psych barte
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THERAPEAUTIC COMMUNICATION
HOME
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THERAPEUTIC COMMUNICATION
T ry expession
R eflection of wordsU se of silenceS et LimitsT ime with client
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THERAPEUTICCOMMUNICATIONS
ORIENTATION Broad Opening Recognition Giving information Silence Offering Self Do you want me to sit
beside you?
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THERAPEAUTIC COMMUNICATION
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THERAPEUTIC COMMUNICATIONSWORKING Focusing Let us discuss this topic more. Exploring Tell me more about it. Encourage Evaluation IS this what you want? Reflecting same idea Restating same statement Verbalizing Implied Are you going to kill
yourself? Seeking Clarification May you please repeat
that statement General lead Please continue.; And then? Limit setting Stop. Interpreting Maybe that thing is very significant
to you.
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TERMINATION Summarizing Let us now sum up.
You have stated earlieretc.
Do you have any questions? Our next therapy Look for changes in behavior Resistance is a common problem
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Therapeutic CommunicationTechniques
Accepting -indicating reception Eg .Yes
I follow what you said Nodding..
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Broad OpeningsAllowing the client to take the initiativein introducing the topic Eg. is there something youd like to talk
about?
Where would you like to begin?
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Consensual Validation
Searching for mutual understanding, for
accord in the meaning of the words Eg. Tell me whether my understanding of it
agrees with yours
Are you using this word to convey that . .?
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Encouraging Comparison
Asking that similarities and differences be
noted Eg. was it something like..?
Have you had similar experiences?
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Encouraging Description of
PerceptionsAsking the client to verbalize what he or
perceives Eg.Tell me when you feel anxious
What is happening?
What does the voice seem to be saying?
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Encouraging Expression
Asking client to appraise the quality of his
or her experience Eg. what are your feelings in regard to..?
Does this contribute to your distress?
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Exploring
Delving further into a subject or idea
Eg. Tell me more about that.Would you describe it more fully?What kind of work?
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F ocusing
Concentrating on a single point
Eg. This point seems worth looking at moreclosely
Of all the concerns youve mentioned,which is most troublesome?
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F ormulating a Plan of Action
-Asking the client to consider kinds of behavior likely to be appropriate in futuresituations Eg. What could you do to let your anger out
harmlessly?
Next time this comes up, what might youdo to handle it?
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General Leads
Giving encouragement to continue
Eg. Go onAnd then?Tell me about it
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Giving Information
Making available the facts that the client
needs Eg. My name isVisiting hours are
My purpose in being here is
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Giving Recognition
Acknowledging, indicating awareness
Eg. Good morning, Mr. SYouve finished your list of things todo.
I noticed that youve combed your hair
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Making Observations
Verbalizing what the nurse perceives
Eg. You appear tense..I notice that your biting your lips
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Offering Self
Making oneself available
Eg. Ill sit with you awhileIll stay here with youIm interested in what you think
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Placing Event in Time or
SequenceClarifying the relationship of events in time
Eg. what seemed to lead up to?Was this before or after?
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Presenting Reality
Offering for consideration that which is real
Eg. I see no one else in the room.Your mother is not here; I am a nurse.
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Reflecting
Directing client actions, thoughts, andfeelings back to client Eg. Client: Do you think I should tell the
doctor? Nurse: Do you think you should?
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Restating
Repeating the main idea expressed
Eg. Client: I cant sleep. I stay awake allnight.
Nurse:You have difficulty sleeping.Client:Im really mad, and upsetNurse: Youre really mad and upset.
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Seeking Information
Seeking to make clear that which is not
meaningful or that which is vague Im not sure that I follow.Have I heard you correctly?
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Silence
Absence of verbal communication, whichprovides time for for the client to putthoughts or feelings into words, regaincomposure, or continue talking Eg. Nurses says nothing but continues to
maintain eye contact and conveys interest.
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Suggesting Collaboration
Offering to share , to strive, to work with
the client for his or her benefit Eg. Perhaps you and I can discuss anddiscover the triggers for your anxiety
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Summarizing
Organizing and summing up that which
has gone before Eg. Have I got this straight?
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Translating into F eelings
seeking to verbalize clients feelings that
he or she expresses only indirectly Eg. Client: Im deadNurse: Are you suggesting that you feellifeless?
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Verbalizing the Implied
Voicing what the client has hinted at or
suggested Eg. Client: I cant talk to you or anyone. Its awaste of time. Nurse: Do you feel that noone understands
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Voicing Doubt
Expressing uncertainty about the reality of
the clients perceptions Isnt that unusual?Really?
Thats hard to believe.
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Nontherapeutic Communication
TechniquesAdvising-telling the client what to do
Agreeing- indicating accord with the
client Eg. I think you should.
Thats right
Indicating accord with the clientthats right. I agree
Agreeing
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Belittling F eelings expressed
Misjudging the degree of the clientscomfort Client: I have nothing to live for..I wish I was
deadNurse: Everybody gets down in the dumps.
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Challenging
Demanding proof from the client But how can you be President of the
Philippines?
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Defending
Attempting to protect someone or something from verbal attack This hospital has a fine reputation.
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Disagreeing
Opposing the clients ideas
Eg. Thats wrong
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Disapproving
Denouncing the clients behavior or ideas
Thats badId rather you wouldnt
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Giving approval
Sanctioning the clients behavior or ideas Thats good. Im glad that..
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Giving Literal Responses
Responding to a figurative comment asthough it were a statement of fact Client: Theyre looking in my head with
television camera.
Nurse: Try not to watch television.
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Indicating the existence of anexternal source
What makes you say that?
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Interpreting
Asking to make conscious that which isunconscious What you really mean is..
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Introducing an unrelated topic
Changing the subject Client: Id like to die.
Nurse: did you have visitors last night?
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Making stereotyped comments
Offering meaningless cliches or tritecomments
Keep your chin up.Just have a positive outlook.
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Probing
Persistent questioning of the clientNow tell me about this problem. I need to
know.
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Reassuring
Indicating there is no reason for anxietyEverything will be alright.
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Rejecting
Refusing to consider or showing contemptfor the clients behavior, ideas
Lets not discuss..
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Requesting an explanation
Asking the client to provide reasons for thoughts, feelings, behaviors, events
Why do you think that?
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Testing
Appraising the clients degree of insightDo you know what kind of hospital this
is?
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Using Denial
Refusing to admit that a problem existsClient: I am nothing.
Nurse: Of course, youre something.
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NONNON--THERAPEUTIC COMMUNICATIONSTHERAPEUTIC COMMUNICATIONS
Overloading blah, blah, blahUnderloading - ignoringValue Judgment use of adjectives
False Reassurance Dont worry, youwill be fine later.Focusing on Self I gave you medsso you are now feeling good
Internal Validation biased judgmentGiving Advice If I were you, illChanging Subject -
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ROLES OF THE PSYCHIATRIC NURSE
COUNSELOR -listens to the patientsverbalizationsPARENT SURROGATE - assists the patients inthe performance of activities of daily livingPATIENT ADVOCATE- enables the patient andhis relatives to know their rights andresponsibilities
TEACHER - assists the patient to learn moreadaptive ways of coping
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TECHNICIAN -facilitates the performance of nursing proceduresTHERAPIST -explores the patients needs,
problems and concerns through variedtherapeutic meansSOCIALIZING AGENT- assists the patient tofeel comfortable with others
WARD MANAGER- creates a therapeuticenvironment
HOME
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ASSESSING BEHAVIORAL SIGNS AND
SYMPTOMS
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ASSESSING BEHAVIORAL SIGNS ANDSYMPTOMS
ALWAYS S END M AIL THRU P OST O FF ICEA-Affect/AppearanceS-SpeechM-Motor Behavior/Mood/MemoryT-Thought ProcessP-Perception
O-Orientation
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General Appearance & Motor
Behavior What does the client look like? How is the clientdressed? Eye contact? Posture?
Speech- clarity, modulation, pitch, speed, barriersto communication
Motor Behavior:
Echopraxia- repeating the movements of another personEx. Everytime the nurse would move or gesture with her hands, the client would copyher gestures
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Echolalia -repeating the speech of another person
Ex. The nurse said to the client, Tell me your name. The client responded, Tell me your
name, Tell me your name.
Waxy Flexibility- having ones arms and legsplaced in a certain position and holding that
same position for hours.Ex. The nurse lifted the clients arm to check the
pulse, and the client left his arm extended inthe same position
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Parkinson-like symptoms- making
mask-like faces, drooling and havingshuffling gait, tremors and muscular rigidity. Seen in people who are onantipsychotic medication.
Ex. The nurse noticed that the clients faceheld no emotion. He walked very stiffly,leaning forward, almost robot-like
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Akathisia - displaying motor restlessness, feeling of muscular quivering; at its worst, patient isunable to sit or lie quietly
Ex. The clients leg kept jiggling upand down when he talked to thenurse. When his feet were still, hisarm would jiggle constantly during the
interview
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Thought ProcessTangentiality -association disturbance in whichthe speaker goes off the topic.
Ex. The nurse asks the client to talk more abouthis family. The client continuously left the topicand talked about boats, animals, his apartmentand so forth.Neologisms - words a person makes up thatonly have meaning for the person himself, oftenpart of a delusional system
Ex. I am afraid to go to the hospital because thenorks are looking for me there.
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Looseness of association- thinking is illogicaland confused. Connections in thought areinterrupted.
Ex. Cant go to the zoo, no money, OhI have ahat, these members make no sense,manWhats the problem?Flight of ideas- constant flow of speech inwhich the person jumps from one topic toanother in rapid succession. There is aconnection between topics although it issometimes hard to identify.
Ex. Say babe, hows it goinggoing to mysisters to get some moneymoney, honey,you got any breadbread and butter, staff of life, aint life grand?
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Blocking - sudden cessation of a thought in themiddle of a sentence. Person is unable tocontinue his train of thought.
Ex. I was going to get a new dress for theIforgot what I was going to say.
Perseveration- involuntary repetition of thesame thought, phrase or motor response todifferent questions or situations:
Ex. N: How are you doing Harry?P: F ine nurse, just fine.N: Did you go for a walk?P: F ine nurse, just fine.
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Confabulation - filling in a memory gapwith detailed believed by the teller tomaintain self-esteem
Ex.The nurse asked Harry who spentthe weekend at home, what he did thatweekend. Well, I just came back fromCalifornia after signing a contract with
MGM for a film on the life of Roosevelt.We have the most marvelous tour at thestudiowent to lunch with the director.
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Circumstantiality -before getting to the pointor answering a question, the person getscaught up in countless details andexplanationsEx.N: Where are you going for the weekendHarry?
P: Well, I first thought of going to mymothers but that was before I rememberedthat she was going to my sisters. My sister is
having a picnic. She always has picnics at thebeach. But I dont like the beach that shegoes to so I decided to some place elseIfinally decided to stay home.
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Word salad- mixture of words that hasno meaning
Ex. I am fineapple pienosalefurniture storetake itslowcellar door
Clang Association- stringing together of words because of their rhymingsounds without regard to their meaning
Ex. Good luck, buck, chuck, duck
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Affect
Flat -absence or near absence of emotional reactionBlunted -severe reduction in emotionalreactionInappropriate disharmony between thestimuli and the emotional reactionBizarre -grimacing, mumbling, giggling
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HALLUCINATIONSA sense perception for which no externalstimuli exist
Visual-seeing things that are not thereEx. During alcohol withdrawal he kept shouting,
I see snakes on the walls!
Auditory-Hearing voices when none ispresent(most common)Ex. I keep hearing my mothers voice telling
me I am bad. She died a year ago.
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Olfactory -smelling smells that do not existEx. I smell my stomach rotting
Tactile - feeling touched sensations in theabsence of the stimuli
Ex. A paranoid man feels electrical impulses fromouter space entering his body and controllinghis mind.
Gustatory -experiencing taste in the absence of stimuliEx. A paranoid woman tastes poison in her foodwhile eating at her sons wedding
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DELUSIONSA false belief held to be true even with evidence tothe contrary.
Persecution -the thought that one is being singledout for harm by others
Ex. An intern believes that the chief of staff is plotting tokill him to prevent the intern from becoming powerful
Grandeur - the false belief that one is a very powerful
and important personEx. A newly admitted patient told the nurse that she was
muse of the United Nations and that she is the mostbeautiful among women.
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Other areas to be assessed:
HistoryOrientationMemoryConcentrationSelf-conceptJudgment- the ability to make logical, rational decisions
Insight- understanding of the nature of a problemPhysiological needs
HOME
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LOSS AND GRIEVING
GRIEF - refers to the subjective emotionsand affect that are a normal response tothe experience of lossANTICIPATORY GRIEVING- when peoplefacing an imminent loss begin to grapplewith the very real possibility of the loss or
death in the near future
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LOSS
Physiologic LossSafe and Security Loss
Love and Belongingness LossSelf-Esteem LossSelf-actualization Loss
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GRIEVING PROCESSKUBLER-ROSSs
DenialAnger
BargainingDepressionAcceptance
Dysfunctional grieving grieving which extendsfrom 4 to 6 weeks leading to CRISIS
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Interventions
Explore clients perception and meaning of thelossAllow adaptive denial
Assist client to reach out for and accept supportEncourage client to examine patterns of copingin past and present situation of lossEncourage client to care for himself
Offer client food without pressure to eatUse effective communication
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CRISISsituation that occurs when an individualshabitual coping ability becomes ineffective
to merit demands of a situationTYPES O F CRISES:MATURATIONAL / DEVELOPMENTAL Normal expected crisis that runs through age
SITUATIONAL Unexpected and sudden event in life
ADVENTITIOUS Calamities, war
CRISIS AND ITS MANAGEMENT
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Characteristics of a Crisis state
Highly individualizedLasts for 4-6 weeks
Self-limitingPerson affected becomes passive andsubmissive
Affects a persons support system
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PHASES O F A CRISIS
Pre-crisis: State of equilibriumInitial Impact (may last a few hours to a fewdays): High level of stress, helplessness,
inability to function sociallyCrisis (may last a brief or prolonged period of time): Inability to cope, projection, denial,rationalization
Resolution: attempts to use problem-solvingskillsPost crisis: may have OLO F or may havesymptoms of neurosis, psychosis
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CRISIS MANAGEMENT
Role of the nurse is to return the client toits pre-crisis state by assisting and guidingthem until they achieved their OLO F .Goal: to enable patient to attain an OLO F
Nurses Primary Role: Active and Directive
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Steps in Crisis Intervention
Identify the degree of disruption the client isexperiencingAssess the clients perception of the event
F ormulate nursing diagnosesInvolve the patient and family if applicable withplanningImplement interventions- new and old coping
mechanismsEvaluate-reassessment, reinforcement
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TYPES OF THERAPIES
Treatment Modalities
I di id l P h h
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Individual Psychotherapy
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Milieu Therapy
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Milieu Therapy
Total environment has an effect on theindividuals behavior Components Physical Environment Interpersonal relationships Atmosphere of safety, caring, and mutual
respect F or alcoholics
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PROGRAMS FOR MILIEU SHOULD HAVE:
an emphasis on group and social interactionNo rules and expectations mediated by peer pressureA view of patients roles as responsible humanbeingsAn emphasis on patients rights for involvement in setting goalsF reedom of movement and informality of relationships with staff Emphasis on interdisciplinary participationGoal-oriented, clear communication
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G Th
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Group Therapy
Number of people coming together, sharing acommon goal, interest or concern, stayingtogether and developing relationshipsF or PTSD and Alcoholics
Phases Orientation- Purpose of the group is stated, Objectives
and expectations are laid out
Working - Leaders role is to keep the group focused,Support for each other to attain group goals
Termination- Leader acknowledges each memberscontribution and experience as a whole
Members prepare for separation
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Characteristics of Group Therapy
Universality You are not aloneInstilling hope and inspiration
Developing social skills by interacting withone another F eeling of acceptance and belongingAltruism Giving of ones self
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Psychoanalytically oriented group therapyPsychodrama
Family therapy
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Assumption of F amily Therapy F or alcoholic and schizophrenic
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Assumption of F amily TherapyClient: Whole familyConcepts: The family is the most fundamental unit of the society. Adaptive or maladaptive patterns of behavior are learned from
the family Dysfunction in the family = dysfunction in the individual
Purpose Improve relationships among family members Promote family function
Resolve family problems
OTHER TYPES O F
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OTHER TYPES O F
THERAPIESSUPPORT GROUPS F or those with AIDS, Mother-Against-Drug
Dependence
SELF -HELP GROUPS Alcoholic Anonymous
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RULES FOR PSYCHOTHERAPEUTIC
MANAGEMENTProvide support, treat patients with respectand dignity Do not place patients in situations wherein
they will feel inadequate or embarrassedTreat patients as individualsProvide reality testing
Handle hostility therapeutically Provide psychopharmacologic treatment
HOME
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BEHAVIORAL THERAPY
Pavlovs Classical Conditioning All behavior are learned
B.F . Skinners Operational Conditioning Reinforcements
B EHAVIORAL THERAPIES
Treatment Modalities
BEHAVIORAL THERAPY
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BEHAVIORAL THERAPY
Behavioral Modification Substance Abuse
Systematic Desensitization - Phobia
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PSYCHOSOMATIC
THERAPYTreatment Modalities
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Electroconvulsive Therapy
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Electroconvulsive Therapy
Effective in most affective disordersThe induction of a grandmal seizure in thebrain.
Abnormal firing of neurons in the braincauses an increase in neurotransmittersNumber of Treatments: 6-12 ,3 times a
week, about .5-2secondsUnilateral or bitemporal
El t l i Th
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Electroconvulsive TherapyIndications:
Patients who require rapid responsePatients who cannot tolerate pharmacotherapy orcannot be exposed to pharmacotherapy Patients who are depressed but have not responded tomultiple and adequate trials of medication
Electroconvulsive Therapy
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Electroconvulsive TherapyPreparations for ECT:
Pretreatment evaluation and clearanceConsentNPO from midnight until after the treatmentAtropine Sulfate-to decrease secretions,succinylcholine (Anectine)- to promote musclerelaxation, Methohexital Sodium(Brevital)-anesthethicEmpty bladderRemove jewelry, hairpins, dentures and otheraccessoriesCheck vital signsAttempt to decrease patients anxiety
Electroconvulsive Therapy
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Electroconvulsive Therapy
Care after ECT: O2 therapy of 100% until patient can breatheunassistedMonitor for respiratory problems, gag reflex
R eorient patientObserve until stableCareful documentation.
Male erectile dysfunction
OTHER THERAPIES