation is also beneficial for a variety of psychosomatic problems like hypertension, peptic ulcer/hypera­cidity, bronchial asthma, and migraine.

Techniques like Shavasana and Yogasana (Yoga) have also been proved to be beneficial to reduce mental tension and restore physical health.

Unwanted Effects of Psychotherapy

(i) Patients may become excessively dependent on therapy or therapist.

(ii) Intensive psychotherapy may be distressing to the patient and result in exacerbation of symp­toms and deterioration in relationships.

(iii) Disorders for which physical treatments would be more appropriate may be missed.

(iv) Ineffective psychotherapy wastes time and money, and damages     patient's morale.

Contra Indications

(i) Psychotic patients with severe behaviour disturbances like excitement.

(ii) Organic psychosis (in acute phase)

(iii)Patients who are unmotivated and unwilling to accept it

 (iv) Group psychotherapy in hysteria, hypochondriasis, etc.

(v) Patients who are unlikely to respond, e.g., Personality disorders (especially antisocial

type), malingering, etc. The phases of psychotherapy are detailed in the next topic under psychoanalytically ori­ented psychotherapy.

Individual Psychotherapy:

Aim: To produce limited but worthwhile changes within a short time - seldom more than six months and often considerably less. Because treatment is focused upon specific problems, the term 'focal psychotherapy' is sometimes used.

Indications:

1. Patients who have difficulties in personal relationships but are free from serious disorders of personality.

2. Those who are interested in gaining psychological understanding of their own behavior, reasonably intelligent, and well motivated to change by their own efforts.

Type

(i) Counselling: This is a particular form of a brief psychotherapy. The term is used in a spe­cific sense to refer to methods developed by Carl Rogers. In these methods, therapist takes the passive role, largely restricting his interventions to comments on the emotional signify cance of the client's utterances ('reflection of feelings'). Rogers believed that this limited procedures, together with the relationship between patients and therapist, was therapeutic.

The term counselling is also applied less specifically to other kinds of brief therapy with limited objectives, in which the therapist takes a more active role.

(ii) Psychoanalytical: Psychoanalysis is the most time consuming form of psychotherapy. Its practitioners receive lengthy training, which involves personal analysis as well as super­vised experience in treating patients.

Psychoanalytic Techniques: (Elements and process)

a) Free Association: Patient is encouraged to talk freely about his own thoughts and feelings. This is the 'basic rule' of analysis, which, with dream analysis, is thought to allow access to unconscious processes. The analyst asks questions to make the material clearer, comforts the patient with any contra indications, and makes interpretations. Otherwise therapist re­mains relatively passive

b) Resistance: As the procedure continues, the patient usually begins to avoid certain topics and may show other forms of resistance to treatment such as rejecting the therapist's inter­pretations.

c) Transference: Gradually the patient's behavior and talk begin to give direct or indirect evidence that he is developing intense but distorted ideas and feelings about the analyst. These distortions result from the transference to the analyst of ideas and feelings related to earlier experiences in the patient's life.

d) Treatment Alliance: It is a realistic approach between the patient and analyst reflecting the patient's wished to achieve change.

e) Acting Out: Patient presents his ideas and feelings not in words (as he is meant to do) but in his behavior within or outside the therapeutic sessions.

f) Interpretations: Interpretation of 'acting out' behavior and about other issues in treatment. At first interpretations are frequently rejected, sometimes because they are inaccurate, but also because ingrained habits of thought can be changed only slowly - they require repeated working through. As interpretations begin to be accepted the patient is said to gain insight.

g) Counter Transference: As treatment progresses the analyst's feelings towards the patient change in ways that are partly realistic and partly distorted by its own previous experiences.

Negative Transference denotes the patient's hostile feelings to the therapist whilst positive transference^Henotes the opposite feelings to the therapist, such as dependency, idealization, or erotic feelings.

If transference develops to such an extent that many of the patient's neurotic problems are re-experienced in relation to the analyst, this is called the transference neurosis, the analysis of the positive transference is an essential part of treatment.

Counter Transference refers to feelings of the therapist towards the patient that are unreal­istic, and so an interference in treatment. Some of these feelings provide the analyst with valuable insights into the patient's problems.

(iii) Psycho Analytically Oriented Psychotherapy:

This treatment employs the basic concepts and methods of psychoanalysis but generally puts less emphasis on the development and analysis of the transference neurosis.

• Treatment is shorter and less intensive than psychoanalysis.

• Aims to bring about less profound changes.

• Therapist takes a more active part.

• Therapist usually sets specific goals, which is not done in psychoanalysis.

Psychoanalytically Oriented Psychotherapy

It is a much more direct form of psychoanalysis. The duration of therapy is much briefer and advice is given to the patient occasionally. The patient and the therapist sit face to face. Addi­tional modes of treatment including drug therapy can be used.

Indications

(i) Presence of long-standing mental conflicts which, although are unconscious, produce symp­tomatology

(ii) High motivation to undergo therapy.

(iii) Patient should have strong 'ego-structure', which can bear frustrations of impulses during therapy.

(iv) Patient should be psychologically minded and should not have significant life stressors

(v) Neurotic disorder, personality disorders.

Phases

Usually the therapy proceeds through three broad phases, namely: An initial phase, a middle phase, and a terminal phase. These phases are not rigidly delineated and the progress from one phase to another will vary from patient to patient. However, certain major themes can be identi­fied in each of these phases.

(i)   The Initial Phase

The focus of this phase of therapy is to get a clear understanding of the nature and cause of the patient's problem and to provide an explanation of the nature of therapy. This phase usually lasts two to four sessions and includes the following steps.

(a) Evaluation of the Patient: A detailed evaluation is a prerequisite before beginning therapy. It in done by collecting detailed history from the patient, from the family members or friends, doing physical and mental state examinations.

(b) Explanation of the Nature of Treatment: It is not uncommon for patients to view their problems as medical conditions even though they suffer from a primary emotional distur­bance. As a result they expect to be treated by medicines. They do not readily accept the possibility of resolving their difficulties by talking with the therapist. Hence it is necessary that the therapist explains in detail the psychotherapeutic intervention that is being recommended as the main treatment.

(c) Development of an Empathic Relationship: The therapist should attempt to build a trust­ing relationship with the patient to enable the patient to share his difficulties. Empathy is the process by which the therapist attempts to understand the emotional state of the patient by trying to place himself in the patient's situation. This is in contrast to sympathy where the depth of emotional involvement is lesser. Often the very process of empathic understanding greatly relieves the patient's distress.

d) Exploration of the Problems and Stress Factors: The therapist should initiate attempts to understand the specific stress factors or conflicts, which have been responsible for the patient's emotional difficulties. This is frequently a slow process and may extend on to the next phase of therapy.

(ii) The Middle Phase

This phase which usually takes about three to five sessions focuses on the problems and the application of specific therapeutic techniques to deal with these problems.

(a)  Strengthening of the Therapeutic Relationship

As the patient and therapist continue to interact, the therapeutic relationship becomes stron­ger. The individual becomes more open to understand the source of his problems and try different methods of dealing with his difficulties.

b) Further Understanding of the Patient's Life Situation

By a process of listening to the life history of the patient, the therapist gets a fuller under­standing of the patient's problems. During this phase, some individuals may continue to experi­ence anxiety about discussing their problems because of the fear that the therapist may disap­prove them. In the interaction, this 'resistance' manifests itself in the form of long pauses, si­lences or diverting the topic. The therapist should handle such blocks by gently reassuring the patient and conveying his positive regard irrespective of what the patient reveals.

c) Application of Therapeutic Techniques

The therapist uses a number of techniques to alleviate the patient's emotional distress. Some of these techniques are ventilation, abreaction, suggestion, persuasion, reinforcement, reassur­ance and explanation. (These are described earlier under the topic 'psychotherapy').

d) Enabling the Development of Insight

Insight refers to the understanding by the patient, of the origin and nature of his problems. Through the use of the above-mentioned techniques, the therapist enables the development of insight. The patient becomes aware of causal link between the conflicts/stress factors and the symptoms.

(iii) The end Phase

The next 3-4 sessions constitute the terminal phase. It includes:

 (a) Strengthening of Insight: Patient’s understanding of the problem is strengthened by restating the silent themes that emerge during therapy.

(b) Reinforcing the Patient's Improvement: As the therapy continues, the patient learns new methods of dealing with his difficulties, and simultaneously his symptoms reduce. The thera­pist should positively reinforce the patient's improvement through assurances such as, "I am happy to note that you are able to deal with your problems better now. If you continue to work along the same lines, I am sure you will be fully capable of managing by yourself.

(c) Preparing the Patient for Termination of Treatment: This is done in a gradual fashion. The therapy sessions are spaced out, thus paving way for a formal termination. Sometimes patients might resist termination of therapy because of the belief that the thera­pist will be ever present to solve all their problems. This is called dependence. The therapist must undo this dependence by gently bringing it to the patient's notice.

The frequency of patient meeting psychotherapist once a week is sufficient. But in crisis situations like suicidal threats, it may be preferable to see the patient more frequently, i.e., once in two or three days. Once the patient has shown satisfactory improvement, it is sufficient to see the patient once in a month.

The length of sessions ranges from few minutes to 30 minutes. But this can be adjusted by the therapist based on his working pattern and the needs of the patient.

The number of such sessions may be "between" 5-10 as required for most of the patients. However, improvement may be seen earlier or later than this.

Cognitive Psychotherapy:

Cognitive psychotherapy is the term applied to psychological treatments intended to change maladaptive ways of thinking and thereby bring about improvement in psychiatric disorders.

A.T.Beck, psychiatrist, identified recurring themes and he suggested that themes should be regarded as part of the primary disorder rather than secondary to either underlying unconscious conflicts or biochemical abnormalities. Beck designed the treatment to alter these recurring thoughts.

Principles:

Therapist attempts to change one or more of distorted ways of thinking that characterizes the disorder.

Techniques:

i. Identify the irrational ideas. Although patients can describe some of the ideas like irrational fear of an object, or the unreasonably pessimistic ideas of a depressed patient, they are usually unaware of others. These unacknowledged ideas are often particularly important in maintaining the disorder.

ii. Elicite irrational ideas through interviews, asking the patient to keep a daily record of thoughts experienced at times.

iii. To change the irrational ideas. Two kinds of techniques are used, verbal and behavioral.

Verbal Techniques are used in two ways: with guidance from the therapist in therapy sessions, and by the patient during every day activities.Techniques used by the therapist - in treatment, sessions are designed to alter intrusive cognitions by giving information, and questioning their logical basis. The therapist also identifies the patient's illogical ways of thinking which allow the intrusive thoughts to persist despite evi­dence that they are false. The therapist also identifies irrational beliefs that make the patient more likely to experience anxiety or depression when he encounters minor problems.

Verbal techniques used by the patient during every day activities:- They are of two friends. First, there are techniques intended to interrupt cognitions (for example, an anxious patient's thoughts that he will die of a heart attack). These methods are forms of distraction, either focusing attention on the immediate environment (for example, by counting objects) or on a normal mental content (for example, mental arithmetic). Alternatively, a sudden sensory stimulus can be ar­ranged, for example by snapping a rubber band on the wrist, a method sometimes called thought stopping.

The second kind of technique is intended to neutralize the emotional effect of irrational thoughts. The patient repeats to himself an appropriate rational response to the irrational thought, for example 'my heart is beating fast because I am feeling anxious, not because I have heart disease'. Because it is difficult for the patient to give priority to reassuring thoughts at times when they are most needed, it is useful for him to carry a 'prompt card' on which the thoughts are written.

Supportive Psychotherapy:

Supportive psychotherapy is used to help a person through a time-limited crisis caused ei­ther by social problems or by physical illness.

Indications:

(i) To relieve distress caused by prolonged physical or mental illness or physical handicap.

(ii) Personality disorders that is unlikely to change with treatment.

Process:

Patients are encouraged to talk about their problems while the therapist listens sympatheti­cally. The therapist offers advice, and may use suggestion deliberately in order to help the pa­tients through a short-lived worsening of the symptoms. He may also arrange practical help. When the problem is insolvable or the illness chronic, he helps the patient to accept in evitable disability and to live as well as possible despite it.

Listening: Is an important part of the supportive therapy. The patient should feel that the therapist has the undivided attention and concern, and that his worries are being taken seriously. When supportive treatment is used in conditions of acute crisis, patients may be helped by the opportunity to release emotions.

Explanation and advice:

Explanations are to be simple, repeated often and also sometimes put in writing, so that the patient can study them at home. Since the distressed patients often remember little of what they are told, advice and explanations should be given in a simple language.

Reassurance: Is valuable but premature reassurance can destroy the patient's confidence in the therapist. It should be offered only when the patient's concerns have been fully understood. Reassurance must be truthful, and if a patient finds he has been deceived, he will lose the basic trust on which all treatment depends. A positive approach to be maintained by encouraging pa­tients to build on their few remaining assets and opportunities

Prestige Suggestion:

In supportive psychotherapy, patients should be encouraged to take responsibility for their own actions and to workout solutions to their problems. Suggestions should be used sparingly; if the patient tries and fails, he may lose confidence not only in himself but also in therapist.

Persuading the patient to do certain things such as, an anxious patient might be told confi­dently that he will be able to cope with a frightening social encounter. This kind of persuasion is called as prestige suggestion.

Relationship:

The relationship between patient and therapist needs to be regulated. That is important in supportive psychotherapy. Intense relationships develop easily when the patient has a dependant personality and the treatment is prolonged. If there is a real need for lengthy treatment, depen­dency should be directed to the staff of the hospital rather than to therapist.

If supports are available from friends and relatives, patients may be encouraged to receive the support. It is essential that patient get support either in a self-help group or at a day centre rather than individual supportive psychotherapy given by a therapist.

BEHAVIOUR THERAPY

Introduction

Behavior therapy involves changing the behavior of the patients to reduce the dysfunction and to improve the quality of life. The principles of behavior therapy are based on the early studies of Classical conditioning by Pavlov (1927) and operant conditioning by Skinner (1938).

Techniques based on classical conditioning

Classical conditioning is the learning of involuntary responses by pairing a stimulus that normally causes a particular response with a new, neutral stimulus after enough parings, the new stimulus will also cause the response to occur. Through classical conditioning ‘the old and undesirable responses can be replaced by the desirable ones.

There are several techniques that have been developed using this type of learning to treat the disorders such as phobias, obsessive compulsive disorder, and similar anxiety disorder. The techniques are ,

1. SYSTEMATIC DESENSITIZATION

Introduction

Systematic desensitization Developed by Wolpe and is based on the behavior principle of counter conditioning    for assisting the individuals to overcome their fear of phobic stimulus.

Meaning

Systematic desensitization, behavioral therapy technique where by a person overcomes the maladaptive anxiety elicited by a situation or an object by approaching the feared situation gradually, in a psycho physiological state that inhibits the anxiety.   

History

The technique of systematic desensitization in which a therapist   guides the client through a series of steps meant to reduce the fear and anxiety, really began with the work of Watson and the classic research study of “little Albert “(Watson and Rayner1920).in that study Watson created a phobic response to a rat by repeatedly pairing the exposure to the rat with a loud, scary noise. his intentions ,carried out by Mary cover  Jones in a later study (Jones 1924),were to undo the damage by paring the rat (now an object creating fear) with a pleasure    producing stimulus ,such as food. This counter conditioning forms the basis for the desensitization procedures (Wolpe 1958)

Indication

Systematic desensitization indicated in the cases of clearly identifiable anxiety     provoking stimulus, such as,

• Phobias
• Obsessive compulsive disorder
• Sexual disorders
• Anxiety disorder
• pain

Steps

Systematic desensitization consist of three steps

1.   Relaxation training

2.   Hierarchy construction

3.   Desensitization of stimulus

Relaxation training

This is first step of systematic desensitization. Relaxation produces physiological effects opposite to those of anxiety:

The signs of relaxation are

a. Physiological signs:  slow heart rate, increased peripheral blood flow and neuromuscular stability, pupil constriction, increased peripheral temperature, decreased oxygen consumption

b. Cognitive signs:  altered state of consciousness, heightened concentration on single mental image.

c. Behavior changes: lack of attention and concern for the environmental stimuli, no verbal interaction, no voluntary change in the position.

Techniques used for relaxation are,

a) Jacobson progressive muscle relaxation: Most often used relaxation training, developed by the psychiatrist Edmund Jacobson. In this client must learn to relax through deep muscle relaxation training.  Patients relax major muscle group in a fixed order, beginning with the small muscle group of the feet and working cephal head or vice versa.

 Procedure:

I. Make the patient in a comfortable position

II. Provide light or soft music /pleasant visual cues

III. Give a brief explanation about the progressive muscle relaxation

IV. Instruct the client to tense each muscle group approximately for 10 seconds

V. Explain the tension of the muscle and uncomfortable the body part feels

VI. Ask the client to relax each muscle

VII. Make client to feel the difference between both the situation

b) Hypnosis: Some clinicians use hypnosis to facilitate the  relaxation.

c) Mental imaginary: it is relaxation method in which patients are instructed to imagine the selves in a place associated with the    pleasant relaxed memories. Such images allow the patients to enter a relaxed d state or experience the relaxation responses

d) Meditation or yoga: present days meditation and yoga are practiced and taught by  the clinician to relax the patients. and it is an immerging trend in the relaxation therapy

2. Hierarchy construction

Hierarchy construction when constructing a hierarchy, clinicians determine the all the conditions that elicit anxiety, and then patients create a hierarchy list t consisting of 19 to 12 scenes in order of increasing the anxiety .

Example:

An example of a hierarchy of events associated with a fesr of elevators as follows

A.   Discuss riding an elevator with the therapist

B.    Look at a picture of an elevator

C.   Walk in to the lobby of a building and see the elevators

D.   Push the button for the elevator

E.    Walk in to the elevator with a trusted person, disembark before the door close

F.    Walk into a elevator with a trusted person; allow the door to close; then open the door and walk out

G.   Rise one floor with a trusted person, and then walk down the stairs

H.   Ride the elevator one floor with a trusted person and ride the elevator back down

I.     Ride the elevator alone

 3. Desensitization

Desensitization of the stimulus in the final step, patients proceed systematically through the list from the least, to the most, anxiety provoking scene while in deeply relaxed state. Under the guidance of the therapist the client begins the item on the list that causes minimal fear and looks at it, thinks about it, or actually confronts it ,all while remaining in a relaxed state. The idea is that the phobic object or the situation is conditioned stimulus that the client has learned to fear because it was originally paired with a real fearful stimulus .by paring the old conditioned s stimulus with a new relaxation response that is compatible with the emotions and the physical arousal associated with the fear, the person’s fear is reduced and relieved .the person then proceeds to the    next item on the   hierarchy until the phobia is gone.

F. Adjunctive use of the drugs

Various drugs are used to hasten the relaxation The advantage of the pharmacological desensitization are threat the preliminary training in the e relaxation can be   shortened, almost all patients can relax adequately .the drugs commonly used are, barbiturate sodium methohexital and diazepam.

3. THERAPEUTIC GRADED EXPOSURE

Therapeutic graded exposure is similar to the systematic desensitization, except the relaxation training not involved and treatment is carried out in a real life context .that is the individual must brought on contact with the warning stimulus to learn firsthand that no dangerous consequences will ensue .exposure is graded according to the hierarchy .for example the patients afraid of cats might progress from looking at a picture of a cat holding one.

4. Aversion therapy

Introduction

Aversion therapy is another way to use the classical conditioning is to reduce the frequency of the   undesirable     behavior, such as smoking or over eating, by teaching the client to pair an unpleasant stimulus that results in undesirable response.

Meaning

It is form of behavior therapy in which an undesirable behavior i s paired with an aversive stimulus to reduce the frequency of the behavior.

Indication

• Alcohol abuse
• Paraphillias
• Homosexuality
• Tranvestism

Types of Aversion therapy

1. Overt sensitization

It is a type of aversion therapy that produces unpleasant consequences for undesirable behavior.  For example if an individual consumes alcohol while on Antabuse therapy, symptoms of severe nausea, vomiting, dyspnoea, palpitation and  headache. Instead of euphoria feeling normally experienced from the alcohol, the individual receives a punishment that is intended to extinguish the unacceptable behavior.

2. Covert sensitization

It relies on the individual produce symptoms rather than on medication.  The technique is under clients control and can be used whenever and whenever it is required. The individual learns through mental imagery to visualize nauseating scenes and even to induce a mild feeling of nausea. It is most effective when paired with relaxation exercises that are performed instead of the undesirable behavior.

Preparation

Depending upon his/her customary practice, a therapist administering aversion therapy may establish a behavioral contract defining the treatment, objectives, expected outcome, and what will be required of the patient. The patient may be asked to keep a behavioral diary to establish a baseline measure of the behavior targeted for change. The patient undergoing this type of treatment should have enough information beforehand to give full consent for the procedure. Patients with medical problems or who are otherwise vulnerable to potentially damaging physical side effects of the more intense aversive stimuli should consult their primary care doctor first.

Aftercare

Patients completing the initial phase of aversion therapy are often asked by the therapist to return periodically over the following six to twelve months or longer for booster sessions to prevent relapse.

Risks

Patients with cardiac, pulmonary, or gastrointestinal problems may experience a worsening of their symptoms, depending upon the characteristics and strength of the aversive stimuli. Some therapists have reported that patients undergoing aversion therapy, especially treatment that uses powerful chemical or pharmacological aversive stimuli, have become negative and aggressive.

Example

• Someone who wants to stop smoking might go to the therapist who uses a rapid smoking techniques, in which the client is allowed to smoke but must take the puff on the cigarette every five or six seconds. As nicotine is a poison, such rapid smoking produces nausea and dizziness, both unpleasant responses.
• Cigarette including the e act of putting in to the mouth, lighting up (CS) which leads to a Pleasurable stimulation response (CR), then Rapid smoking (US) which leads to Nausea and dizziness (UR). Repeated practice lead to the unconditioned response (UR) to a conditioned response (CR).
• Use of a drug called disulfiram to treat the alcoholism is another example for the aversion therapy. This medicine is properly prescribed and monitored results in several aversive reactions when combined with the alcohol. The person may experience nausea, vomiting and anxiety, and even more serious symptoms making this drug an effective deterrent for drinking for people who are unable to quit by other means.

5. FLOODING

Introduction

Flooding was invented by a psychologist named Thomas Stampfl. Flooding is an effective form of treatment for phobias amongst other psychopathologies. It works on the behaviorist principles of classical conditioning.

Meaning

It is behavior therapy technique in which the person is rapidly and intensely exposed to the fear provoking situation or object and prevented from making the usual avoidance or escape response.

Indication

·         Phobias

·         Post traumatic stress disorder

·         Obsessive compulsive disorder

Procedure

Flooding is based on the premise that   escaping from an anxiety provoking reinforces the anxiety through conditioning .client is prevented from the conditioned avoidance of the behavior by not allowing the patient to escape the situation .no relaxation therapy is used and patient experiences fear. Which gradually subsides after some time. The success of the procedure depends on having the patients remain in the fear generating situation until they are calm and feel a sense of mastery.

ADVANTAGE OF CLASSICAL CONDITIONING TECHNIQUES

• Short duration of therapy
• Easy to train the clients
• Cost effective
• Duration of treatment is  usually 6-8 weeks

APPLICATION TO THE NURSING

Widely used in mental health setting....

1. Phobia
2. Anxiety disorder
3. Obsessive compulsive disorder
4. Alcohol and drug abuse
5. Certain sexual disorder  such as paraphilia, transvestism, homosexuality
6. Physical disability
7. Chronic pain
8. Rehabilitation center

CONCLUSION

Behavior therapy is based on the theories of operant conditioning by Skinner and classical conditioning by Pavlov. Behavior therapy has not only influenced the mental health care, but, under the rubric of behavioral medicine, it has also made inroads into other medical specialties.

GROUP THERAPY

INTRODUCTION

Human beings live in a social world in which their ability to gain esteem and self definition significantly follows from their success in their personal relationships. Psychotherapy in a group setting provides a social arena in which the members can learn about their assets and deficits through interactions with peers and authority. Members also have opportunity to experiment with newly learned behaviors in the protected environment of the group in preparation for using them in the external world.

HISTORY

Group psychotherapy began at the turn of the century when Joseph Pratt, a Boston physician, recognized the positive effects of bringing the tuberculosis patients who did not have access to sanatoria.

Their recovery requires strict hygienic regimens in their impoverished homes. Using regular group meetings he educated his patients as to how to combat the diseases.  Other psychiatrists were influenced by this method. Cody Marsh even included dance classes in his hospital, he said that “By the crowd they have been broken; by the crowd they shall be healed”. The role of the charismatic leader and the dynamics of group relationships were recognized by Freud later.

Group therapy received a stimulus during World War II when many therapists were initially exposed to group works during their military experience. Theoreticians from England and US applied psychoanalytic or interpersonal theory to group therapy concepts. Interest in group process, stimulated by the work of Kurt Lewin. The social revolutions in the 1960s resulted in the beginning of sensitivity training experiences (T groups), and a variety of personal growth groups. The emergence of transactional analysis, gestalt theory, bioenergetics, existential models for group therapy and many additional innovative variations have enriched the group therapy fields.

In Britain and  America during the second world war, an appreciation of group psychology lead to a wide range of innovations, the most important are the following- the use of the group approaches for the selection and allocation of work responsibilities, studies of group morale, the integration of psychiatric knowledge in the management of large groups through the role of the command psychiatrist.

Early pioneers – Jocob Moreno was the innovator of group psychodrama. He also introduced sociometry, a scientific method for the study of group affiliation and group conflicts. Slavson was an educationalist of psychoanalytic persuasion that became the central figure in the development of group therapy and group psychodrama. His organizational efforts leads to the formation of American Group Psychotherapy Association. Alexander Wolf and Emanuel Schwarts began to apply psychoanalytic ideas to the group therapy in the late 1930’s in their therapy people underwent psychoanalytic therapy under the group setting.

DEFINITION OF GROUP

A group is a collection of individuals whose association is founded on commonalities of interest, norms and values. Membership in the groups may be by chance, by choice or by circumstances

DEFINITION OF GROUP THERAPY

1. A type of psychiatric care in which several patients meet with one or more therapists at the same time. The patients form a support group for each other as well as receiving expert care and advice. 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.
2. A type of psychoanalysis in which patients analyze each other with the assistance of one or more psychotherapists, as in an "encounter group
3. A form of psychotherapy that involves sessions guided by a therapist and attended by several clients who confront their personal problems together. The interaction among clients is considered to be an integral part of the therapeutic process.
4. Group therapy 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).

Cognitive behaviour group therapy

Definition: A form of group therapy developed according to the principles of cognitive-behavioral therapy (CBT). The two primary techniques used in cognitive-behavioral group therapy (also known as CBGT) are cognitive restructuring (changing negative thinking patterns) and exposure (facing feared situations). Also Known As: CBGT

PRINCIPAL MODELS OF PSYCHODYNAMIC GROUP THERAPY

The therapist

The therapist is responsible to the group and to the institution in which it is set. He should have an appropriate training to perform the task. A formal qualification in psychotherapy is the ideal training. This will have included theory, personal therapy for the therapist and clinical supervision. Mental health professionals from all the disciplines make an active contribution to a rich and diverse service with the training requirement of theory and supervision.

The establishment of a group begins as a management task in the definition of its goals , recruitment of its members , protection of its setting , venue etc. it evolves as a therapeutic task in which the therapist is responsible for maintaining the therapeutic attitude to the individual members and to the group as a whole.

Structure, process and content: the dynamic element of the group.

Structure-Structure describes the more enduring aspects of any group’s make up- the architecture of the interpersonal relationships are conceptualized in terms of setting and its boundaries and then conceptualizes in the bond between each individual , the therapist and the group as a whole.

Process -Process describes the fluid and the dynamics fluctuations of emotions and experiences , the business of relating and communicating the changes of association and the inter member responses

Content-The content of a group’s exchange in its visible and audible events in the narrative line and dramatic content of peoples encounters, the topics raised , discussed and the thematic development.

              Structure

Process -----------------Outcome

  The dynamic elements of a group

Models of group therapy

A.    INTERPERSONAL GROUP THERAPY

The focus is on interpersonal learning as a primary mechanism of change. The group provides the antidotes to mal adaptive interpersonal beliefs and behaviors through feedback from others and encouragement to experiment with healthier behaviors, first with in the group and the outside. The joint examination of inter group transference reactions allows members to replace processes that have a historical origin in the ‘there and then’ – the dynamic past – with in those more appropriate to the here and now – the dynamic present

The elements of an interpersonal group

The model represents that the interpersonal dynamics are kept at fore front of member’s attention by the therapist. The inter personal approach places the therapist among the other members of the group with out giving him or her distinctive identity or any formal demarcation for the boundaries of the group as a whole.

Yalom suggested 11 curative factors according to this model. They are

·    Instillation of hope

·    Universality

·    Imparting information

·    Altruism

·    Corrective recapitulation of primary family group

·    Development of socializing techniques

·    Imitative behaviour

·    Interpersonal learning

·    Group cohesiveness

·    Catharsis

·    Existential factors

B. THE TAVISTOCK MODEL

This model is developed by Bion. According to this model, in a group at any point of time, its culture and climate are governed by primitive unconscious anxieties that impede its capacity for a rational work. This is a therapist centered approach. The two –body psychology used here to enforce a series of interactions and it helps to reduce the complexity and the constraints of the group work.

The element of Tavstock group.

C. THE GROUP ANALYTIC MODEL

Groups may begin with relatively high level of group activity and leadership activity, referred to as dynamic administration. This approach integrates the important aspects of the other two models. The therapist is encouraged to address the individuals as well as the whole group. This concept is developed by an integrated set of concepts of structure, process and outcome.

The elements of a group analytic group

Indications for group therapy & selection of patients

In group therapy, the interaction of group members offer possibilities for change and growth. But whether patients referred for group psychotherapy are going to benefit from the treatment depends to a large extent on their careful selection and preparation. Group therapy appears to be most useful for patients whose problems are mainly in relationships with other people. The most expected candidates for group therapy define their problem as interpersonal, they are committed to bring change in relationship, are willing to be influenced by the group and engage in appropriate self disclosure.

Patients should be offered a group that is best suited for their problem and it should be ascertained whether the patient is suitable for group therapy or not. For this a therapist needs a great deal of information. A screening interview, psychiatric history and mental status examination can help to select patients for group therapy. There are some inclusion and exclusion criteria for group therapy.

Inclusion criteria

·    Ability to perform the group task

·    Problem areas are compatible with goals of the group

·    Motivation to change

Exclusion criteria

·    Marked incompatibility with group norms for acceptable behaviour

·    Inability to tolerate group setting

·    Severe incompatibility with one or more of the other member

·    Tendency to assume deviant role

COMPOSITION OF GROUPS

Size---Group therapy has been successful with as few as three members and as many as 15 but most therapists consider 8-10 members the optimal size.

Homogeneous versus heterogeneous groups

Many therapists believe that a group should be as heterogeneous as possible to ensure maximum interaction. Patients with different diagnostic categories and behavioural patterns, and patients from different races, social levels, educational and backgrounds should be brought together. Patients between 20 and 65 years of age can be effectively included. Age differences aid in relieving and rectifying interpersonal difficulties.

Homogeneous group is more suitable for children and adolescents. Patients with similar problems like substance abuse, mild to moderate depression etc. can also be benefited in a homogeneous group.

Open versus closed group

The closed groups begin and end with same membership. The open group permits termination of members at different points and their substitution by new patients

Frequency and length of sessions

Group therapies can be conducted once or twice a week, each session lasting for 1-2 hours

HOW DOES GROUP PSYCHOTHERAPY WORK?

Members of the group share with others personal issues which they are facing. A participant can talk about events s/he was involved in during the week, her/his responses to these events, problems s/he had tackled, etc. The participant can share his/her feelings and thoughts about what happened in previous sessions, and relate to issues raised by other members or to the leader's words. Other participants can react to her/his words, give her/him feedback, encourage, give support or criticism, or share their thoughts and feelings following his/her words. The subjects for discussion are not determined by the leader but rise spontaneously from the group. The member in the group feels that (s) he is not alone with her/his problem and that there are others who feel the same. The group can become a source of support and strength in times of stress for the participant. The feedback (s) he gets from others on her/his behavior in the group can make her/him become aware to maladaptive patterns of behavior, change her/his point of view and help him/her adopt more constructive and effective reactions. It can become a laboratory for practicing new behaviors.

Frequently the people you meet in the group represent others in your past or current life with whom you have difficulty. In group therapy you have the opportunity to work through these situations.

WHO CAN BENEFIT FROM GROUP PSYCHOTHERAPY?

Group psychotherapy is suitable for a large variety of problems and difficulties, beginning with people who would like to develop their interpersonal skills and ending with people with emotional problems like anxiety, depression, etc. There are support groups for people in the same situation or crisis (e.g. groups for bereaved parents, groups for sexually abused women), but usually the recommendation for the therapeutic group is to be as heterogeneous as possible and represent a micro-cosmos. For that reason in building the group, the leader will try to include men and women, young and old people, married and singles, etc. The group is especially effective for people with interpersonal difficulties and problems in relations. Whether these difficulties are in social, working, couple or even sexual relations, the participant can benefit a lot in these areas.

Groups are ideally suited to people who are struggling with relationship issues like intimacy, trust, self-esteem. The group interactions help the participants to identify, get feedback, and change the patterns that are sabotaging the relations. The great advantage of group psychotherapy is working on these patterns in the "here and now" - in a group situation more similar to reality and close to the interpersonal events.

THERAPEUTIC FACTORS IN GROUP THERAPY

Following therapeutic factors in group therapy have been listed by Kaplan & Sadock (1983)

·    Abreaction ·    Acceptance ·    Altruism ·    Catharsis ·    Cohesion ·    Consensual validation ·    Contagion ·    Corrective familial experience ·    Empathy ·    Ventilation

·    Identification ·    Imitation ·    Insight ·    Inspiration ·    Interaction ·    Interpretation ·    Learning ·    Reality testing ·    Transference ·    Universalization

TYPES OF THERAPEUTIC GROUPS

1. Self help groups

2. Medication groups

3. Interpersonal group therapy

4. Encounter groups

5. Psychodrama

Supportive groups

In this approach, therapist ensures that

1. The experiences of the group members are used positively

2. Relationship between group members is cordial

3. It should not become too intense

4. Protect vulnerable patients when necessary

5. Each member is supported and gives support to other members

Self help groups

These groups are organized and led by patients or ex-patients who have learned ways of overcoming or adjusting to their difficulties. The group members benefit from this experience, from the opportunity to talk about their own problems and express their feelings and mutual support. Examples include self help groups for people who suffer from problems like alcohol dependence, groups of parents of handicapped children, etc.

Medication groups

These groups have been used for the treatment of recurrent depression and bipolar disorder. The emphasis is on compliance with prescribed medication. The goals include increasing the patients' knowledge about medication, increasing compliance, educating patients about their illness, decreasing their isolation and helping them to express their feelings in a nonjudgmental environment

Interpersonal group therapy

This approach was developed from the work of Yalom (1985). Treatment is focused on problems in current relationships and examines the ways in which these problems are reflected in the group. The past is discussed only in so far as it helps to make sense of the present problems. The treatment is divided into three stages.

First stage – The group members try to depend on the therapist, seeking expert advice about their problems and about the way they should behave in the group. In this first stage some members may leave the group due to anxiety in talking in the group or the therapists' refusal to solve their problem.

Second stage – The remaining members begin to know each other better, they discuss their problems and try to seek answers to their problems. During this period maximum change can be expected. The therapist encourages looking into current problems and relationships.

Third Stage – The group in this stage can become dominated by the residual problems of the members who have made least progress and shows most dependency. These points are discussed before ending the group.

Encounter groups

In encounter groups the interaction between members is made more intense and rapid in the hope that this will lead to greater change. The encounter can be entirely verbal, like using challenging language, or it can include touching or hugging between the participants. Sometimes the experience is further intensified by prolonging the group session for whole day or even longer. This is not suitable for people with emotional problems.

Psychodrama

In psychodrama, the group enacts events from the life of one member in scenes reflecting either current relationships or those of the family in which the person grew up. This provokes strong feelings in the person represented. The drama is followed by discussion. Instead of personal experiences of one member the drama can also focus on problems that all participants share, for e.g.. – how to deal with authority. This method is called sociodrama.

INPATIENT GROUP THERAPY

 Group therapy is an important part of hospitalized patients' therapeutic experiences. Groups may be organized in many ways in a ward. The goals of each group vary, but they all have common purpose to increase patients' awareness of themselves through interaction with other group members who provide feedback about their behaviour, to provide patients with improved interpersonal social skills and decrease isolation.

Lazell (1921) is credited with founding inpatient group therapy. He developed group treatment of schizophrenia patients. On the basis of this experience he listed the following advantages of group therapy in schizophrenia:

1. Patients become more socialized than in the past

2. They become aware that they are not alone with their problems

3. They become more comfortable in the hospital setting

4. They continued to discuss the topics with each other for sometime even after the session ended. This improved their interaction pattern.

Marsch (1931) used lecture approach with patients but supplemented his lectures with other techniques like music, dance and inspirational reading.

VARIOUS MODELS OF INPATIENT GROUP PSYCHOTHERAPY

 Contemporary models of inpatients group psychotherapy share several features. Most models establish highly specific goals according to the particular needs of the patients.

1.Skills development model

This includes educative model, problem solving model, social skill model, etc.

Educative model – This was developed by Maxmen (1978). Problems discussed are specifically related to those problems for which members were hospitalized. Patients are helped to recognize circumstances that lead to an exacerbation of symptoms, strategies of coping, etc.

Problem solving model – This approach, based on work of Spivack & Shure (1974), assumes that psychiatric patients are deficient in problem solving, and helps members to acquire good interpersonal problem solving skills. Group members are taken through a series of problem solving steps:

·    Clarifying the problem

·    Generating alternatives

·    Evaluating alternatives

·    Role playing

·    Reporting back to the group on the outcome of different solutions

Social skills model – The behaviorally oriented social skill model fosters acquisition of various interpersonal skills by dividing each skill into multiple behavioral components. For e.g. – the skill of initiating a conversation may be divided into basic components as standing on appropriate distance from another person, greeting him/her, formulating questions and listening to the response.

2. Interpersonal model

The model emphasizes on the social isolation of the inpatients and the difficulties they face in interacting with other people. Focus is placed on the patients' current interpersonal problems and the here and now interaction during each session. Within each session, members set an agenda related to an interpersonal problem that can be addressed within a single session.

Some problems faced in group therapy

Formation of sub-groups - some members may form a coalition based on age, class shared values or other characteristics. This disrupts the therapeutic process.

1. Members who talk too much - some members in a group are too talkative, and does not allow other members to talk. As meetings continue, group is likely to become dissatisfied.

2. Members who talk too little - some members are too silent and talk very less. They are generally awkward in company, some may be afraid of talking and revealing problem.

3. Conflict between members - many times conflict between members can develop. It can be due to disagreement with others' views, criticism of one group member by another, etc.

4. The usual focus of a group is on current problem of the members. The past experiences of members only assist in understanding. Sometimes group members talk excessively about past and avoid their present difficulties.

HOW TO CHOOSE A GROUP-PSYCHOTHERAPIST

When choosing a group psychotherapist you should look for a well-trained, reliable, and ethical professional. If you are in individual therapy you should consult your therapist and be sure that your group and individual therapists can collaborate. Reputable group psychotherapists usually belong to professional associations. In the U.S.A, for example, membership in AGPA (the American Group Psychotherapy Association), and certification as a Group Psychotherapist by AGPA assures some degree of expertise. An experienced group therapist will usually interview you before your entering the group and will answer your questions about the group and his/her experience without being uneasy. You can also ask the prospective therapist how many years experience (s) he has in the particular modality and as a therapist generally. Make sure you clarify fees (including costs for missed sessions). Above all, trust your feelings: If you do not feel you can trust the therapist, find another.

Role of the therapist

 The therapist should actively structure the discussion in a way that encourages the group members to stay in a topic.

1. Decision to establish a group

·    Determine setting and size of the group

·    Choose frequency and length of the group sessions

·    Decide on open Vs closed groups

·    Select a co-therapist for the group

·    Formulate policy on the group therapy with other therapeutic modalities

2. Act of creating a therapy group

·         Formulate appropriate group

·         Select patients who can perform the group task

·         Prepare patient for group therapy

3. Construction and maintenance of the therapeutic environment

·         Build the culture of the group explicitly and simplicity

·         Identify and resolve common problems (membership turn over, sub-grouping, conflict)

4. Therapist should take cue from the process of the group.

5. When members interact spontaneously around an appropriate issue, the therapist should be quiet and allow the patients to feel a sense of mastery.

6. If members are trying to form some sub-groups, therapist should discourage them by asking the group to discuss the reasons for their formation or try to find some similarity with all members.

7. Therapist should try to include all members in the group discussion by asking each one to express their views and feelings. Therapist should assist silent members to speak and should understand their reasons for silence.

8. When there is conflict between members then therapist should not take sides rather encourage whole group to discuss issue in a way that leads them to understand why conflict has arisen.

9. Above all, it is the therapist's task to help the group develop into a cohesive unit with an atmosphere maximally conducive to the operation of curative factors and where confidentiality and non judgmental approach can be communicated to the group members.

WHY IS GROUP THERAPY HELPFUL?

1.  When people come into a group and interact freely with other group members, they usually recreate those difficulties that brought them to group therapy in the first place. Under the direction of the group therapist, the group is able to give support, offer alternatives, and comfort members in such a way that these difficulties become resolved and alternative behaviors are learned.

2.  The group also allows a person to develop new ways of relating to people.

3.   During group therapy, people begin to see that they are not alone and that there is hope and help. It is comforting to hear that other people have a similar difficulty, or have already worked through a problem that deeply disturbs another group member.

4.  Another reason for the success of group therapy is that people feel free to care about each other because of the climate of trust in a group.

5.  As the group members begin to feel more comfortable, you will be able to speak freely. The psychological safety of the group will allow the expression of those feelings which are often difficult to express outside of group. You will begin to ask for the support you need. You will be encouraged tell people what you expect of them.

Limitations of group therapy 

1. Not suitable when patient suffers from severe depression and suicide is a risk.

2. Similarly, manic patients are difficult to manage in the group setting. They tend to display excessive elation, talkativeness and irritability which are often difficult to control.

3. Patients with sub-normal intellectual level may not get adequate benefit from the group situation

ROLE OF NURSE IN GROUP THERAPY

 Nurse participates in the group activities on a daily basis. In health care setting the nurse serves on or led task groups that create policy, describe procedures and plan client care. They are also involved in a variety of other groups aimed at the institutional efforts of serving the clients. Nurses are encouraged to use the steps of the nursing process as a framework for task group leadership

In psychiatry nurses may lead various types of therapeutic  groups such as client education, assertiveness training, support , parent and transition to  discharge groups among others. To function effectively in the leadership capacity for these groups, nurses need to be able to recognize various processes that occur in the groups such as phases of group development. They also should be able to select appropriate leaderships style for the type of groups being lead. Nurses may develop these skills as a part of their training or they may pursue additional studies.

Leading therapeutic group is within the realm of nursing practice because group work is such a therapeutic approach. Nurses working in this field should continuously strive for expanding their knowledge and use of nursing process for the effective therapeutic approach.

Cognitive Therapy

Cognitive therapy is a short-term, structured therapy that uses active collaboration between patient and therapist to achieve its therapeutic goals, which are oriented toward current problems and their resolution.

Cognitive therapy is used with depression, panic disorder, obsessive-compulsive disorder, personality disorders, and somatoform disorders. Therapy is usually conducted on an individual basis, although group methods are sometimes helpful. A therapist may also prescribe drugs in conjunction with therapy.

The treatment of depression can serve as a paradigm of the cognitive approach.

Cognitive therapy assumes that perception and experiencing, in general, are active processes that involve both inspective and introspective data. The patient's cognitions represent a synthesis of internal and external stimuli. The way persons appraise a situation is generally evident in their cognitions (thoughts and visual images).

Those cognitions constitute their stream of consciousness or phenomenal field, which reflects their configuration of themselves, their world, their past, and their future.

Alterations in the content of their underlying cognitive structures affect their affective state and behavioral pattern.

Through psychological therapy, patients can become aware of their cognitive distortions. Correction of faulty dysfunctional constructs can lead to clinical improvement.

Cognitive Theory of Depression

According to the cognitive theory of depression, cognitive dysfunctions are the core of depression, and affective and physical changes and other associated features of depression are consequences of cognitive dysfunctions. For example, apathy and low energy result from a person's expectation of failure in all areas. Similarly, paralysis of will stems from a person's pessimism and feelings of hopelessness. From a cognitive perspective, depression can be explained by the cognitive triad, which explains that negative thoughts are about the self, the world, and the future.

The goal of therapy is to alleviate depression and to prevent its recurrence by helping patients to identify and test negative cognitions, to develop alternative and more flexible schemas, and to rehearse both new cognitive and behavioral responses. Changing the way a person thinks can alleviate the psychiatric disorder.

Strategies and Techniques

Therapy is relatively short and lasts about 25 weeks. If a patient does not improve in this time, the diagnosis should be reevaluated. Maintenance therapy can be carried out over years. As with other psychotherapies, therapists' attributes are important to successful therapy. Therapists must exude warmth, understand the life experience of each patient, and be genuine and honest with themselves and with their patients. They must be able to relate skillfully and interactively with their patients. Cognitive therapists set the agenda at the beginning of each session, assign homework to be performed between sessions, and teach new skills. Therapist and patient collaborate actively. The three components of cognitive therapy are didactic aspects, cognitive techniques, and behavioral techniques.

Didactic Aspects

The therapy's didactic aspects include explaining to patients the cognitive triad, schemas, and faulty logic. Therapists must tell patients that they will formulate hypotheses together and test them over the course of the treatment. Cognitive therapy requires a full explanation of the relationship between depression and thinking, affect, and behavior, as well as the rationale for all aspects of treatment. This explanation contrasts with psychoanalytically oriented therapies, which require little explanation.

Cognitive Techniques

The therapy's cognitive approach includes four processes: eliciting automatic thoughts, testing automatic thoughts, identifying maladaptive underlying assumptions, and testing the validity of maladaptive assumptions.

Eliciting Automatic Thoughts

Automatic thoughts, also called cognitive distortions, are cognitions that intervene between external events and a person's emotional reaction to the event. For example, the belief that people will laugh at me when they see how badly I bowl is an automatic thought that occurs to someone who has been asked to go bowling and responds negatively. Every psychopathological disorder has its own specific cognitive profile of distorted thought, which, if known, provides a framework for specific cognitive interventions.

Testing Automatic Thoughts

Acting as a teacher, a therapist helps a patient test the validity of automatic thoughts. The goal is to encourage the patient to reject inaccurate or exaggerated automatic thoughts after careful examination. Patients often blame themselves when things that are outside their control go awry. The therapist reviews the entire situation with the patient and helps reassign the blame or cause of the unpleasant events. Generating alternative explanations for events is another way of undermining inaccurate and distorted automatic thoughts.

Identifying Maladaptive Assumptions

As the patient and therapist continue to identify automatic thoughts, patterns usually become apparent. The patterns represent rules or maladaptive general assumptions that guide a patient's life. Samples of such rules are In order to be happy, I must be perfect and anyone doesn't like me, I'm not lovable. Such rules inevitably lead to disappointments and failure and, ultimately, to depression.

Testing the Validity of Maladaptive Assumptions

Testing the accuracy of maladaptive assumptions is similar to testing the validity of automatic thoughts. In a particularly effective test, therapists ask patients to defend the validity of their assumptions.

Behavioral Techniques

Behavioral and cognitive techniques go hand in hand; behavioral techniques test and change maladaptive and inaccurate cognitions. The overall purposes of such techniques are to help patients understand the inaccuracy of their cognitive assumptions and learn new strategies and ways of dealing with issues.

Among the behavioral techniques in cognitive therapy are scheduling activities, mastery and pleasure, graded task assignments, cognitive rehearsal, self-reliance training, role-playing, and diversion techniques. One of the first things done in therapy is scheduling activities on an hourly basis. Patients keep records of the activities and review them with the therapist. In addition to scheduling activities, patients are asked to rate the amount of mastery and pleasure their activities bring them. Patients are often surprised to learn that they have much more mastery of activities and enjoy them more than they had thought.

To simplify the situation and allow mini accomplishments, therapists often break tasks into subtasks, as in graded task assignments, to show patients that they can succeed. In cognitive rehearsal, patients imagine and rehearse the various steps in meeting and mastering a challenge.

Patients (especially inpatients) are encouraged to become self-reliant by doing such simple things as making their own beds, doing their own shopping, and preparing their own meals. This process is called self-reliance training. Role-playing is a particularly powerful and useful technique to elicit automatic thoughts and to learn new behaviors. Diversion techniques are useful in helping patients get through difficult times and include physical activity, social contact, work, play, and visual imagery.

Imagery or thought stoppage can treat impulsive or obsessive behavior. For instance, patients imagine a stop sign with a police officer nearby or another image that evokes inhibition at the same time that they recognize an impulse or obsession that is alien to the ego. Similarly, obesity can be treated by having patients visualize themselves as thin, athletic, trim, and well muscled, and then training them to evoke this image whenever they have an urge to eat. Hypnosis or autogenic training can enhance such imagery. In a technique called guided imagery, therapists encourage patients to have fantasies that can be interpreted as wish fulfillments or attempts to master disturbing affects or impulses.

Efficacy

Cognitive therapy can be used alone in the treatment of mild to moderate depressive disorders or in conjunction with antidepressant medication for major depressive disorder. Studies have clearly shown that cognitive therapy is effective and in some cases is superior or equal to medication alone. It is one of the most useful psychotherapeutic interventions currently available for depressive disorders, and it shows promise in the treatment of other disorders.

Cognitive therapy has also been studied as a way of increasing compliance with lithium (Eskalith) prescription by patients with bipolar I disorder and as an adjunct in treating withdrawal from heroin.

FAMILY THERAPY

Family therapy can be defined as any psychotherapeutic endeavor that explicitly focuses on altering the interactions between or among family members and seeks to improve the functioning of the family as a unit, or its subsystems, and/or the functioning of individual members of the family.

 Both family and couple therapy aim at some change in relational functioning. In most cases, they also aim at some other change, typically in the functioning of specific individuals in the family. Family therapy meant to heal a rift between parents and their adult children is an example of the use of family therapy centered on relationship goals.

Family therapy aimed at increasing the family's coping with schizophrenia and at reducing the family's expressed emotion is an example of family therapy aimed at individual goals (in this case, the functioning of the person with schizophrenia), as well as family goals.

Indications

The presence of a relational difficulty is a clear indication for family and couple therapy. Couple and family therapies are the only treatments that have been shown to be efficacious for such problems as marital maladjustment, and other methods, such as individual therapy, have been shown to often have deleterious effects in these situations. Couple and family therapy has also been demonstrated to have a clear and important role in the treatment of numerous specific psychiatric disorders, often as a component within a multimethod treatment.

Of course, as with any therapy, the indications for family and couple therapy are broad and vary from case to case. Family therapy is a therapeutic collage of ideas regarding the underpinnings of family and individual stability and change, psychopathology, and problems in living, as well as relational ethics. Family therapy might better be called systemically sensitive therapy and, in this sense, reflects a basic worldview as much as a clinical treatment methodology. For therapists thus inclined, then, all clinical problems involve salient interactional components; thus, some kind of family (or other functionally significant others') involvement in therapy is always called for, even in treatment that emphasizes individual problems.

An impressive array now exists of common clinical disorders and problems, including child, adolescent, and adult disorders, for which research has demonstrated family or couple treatment methods to be effective. In a few instances, couple and family interventions are probably even the treatment of choice, and for several disorders, the research argues for family intervention to be an essential part of treatment.

Techniques

Initial Consultation

Family therapy is familiar enough to the general public for families with a high level of conflict to request it specifically. When the initial complaint is about an individual family member, however, pretreatment work may be needed. Underlying resistance to a family approach typically includes fears by parents that they will be blamed for their child's difficulties, that the entire family will be pronounced sick, that a spouse will object, and that open discussion of one child's misbehavior will have a negative influence on siblings. Refusal by an adolescent or young adult patient to participate in family therapy is frequently a disguised collusion with the fears of one or both parents.

Interview Technique

The special quality of a family interview springs from two important facts. A family comes to treatment with its history and dynamics firmly in place. To a family therapist, the established nature of the group, more than the symptoms, constitutes the clinical problem. Family members usually live together and, at some level, depend on one another for their physical and emotional well-being. Whatever transpires in the therapy session is known to all. Central principles of technique also derive from these facts. For example, the therapist must carefully channel the catharsis of anger by one family member toward another. The person who is the object of the anger will react to the attack, and the anger may escalate into violence and fracture relationships, with one or more member withdrawing from therapy. For another example, free association is inappropriate in family therapy because it can encourage one person to dominate a session. Thus, therapists must always control and direct the family interview.

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Frequency and Length of Treatment

Unless an emergency arises, sessions are usually held no more than once a week. Each session, however, may require as much as 2 hours. Long sessions can include an intermission to give the therapist time to organize the material and plan a response. A flexible schedule is necessary when geography or personal circumstances make it physically difficult for the family to get together. The length of treatment depends both on the nature of the problem and on the therapeutic model. Therapists who use problem-solving models exclusively may accomplish their goals in a few sessions, whereas therapists using growth-oriented models may work with a family for years and may schedule sessions at long intervals. Table 35.4-2 summarizes one model for treatment termination.

MODIFICATIONS OF TECHNIQUES

Family Group Therapy

Family group therapy combines several families into a single group. Families share mutual problems and compare their interactions with those of the other families in the group. Treatment of schizophrenia has been effective in multiple family groups. Parents of disturbed children may also meet together to share their situations.

Social Network Therapy

In social network therapy, the social community or network of a disturbed patient meets in group sessions with the patient. The network includes those with whom the patient comes into contact in daily life, not only the immediate family but also relatives, friends, tradespersons, teachers, and coworkers.

Paradoxical Therapy

With the paradoxical therapy approach, which evolved from the work of Gregory Bateson, a therapist suggests that the patient intentionally engage in the unwanted behavior (called the paradoxical injunction) and, for example, avoid a phobic object or perform a compulsive ritual. Although paradoxical therapy and the use of paradoxical injunctions seem to be counterintuitive, the therapy can create new insights for some patients. It is used in individual therapy as well as in family therapy.

Reframing

Reframing, also known as positive connotation, is a relabeling of all negatively expressed feelings or behavior as positive. When the therapist attempts to get family members to view behavior from a new frame of reference, “This child is impossible” becomes “This child is desperately trying to distract and protect you from what he or she perceives as an unhappy marriage.” Reframing is an important process that allows family members to view themselves in new ways that can produce change.

Goals

Family therapy has several goals: to resolve or reduce pathogenic conflict and anxiety within the matrix of interpersonal relationships; to enhance the perception and fulfillment by family members of one another's emotional needs; to promote appropriate role relationships between the sexes and generations; to strengthen the capacity of individual members and the family as a whole to cope with destructive forces inside and outside the surrounding environment; and to influence family identity and values so that members are oriented toward health and growth. The therapy ultimately aims to integrate families into the large systems of society, extended family, and community groups and social systems, such as schools, medical facilities, and social, recreational, and welfare agencies.

MARITAL THERAPY

Couples or marital therapy is a form of psychotherapy designed to psychologically modify the interaction of two persons who are in conflict with each other over one parameter or a variety of parameters- social, emotional, sexual, or economic. In couples therapy, a trained person establishes a therapeutic contract with a patient-couple and, through definite types of communication, attempts to alleviate the disturbance, to reverse or change maladaptive patterns of behavior, and to encourage personality growth and development.

Marriage counseling may be considered more limited in scope than marriage therapy: Only a particular familial conflict is discussed, and the counseling is primarily task oriented, geared to solving a specific problem, such as child rearing. Marriage therapy, by contrast, emphasizes restructuring a couple's interaction and sometimes explores the psychodynamics of each partner. Both therapy and counseling stress helping marital partners cope effectively with their problems. Most important is the definition of appropriate and realistic goals, which may involve extensive reconstruction of the union or problem-solving approaches or a combination of both.

Types of Therapies

Individual Therapy

In individual therapy, the partners may consult different therapists, who do not necessarily communicate with each other and indeed may not even know each other. The goal of treatment is to strengthen each partner's adaptive capacities. At times, only one of the partners is in treatment; and, in such cases, it is often helpful for the person who is not in treatment to visit the therapist. The visiting partner may give the therapist data about the patient that may otherwise be overlooked; overt or covert anxiety in the visiting partner as a result of change in the patient can be identified and dealt with; irrational beliefs about treatment events can be corrected; and conscious or unconscious attempts by the partner to sabotage the patient's treatment can be examined.

Individual Couples Therapy

In individual couples therapy, each partner is in therapy, which is either concurrent, with the same therapist, or collaborative, with each partner seeing a different therapist.

Conjoint Therapy

In conjoint therapy, the most common treatment method in couples therapy, either one or two therapists treat the partners in joint sessions. Cotherapy with therapists of both sexes prevents a particular patient from feeling ganged up on when confronted by two members of the opposite sex.

Four-Way Session

In a four-way session, each partner is seen by a different therapist, with regular joint sessions in which all four persons participate. A variation of the four-way session is the roundtable interview, developed by William Masters and Virginia Johnson for the rapid treatment of sexually dysfunctional couples. Two patients and two opposite-sex therapists meet regularly.

Group Psychotherapy

Group therapy for couples allows a variety of group dynamics to affect the participants. Groups usually consist of three to four couples and one or two therapists. The couples identify with one another and recognize that others have similar problems; each gains support and empathy from fellow group members of the same or opposite sex. They explore sexual attitudes and have an opportunity to gain new information from their peer groups, and each receives specific feedback about his or her behavior, either negative or positive, which may have more meaning and be better assimilated coming from a neutral, nonspouse member, for example, than from the spouse or the therapist.

Combined Therapy

Combined therapy refers to all or any of the preceding techniques used concurrently or in combination. Thus, a particular patient-couple may begin treatment with one or both partners in individual psychotherapy, continue in conjoint therapy with the partner, and terminate therapy after a course of treatment in a married couples group. The rationale for combined therapy is that no single approach to marital problems has been shown to be superior to another. A familiarity with a variety of approaches thus allows therapists a flexibility that provides maximal benefit for couples in distress.

Indications

Whatever the specific therapeutic technique, initiation of couples therapy is indicated when individual therapy has failed to resolve the relationship difficulties, when the onset of distress in one or both partners is clearly a relational problem, and when couples therapy is requested by a couple in conflict. Problems in communication between partners are a prime indication for couples therapy. In such instances, one spouse may be intimidated by the other, may become anxious when attempting to tell the other about thoughts or feelings, or may project unconscious expectations onto the other. The therapy is geared toward enabling each partner to see the other realistically.

Conflicts in one or several areas, such as the partners' sexual life, are also indications for treatment. Similarly, difficulty in establishing satisfactory social, economic, parental, or emotional roles implies that a couple needs help. Clinicians should evaluate all aspects of the marital relationship before attempting to treat only one problem, which could be a symptom of a pervasive marital disorder.

Contraindications

Contraindications for couples therapy include patients with severe forms of psychosis, particularly patients with paranoid elements and those in whom the marriage's homeostatic mechanism is a protection against psychosis, marriages in which one or both partners really want to divorce, and marriages in which one spouse refuses to participate because of anxiety or fear.

Goals

Nathan Ackerman defined the aims of couples therapy as follows: The goals of therapy for partner relational problems are to alleviate emotional distress and disability and to promote the levels of well-being of both partners together and of each as an individual. Ideally, therapists move toward these goals by strengthening the shared resources for problem solving, by encouraging the substitution of adequate controls and defenses for pathogenic ones, by enhancing both the immunity against the disintegrative effects of emotional upset and the complementarity of the relationship, and by promoting the growth of the relationship and of each partner.

Part of a therapist's task is to persuade each partner in the relationship to take responsibility in understanding the psychodynamic makeup of personality. Each person's accountability for the effects of behavior on his or her own life, the life of the partner, and the lives of others in the environment is emphasized, and the result is often a deep understanding of the problems that created the marital discord.

Couples therapy does not ensure the maintenance of any marriage or relationship. Indeed, in certain instances, it may show the partners that they are in a nonviable union that should be dissolved. In these cases, couples may continue to meet with therapists to work through the difficulties of separating and obtaining a divorce, a process that has been called divorce therapy.

Relaxation therapy

Relaxation therapy is a process that focuses on using a combination of breathing and muscle relaxation in order to deal with stress. The use of various techniques within this process can come in handy when dealing with daily stress or working through unanticipated situations that produce a great deal of physical and emotional tension. While the essentials of relaxing therapy can be employed without the presence of a health professional, it is often a good idea to learn the basics with a trained practitioner.

Muscle relaxation therapy involves learning how stressful circumstances can cause the body’s autonomic nervous system to activate. When some type of emotional or physical stimulation connected with stress occurs, this system will kick into action. The result is that the heart begins to beat faster, breathing becomes more rapid, and blood vessels around the body begin to dilate. While a reaction of this type is beneficial when there is a need to defend the body from some type of adversary.

By employing relaxation therapy, it is possible to begin reversing the stimulation to the nervous system and restore the body and mind to a more balanced state. The key to the therapy is consciously regulating the breathing. This means becoming aware of the current rate of the inhalation and exhalation phases of the breathing process and making a conscious effort to incrementally slow them down to a more equitable pace. As the individual is able to slow the breathing rate, this also has a calming effect on the rapid heartbeat and helps to lessen the urge of “flight or fight.”

Relaxation therapy may include other elements along with the controlled breathing. Seeking a quiet spot to initiate the process can also help expedite the achievement of a calm state. For some people the use of aromatherapy in conjunction with relaxation therapy techniques is also helpful. Music or relaxation tapes of nature sounds like a waterfall may also help enhance the effect of the therapy.

Before engaging any type of relaxation therapy system on your own, it is a good idea to work with an individual with some type of relaxation therapy training. Doing so will help you master the basic patterns of breathing that you want to achieve during the therapy, as well as help you discover what other components tend to be most helpful in your particular situation. Once you have gained confidence in your ability to utilize relaxation therapy, you can employ the strategy any time that you feel your stress level rising.

BIOFEEDBACK

Biofeedback involves the recording and display of small changes in the physiological levels of the feedback parameter. The display can be visual, such as a big meter or a bar of lights, or auditory. Patients are instructed to change the levels of the parameter, using the feedback from the display as a guide. Biofeedback is based on the idea that the autonomic nervous system can come under voluntary control through operant conditioning. Biofeedback can be used by itself or in combination with relaxation. For example, patients with urinary incontinence use biofeedback alone to regain control over the pelvic musculature. Biofeedback is also used in the rehabilitation of neurological disorders. The benefits of biofeedback may be augmented by the relaxation that patients are trained to facilitate.

Theory

Neal Miller demonstrated the medical potential of biofeedback by showing that the normally involuntary autonomic nervous system can be operantly conditioned by use of appropriate feedback. By means of instruments, patients acquire information about the status of involuntary biological functions, such as skin temperature and electrical conductivity, muscle tension, blood pressure, heart rate, and brain wave activity. Patients then learn to regulate one or more of these biological states that affect symptoms. For example, a person can learn to raise the temperature of his or her hands to reduce the frequency of migraines, palpitations, or angina pectoris. Presumably, patients lower the sympathetic activation and voluntarily self-regulate arterial smooth muscle vasoconstrictive tendencies.

Methods

Instrumentation

The feedback instrument used depends on the patient and the specific problem. The most effective instruments are the electromyogram (EMG), which measures the electrical potentials of muscle fibers; the electroencephalogram (EEG), which measures alpha waves that occur in relaxed states; the galvanic skin response (GSR) gauge, which shows decreased skin conductivity during a relaxed state; and the thermistor, which measures skin temperature (which drops during tension because of peripheral vasoconstriction). Patients are attached to one of the instruments that measures a physiological function and translates the measurement into an audible or visual signal that patients use to gauge their responses. For example, in the treatment of bruxism, an EMG is attached to the masseter muscle. The EMG emits a high tone when the muscle is contracted and a low tone when at rest. Patients can learn to alter the tone to indicate relaxation. Patients receive feedback about the masseter muscle, the tone reinforces the learning, and the condition ameliorates all of these events interacting synergistically.

Many less-specific clinical applications (e.g., treating insomnia, dysmenorrhea, and speech problems; improving athletic performance; treating volitional disorders; achieving altered states of consciousness; managing stress; and supplementing psychotherapy for anxiety associated with somatoform disorders) use a model in which frontalis muscle EMG biofeedback is combined with thermal biofeedback and verbal instructions in progressive relaxation

Relaxation Therapy

Muscle relaxation is used as a component of treatment programs (e.g., systematic desensitization) or as treatment in its own right (relaxation therapy). Relaxation is characterized by (1) immobility of the body, (2) control over the focus of attention, (3) low muscle tone, and (4) cultivation of a specific frame of mind, described as contemplative, nonjudgmental, detached, or mindful.

Progressive relaxation was developed by Edmund Jacobson in 1929. Jacobson observed that: When an individual lies relaxed, in the ordinary sense, the following clinical signs reveal the presence of residual tension: respiration is slightly irregular in time or force; the pulse-rate, although often normal, is in some instances moderately increased as compared with later tests; voluntary or local reflex activities are revealed in such slight marks as wrinkling of the forehead, frowning, movements of the eye balls, frequent or rapid winking, restless shifting of the head, a limb or even a finger; finally, the mind continues to be active, and once started, worry or oppressive emotion will persist. It is amazing that a faint degree of tension can be responsible for all this.

Learning relaxation, therefore, involves cultivating a muscle sense. To develop the muscle sense further, patients are taught to isolate and contract specific muscles or muscle groups, one at a time. For example, patients flex the forearm while the therapist holds it back to observe tenseness in the biceps muscle. (Jacobson used the word tenseness rather than tension to emphasize the patient's role in tensing the muscles.) Once this sensation is reported, Jacobson would say, This is your doing! What we wish is the reverse of this simply not doing. Patients are repeatedly reminded that relaxation involves no effort. In fact making an effort is being tense and therefore is not to relax. As the session progresses, patients are instructed to let go further and further, even past the point when the body part seems perfectly relaxed.

Patients would work in this fashion with different muscle groups, often over more than 50 sessions. For example, an entire session might be devoted to relaxing the biceps muscle. Another feature of Jacobson's method was that instructions were given tersely so they would not interfere with a patient's focus on muscle sensations; suggestions commonly used today were avoided. Patients were also frequently left alone, while the therapist attended to other patients.

In psychiatry, relaxation therapy is mainly used as a component of multifaceted broad-spectrum programs. Its use in desensitization was mentioned previously. Relaxing breathing exercises are often helpful for patients with panic disorder especially that considered to be related to hyperventilation. In the treatment of patients with anxiety disorders, relaxation can serve as an occasion-setting stimulus (i.e., as a context of safety in which other specific intervention can be confidently tried).

Later Adaptation of Progressive Muscular Relaxation

Joseph Wolpe chose progressive relaxation as a response incompatible with anxiety when designing his systematic desensitization treatment (discussed below). For this purpose, Jacobson's original method was too lengthy to be practical. Wolpe abbreviated the program to 20 minutes during the first six sessions (devoting the remainder of these sessions to other things, such as behavioral analysis). In a later modification of progressive relaxation, patients completed work with all the principal muscle groups in one session. Once the patients have mastered this procedure (typically after three sessions), these groups are combined into larger groups. Finally, patients practice relaxation by recall (i.e., without tensing the muscles).

Autogenic Training

Autogenic training is a method of self-suggestion that originated in Germany. It involves the patients directing their attention to specific bodily areas and hearing themselves think certain phrases reflecting a relaxed state. In the original German version, patients progressed through six themes over many sessions.

Applied Tension

Applied tension is a technique that is the opposite of relaxation; applied tension can be used to counteract the fainting response. The treatment extends over four sessions. In the first session, patients learn to tense the muscles of the arms, legs, and torso for 10 to 15 seconds (as if they were bodybuilders). The tension is maintained long enough for a sensation of warmth to develop in the face. The patients then release the tension, but do not progress to a state of relaxation. The maneuver is repeated five times at half-minute intervals. This method can be augmented with feedback of the patient's blood pressure during the muscle contraction; increased blood pressure suggests that appropriate muscle tension was achieved. The patients continue to practice the technique five times a day. An adverse effect of treatment that sometimes develops is headache. In this case, the intensity of the muscle contraction and the frequency of treatment are reduced.

Patients with blood and injury phobia show a unique, biphasic response when exposed to a phobic stimulus. The first phase is associated with increased heart rate and blood pressure. In the second phase, however, blood pressure suddenly falls and the patient faints. To treat the problem, patients are shown a series of slides that are provocative (e.g., mutilated bodies). They are coached in identifying early warning signs of fainting, such as queasiness, cold sweats, or dizziness, and in applying the learned muscle tension response quickly, contingent on these warning signs. Patients can also perform applied tension while donating blood or watching a surgical operation. The technique of isometric tension raises blood pressure, which prevents fainting.

Applied Relaxation

Applied relaxation involves eliciting a relaxation response in the stressful situation itself. The previous discussion showed that this is not advisable right away because of the possible ironic effects of relaxation. Therefore, patients should first practice relaxation in nonstressful circumstances. The method developed by Lars-Granst and coworkers in Sweden has been proved efficacious for panic disorder and generalized anxiety disorder. Establishing the relaxation response in the patient's natural environment consists of seven phases of one to two sessions each: progressive relaxation, release-only relaxation, cue-controlled relaxation, differential relaxation, rapid relaxation, application training, and maintenance

Results

Biofeedback, progressive relaxation, and applied tension have been shown to be effective treatment methods for a broad range of disorders. They form one basis of behavioral medicine in which the patient changes (or learns how to change) behavior that contributes to illness. They form a basis on which many complementary and alternative medical procedures are effective (e.g., yoga and Reiki) in which relaxation is an important component. Relaxation also informs more mainstream treatments, such as hypnosis.

THERAPEUTIC COMMUNITY

Introduction

• The therapeutic community (TC) for the treatment of drug abuse and addiction has existed for about 40 years.
• TCs are drug-free residential settings that use a hierarchical model with treatment stages that reflect increased levels of personal and social responsibility.
• The goals are to effect a complete change of lifestyle, including abstinence from substances, to develop a personal honesty, responsibility and useful social skills and to eliminate antisocial attitudes and criminal behavior .

History

Under the influence of Maxwell Jones, Main, Wilmer and developed the concept of the therapeutic community and its attenuated form - the therapeutic milieu - caught on and dominated the field of inpatient psychiatry throughout the 1960's. The aim of therapeutic communities was a more democratic, user-led form of therapeutic environment, avoiding the authoritarian and demeaning practices of many psychiatric establishments of the time. The central philosophy is that clients are active participants in their own and each other's mental health treatment and that responsibility for the daily running of the community is shared among the clients and the staff. 'TC's have sometimes eschewed or limited medication in favour of group-based therapies.

 Definition

“A therapeutic community is a drug-free environment in which people with addictive (and other) problems live together in an organized and structured way in order to promote change and make possible a drug-free life in the outside society. The therapeutic community forms a miniature society in which residents, and staff in the role of facilitators, fulfill distinctive roles and adhere to clear rules, all designed to promote the transitional process of the residents” ( Ottenberg 1993)

Stuart and Sundeen defined therapeutic community as “a therapy in which patient’s social environment would be used to provide a therapeutic experience for the patient by involving him as an active participant in his own care and the daily problems of his community”.          

Objectives

• To use patient’s social environment to provide a therapeutic experience for him
• To enable the patient to be an active participant in his own care and become involved in daily activities of his own community
• To help patient to solve problems ,plan activities and to develop the necessary rules and regulations for the community
• To increase their independence and gain control over many of their own personal activities
• To enable the patient to become aware of how their behavior affects others

Elements of therapeutic community

• Free communication
• Shared responsibility
• Active participation
• Involvement in decision making
• Understanding of the roles ,responsibilities ,limitations and authorities

 Components of therapeutic community

 a) Daily community meetings

• These meetings are composed of 60-90 patients. All levels of unit staff are involved, including administrative personnel. Acute patients are not involved in the meetings.
• Meetings should be held regularly for 60 minutes
• Discussion should focus mainly on day to day life in the unit
• During discussion patients feelings and behaviors are examined by other members
• Frank discussion are encouraged ,these may take place with much out poring of emotions and anger

b) Patient Government or Ward council

• The purpose of patient government is to deal with practical unit details such as house-keeping functions, activity planning and privileges
• A group of 5-6 patients will have specific responsibilities, such as house keeping, physical exercise, personal hygiene, meal distribution, a group to observe suicidal patients. Staff  members should be always available
• All decisions should be feedback to the community through the community meetings

c) Staff meetings or Review

•  A staff meeting should be held following each community meeting (patients are excluded and only staff are present). In this meeting the staff would examine their own responses, expectations and prejudice.

 d) Living and learning opportunities

•  Learning opportunities are provided within the social milieu, which should provide realistic learning experiences for the patients.

Length of treatment in a therapeutic community

In general, individuals progress through drug addiction treatment at varying speeds, so there is no predetermined length of treatment. Those who complete treatment achieve the best outcomes, but even those who drop out may receive some benefit. Good outcomes from TC treatment are strongly related to treatment duration, which likely reflects benefits derived from the underlying treatment process. Individuals who complete at least 90 days of treatment in a TC have significantly better outcomes on average than those who stay for shorter periods.

Traditionally, stays in TCs have varied from 18 to 24 months. Recently, however, funding restrictions have forced many TCs to significantly reduce stays to 12 months or less and/or develop alternatives to the traditional residential model .For individuals with many serious problems (e.g., multiple drug addictions, criminal involvement, mental health disorders, and low employment), research again suggests that outcomes were better for those who received TC treatment for 90 days or more.

In the TC, the level of treatment engagement and participation is related to retention and outcomes. Treatment factors associated with increased retention include having a good relationship with one's counselor, being satisfied with the treatment, and attending education classes. Important attributes linked to treatment retention include self-esteem, attitudes and beliefs about oneself and one's future, and readiness and motivation for treatment. Retention can be improved through interventions to address these areas.

Structure of the therapeutic community

TCs are physically and programmatically designed to emphasize the experience of community within the residence. The residential capacity of TCs can vary widely; a typical program in a community-based setting accommodates 40 to 80 people. TCs are located in various settings, often determined by need, funding sources, and community tolerance. Some, for example, are situated on the grounds of former camps and ranches or in suburban houses. Others have been established in jails, prisons, and shelters. Larger agencies may support several facilities in different settings to meet various clinical and administrative needs.

The treatment process: therapy, education and training

The elements of treatment at the TC typically include substance abuse treatment, education (General Equivalency Diploma or, in some cases, university courses), primary medical and dental care, vocational skills training (e.g. culinary arts, carpentry, general maintenance, mechanical systems, general contracting, computer skills, or substance abuse counseling), on- and off-site job placement, and in rare cases, on-site resident-run businesses. Other supports include legal services, advocacy, and life skills counseling. There is no formal religious component to treatment, education or training. In fact, experts caution against the introduction of religion as an aspect of daily life in the TC.

TC treatment can be divided into three major stages.

Stage 1. Induction and early treatment: This phase typically occurs during the first 30 days to assimilate the individual into the TC. Once the intake process of interviews and assessments is complete, new arrivals to the TC are often housed in rooms with six to eight bunkmates. It is generally expected that new residents must be medically detoxified prior to beginning the program. Leader who is responsible for the orientation of the new resident to the rules and expectations of the TC.

Work is often identified as one of the central components of the therapeutic approach. As such, job assignments or “functions” begin immediately for new residents, usually with basic housekeeping or maintenance chores. The work-centered approach is intended to serve multiple purposes.

• First, by beginning with general maintenance work, the resident acquires knowledge of the facility’s physical layout and organizational structure.
• Second, daily work is believed to instill an ethic of discipline and hard work that is desirable according to the TC treatment model.
• Third, putting new residents to work immediately reinforces the broader nature of the TC as a structured, merit-based program, where residents earn privileges and seniority by complying with all rules and behavioral expectations. In this case, the implied goal for the new resident is to move up a strict hierarchy of jobs and departments to more desirable positions.
• Lastly, the work is often physically demanding, leaving residents physically tired at the end of the day so that they have no time to think about leaving and returning to their previous  lifestyle.

Progression from phase one to phase two is be made on the recommendation of staff members and, to a lesser extent, the broader peer group, and  is typically judged on the basis of the individual resident’s attitude, work competence and peer relations.

Stage 2. Primary treatment

In Phase two the resident is expected to take on more responsibility for the welfare of others, particularly newcomers. At this stage, he or she is normally introduced to three vocational training areas. Training takes place during the daytime hours, with expected study time in the evening. Residents typically begin courses to improve literacy, develop computer skills and achieve a General Equivalency Diploma (GED). Residents are also typically expected to continue with their encounter groups, with the goal of adopting positive beliefs and attitudes toward themselves and others. By the end of phase two,  residents are normally expected to have completed their GED, choose one vocation training area in which to specialize, participate in encounter groups, deal with more daily responsibility, and adhere to the rules and regulations of the facility. Often  uses a structured model of progression through increasing levels of prosocial attitudes, behaviors, and responsibilities. The TC may use interventions to change the individual's attitudes, perceptions, and behaviors related to drug use and to address the social, educational, vocational, familial, and psychological needs of the individual.

Stage 3

Entry into phase three normally begins when the resident has applied for, and has been accepted to train in a vocational area on a full-time basis, with the intention of completing a certificate in the program or trade, and finding related work outside of the facility after leaving. Residents may be reimbursed nominally for their vocational work. The money is saved so they will have money to begin their new lives once they exit the program. During this phase, residents may be encouraged to attend social activities outside of the facility accompanied by other members, as well as re-establish contact with their   families of origin. A family reunification program is sometimes established.

Stage 4. Re-entry At this point residents typically share accommodations and bathrooms with a smaller number of residents in a more home like setting. It is believed that by this phase, residents have acquired skills and coping abilities to allow them to “re-enter” society.These skills often include a GED, vocational training, computer literacy, and relationship and coping skills. If any money has been saved for the resident, these funds will be released with the expectation that a bank account will be opened for living expenses.

Staffing

TCs are often staffed by a carefully chosen group of professionals who receive training in the specifics of the TC model. Experts suggest that program staff should comprise a mix of self-help recovered professionals and other traditional professionals (e.g.  nurses, physicians, lawyers, case workers, counselors) 8). An average resident to staff ratio was cited as approximately 15:1.

Resident profile and special populations

 Many residents have been drug addicted for years and have a history of criminal activity or other legal problems. Other common factors include multi-generational poverty and homelessness. most TCs stipulate that residents must be healthy enough to undertake physical labor and participate in training programs and other group-related activities. Potential residents are generally deemed inadmissible in the case of a history of kidnapping, rape, arson, child molestation, suicide attempts.

The screening and intake process for TC residents is rigorous, typically involving an initial visit or phone call, admission to a waiting list, an orientation process, one or more intake interviews, medical, legal and psychological assessments, and consent to treatment. A thorough intake process is considered to be particularly critical in light of the high rate of drop-out which commonly reaches 50% within the first 30 days.

The daily regimen

A typical TC day begins at 7 a.m. and ends at 11 p.m. and includes morning and evening house meetings, job assignments, groups, seminars, scheduled personal time, recreation, and individual counseling. As employment is considered an important element of successful participation in society, work is a distinctive component of the TC model.

In the TC, all activities and interpersonal and social interactions are considered important opportunities to facilitate individual change. These methods can be organized by their primary purpose, as follows:

• Clinical groups (e.g., encounter groups and retreats) use a variety of therapeutic approaches to address significant life problems.
• Community meetings (e.g., morning, daily house, and general meetings and seminars) review the goals, procedures, and functioning of the TC.
• Vocational and educational activities occur in group sessions and provide work, communication, and interpersonal skills training.
• Community and clinical management activities (e.g., privileges, disciplinary sanctions, security, and surveillance) maintain the physical and psychological safety of the environment and ensure that resident life is orderly and productive.

Advantages of therapeutic community

• Patient develops harmonious relationships with other members of the community
• Gains self –confidence
• Develops leadership skills
• Learns to understand and solve problems of self and others
• Becomes socio-centric
• Learns to live and think collectively with the members of the community
• It provides opportunity to participate in the formulation of hospital rules and regulations that affect patient’s personal liberties like bedtime, meal time, weekend permission, control of radio or T.V, social activities , late night privileges.

Disadvantages of therapeutic community

• Role blurring between staff and patient
• Group responsibility can easily become nobody’s responsibility
• Individual needs and concerns may not be met
• Patient find the transition to community difficult

Role of the nurse

• Providing and maintaining a safe and conflict free environment through role modeling and group leadership
• Sharing of responsibilities with patient
• Encouraging patient to participate in decision making functions
• Assisting patients to assume leadership roles
• Giving feedback
• Carrying out supervisory functions

 Conclusion

Several studies have found that this approach to treatment is successful in substantially improving the quality of life for members. A study of patients at the Cassel Hospital showed that 98% of patients are too disturbed on admission to find employment, but that five years later 90% have jobs. Re-admission and re-conviction rates have been found to drop considerably after treatment in a therapeutic community.

MILIEU THERAPY

'Milieu' is a French word meaning ".Middle Place". In the English language, milieu means "environment" or – “setting”, as used in psychiatric mental health nursing, it refers to the people and all other social and physical factors in the environment with which the client interacts.

Concept of Milieu Therapy:

A therapeutic milieu is a 24 - hour environment designed to provide a secure retreat for individuals whose capacities for coping with reality have deteriorated. The therapeutic milieu gives them opportunities to acquire adaptive coping skills. By offering secure, comfortable physi­cal facilities for sleeping, dining, bathing, and engaging in recreational, occupational, social, psychiatric and medical therapies, the therapeutic milieu does many advantages.

Functions of Milieu Therapy:

1. Shelters clients physically from what they perceive as painful, terrifying stressors.

2. Protects clients physically from discharges of their own and others' maladaptive behav­iors.

3. Supports the physiological existence of clients.

4. Provides pleasant, attractive, sensory stimulation to clients.

5. Educates clients and their families about adaptive, effective coping.

Characteristics of a Therapeutic Milieu / Elements of MT

1. Individual Treatment Program

A therapeutic milieu is tailored to the client's individual needs without infringing on the needs and rights of other clients. A definite structure, schedule, overall guidelines and social controls are set forth to provide organization and predictability.

2. Self - Governance

To avoid the cultivation of dependence and regression, clients are encouraged to participate in decision - making regarding milieu issues. Structured community meetings client-team meet­ings and client-team committee meetings held at regular scheduled intervals to help the client to find opportunities to develop decision - making skills by involving in milieu decisions.

3. Progressive Levels of Responsibility

In a therapeutic milieu, clients are expected to assume a responsible role in the maintenance of the environment. The degree of responsibility expected of clients is depending upon their capabilities. This approach is a form of behavior modifications in that it rewards and reinforces adaptive behavior. The level of responsibility assigned to clients depends upon the speed of im­provement they show in their illness process.

4. A Variety of Meaningful Activities

To minimize social withdrawal and regression, therapeutic milieu must provide each client with an individual activity schedule. Such activities may include structured exercise classes, jog­ging, training in interpersonal skills (eg: Assertiveness training, listening, parenting) grooming classes, arts, crafts, relaxation training and stress management classes, dance classes, and work and occupational therapies.

5. Links with the Client's Family

Therapeutic milieu provides opportunities for clients to re enter the main stream of family life at their own pace. Links with the family is accomplished in several ways. Family visits are incorporated into the overall therapeutic milieu program by including family members in selected milieu activities. Family counseling’s are provided to help clients and their families work through the conflicts and problems that inevitably arise during visits.

Including family members in selected milieu activities, such as mental health classes, inter­personal skill classes, and medication classes, enables mental health team members to observe family dynamics and to model adaptive interpersonal behaviors to both clients and their families.

6. Links with the Community

Activities occurring outside the structured milieu, such as shopping trips, picnics, camping trips, attending movies and plays, serve to link clients to community life. Participating in such activities with mental health team members help clients develop the social skills and confidence needed to re enter the community.

7. Effective Working Relationships among Mental Health Team Members

Interpersonal conflict occasionally occurs in any group of people. When mental health team members can engage in effective conflicts resolution, they are more likely to trust each other and to act and interact as a mental health team and not as a "lone therapist". Mental health team members who can resolve interpersonal conflicts are effective role models for clients.

8. Humanistic Mental Health Team Members

Mental Health Team Members need to possess the following attributes:

a) Optimistic attitudes toward people in general.

b) The ability to inspire hopefulness in clients and in others.

c) Creativity in working toward more effective ways of involving clients in the environment.

d) Lack of fear or prejudice when confronted with persons exhibiting unconventional or aber­rant behavior.

e) Willingness to maintain frequent personal contacts with clients on a daily basis.

f) The ability to set limits on their own behavior and the behavior of others in a non-punitive manner.

g) Willingness to share control and decision making with team members and clients.

h) The belief that controls and limits should be provided by the people to the greatest extent possible, rather than by locked doors, physical restraints or psycho chemotherapeutic agents.

Components of a Therapeutic Milieu

Comfortable, secure physical facilities, the mental health team and the therapeutic milieu program are the three essential components of a therapeutic milieu. The total milieu acting as the primary therapeutic agent is referred to as milieu therapy.

Milieu Therapy Approach

Milieu therapy is a group therapy approach that uses a total living experience - recreational, occupational, psychosocial, psychiatric, nursing, and medical therapies, plus mental health team - client relationships - to accomplish therapeutic objectives. Some of those objectives are,

a) Correct or redefine their perceptions of stressors.

b) Correct maladaptive coping behavioral patterns.

c) Develop adaptive coping behavioral patterns.

d) Acquire interpersonal and stress management skills in order to conduct themselves more effectively in the environment and strengthen or correct their coping abilities.

Nurses' Role in Milieu Therapy

1. Use nursing process to provide comprehensive care.

2. Provide direct client care

• Manages the day-to-day care of individual clients.

• Assists the client for re-entry into the community.

3. Give indirect client care «

• Maintains ongoing communication with other mental health team members.

• Enforces rules, policies and regulations of therapeutic milieu.

• A schedule, assigns, manages, and evaluates clinical work.

4. Administer medication and give medication teaching

5. Provide psychosocial care

• Uses informal group interventions such as community meetings and structured or un­structured group therapy sessions to assist client with problems in their current life situ­ations.

• Conducts brief, "on-the-spot" counseling with clients and families

• Sets limits to deal with behaviors destructive to the self, others, or the environment.

• Helps the clients use their time productively for leisure and work.

• Involves withdrawn clients in the milieu

• Encourages clients who have low self-esteem to value themselves.

• Serves as a role model by demonstrating inter personal effectiveness in relating to cli­ents and other mental health team members.

• Conducts one-to-one therapy sessions daily with selective clients.

• Conducts group therapy on a daily basis to help clients to gain self-awareness about how they behave in groups.

• Uses attitude therapy-Active friendliness, passive friendliness, kind firmness, matter-of-factness and no demand are some of the fundamental attitudes that nurses make use.

6. Provide mental health teaching

• Psychotropic medications, methods of coping, inter personal effectiveness (eg. Assertiveness training, communication, problem-solving skills, parenting skills and so forth) stress management, relaxation and physical exercise etc.

7. Encourage clients to help and support each other individually and as a group.

8. Assist clients to understand each other's feelings and problems.

9. Conduct community meetings

10. Participate freely in milieu activities

OCCUPATIONAL THERAPY

Occupational therapy helps individuals perform tasks in their daily living and working environments. When accidents, disease, or other difficulties inhibit one’s ability to engage in routine activities, occupational therapy assists by promoting, restoring, maintaining or modifying life skills.

Occupational therapists are educated in human growth and development with specific emphasis placed on the social, emotional, and physiological effects of illness and injury.

Occupational therapists treat conditions that are physically, mentally, developmentally or emotionally disabling. They focus on helping a person improve basic motor functions and reasoning abilities; also help patients compensate for permanent loss of function. Individuals can lead more independent, productive, and satisfying lives through treatments that address:

• self care (dressing, bathing, eating)
• participating in work or school
• care of one’s surroundings: (attending children, shopping, managing the home)
• enjoying recreation and leisure 
• engaging in social activities

Activities can be divided into the following categories

·         Creative activities, e g:pottery,puppetry

·         Commercial ,e g: typing, book keeping

·         Domestic, e g: cooking home management

·         Industrial, e g: printing, assembly work

·         Intellectual, e g: solving crosswords/ puzzles

·         Recreation, e g: games, dancing

·         Those enriching social relationships of helping out of the poor children, organizing functions for geriatric patients.  

The Goal of OT

Occupational Therapy has the same goal in mind (increasing function and independence) in regards to physical disabilities and limitations, and therapist  use repetitive exercises, in the context of a "functional activity". This refers to performing meaningful activities while simultaneously working on increasing function and mobility.

Occupational therapy is a health profession whose goal is to help people achieve independence, meaning and satisfaction in all aspects of their lives.

Definition

Occupational therapy promotes health by enabling people to perform meaningful and purposeful occupations. Occupation is defined as "active process of living: from the beginning to the end of life, ... occupations are all the active processes of looking after ourselves and others, enjoying life, and being socially and economically productive over the lifespan and in various contexts". These include (but are not limited to) work, leisure, self care, domestic and community activities. Occupational therapists work with individuals, families, groups, communities and organizations to facilitate health, well-being and justice through engagement in occupation. Occupational therapists are becoming increasingly involved in addressing the impact of social, political and environmental factors that contribute to exclusion and occupational deprivation.

The World Federation of Occupational Therapists provides the following definition of Occupational Therapy: "Occupational therapy is as a profession concerned with promoting health and well being through occupation. The primary goal of occupational therapy is to enable people to participate in the activities of everyday life. Occupational therapists achieve this outcome by enabling people to do things that will enhance their ability to participate or by modifying the environment to better support participation." Occupational therapists use careful analysis of physical, environmental, psychosocial, mental, spiritual, political and cultural factors to identify barriers to occupation. Occupational therapy draws from the fields of medicine, psychology, sociology, anthropology, and many other disciplines in developing its knowledge base. A new discipline of occupational science has been developed to enhance the evidence base of the profession.

Evolution of the philosophy of occupational therapy

The philosophy of occupational therapy has evolved over the history of the profession. The philosophy articulated by the founders that have owed much to the ideals of romanticism , pragmatism and humanism which are collectively considered the fundamental ideologies of the past century.

One of the most widely cited early papers about the philosophy of occupational therapy was presented by Adolf Meyer, a psychiatrist who had emigrated to the United States from Switzerland in the late 19th Century and who was invited to present his views to a gathering of the new occupational therapy society in 1922. At the time, Dr. Meyer was one of the leading psychiatrists in the United States and head of the new psychiatry department and Phipps Clinic at Johns Hopkins University in Baltimore, Maryland.

William Rush Dunton, a supporter of the National Society for the Promotion of Occupational Therapy, now the American Occupational Therapy Association, sought to promote the ideas that occupation is a basic human need, and that occupation was therapeutic. From his statements, came some of the basic assumptions of occupational therapy, which include:

• Occupation has an effect on health and well-being.
• Occupation creates structure and organizes time.
• Occupation brings meaning to life, culturally and personally.
• Occupations are individual. People value different occupations.

Occupational therapy is divided into two broad categories:

1.      Activity therapy.

2.      Vocational training.

Activity therapy

            Actual disturbing symptoms or needs are taken into consideration. It is not usually connected with the person’s occupation. For eg. Finger painting or clay work for regressed patients.

Activities suggested for patients

Neurotics

            In neurotics the emotional conflict is main problem rather than lack of work practice. Activities encouraging social responsibility which divert from pre-occupying thoughts are used.

Manic patients

·         Isolated activities are preferred as he may interferes with the work of others

·         In the hospital, sweeping , swabbing, washing, plates, weaving, washing clothes be given. 

 Depressive patients

            Activities should be short-term creative and interesting and in small encouraging groups. Activities in open air and physical exercise are very good.

For example, Horticulture , out door games.

Schizophrenics

            Emphasis should be on social skill training especially personal, hygiene .Regular exercise and work involving graded task with less decision making to be given. Small group activities are indicated which facilitate communication and interpersonal relationship.

Addicts

            Constructive work, which fosters and raises patient image and confidence in the minds of others are used. Industrial activities fostering specific talents are very useful.

Mentally Challenged

          Training in vocational and social skill to be given.

Vocational Training

            The main aspects to be looked into are:

Ø  Patients illness and its duration

Ø  Past working experience

Ø  Present interest of the patient

Ø  Current mental status

Ø  Family resources

Ø  Current abilities of the patient

Occupational therapy process

An Occupational Therapist works systematically through a sequence of actions known as the occupational therapy process. There are several versions of this process as described by numerous writers. Creek (2003) has sought to provide a comprehensive version based on extensive research. This version has 11 stages, which for the experienced therapist may not be linear in nature. The stages are:

• Referral
• Information gathering
• Initial assessment
• Needs identification/problem formation
• Goal setting
• Action planning
• Action
• Ongoing assessment and revision of action
• Outcome and outcome measurement
• End of intervention or discharge
• Review

Canadian Practice Process Framework (CPPF), which portrays eight action points for the process of occupation-based, client-centered enablement.

Fearing, Law and Clark (1997) suggested a 7 stage process which includes:

• identifying of occupational performance issues
• choosing a theoretical frame of reference
• assessing factors contributing the identified occupational performance issue(s)
• considering the strengths and resources of both client and therapist
• negotiating targeted outcomes and developing an action plan
• implementing the plan through occupation
• evaluating outcomes

A central element of this process model is the focus on identifying both client and therapists strengths and resources prior to beginning to develop the outcomes and action plan.

Areas of practice in occupational therapy

            The categorization from the American Occupational Therapy Association is, such as physical, mental, and community practice (AOTA, 2009). For example, acute physical or mental health settings (e.g.: hospitals), sub-acute settings (e.g.: aged care facilities), outpatient clinics and community settings.

Mental health

According to the American Occupational Therapy Association (AOTA), occupational therapists work with the Mental Health population throughout the life span and across many treatment settings where mental health services and psychiatric rehabilitation are provided (AOTA, 2009). Just as with other clients, the OT facilitates maximum independence in activities of daily living (dressing, grooming, etc.) and instrumental activities of daily living (medication management, grocery shopping, etc.). According to the American Occupational Therapy Association, OT improves functional capacity and quality of life for people with mental illness in the areas of employment, education, community living, and home and personal care through the use of real life activities in therapy treatments (AOTA, 2005).

Geriatric, Adult, Adolescents, and Children with any kind of mental illness or mental health issues. These conditions include but are not limited to: Schizophrenia, substance abuse, addiction, dementia, Alzheimer’s, mood disorders, personality disorders, psychoses, eating disorders, anxiety disorders (including post-traumatic stress disorder, separation anxiety disorder) (Cara & MacRae, 2005), and reactive attachment disorder (children only) (Lambert, 2005).

Typical issues that are addressed are as follows: Helping people acquire the skills to care for themselves or others including; keeping a schedule, medication management, employment, education, increasing community participation, community access (grocery store, library, bank, etc.), money management skills, engaging in productive activities to fill the day, coping skills, routine building, building social skills, and childcare (Cara & MacRae, 2005).

Areas that Mental Health OT's could work in are as follows:

• Mental health inpatient units
• Adolescent, adult and older people's acute mental health wards
• Adult and older people's rehabilitation wards
• Prisons/secure units (Forensic psychiatry)
• Psychiatric intensive care unit
• Specialist units for Eating Disorders, Learning disabilities
• Community based mental health teams
• Child and adolescent mental health teams
• Adult and older people's community mental health teams
• Rehabilitation and recovery and Assertive Outreach community teams
• Primary care services in GP practices
• Home treatment teams
• early intervention in psychosis teams
• Specialist learning disability, eating disorder community services
• Day services
• Vocational Services
• Dementia & Alzheimer Care: OTs focus on adapting activities as the client progresses through the illness (Hofmann, 2008) OT also works with caregivers to teach them how to grade activities to the client’s ability. Interventions are based on using the client’s strengths to increase their quality of life and their relationships with caregivers. Use of social interactions, communication, memory, safety and self maintenance.

Community

Community based practice involves working with people in their own environment rather than in a hospital setting. It often combines the knowledge and skills related to physical and mental health. It can also involve working with atypical populations such as the homeless or at-risk populations. Examples of community-based practice settings:

• Health promotion and lifestyle change: Remaining healthy is the goal of all people in a society, including people with chronic disabling or health conditions. Achieving health requires skills to self-manage conditions that might limit their ability to function in daily life. The occupational therapist helps people acquire these skills (Wilcock, 2005).
• Private Practice
• Aging in place: Occupational therapists implement environmental modifications in senior housing, assisted living, long-term-care facilities, and homes (Yamkovenko, 2008) Environmental modifications can include rearranging furniture, building ramps, widening doorways, grab bars, special toilet seats, and other safety equipment to use performance capabilities to their fullest (Moyers & Christiansen, 2004).
• Low Vision: Occupational therapists help clients use their remaining vision to complete their daily routines with compensation, remediation, disability prevention and health promotion. Compensations or that modifications to the environment may include proper lighting, color contrast, reducing clutter and education on adaptive equipment (Golembiewski, 2004).
• Intermediate care services
• Driving Centers: Driving is an instrumental activity of daily living and an occupational therapist may evaluate and treat skills needed to drive such as vision, executive function or memory. If a client needs more skilled assessment and training they would refer them to an OT Driver Rehabilitation Specialist which could do on the road assessment, training in adaptive equipment and make more specific recommendations.
• Day centres
• Schools
• Child development centres
• People's own homes, carrying out therapy and providing equipment and adaptations
• Work and Industry: To be a healthy successful worker there must be a person environment fit between the task, the equipment, and the person’s skills
• Homeless Shelters
• Educational Settings
• Refugee Camps.

New Emerging Practice Areas for Therapy

• Children & Youth:
• Psychosocial Needs of Children & Youth
• Health & Wellness:
• Health & Wellness Consulting
• Design & Accessibility Consulting & Home Modification
• Ergonomic Consulting
• Private Practice Community Health Services
• Productive Aging:
• Driver Rehabilitation & Training
• Low Vision Services
• Rehabilitation, Disability, & Participation:
• Technology & Assistive Device Development & Consulting
• Work & Industry:
• Ticket to Work Services
• Welfare to Work Services

Occupational therapy approaches

Services typically include:

• Teaching new ways of approaching tasks
• How to break down activities into achievable components e.g. sequencing a complex task like cooking a complex meal
• Comprehensive home and job site evaluations with adaptation recommendations.
• Performance skills assessments and treatment.
• Adaptive equipment recommendations and usage training.
• Environmental adaptation including provision of equipment or designing adaptations to remove obstacles or make them manageable
• Guidance to family members and caregivers.
• The use of creative media as therapeutic activity

Activity analysis

Activity analysis has been defined as a process of dissecting an activity into its component parts and task sequence in order to identify its inherent properties and the skills required for its performance, thus allowing the therapist to evaluate its therapeutic potential.

Theoretical Frameworks

Frames of Reference/Generic models

Frames of reference or generic models are the overarching title given to a collation of compatible knowledge, research and theories that form conceptual practice. More generally they can be defined as "those aspects which influence our perceptions, decisions and practice".

Occupational Therapy Frame of References/Models:

• Person Environment Occupation Performance Model (PEOP) (Charles Christiansen & Carolyn Baum)
• Occupational Performance Model (OPM)
• Kawa Model (Michael K. Iwama)
• Model of Human Occupation (MOHO) (Gary Kielhofner and others)
• Canadian Model of Occupational Performance and Engagement (CMOP-E)
• Biomechanical
• Rehabilitative (compensatory)
• Neurofunctional (Gordon Muir Giles and Clark-Wilson)
• Cognitive Disabilities
• Sensory Integration
• Lifestyle Performance Model (Fidler)

Challenges for occupational therapy

A key challenge for occupational therapy is to develop and maintain a definition of its nature and scope  assert that while this presents a challenge, it also results in a unique flexibility which allows the discipline to move with the flow of social, cultural and environmental change. This difficulty in definition may be a cause of chronic strain for practitioners and may also contribute to a lack of role definition and subsequent blurring.

Advantages of occupation therapy

·         It diverts the mind from morbid state

·         It decreases his hallucinations as he concentrate on the activities

·         It increases his socialization as he has to work with others

·         It provides incentive and goal

·         Help to maintain normal work habit

·         Channelizes the psychomotor activities

·         It enables to have a feeling of achievement

·         It stimulates interest and attention

·         Teaches social skills

·         It increases self-esteem

·         It helps the rehabilitation with return of self-confidence

·         It satisfies the emotional needs likes, love acceptance and security through activities.

The therapeutic tools used in occupational therapy are the self, group and group activities, therapeutic milieu, creative & manual arts, recreational activities library & educational activities, leisure activities & domestic activities.

            Occupational therapy differs for the short-stay and the long-stay patients. It differs from patient to patient. It is a treatment which is given under expert medical personal for mental psychological problems. The therapist should  have a knowledge  of the disease, disabilities of the patient before providing specific occupation for the patient.

    Nurses responsibility in Occupational Therapy

• Apply their specific knowledge to enable people to engage in activities of daily living that have personal meaning and value.
• Develop, improve, sustain, or restore independence to any person who has an injury, illness, disability or psychological dysfunction.
• Consult with the person and the family or caregivers and, through evaluation and treatment, promote the client's capacity to participate in satisfying daily activities.
• Address by intervention the person's capacity to perform, the activity being performed, or the environment in which it is performed.
• Provide the client with skills for the job of living - those necessary to function in the community or in the client's chosen environment.

Training Tips in Occupation Therapy for Patients

·         Develop good interpersonal relationship

·         Select a type of work depending upon his experience, interest, mental and physical condition. Keeping in mind the families interest and resources

·         Start with simple work in a comfortable environment

·         Once one teaching has occurred give time for over learning

·         Support & use various types of reinforces to motivate the patient

·         Assess work behavior using work behavior assessment scale & reward him accordingly.

·         Educate patient and family members regarding, need and positive effect of work for the patient.

RECREATIONAL THERAPY

Recreational therapy, also referred to as recreation therapy and therapeutic recreation, is a treatment service designed to restore, remediate and rehabilitate a person’s level of functioning and independence in life activities, to promote health and wellness as well as reduce or eliminate the activity limitations and restrictions to participation in life situations caused by an illness or disabling condition.

Recreation can be thought of as creating again or refreshing oneself by some form of play, amusement or relaxation. Play is a powerful tool as it helps in ventilation, act out aggression, achieve motor mastery in children and recalling childhood success as adults.

             Recreation therapy is defined by American Therapeutic Recreational Association(1991)as, “ treatment services which restore immediate or rehabilitate in order to improve functioning and independence as well as reduce or eliminate the effect of illness or disability”.

            Nurses should organize recreational activities in the wards such as a audiovisual programmes, cooking sessions, special outing to temples, garden, sight seeing, or ball games, etc. Nurse has to select the activity based on the treatment goal, patient ability, lifestyle tolerance in social involvement & interaction, ect.

The four primary goals of recreational therapy are:

1.      Provide clients with structured normal activities of daily living.

2.      Assist client in developing leisure skills and interest suitable of their lifestyles.

3.      Augment verbal psychotherapy and other activity therapies.

4.      Observe client reaction and evidence of progression or regression.

5.      The nurses role include providing promoting activities and interaction that foster independence, responsibility and problem solving skills.

MUSIC THERAPY

Music therapy is both an allied health profession and a field of scientific research which studies correlations between the process of clinical therapy and biomusicology, musical acoustics, music theory, psychoacoustics and comparative musicology.

Music has always been a great healer. In the Bible, we learn about how David played the harp to help ease his severe depression of King Saul. Music is a significant mood-changer and reliever of stress, working on many levels at once.

It is an interpersonal process in which a trained music therapist uses music and all of its facets—physical, emotional, mental, social, aesthetic, and spiritual—to help clients to improve or maintain their health. Music therapists primarily help clients improve their observable level of functioning and self-reported quality of life in various domains (e.g., cognitive functioning, motor skills, emotional and affective development, behavior and social skills) by using music experiences (e.g., singing, songwriting, listening to and discussing music, moving to music) to achieve measurable treatment goals and objectives.

Many experts suggest that it is the rhythm of the music or the beat that has the calming effect on us although we may not be very conscious about it. They point out that when we were a baby in our mother's womb, we probably were influenced by the heart beat of our mother. We respond to the soothing music at later stages in life, perhaps associating it with the safe, relaxing, protective environment provided by our mother.

Whenever the proper sounds were experienced an amazing right/left brain hemisphere synchronization occurred. The normal voltage spiking pattern changed to a smooth sinusoidal waveform and the usual voltage differential equalized. The entire human energetic system is extremely influenced by sounds, the physical body and chakra centers respond specifically to certain tones and frequencies. Special consideration should be given to the positive effects of one actually playing or creating music themselves.

Among the first stress-fighting changes that take place when we hear a tune is an increase in deep breathing. The body's production of serotonin also accelerates. Music was found to reduce the pain during dental procedures. Playing music in the background while we are working, seemingly unaware of the music itself, has been found to reduce the stress. Music was found to reduce heart rates and to promote higher body temperature - an indication of the onset of relaxation. Combining music with relaxation therapy was more effective than doing relaxation therapy alone.

Referrals to music therapy services may be made by a treating physician or an interdisciplinary team consisting of clinicians such as physicians, psychologists, physical therapists, and occupational therapists.

Music therapists are found in nearly every area of the helping professions. Some commonly found practices include developmental work (communication, motor skills, etc.) with individuals with special needs, songwriting and listening in reminiscence/orientation work with the elderly, processing and relaxation work, and rhythmic entrainment for physical rehabilitation in stroke victims.

Robert Burton wrote in the 17th century in his classic work, The Anatomy of Melancholy, that music and dance were critical in treating mental illness, especially melancholia.It is considered one of the expressive therapies.

Definition

            Music therapy is defined as the use of music in accomplishment of therapeutic aims. The restoration, maintenance  and improvement of mental and physical health.

            The music may be recorded music, song writing movement and music instrument.

 Goal

• it increase communication skills
• it helps in expression of feelings of patient who does not speaks with others. Through music he expresses his aggressive feelings by singing loudly in the group song.
• Improves self – esteem.
• Reduces maladaptive (stereotypic, compulsive, self-abusive, disruptive behavior, etc)
• Increases interaction with others
• Increase attending behavior
• Improve fine and gross motor skills
• Improves auditory perception.

Forms

There are a few different philosophies of thought regarding the foundations of music therapy. One is based on education and two are based on music therapy itself.  In addition, there are philosophies based on psychology, and one based on neuroscience.

The two philosophies that developed directly out of music therapy are Nordoff-Robbins and the Bonny Method of Guided Imagery and Music.

Music therapists work many times with individuals who have behavioral-emotional disorders. To meet the needs of this population, music therapists have taken current psychological theories and used them as a basis for different types of music therapy. Different models include behavioral therapy, cognitive behavioral therapy, and psychodynamic therapy.

The therapy model based on neuroscience is called "neurological music therapy" (NMT). A definition of NMT is "NMT is based on a neuroscience model of music perception and production, and the influence of music on functional changes in nonmusical brain and behavior functions." In other words, NMT studies how the brain is without music, how the brain is with music, measures the differences, and uses these differences to cause changes in the brain through music that will eventually effect the client non-musically. As internationally known professor and researcher  Thaut said, "The brain that engages in music is changed by engaging in music."

In 2002, the World Congress of Music Therapy was held in Oxford, on the theme of Dialogue and Debate. In November 2006, Dr. Michael J. Crawford and his colleagues again found that music therapy helped the outcomes of schizophrenic patients. In 2009, he and his team were researching the usefulness of improvisational music in helping patients with agitation and also those with dementia.

 Music As stroke therapy

Music has been shown to affect portions of the brain. Part of this therapy is the ability of music to affect emotions and social interactions. Research by Nayak et al. showed that music therapy is associated with a decrease in depression, improved mood, and a reduction in state anxiety. Both descriptive and experimental studies have documented effects of music on quality of life, involvement with the environment, expression of feelings, awareness and responsiveness, positive associations, and socialization. Additionally, Nayak et al. found that music therapy had a positive effect on social and behavioral outcomes and showed some encouraging trends with respect to mood.

More recent research suggests that music can increase patient's motivation and positive emotions. Current research also suggests that when music therapy is used in conjunction with traditional therapy it improves success rates significantly. Therefore, it is hypothesized that music therapy helps stroke victims recover faster and with more success by increasing the patient's positive emotions and motivation, allowing them to be more successful and driven to participate in traditional therapies.

Current research shows that when music therapy is used in conjunction with traditional therapy, it improves rates of recovery, and emotional and social deficits resulting from stroke.

A study by Jeong & Kim examined the impact of music therapy when combined with traditional stroke therapy in a community-based rehabilitation program. Thirty-three stroke survivors were randomized into one of two groups: the experimental group, which combined rhythmic music and specialized rehabilitation movement for eight weeks; and a control group, that received referral information for traditional therapy (and were assumed to have sought traditional therapy). The results of this study showed that participants in the experimental group gained more flexibility, wider range of motion, more positive moods, and increased frequency and quality of social interactions.

In heart disease

Some music may reduce heart rate, respiratory rate, and blood pressure in patients with coronary heart disease, according to a 2009 Cochrane review of 23 clinical trials. Benefits included a decrease in blood pressure, heart rate, and levels of anxiety in heart patients.

In epilepsy

Research suggests that listening to Mozart's piano sonata K448 can reduce the number of seizures in people with epilepsy. This has been called the "Mozart effect".

Experimental approaches

Music therapist, music researcher and experimental composer Enrico Curreri clinically explored theories and concepts developed by the American composer John Cage. For example, in various music therapy sessions with a patient diagnosed with depression and anxiety disorder. In addition, Curreri has been clinically investigating experimental music/sound/noise music, free improvisation and microtonal music to help assist in understanding the creative process in adult patients with mental illness.

 Guidelines to Maximize With Music Therapy - There is not a single music that is good for everyone. People have different tastes.

	To wash away stress, try taking a 20-minute "sound bath." Put some relaxing music on your stereo, and then lie in a comfortable position on a couch or on the floor near the speakers. For a deeper experience, you can wear headphones to focus your attention and to avoid distraction.
	Choose music with a slow rhythm - slower than the natural heart beat which is about 72 beats per minute. Music that has repeating or cyclical pattern is found to be effective in most people.
	As the music plays, allow it to wash over you, rinsing off the stress from the day. Focus on your breathing, letting it deepen, slow and become regular. Concentrate on the silence between the notes in the music; this keeps you from analyzing the music and makes relaxation more complete.
	If you need stimulation after a day of work, go for a faster music rather than slow calming music.
	When going gets tough, go for a music you are familiar with - such as a childhood favorite or favorite oldies. Familiarity often breeds calmness.
	Take walks with your favorite music playing on the walkman. Inhale and exhale in tune with the music. Let the music takes you. This is a great stress reliever by combining exercise (brisk walk), imagery and music.
	Listening to the sounds of nature, such as ocean waves or the calm of a deep forest, can reduce stress. Try taking a 15- to 20-minute walk if you're near the seashore or a quiet patch of woods. If not, you can buy tapes of these sounds in many music stores. Advantages   Facilitates emotional expressions.   Improves cognitive skills like learning, listening and attention span.   Social interaction is stimulated. Nurses responsibility in music therapy Ø  Organizing music program for the patient & by the patients. Ø  Encourage patient to participate in music activities . Ø  Observe their nonverbal expression during music . Ø  Provide positive reward to participating in the program.

PLAY THERAPY

Play therapy is generally employed with children aged 3 through 11 and provides a way for them to express their experiences and feelings through a natural, self-guided, self-healing process. As children’s experiences and knowledge are often communicated through play, it becomes an important vehicle for them to know and accept themselves and others. Through play a child learns to express his emotions and it serves as a tool in the development of the child.

Play Therapy is the systematic use of a theoretical model to establish an interpersonal process wherein play therapists use the therapeutic powers of play to help clients prevent or resolve psychosocial challenges and achieve optimal growth and development. A working definition might be a form of counseling or psychotherapy that therapeutically engages the power of play to communicate with and help people, especially children, to engender optimal integration and individuation.

Play Therapy is often used as a tool of diagnosis. A play therapist observes a client playing with toys (play-houses, pets, dolls, etc.) to determine the cause of the disturbed behavior. The objects and patterns of play, as well as the willingness to interact with the therapist, can be used to understand the underlying rationale for behavior both inside and outside the session.

Play has been determined to be an essential component of healthy child development. Play has been directly linked to cognitive development

Functions of Play therapy

Play therapy has two tenets of functions. They are curative function and diagnostic function.

Curative functions

·   It releases tension and pent –up emotions.

·   It allows compensation for loss and failures.

·   It improves emotional growth through his relationship with other children.

·   It provides an opportunity to the child to act out his fantasies and conflicts, to get rid of aggression and to learn positive qualities from other children.

Diagnostic functions

·         It gives the therapist a chance to explore family relationships of the child and discover what difficulties are contributing to the child’s problem.

·         It allows studying hidden aspects of the child’s personality.

·         It is possible to obtain a good idea of the intelligence level of the child.

·         Through play the inter- sibling relationships can be adequately studied.

Types of play therapy

                    Individual  vs group play therapy :    In individual therapy the child is allowed to play by himself and the child is allowed to play by himself and the therapist’s attention is focused on this one child alone. In group play therapy other children are involved.  

                    Free play vs controlled play therapy :  In free play the child is given freedom in deciding with what toys he wants to play. In controlled play therapy, the child is introduced into a scene where the situation or setting is already established.

                    Structured vs unstructured play therapy :  Structured play therapy involves organizing the situation in such a way so as to obtain more information. In unstructured play therapy no situation is set and no plans are followed.

                    Directive vs non-directive play therapy  :  In  directive play therapy , the therapist totally sets the directions, where as in non- directive play therapy, the child receives no directions. Play therapy is generally conducted in a play room. The play room should be suitable stocked with adequate play materials,  depending upon the problems of the child.

Efficacy of Play Therapy

Research examining the effectiveness of play therapy related to conduct disorder, aggression and oppositional behavior have been undertaken.

Authors (Dogra and Veeraraghavan, 1994) found parents and their children (ages 8–12) who had been diagnosed with conduct disorder and were exhibiting significant aggression, after receiving sixteen sessions of nondirective play therapy and parental counseling, showed significantly less “extra punitive” responses and significantly higher “impunitive” and “need-persistence” compared to the control group. Additionally, they exhibited significant positive change in adjustment while significantly decreasing aggressive behaviors. Authors studying school maladjustment (Wong et al., 1996), using the board game ‘Stacking the Deck’ to teach social skills to boys diagnosed with conduct disorder (ages 16–17) who were mildly retarded, found eight sessions or less showed “clear improvements after unit training.”

Schmidtchen, Hennies and Acke (1993) compared a treatment group of children (ages 5–8), who exhibited behavioral disturbances and received thirty sessions of nondirective play therapy, with a control group receiving non-play therapy social education. Results showed a decrease in behavioral disturbances and an increase in “person-centered competencies.”

Kaduson and Finnerty (1995only in the final group. Results indicated biofeedback was the most effective in improving the child’s self-perception of self-control. All three groups indicated a significant improvement in sociability and attention. Peer play therapy groups combined with art therapy groups, and family play therapy groups combined with art therapy groups, have been shown (Springer, et al., 1992) to improve depression and hyperactivity scores, in both boys and girls, according to the Child Behavior Checklist in children who have at least one parent who is suffering from alcohol or drug dependency.

Systematic model

The therapist's office will schedule an appointment with several children. In one session there can be as many as 2-5 children interacting. This organic interaction allows the psychologist and psychiatrist to properly evaluate the child’s emotions and feelings. This form of therapy allows the child to unknowingly reveal his emotion, while playing with other children.

Along with children interacting with other children, the therapist will have the child play with certain toys in order to determine his concentration and source of any stress. Each toy and each style of enjoying them represents a different emotion and feeling.

It is believed that as people interact with others, they may work through their internal anxieties. In this idea, children should be encouraged to play, in order to develop as a healthy child.

The therapist will engage in desensitization exercises, in order to eliminate stress for children. These exercises include teaching the child how to relearn certain behavior through a formal system of tests.

Sand tray Therapy

The technique was developed by the Swiss therapist Dora M. Kalff (1904-1990) and Margaret Lowenfeld

Sandtray, sandbox or sandplay therapy is a form of experiential workshop which allows greater exploration of deep emotional issues. Sandplay therapy is suitable for children and adults and allows them to reach a deeper insight into and resolution of a range of issues in their lives such as deep anger, depression, abuse or grief. Through a safe and supportive process they are able to explore their world using a sand tray and a collection of miniatures. Accessing hidden or previously unexplored areas is often possible using this expressive and creative way of working which does not rely on “talk” therapy.

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