Other Interventions for Psychiatric Conditions

Interventions List

• Biological theories include psychopharmacology and brain stimulation therapy (ECT).
• Psychosocial interventions include milieu therapy and relaxation exercises.
• Psychosocial therapy includes psychoanalysis, interpersonal therapy, reality therapy, cognitive behavioral therapy, dialectical behavioral therapy, and behavior therapy.
• Behavior therapy includes operant conditioning, exposure therapy, and aversion therapy.

Electroconvulsive Therapy

• This involves focused electrical stimulation of the brain.
• It induces a grand mal seizure by applying electrical current to the brain using electrodes.
• Electrodes are placed bilaterally or unilaterally on the right frontotemporal area.
• It can be used for major depression, especially treatment-resistant depression, refusal to eat/take medications, and suicidality.
• Also used for mania, acute schizophrenia with marked catatonia, OCD, NMS, and Parkinson's Disease.

Electroconvulsive Therapy - Efficacy and Process

• It remains a controversial treatment.
• Research shows significant improvements in 80% of major depression patients.
• Patients are given a muscle relaxant before the procedure.
• Treatment length typically ranges from 6-12 sessions; some may need 20 sessions.
• Administered 3x a week, it can be performed on an inpatient or outpatient basis.

Electroconvulsive Therapy - Contraindications and Risks

• Contraindications include cardiovascular issues, neurological conditions, complicated pregnancy, severe osteoporosis, and pulmonary disorders.
• Side effects include temporary memory loss, confusion, and cognitive deficits in processing speed, attention, and problem-solving.
• Mortality risk is 0.002% per treatment or 0.01% per patient.
• Brain imaging studies show no evidence of brain damage.

ECT and the Nurse

• Pre-treatment includes a complete physical exam, blood and urine studies, skeletal history, and x-ray.
• It is essential to obtain informed consent.
• Patients should be NPO for 6-8 hours before the procedure.
• Vital signs are checked 1 hour prior to the procedure.
• Premedications, such as Atropine and a muscle relaxant (succinylchloride), are given 30 minutes before treatment.
• A BP cuff is applied above systolic pressure on one leg to observe seizure activity.
• Administer oxygen.

ECT and the Nurse - During and Post Treatment

• During treatment, the patient lies supine on the treatment table.
• IV anesthesia is administered.
• The APA recommends a seizure duration of >15 seconds.
• Maintain a patent airway with an oropharyngeal airway and suctioning.
• Electrode placement is performed.
• Post-treatment involves monitoring vital signs every 15 minutes (q15) for the first hour.
• The patient is placed in a side-lying position.
• The patient to oriented to time and place.

Psychosocial Interventions

• These aren't therapies in a formal sense but rather interventions within the scope of practice for generalist and psychiatric nurses with basic education.

Milieu Therapy

• The environment is a space where there is emotional, social, and psychological healing.
• Aspects of the Milieu include private, group, common, and recreational areas.
• Focus is on morning and daily routines and scheduled staff, rules, expectations.
• Staff acts as models and communicate therapeutically.

Relaxation Exercises

• Deep breathing exercises
• Progressive relaxation
• Meditation
• Mental imagery

Pyschosocial Therapy

• These are also known as psychotherapies.
• They refer to specialized treatment strategies.
• Requires advanced education, licensure, or certification

Psychoanalysis

• Dream analysis
• Free association
• Hypnosis, a deep relaxation during which the therapist asks the client questions

Interpersonal Therapy

• Psychiatric disorders are influenced by interpersonal relationships.
• The overall goal is decrease psychiatric symptoms.
• This is done through the improvement in current interpersonal skills.
• Has success in treating major depressive disorder.
• Sessions occur weekly from about 12-16 weeks.

Reality Therapy

• A therapeutic approach that helps take responsibility for actions.
• This makes more effective choices to improve lives.
• Key elements include focus on reality, personal responsibility, and behavioral change.
• Key elements include focusing on the present, assuming personal responsibility, and implementing behavioral changes.

Sample or Reality Therapy

• An example is John, a man working in a job lacking motivation and he has poor metrics
• Says his supervisor is unfair
• He is frustrated, avoid trying or doing his best
• Therapist will ask: "It appears to me that the way you handle this situation is through shutting down, but it did not get the results you want. What do you think of other ways to improve your situation?"

Where to Use Reality Therapy?

• Depression
• Anxiety
• Alcoholism, addiction, substance abuse
• Relationship issues
• Behavioral problems
• Anger management

Cognitive Behavioral Therapy

• Thinking influences behavior, which creates thought distortions.
• Thought distortions are reframed by challenging patterns of thinking.
• This contributes to more positive mood and attitude.
• It is useful in mood disorders, schizophrenia, eating disorders, post-traumatic stress disorders, substance use disorders, and personality disorders.

Cognitive Behavioral Therapy - Interpretation Example

• At a party, Cory asks, "How is it going?".
• This makes the person feel anxious.
• The automatic thought leads to "cory thinks I am crazy. I must really look bad for him to be concerned."
• An alternate/positive interpretation is, "He really cares about me. He noticed that I look better than before I went into the hospital and wants to know if I feel better too."

Dialectical Behavioral Therapy

• This approach treats borderline personality disorder (BPD) and suicidal ideation.
• DBT focuses on learning how to regulate troubling emotions.
• In CBT thoughts were reframed.

Behavior Therapy

• Includes Operant Conditioning
• Includes Exposure Therapy
• Includes Aversion Therapy

Operant Conditioning

• Uses rewards for positive reinforcement.
• It is useful in patients with severe mental illness to help them increase their level of self-care.
• Is useful for children that may be mute, autistic, or developmentally disabled

Operant Conditioning Example

• When mothers give a child candy, the child is more likely to continue that behavior.
• This results from positive reinforcement of negative behavior.
• When a mother scolds a child, acting out may continue.
• The child will behave to get what they want-attention.
• Ignoring negative behavior but gives attention when acting appropriately.
• Provides a positive reward for appropriate behavior.

Exposure Therapy

• Used for fears, phobias, or traumatic memories.
• Also helps with phobias, panic disorder, social anxiety disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and generalized anxiety disorder.

Exposure Methods include:

• Imaginal exposure: Patients imagine and confront fear. This could mean a recall responses to spiders and describe thoughts and feelings.
• In vivo exposure: Patients actually and directly confront their fears in real-world. This may mean beginning with simply watching planes take off and then discussing feelings.
• Virtual reality exposure: A combination of imaginal and in vivo exposure. A patient with a fear of elevators may use virtual reality goggles and audio to explore approaching and then entering the virtual elevator in safety.

Categories of Exposure Therapy

• Systematic desensitization pairs incremental exposure and relaxation techniques. The steps include seeing a picture, touching, and holding the snake.
• Flooding involves directly confronting the most feared object or situation. The patient would manage and process those new feelings.

Aversion Therapy

• Treats things like alcohol use disorder, paraphilic disorders, shoplifting, aggressive behavior, and self-mutilation.
• Pairs target behavior with a negative stimulus.
• This is done to extinguish undesirable behavior.
• An example is showing a shoplifter a picture of a shop and giving an electrical shock and/or bitter food.