Chapter Two PDF

Chapter Two 10/03/2024 Ahmad M. Al Sayeh 1  ✓Therapeutic Relationship ✓Cognitive behavioral therapy (CBT) ✓The therapeutic communication ✓Complementary Therapies technique ✓Restraints a...

Chapter Two 10/03/2024 Ahmad M. Al Sayeh 1  ✓Therapeutic Relationship ✓Cognitive behavioral therapy (CBT) ✓The therapeutic communication ✓Complementary Therapies technique ✓Restraints and Seclusion ✓Informed Consent ✓Crisis Intervention Chapter Two ✓Milieu Therapy ✓The Holistic Psychosocial Assessment ✓Family Therapy Electroconvulsive Therapy (ECT) 14 10/03/2024 Ahmad M. Al Sayeh 2  Therapeutic Relationship/Alliance The therapeutic relationship is not concerned with the skills of the mental health professional but rather the attitudes and the relationship between the mental health professional and the client. This relationship comes out of the creation of a safe environment, conducive to communication and trust. An alliance is formed when the professional and the client are working together cooperatively in the best interest of the client. The therapeutic relationship begins the moment the mental health professional and client first meet (Shea 1999). 10/03/2024 Ahmad M. Al Sayeh 3 Core Elements of a Therapeutic Relationship Communication/rapport - It is important to establish a connection before a relationship can develop. Encouraging the client to speak, using open-ended questions, is helpful. Asking general (not personal) questions can relax the client in an initial session. It is important to project a caring, nonjudgmental attitude 10/03/2024 Ahmad M. Al Sayeh 4  Trust - A core element of a therapeutic relationship is trust. Many clients have experienced disappointment and unstable, even Core Elements of abusive relationships. Trust develops over time a Therapeutic and remains part of the process. Without trust, a Relationship therapeutic relationship is not possible. Other important elements are confidentiality, setting boundaries, consistency. 5 Ahmad M. Al Sayeh 10/03/2024  Dignity/Respect - Many clients have been abused and humiliated and have low self- esteem. If treated with dignity through the therapeutic relationship, clients can learn to regain their dignity. Core Elements of Empathy - Empathy is not sympathy a Therapeutic (caught up in client's feelings) but is, rather, Relationship open to understanding the "client's perceptions" and helps the client understand these better through therapeutic exploration. 6 Ahmad M. Al Sayeh 10/03/2024  Genuineness - In some way genuineness relates to trust because it says to the client: I am honest and I am a real person. Again, it will allow the Core Elements of client to get in touch with her/his "real" feelings and to learn from and grow from the relationship. a Therapeutic Therapeutic Use of Self Relationship Ability to use one's own personality consciously and in full awareness to establish relatedness and to structure interventions (Travelbee 1971). Requires self awareness and self understanding. 7 Ahmad M. Al Sayeh 10/03/2024  Phases of Relationship Development Orientation phase This is the phase where the mental health professional and client first meet and where initial impressions are formed. ✓ Rapport is established and trust begins. ✓ The relationship and the connection are most important. ✓ Client is encouraged to identify the problem(s) and become a collaborative partner in helping him/herself. ✓ Once rapport and a connection are established, the relationship is ready for the next phase. 10/03/2024 Ahmad M. Al Sayeh 8  Identification phase -In this phase the mental health professional and Client are :- 10/03/2024 Development Relationship Clarifying perceptions and setting expectations, in and for the relationship. Phases of Ahmad M. Al Sayeh Getting to know and understand each other 9  Phases of Relationship Development Exploitation (working) phase - The client is committed to the process and to the relationship and is involved in own self help; takes responsibility and shows some independence. ✓ This is also known as the working phase, because this is where the hard work begins. ✓ Client must believe and know that the mental health professional is caring and on his/her side when dealing with the more difficult issues during therapeutic exploration. 10/03/2024 Ahmad M. Al Sayeh 10  Phases of Relationship Development Resolution phase - The client has gained all that he/she needs from the relationship and is ready to leave. ✓ This may involve having met stated goals or resolution of a crisis ✓ Be aware of fear of abandonment and need for closure. ✓ Both mental health professional and client may experience sadness,which is normal Dependent personalities may need help with terminat- tion, reflecting upon the positives and the growth that has taken place through the relationship. (Peplau 1992) 10/03/2024 Ahmad M. Al Sayeh 11 Phases of Relationship Development Nonverbal communication may be a better indication of what is going on with a client than verbal explanations. Although verbal is important, it is only one component of an evaluation. Equally important to develop your skills of observation. Some clients are not in touch with their feelings, and only their behaviors (clenched fist, head down, arms crossed) will offer clues to feelings. 10/03/2024 Ahmad M. Al Sayeh 12  Nonverbal communication Nonverbal communication may offer the client clues as to how the mental health professional is feeling, as well. Physical appearance- A neat appearance is suggestive of someone who cares for him/herself and feels positive about self Clients with schizophrenia or depression may appear disheveled and unkempt. 10/03/2024 Ahmad M. Al Sayeh 13  Nonverbal communication Body movement/ posture - Slow or rapid movements can suggest depression or mania; a slumped posture, depression. Medication induced body movements and postures include: pseudoparkinsonism (antipsychotic); akathisia (restlessness/moving legs [antipsychotic]). Warmth (smiling) and coldness (crossed arms)are also non-verbally communicated. 10/03/2024 Ahmad M. Al Sayeh 14  Nonverbal communication Touch - touch forms a bridge or connection to another. Touch has different meanings based on culture, and some cultures touch more than others. Touch idea/bel can have a very positive effect, but touching requires permission to do so. Many psychiatric clients have had" boundary violations," and so an innocent touch may be misinterpreted. 10/03/2024 Ahmad M. Al Sayeh 15  Nonverbal communication Eyes - The ability to maintain cye contact during conversation offers clues as to social skills and self esteem. Without eye contact, there is a "break in the connection" between two people. A lack of eye contact can suggest suspiciousness, something to hide. Remember cultural interpretations of eye contact. 10/03/2024 Ahmad M. Al Sayeh 16  Nonverbal communication Voice – voice can be a clue to the mood of a client. Pitch, loudness, and rate of speech are all important clues. Manic clients speak loudly, rapidly, and with pressured speech. Anxious clients may speak with a high pitch and rapidly. Depressed clients speak slowly, and obtaining information may feel like "pulling teeth. 10/03/2024 Ahmad M. Al Sayeh 17 Therapeutic Communication Techniques 10/03/2024 Ahmad M. Al Sayeh 18 Therapeutic Communication Techniques 10/03/2024 Ahmad M. Al Sayeh 19 Therapeutic Communication Techniques 10/03/2024 Ahmad M. Al Sayeh 20 Therapeutic Communication Techniques 10/03/2024 Ahmad M. Al Sayeh 21  The Holistic Psychosocial Assessment Psychosocial Assessment: Is a process or tool used to assess the client's level of psychological and sociological ha functioning for the purpose of eliciting evidence of dysfunction and helps in detecting and identifying etiological factors of psychopathology. It provides more specific, and accurate information about current behavior and mental capabilities. This tool assists the therapists to formulate a care plan for a client. Ahmad M. Al Sayeh 10/03/2024 22  Psychosocial Assessment: For a comprehensive holistic assessment, the seven dimensions of the person have to be assessed: (physical, emotional, intellectual, social, spiritual environmental and occupational). Ahmad M. Al Sayeh 10/03/2024 23  Psychosocial Assessment: Meanwhile, the person is more than the simple combination of these dimensions. A holistic framework includes all aspects of the person and how these aspects interact to affect the whole person in cases of health and illness. The balance in all dimensions of a person is valued, and no dimension can be considered in isolation from the others. 10/03/2024 Ahmad M. Al Sayeh 24  First: Physical Dimension Assessment of physical dimension includes: talking history, doing physical examination, and examining the diagnostic tests. It involves everything associated with a person's physical body (demographic data, diet, sleep, physical activity , sexual activity, habits, genetics, health history, family health history, review of systems..... etc). All these aspects interact constantly with each other. 10/03/2024 Ahmad M. Al Sayeh 25  General Appearance 1. Facial expression: may be animated, masked, sad or depressed, angry, color of face (pale, reddened... etc ). a. Blank: Empty, showing no response to any thing, showing no meaning. b. Fear: Is an emotional response to a consciously recognized external threat or danger. Ahmad M. Al Sayeh 10/03/2024 26  General Appearance c. Anxiety: apprehension and a marked continuous feeling of threat to some value, which the individual holds essential to his or her existence although external events do not justify it. 2. Posture: Is the way that a person hold his body and is often an indication of how he is feeling, for example: Relaxed, Tense, Erect, Slouching (leaning away from the care giver), sitting, lying... etc. 10/03/2024 Ahmad M. Al Sayeh 27  General Appearance a. Catatonia: Type of schizophrenia characterized by immobility with rigidity or inflexibility. b. Waxy flexibility: a condition found in catatonic schizophrenia in which the Extremities have a wax like rigidity and will remain for long periods in any placed positions, no matter how uncomfortable. a. Mannerisms: Habitual repeated small movements and not in themselves abnormal. b. Narcissism: Excessive love of self and preoccupation with one's own needs accompanying in attention to the needs of others. It is frequent in some immature personalities 10/03/2024 Ahmad M. Al Sayeh 28  General Appearance 2.Dress: Refers to the way a person feels about himself, and his capacity for social judgment is usually reflected in the way he dresses, for example: Neat, Careless, Smelling, Soiled.... etc. 3.Motor activity: The way in which a person moves his body, for example: Agitated , Restless, Tremors, Motor retardation (slow movement), Akathisia (extreme restlessness), Akinasia. (complete or partial loss of muscle movement), Dyskinesia (excessive movement of mouth, protruding tongue, facial grimacing; (common side effect of the major tranquilizers); Parkinsonian movement (fine tremor accompanied by muscular rigidity). 10/03/2024 Ahmad M. Al Sayeh 29  General Appearance a. Overactivity : It's physical activity that is described as restlessness, this varies from mild activity to an inability to sit still or relaxed. In severe cases the client can do nothing constructive and may break into violent and destructive attacks. b. Under-activity: Retardation - General slowing down of activity. Stupor - A state of lethargy and unresponsiveness in which a person seems unaware of his surroundings, but he Is conscious. This condition occurs in neurological as well as psychiatric disorder. 10/03/2024 Ahmad M. Al Sayeh 30  General Appearance c. Compulsion: An irrational way to act that is usually contrary to one's ordinary judgments or standards. Yet results in over anxiety if not completed. Special patterns of motor activity: Stereotype - the use of monotonous repetition of verbal, intellectual, emotional or motor activity. Example "echopraxia, echolalia. Echopraxia: Meaningless limitation of motions or actions made by others. Echolalia: Automatic repetition by one person of what is said by another. 10/03/2024 Ahmad M. Al Sayeh 31  General Appearance Negativism: Strong resistance, and consistently doing the opposite of what they are told. "Suggestion or advice“. Ambivalence: Opposing emotions, desires or attitudes at the same time toward an object, person, goal or situation. 5. Reaction to Caregiver: Includes the way that a patient relates with or responds to a caregiver, for example: Friendly, Hostile, and Suspicious. 10/03/2024 Ahmad M. Al Sayeh 32 Ahmad M. Al Sayeh The components of 1. Individual's 2. Client's self- the emotional affect (happy, sad, report of his Second: dimension include: angry, anxious...). feeling. Emotional 4. The 5. Duration and Dimension 3. The congruency of affect with the appropriateness of quality of the affect to the person's emotional client's self-report situation. responses. 6. Posttraumatic responses 10/03/2024 33 Second: Emotional Dimension The ability to make decisions is influenced by a person's feelings. Feelings affect relationship with others, physical functioning, ability to make judgments, and ability to become self-actualized. Affect: is a person's display of emotion or feelings that he is experiencing. Mood: is the subjective way a client explains his feelings. 10/03/2024 Ahmad M. Al Sayeh 34 Second: Emotional Dimension 1. Inappropriate affects: a. As an observer, you see a client who is not responding as expected in a given situation. b. The content of a person's discussion does not fit with the emotions accompanying his statements ( inconguency ) 2. Pleasurable affects: a. Euphoria-excessive and inappropriate feeling of well-being. b. Exaltation - intense elation accompanied of grandeur 10/03/2024 Ahmad M. Al Sayeh 35 Ahmad M. Al Sayeh Second: Emotional Dimension 3. Unpleasurable affects a. Depression - b. Anxiety-feeling c. Fear-excessive d. Agitation- (dysphoria): hopeless feeling of of apprehension fright of Anxiety sadness; grief or that is caused by consciously associated with mourning; conflicts of which recognized severe motor prolonged and excessive sadness the client is not danger. restlessness associated with a aware. loss. 10/03/2024 36  Second: Emotional Dimension e. Ambivalence-Alternating and opposite feelings occurring in the same person about the same object f. Aggression-range, anger or hostility that is excessive seems unrelated to a person's current situation. j. Mood Swings (liability) alternating periods of elation and depression or anxiety in the same person within a limited time period. 4. Lack of affects: Blunted or flat affect a normal range of emotions is missing. This can be found in depression, some forms of schizophrenia, and some types of organic brain syndrome. 10/03/2024 Ahmad M. Al Sayeh 37 emotional dimension? 1.Affect: Observe the client's predominant feeling (anxious, sad, or angry), affect (flat or blunted), or indifference to feelings. How to assess 2. Client self report: "What are your feelings at this time?" If he responds with "better" follow up on what he was Ahmad M. Al Sayeh feeling before he was better, and ask him what contributed to his better feelings. Ask what he means by "better," that is, what is better (his mood, his appetite) 10/03/2024 38  How to assess emotional dimension? 3. Congruency of affect with client's self- report: "You say you're fine, but you look very worried (sad, annoyed).“ 4.Appropriateness of affect to situation: Considering the situation, are the client's feelings appropriate? For example, is the client crying over her husband's death 12years ago (inappropriate)? 5. Duration: "How long have you been feeling this way?“ 6. Quality: Do the client's feelings seem shallow and superficial? 10/03/2024 Ahmad M. Al Sayeh 39  How to assess emotional dimension? Do the client's feelings seem appropriately intense? Does the client's expression of feelings scem childlike or juvenile (pouring)? Does the client's mood swing from happy to sad (labile) quickly? Is the client's mood reasonably stable? 7. Posttraumatic response: Symptoms that develop following a psychological distressing that outside the range of usual human experience (illnesses, injuries, disasters, war experiences, panic attack). Ahmad M. Al Sayeh 10/03/2024 40  Third: Intellectual Dimension The components of this dimension include: 1. Perception: has a particular significance for clients with psychiatric problems since determinations are made concerning the reality or distortion of the client's perception. 2. Cognition: aspects of cognition include memory, orientation, fund of information ability to think abstractly, defense mechanisms, and providing information about the client's mental status. 10/03/2024 Ahmad M. Al Sayeh 41  Third: Intellectual Dimension 3. Communication: includes manner of speaking, quality and quantity of speech, degree of flexibility in thinking. 1. Perception: Hallucination is a false sensory stimuli in the absence of an actual external stimuli, are not under the control of the client they are usually real to him. Types of hallucination: Auditory, Visual, Olfactory, Gustatory, and Tactile. Illusion: is a false perception and misinterpreting of actual external stimuli. 10/03/2024 Ahmad M. Al Sayeh 42 How to assess perception? ✓ Assess for the presence of disturbed thinking such as phobias, obsessions, illusions, or delusions during the course of the interview. ✓ Determine the presence or absence of hallucinations by asking, "Do you ever hear voices that others do not hear or see things others do not see?“ 10/03/2024 Ahmad M. Al Sayeh 43 Third: Intellectual Dimension Cognition: Thinking It is the process or way in which the person thinks; the reasoning he uses about the world; the way he connects or associates these thoughts; and his over all organization of thoughts. 10/03/2024 Ahmad M. Al Sayeh 44  Third: Intellectual Dimension Some examples of thinking disorders: 1. Disturbance in thought process: a. Loose associations when a person's thoughts are poorly connected or poorly organized. b. Circumstantiality the person frequently digresses, but eventually reaches a conclusion. c. Tangentiality-the person frequently digresses and finally forgets his initial reason for beginning a discussion. 10/03/2024 Ahmad M. Al Sayeh 45  Third: Intellectual Dimension d. Flight of ideas - rapid Preservation connected speaking with quick thought; frequently seen changing from one in manic patients. thought to another f. Blocking-occur when e. Preservation-repetition the mind ceases to of the same word in reply produce thoughts for no to different questions apparent reason. 10/03/2024 Ahmad M. Al Sayeh 46 Ahmad M. Al Sayeh Third: Intellectual Dimension L. Poverty of thought: h. Confabulation: a few verbal g. Neologism: A communications or The fabrication of word that is ones that convey little stories in response invented or made up information because to questions or by condensing other of vagueness, empty, events that are not repetition or words into new one. recalled. stereotyped or obscure phrases. 10/03/2024 47  1.Disturbance in thought content: 1.Delusions: c. Delusion of guilt: Incorrect beliefs about a. Delusion of being controlled; the person an event that happened in the past and believes his actions and thoughts are not his which the client considers it a sinful behavior own, but put upon him by external sources. b. Persecutory delusions: A false hut unshakably held belief those others deliberately in tent to harm one 10/03/2024 Ahmad M. Al Sayeh 48  1.Disturbance in thought content: d. Grandiose delusion: A false but unshakably held beliefs of a person that he or she is far more important and powerful than he or she actually is. In correct belief and firmly held ideas of great power, health, wealth and influence. e. Hypochondriacal delusions: Excessive complaining about many different bodily aches and pains. f. Nihilistic delusion: Means "delusion of nothingness". Non-existence of the self or part of the self. 10/03/2024 Ahmad M. Al Sayeh 49  1.Disturbance in thought content: 2. Ideas of reference - False but strongly held beliefs that much of what others say and do refers to oneself 3. Depersonalization: The experience of feelings of un-realness about the self for the environment related to Nihilistic delusion. 4. Passivity feeling: the belief of influence by others - the client may develop the idea that his body, his thoughts and his feelings are all controlled by someone powerful. 10/03/2024 Ahmad M. Al Sayeh 50 1.Disturbance in thought content: 5.Overvalued ideas: It is the exaggeration of a particular aspect of the person's life appearance or personality which has a definite factual base 6.Obsession - Persistent thought or idea with which the mind is continually and in voluntarily preoccupied and which suggests an irrational act. The thought cannot be eliminated by logic or reason and usually gives rise to a compulsion 10/03/2024 Ahmad M. Al Sayeh 51  Types of phobia: 8. Phobia: irrational fear of an object or an environmental situation. Types of phobia: A. Acrophobia-fear from heights. B. Claustrophobia-fear from closed places C. Mysophobia fear from dirt D. Nyctophobia fear from dark. E. Pyrophopia fear from fire 10/03/2024 Ahmad M. Al Sayeh 52  Types of memory: 4.Memory: Is the ability of the mind to recall events that have previously occurred. Types of memory: Recent: for events that have happened during the previous few days. Remote: which includes remembering events that occurred from the person's first recollections of childhood, through adolescence, adulthood and up until the current week. 10/03/2024 Ahmad M. Al Sayeh 53  Types of memory: Memory loss is one of the most important signs of organic brain syndrome (OBS). The two types of OBS are: delirium which is an acute brain disorder which is usually reversible, and dementia, which is a chronic, usually irreversible brain disease. Memory Amnesia: The loss of memory or forgetting a large block of coordinated or sequential activity and/or events that occurred and recorded when the person was awake. 10/03/2024 Ahmad M. Al Sayeh 54  Types of Amnesia: 1. Anterograde amnesia a loss of memory in which the person cannot remember events that happened after the damage occurred. 2. Dissociative amnesia - The forgetting of selected specific rarely unpleasant or Traumatic events or matters related to the personal identity. 3. Fugue state dissociative reaction in which a person continues to free from some 'traumatic event and is unable to remember much of what happened before the experience began including his or her identity 10/03/2024 Ahmad M. Al Sayeh 55 Types of Amnesia: 4. Dysmenesia Impairment in the ability to retain and recall information. 5. Hypermnesia - excessively retentive memory. 6. Confabulation-Filling gaps in memory usually without awareness. With false but some times plausible content that may succeed in concealing a deficit. The filling could be imaginary stories which the teller believes to be true. 8. De-Ja-vu-a sense that one has been in a particular place before or has done particular thing before. 10/03/2024 Ahmad M. Al Sayeh 56 Ahmad M. Al Sayeh How to assess memory? 1 2 3 Assess client's immediate Assess client's recent Assess client's remote memory (past 24 hours). memory (past 6 weeks). memory (beyond 6 weeks). "Tell me about your childhood." 10/03/2024 57 Ahmad M. Al Sayeh Intellectual Performance ASSESSMENT OF 1) CAPACITY FOR 2) GENERAL 3) ATTENTION 4) SOCIAL 5) INSIGHT TO THE PERSON'S ABSTRACTION INTELLIGENCE AND JUDGMENT ILLNESS INTELLECTUAL CONCENTRATION PERFORMANCE INCLUDE: 10/03/2024 58  Intellectual Performance 1) Capacity for Abstraction; is the person's capacity to generalize, to find meaning in symbols, and to conceptualize objects and events. Two ways to test for the person's capacity for abstraction are through the interpretation of proverbs and similarities. 10/03/2024 Ahmad M. Al Sayeh 59  Intellectual Performance How to assess capacity of abstraction? Can the client conceptualize, generalize, or come to a conclusion by a logical reasoning Process? Does he think concretely? For example, therapist: "What brought you to the hospital? Client: "The police." (Concrete) Client: "I'm so nervous and uptight I can't think straight anymore." (Abstract) 10/03/2024 Ahmad M. Al Sayeh 60  Intellectual Performance 2. General Intelligence: The person's fund of information and vocabulary. How well are they attuned to what is going on in the environment? Can they relate recent news stories? Can they name five capitals in the Arab World? 10/03/2024 Ahmad M. Al Sayeh 61 Intellectual Performance 3. Attention and Concentration: is another way to assess the person's intellectual performance. The nurse can begin by reading two or three numbers and then proceeds to a more difficult series of five and six numbers and then ask the person to repeat then first forward and then backward 10/03/2024 Ahmad M. Al Sayeh 62  4. Social Judgment: the ability to behave in a socially appropriate manner. Does the client behave in a socially acceptable manner ? Intellectual Ask client if he found a stamped and addressed letter, Performance what would he do with it? How well does he manage his money ? How realistic are his job expectations? 10/03/2024 Ahmad M. Al Sayeh 63  5. Insight to illness: the person's awareness to his condition. Is the client aware that he is ill? *Lack of insight - No belief that he is sick *Partial insight: The person Intellectual believes that he is due to physical illness or nervous Performance breakdown but not due to behavioral problem in the hospital. *Full insight: The person identifies clearly his behavioral problem 10/03/2024 Ahmad M. Al Sayeh 64  Intellectual Performance Confusion: A state characterized by bewilderment, perplexity and environmental disorientation and faulty judgment. Disorganized memory, slow grasp, difficulty to express oneself logically. 10/03/2024 Ahmad M. Al Sayeh 65 Types of confusion: a. Objective confusion: The surgical confusion is apparent to an outsider observer. b. Subjective confusion: The client complains of feelings of being disorganized. forgetful and without clear aim or purpose, but if they are involved in concentrated activity or conversation, they can be brought into adequate contact with their surroundings. 10/03/2024 Ahmad M. Al Sayeh 66 3.Communication: In this category we are evaluating , how the client Rate: slow, fast, hesitant is communicating, rather Volume :loud, soft, inaudible, whispering than what he is telling us. The ways in which a Clarity: clear, slurred person's speech should be Amount: talkative, verbose, silent evaluated are as follows: 10/03/2024 Ahmad M. Al Sayeh 67  1.Disturbances of speech rate : Flight of ideas: Sudden, rapid shift from one idea to another before the preceding one has been concluded Pheasure of talk: Movement of thoughts rapidly that the client words come tumbling from him at great speed. Clang association: Connecting one word with another which have a superficial resemblance to it. 10/03/2024 Ahmad M. Al Sayeh 68  1.Disturbances of speech rate : Retardation: Slowing of speech it is an effort for the client to talk, he usually states he has no thoughts or words to speak or comes to him slowly. Mutism: Inability to speak "silence" although the client may have thoughts in his mind Aphonia : Paralysis of function of the vocal cord that leads to mutism. Aphasia: In ability of the client to find the correct words in which to express his thoughts due to organic damage to speech centre in the brain that will lead to mutism. 10/03/2024 Ahmad M. Al Sayeh 69  2. Disturbance in the form of speech Blocking-A sudden and complete stoppage and interruption in the client's talk that will last for few seconds to minutes after which he will proceed, where he stopped or start a different topic completely. Word-salad-a jumble of words and phrases that lacks logical coherence and meaning Incoherence - Without logical connection disjoint, lacking orderly continuity or relevance 10/03/2024 Ahmad M. Al Sayeh 70  2. Disturbance in the form of speech Neologism- A newly coined words or terms that is meaningful only to the client a new language that is created by the client. Circumstantiality - Disturbance in associative thought process in which the person digresses into unnecessary details and inappropriate thoughts before communicating the central idea Preservation - Abnormal persistent repetition of one single theme. 10/03/2024 Ahmad M. Al Sayeh 71  How to assess communication? Does the client use Tangentiality or circumstantiality when expressing ideas? Is there evidence of blocking, flight of ideas, or loose of association? What kind of words does the client use (highly educated, poorly educatedy? What is his tone of voice (monotone, loud)? 10/03/2024 Ahmad M. Al Sayeh 72  How to assess communication? Is the client's speech excessive, pressured, and rapid-fire? Is he verbally active, inactive, and mute? Is the client open and able to change when new ideas are presented? Does his thinking seem rigid and inflexible? 10/03/2024 Ahmad M. Al Sayeh 73  Fourth: Social Dimension The component of the social dimension includes self-concept, interpersonal relationships, family unit, and social role functioning, cultural and environmental factors. 1. Self-concept: to elicit the clients overall view of self : Self-concept and its components (self esteem and self identity) are in the social dimension because of the strong influence society and social relationships have in the formation of self 10/03/2024 Ahmad M. Al Sayeh 74 Fourth: Social Dimension a. Ideal self- to elicit the client's perception of how he would like to be What kinds of goals and aspirations do you have for yourself ? In what ways are you reaching your goals and aspirations?" Consider if they are realistic for the client b. Perceived self- to elicit client's view of self. What kind of person would you Say you are? Describe yourself ? What are your thoughts and feelings about yourself? How do you think others view you ? Do you see yourself with mostly positive or mostly negative characteristics? 10/03/2024 Ahmad M. Al Sayeh 75 Fourth: Social Dimension c. Self-esteem- to elicit client's judgment of his worth. How important are you to yourself? to others? Who are you important to ? Who is important to you? How much do you like yourself? Consider eye contact as a measure of self-esteem with an awareness of the cultural influences regarding eye contact. 10/03/2024 Ahmad M. Al Sayeh 76 Fourth: Social Dimension 2. Interpersonal relationship: How do you get along with your family, friends, people at work (school) and in the community?“ Do you think most people are basically good and can be trusted? 10/03/2024 Ahmad M. Al Sayeh 77 Fourth: Social Dimension Do you think most people are generally reliable? With how much ease or discomfort can you discuss differences with others? Consider client's responses to stressful event and his ability to give and receive nurturing. What do you do when you are sad (mad)? Who is supportive of you? "Who needs your support? Consider client's school and work record. Consider client's participation in community activities. Is he a leader or a follower? How much responsibility for his own actions does the client accept? 10/03/2024 Ahmad M. Al Sayeh 78  Fourth: Social Dimension 3. Family unit : Consider the following members: grandparents, parents, siblings, aunts, uncles, nieces, nephews, spouse, and children. Where were you in the order of birth (first, second)? Who in the family is supportive of you? Describe your family communication (who talks to whom, who makes decisions). What is your role in the family? In what ways is your role satisfying?" "In what ways are you dissatisfied? 10/03/2024 Ahmad M. Al Sayeh 79 Fourth: Social Dimension 4. Social role functioning: What is your role in the family? In what ways are you satisfied or dissatisfied? Tell about your job? 5.Cultural factors: traditions, customs, norms 10/03/2024 Ahmad M. Al Sayeh 80 Fourth: Social Dimension Stressors safety factors. Resources Sixth: Occupational Dimension safety factors, resources 10/03/2024 Ahmad M. Al Sayeh 81  Seventh: Spiritual Dimension It allows an individual to experience and understand the reality of his existence in unique ways that go beyond the usual limits. Component of this dimension 1. Person's philosophy of life (values and beliefs about health and illness).What are your thoughts and feelings about life in general? Tell me what you think the cause of your illness ? What important things influence your life? 10/03/2024 Ahmad M. Al Sayeh 82 Seventh: Spiritual Dimension 2. Religion. What religion are you 3. Spiritual beliefs. What kind of things contributes meaning to your life? 4. Perception of faith. From where (whom) you get strength? 5. Hope or despair. Do you feel helpless? 10/03/2024 Ahmad M. Al Sayeh 83  Seventh: Spiritual Dimension 6. Self-actualizing. What does the future hold for you? 7. Aesthetic sense. What do you enjoy about nature? What is your favorite season? 8. Beliefs about life and death. What do you think will happen to you when you die? 10/03/2024 Ahmad M. Al Sayeh 84 Variety of terms used Defense mechanisms: Unconscious intra psychic processes that are employed to seek relief from emotional conflict and freedom from anxiety. Neurosis - Any faculty or inefficient way of coping with anxiety or inner conflict, usually involving mechanisms that may ultimately lead to neurotic disorder. 10/03/2024 Ahmad M. Al Sayeh 85 Variety of terms used Psychosis - Any major mental disorder of organic or emotional origin characterized by extreme disorganization of personality often accompanied by a loss of contact with reality and abnormal mental content. Schizophrenia - It is psychotic disorder that is characterized by thinking disorder , distortion of reality, disturbances of language and communication, withdrawal from social interaction and fragmentation of thought perception and emotional reaction. 10/03/2024 Ahmad M. Al Sayeh 86 Variety of terms used Mania- It is a mood state of extreme excitement with loss of reality testing characterized by over activity, over talkativeness some times violent destructive or self destructive behavior. Distractibility- failure to pay attention to some specific tasks so that the client is bombarded by a wide variety of stimuli, to all of which he feels the need to give some attention. Disorientation - Loss of awareness of the position of self-in terms of time, space or other people. Does client know his name, the date, and where he 10/03/2024 Ahmad M. Al Sayeh 87  Informed Consent According to law, all individuals have the right to decide whether to accept or reject treatment (Guido, 2006). A health-care provider can be charged with assault and battery for providing life- sustaining treatment to a client when the client has not agreed to it. The rationale for the doctrine of informed consent is the preservation and protection of individual autonomy in determining what will and will not happen to the person's body (Guido, 2006). 10/03/2024 Ahmad M. Al Sayeh 88 Informed Consent A client's refusal to accept treatment may be challenged under the following circumstances (Aiken, 2004; Guido, 2006; Levy & Rubenstein, 1996; Mackay, 2001): 1. When a client is mentally incompetent to make a decision and treatment is necessary to preserve life or avoid serious harm 2. When refusing treatment endangers the life or health of another 3. During an emergency, in which a client is in no condition to exercise judgment 10/03/2024 Ahmad M. Al Sayeh 89 Informed Consent 4. When the client is a child (consent is obtained from parent or surrogate) 5. In the case of therapeutic privilege: Information about a treatment may be withheld if the physician can show that full disclosure would a. hinder or complicate necessary treatment, b. cause severe psychological harm, or c. be so upsetting as to render a rational decision by the client impossible 10/03/2024 Ahmad M. Al Sayeh 90  Milieu Therapy Definition Milieu therapy is a socioenvironmental therapy in which the attitudes and behaviors of the staff in a treatment service and activities prescribed for the clients are determined by the clients' emotional and interpersonal needs. (APA, 1994).A scientific structuring of the environment in order to effect behavioral changes and to improve the psychological health and functioning of the individual (Skinner, 1979). 10/03/2024 Ahmad M. Al Sayeh 91 Milieu Therapy The word milieu is French for "middle." The English translation of the word is "surroundings or environment." In psychiatry, therapy involving the milieu, or environment, may be called milieu therapy, therapeutic community, or therapeutic environment. The goal of milieu therapy is to manipulate the environment so that all aspects of the client's hospital experience are considered therapeutic 10/03/2024 Ahmad M. Al Sayeh 92 Therapeutic Milieu In the therapeutic milieu the entire environment of the hospital is set up so that every action, function, and encounter is therapeutic. The therapeutic community is a smaller representation of the larger community/society outside. The coping skills and learned behaviors within the community will also translate to the larger outside community 10/03/2024 Ahmad M. Al Sayeh 93 Seven Basic Assumptions Skinner (1979) outlined seven basic assumptions on which a therapeutic community is based: 1. The health in each individual is to be realized and encouraged to grow. 2. Every interaction is an opportunity for therapeutic intervention,. 3. The client owns his or her own environment 4. Each client owns his or her own behavior. 5. Peer pressure is a useful and powerful tool. 6. Inappropriate behaviors are dealt with as they occur. 7. Restrictions and punishment are to be avoided. 10/03/2024 Ahmad M. Al Sayeh 94 Conditions that promote a therapeutic community 1. Basic physiological needs are fulfilled 2. The physical facilities are conducive to achievement of the goals of therapy 3. A democratic form of self-government exists 4. Responsibilities are assigned according to client capabilities 5. A structured program of social and work related activities is scheduled 6. as part of the treatment program 7. Community and family are included in the program of therapy in an effort to 8. facilitate discharge from treatment 10/03/2024 Ahmad M. Al Sayeh 95 The role of the nurse Milieu therapy can take place in a variety of inpatient and outpatient settings. In the hospital, nurses are generally the only members of the interdisciplinary treatment (IDT) team who spend time with the clients on a 24-hour basis, and they assume responsibility for management of the therapeutic milieu. In all settings, the nursing process is used for the delivery of nursing care. Nurses play a crucial role in the assessment, diagnosis, outcome identification, planning, implementation, and evaluations of the environment are necessary for the successful management of a therapeutic milieu 10/03/2024 Ahmad M. Al Sayeh 96 The role of the nurse They are responsible for ensuring that clients' basic needs are fulfilled; assessing physical and psychosocial status; ad ministering medication; helping the client develop trusting relationships; setting limits on unacceptable behaviors; educating clients; and ultimately, helping clients, within the limits of their capability, to be- come productive members of society 10/03/2024 Ahmad M. Al Sayeh 97 Group Interventions Stages of Group Development 1) The Initial Stage (in/out) Leader orients the group and sets up the ground rules, including confidentiality. There may be confusion and questions about the purpose of the group. members question themselves in relation to others and how they will fit in the group 10/03/2024 Ahmad M. Al Sayeh 98 Group Interventions II. The Conflict Stage (top/bottom) Group is concerned with pecking order, role, and place in group. There can be criticism and judgment. Therapist may be criticized as group finds its way. 10/03/2024 Ahmad M. Al Sayeh 99 Group Interventions III. Cohesiveness (Working) Stage (near/far) After conflict comes a group spirit, and a bond and trust develop among the members. Concern is now with closeness, and an "us versus them "attitude develops: those in the group versus those outside the group. Eventually becomes a mature working group. 10/03/2024 Ahmad M. Al Sayeh 100 Group Interventions IV. Termination Difficult for long-term groups; discuss well before termination. There will be grieving and loss. (Yalom 1995, 10/03/2024 Ahmad M. Al Sayeh 101 Personal and Sleep Hygiene Self-care deficit may be related to factors such as regression, excessive ritualistic Behavior , acute confusion, psychosis, anxiety, or depression. Nurses use the phrase activities of daily diving (ADL) to describe the client's ability to feed, bathe, dress, and toilet himself or herself. A depressed individual may, for example, neglect personal hygiene, dress slovenly, and exhibit a poor appetite. 10/03/2024 Ahmad M. Al Sayeh 102 Personal and Sleep Hygiene Nursing interventions would focus on promoting participation in bathing, dressing, and eating; encouraging independence; and exploring the client's feelings about the need for assistance. The presences of perceptual, visual, hearing, cognitive, or physical deficits determine the interventions the nursing staff uses. 10/03/2024 Ahmad M. Al Sayeh 103 Personal and Sleep Hygiene Sleep pattern disturbances are described frequently by clients in the psychiatric setting. Depressed clients complain of the inability to stay asleep, or may complain of sleeping too much. Clients experiencing anxiety generally complain of the inability to fall asleep. 10/03/2024 Ahmad M. Al Sayeh 104 Personal and Sleep Hygiene Various nursing interventions are helpful in promoting an optimal balance of rest and activity. Interventions are based on the client's inability to fall asleep or to stay asleep. Generic interventions include reducing noise, avoiding napping during the day, avoiding using the bed and bedroom for activities other than sleep, avoiding caffeinated beverages after mid afternoon 10/03/2024 Ahmad M. Al Sayeh 105 Protective Care: The potential for violence is inherent in an inpatient psychiatric unit. At times, it is necessary to prevent clients from harming themselves or others, but the stabilization of clients with dangerous behavior requires the flexible use of seclusion and restraints. The potential for violence is inherent in an inpatient psychiatric unit. At times, it is necessary to prevent clients from harming themselves or others, but the stabilization of clients with dangerous behavior requires the flexible use of seclusion and restraints. 10/03/2024 Ahmad M. Al Sayeh 106 Behavioral Therapy: Behavioral therapy is a "mode of treatment that focuses on modifying observable and, at least in principle, quantifiable behavior by means of systematic manipulation of the environment and variables thought to be functionally related to the behavior' (American Psychiatric Association, 1994). It aims to eliminate symptoms such as temper tantrums and bed-wetting or to develop desirable behavior. Behaviorists believe that problem behaviors are learned, and therefore can be eliminated or replaced by desirable behaviors through new learning experiences. 10/03/2024 Ahmad M. Al Sayeh 107 Behavioural Therapy *Rowe (1989) lists the following general principles of behavior therapy'. - Faulty learning can result in psychiatric disorders. - Behavior is modified through the application of principles of learning. - Maladaptive behavior is considered to be deficient or excessive; thus, behavior therapy seeks to promote appropriate behavior or decrease or eliminate the frequency, duration, or place of occurrence of inappropriate behavior. 10/03/2024 Ahmad M. Al Sayeh 108 Behavioural Therapy - One's social environment is a source of stimuli that support symptoms; therefore, it also can support changes in behavior through appropriate treatment measures. Behavior therapy techniques include behavior modification and systematic desensitization aversion therapy, cognitive behavior therapy, assertiveness training, implosive therapy, and limit setting. A discussion of each follows. 10/03/2024 Ahmad M. Al Sayeh 109 a. Behavior Modification and Systematic Desensitization Two models of learning theory' are used in behavior modification: - Pavlov's theory of conditioning, which states that a stimulus elicits a response (a red delicious apple stimulates onc's salivary glands) - Skinner's operant conditioning theory, which states that the results of a person's behavior determine whether the behavior will reoccur in the future (a child is permitted to stay home from school because he did not finish his homework assignment). 10/03/2024 Ahmad M. Al Sayeh 110 a. Behavior Modification and Systematic Desensitization In operant conditioning, good behavior is rewarded with physical reinforces (eg , food) or social reinforcers (eg , approval, tokens of exchange), the reinforces are withheld if maladaptive behavior occurs. Such rewards generally encourage positive or good behavior, bringing about a change in attitudes and feelings. Operant conditioning has been successful in teaching language to autistic children, teaching ADL and social skills to cognitively disabled children and adults, and leaching social skills to regressed psychotic clients 10/03/2024 Ahmad M. Al Sayeh 111 a. Behavior Modification and Systematic Desensitization Systematic desensitization is based on Pavlov's theory of conditioning. This behavior therapy eliminates client's fears or anxieties by stressing relaxation techniques that inhibit anxious responses. 10/03/2024 Ahmad M. Al Sayeh 112 B. Aversion Therapy: Aversion therapy uses unpleasant or noxious stimuli to change inappropriate behavior. The stimulus may be a chemical, such as Antabuse or apomorphine , used to treat alcoholics electrical, such as apad - and-buzzer apparatus, used to treat children who have urinary incontinence while sleeping; or visual, such as films of an auto accident shown to drivers who Tare arrested for speeding or for driving While under the influence of alcohol or drugs. Aversion therapy has been used in the treatment of alcoholism and compulsive unacceptable or criminal Social behaviour 10/03/2024 Ahmad M. Al Sayeh 113 C. Cognitive behavioral therapy (CBT) Cognitive behavioral therapy (CBT) deals with the Cognitive behavioral therapy (CBT) deals with the relationship between cognition, emotion, and behavior. ❖ Cognitive aspects are: automatic thoughts, assumptions, and distortions. ❖ Individuals are often unaware of the automatic thoughts that may affect beliefs and behaviors , such as I never do well in school or I am stupid. 10/03/2024 Ahmad M. Al Sayeh 114 C. Cognitive behavioral therapy (CBT) ❖ Deep - seated beliefs or "schemas" affect our perceptions of the world as well. ❖ And finally , individuals are also influenced by distortions in their thinking. - Important aspects of CBT include agenda setting , review , feedback , and homework... ❖ Fearful, dysfunctional clients respond better to behavioral versus cognitive interventions. This may involve task or activity assignments. 10/03/2024 Ahmad M. Al Sayeh 115 Other behavioral interventions are: systematic desensitization techniques, and in vivo interventions (phobias/agoraphobia). Distortions in Thinking ❖Catastrophizing - an uncomfortable event is turned into acatastrophe. ❖ Dichotomous thinking - either/or thinking, such as I am good or I am evil. ❖Mind reading - believes that the person knows what the other is thinking without clarifying. 10/03/2024 Ahmad M. Al Sayeh 116 Other behavioral interventions are: ❖ Selective abstraction - focusing on one aspect rather than all aspects. Individual hears only the one negative comment during a critique and does not hear the five positive comments. ❖Fortune telling - anticipates a negative future event without facts or outcome. I know I am going to fail that test. ❖ Overgeneralization - one event is now representative of the entire situation. 10/03/2024 Ahmad M. Al Sayeh 117  CLINICAL PEARL CBT has been shown to be quite effective in treating depression and anxiety disorders (panic/phobia/OCD) and is very helpful when used in conjunction with medication. Through CBT, clients learn to change their thinking and to "reframe" their views/thoughts as well as.learn tools/techniques to deal with future episodes. CBT provides the Client with a sense of control over his/her fears, depression, and anxiety, as there is an active participation in treatment and outcome. 10/03/2024 Ahmad M. Al Sayeh 118 A. Behavior Modification and Systematic Desensitization d. Assertiveness Training: During assertiveness training, clients are taught how to appropriately relate to others using frank, honest, and direct expressions, whether these are positive or negative in nature. In other words, one voices opinions openly and honestly without feeling guilty. One is encouraged not tobe afraid to show an appropriate response, negative or positive, to an idea or suggestion. 10/03/2024 Ahmad M. Al Sayeh 119  Others may show inconsiderate aggression and disrespect for the rights of others. Assertiveness training tcaches onc to ask for what is wanted, take a position on various issues, and initiate specific action to obtain what one wants whill respecting the rights of others. Such training is beneficial to both mentally ill and mentally healthy persons. 10/03/2024 Ahmad M. Al Sayeh 120 e. Implosive Therapy: Implosive therapy, or flooding, is the opposite of systematic desensitization. Persons are exposed to intense foams of anxiety producers, either in imagination or in real life. Flooding is continued until the stimuli no longer produce disabling anxiety. Implosive therapy is used in the treatment of phobias and other problems causing maladaptive anxiety. Virtual reality is an example of this type of therapy. It is used to treat clients with phobias. 10/03/2024 Ahmad M. Al Sayeh 121 f. Limit Setting: Limit setting is an important aspect of the therapeutic milieu. Limits reduce anxiety, mini manipulation, provide a framework for the client to function in, and enable a client to learn make requests. Eventually the client learns to control her or his own behavior. The first step limit setting is to give advanced warning of the limit and the consequencesn that will follow the client does not adhere to the limit. Choices should be provided whenever possible because they allow the client a chance to participate in the limit setting. 10/03/2024 Ahmad M. Al Sayeh 122 Complementary Therapies Art therapy – the use of art media, images, and the creative process to reflect human personality, interests, concerns, and conflicts. Very helpful with children and traumatic memories. Biofeedback – learned control of the body’s physiological responses either voluntarily (muscles) or involuntarily (autonomic nervous system), such as the control of blood pressure or heart rate. Dance therapy - as the mind/body is connected, dance therapy focuses on direct expression of emotion through the body, affecting feelings, thoughts, and the physical and behavioral responses. 10/03/2024 Ahmad M. Al Sayeh 123 Complementary Therapies Guided imagery - imagination is used to visualize improved health; has positive effect on physiological responses. Meditation - self-directed relaxation of body and mind; health producing benefits through stress reduction. Others: humor therapy, deep-muscle relaxation, prayer, acupressure, Rolfing, pet therapy, massage therapy, and so forth. 10/03/2024 Ahmad M. Al Sayeh 124 Crisis Intervention Phases I. Assessment - What caused the crisis, and what are the individual's responses to it? II. Planning intervention - Explore individual's strengths, weaknesses, and support systems, and coping skills in dealing with the crisis. III. Intervention - Establish relationship, help understand event and explore feelings and explore alternative coping strategies. 10/03/2024 Ahmad M. Al Sayeh 125 Crisis Intervention Phases IV. Evaluation/reaffirmation - Evaluate outcomes/plan for future/evaluate need for follow-up. (Aguilera 1998) Prevention/Management of Assaultive Behaviors Assessment of signs of anger is very important in prevention and in intervening before anger escalates to assault/violence 10/03/2024 Ahmad M. Al Sayeh 126 Early Signs of Anger Muscular tension: clenched fist Face: furled brow, glaring eyes, tense mouth, clenched teeth, flushed Face. Voice: raised or lowered If anger is not identified and recognized at the preassaultive tension state, this can progress to aggressive behavior. 10/03/2024 Ahmad M. Al Sayeh 127 Anger Management Techniques Remain calm Help client recognize anger Find an outlet: verbal (talking) or physical (exercise) Help client accept angry feelings; not acceptable to act on them Do not touch an angry client Medication may be needed 10/03/2024 Ahmad M. Al Sayeh 128 Signs of Anger Escalation Verbal/physical threats Pacing appear agitated Throwing objects Appears suspicious/disproportionate anger Acts of violence/hitting 10/03/2024 Ahmad M. Al Sayeh 129 Anger Management Techniques Speak in short command sentences: Joe, calm down. Never allow yourself to be cornered with an angry client; always have an escape route (open door behind you). Request assistance of other staff. Medication may be needed; offer voluntarily first. 10/03/2024 Ahmad M. Al Sayeh 130 Anger Management Techniques Restraints and/or seclusion may be needed (see Use of Restraints in Basics tab; also client restraint and management figures below) Continue to assess/reassess (ongoing) When stabilized, help client identify early signs/triggers of anger and alternatives to prevent future anger/escalation Terrorism/Disasters (See Posttraumatic Stress Disorder, Stages of Death and Dying, and Complicated versus Uncomplicated Grief in the Disorders Tab; see also Suicide Assessment below) 10/03/2024 Ahmad M. Al Sayeh 131  Restraints and Seclusion "The right to freedom from restraint or seclusion except in an emergency situation.“ in psychiatry, the term restraints generally refers to a set of leather straps that are used to restrain the extremities of an individual whose behavior is out of control and who poses an inherent risk to the physical safety and psychological well-being of the individual and staff. Restraints are never to be used as punishment or for the convenience of staff. 10/03/2024 Ahmad M. Al Sayeh 132 Restraints and Seclusion Other measures to decrease agitation, such as "talking down" (verbal intervention) and chemical restraints (tranquilizing medication) are usually tried first. If these interventions are ineffective, mechanical restraints may be instituted (although some controversy cxists as to whether chemical restraints are indeed less restrictive than mechanical restraints). 10/03/2024 Ahmad M. Al Sayeh 133 Restraints and Seclusion The Joint Commission has released a set of revisions to restraint and seclusion standards. The intent of these revisions is to reduce the use of this intervention as well as to provide greater assurance of safety and protection to individuals placed in restraints or seclusion for reasons related to psychiatric disorders or substance abuse (Medscape Wire, 2000) 10/03/2024 Ahmad M. Al Sayeh 134 in addition to others, these provisions provide the following guidelines: 1. In the event of an emergency, restraints or seclusion may be initiated without a physician's order. 2. As soon as possible, but no longer than I hour after the initiation of restraints or seclusion, a qualified staff member must notify the physician about the individual's physical and psychological condition and obtain a verbal or written order for the restraints or seclusion. 10/03/2024 Ahmad M. Al Sayeh 135 in addition to others, these provisions provide the following guidelines: 3. Orders for restraints or seclusion must be reissued by a physician every 4 hours for adults age 18 and older, every 2 hours for children and adolescents ages 9 to 17 and every hour for children younger than 9 years. 4. An in-person evaluation of the individual must be made by the physician within 4 hours of the initiation of restraints or seclusion of an adult age 18 or older, and within 2 hours for children and adolescents ages 17 and younger. 5. Minimum times for in-person reevaluations by a physician include 8 hours for individuals ages 18 years and older, and 4 hours for individuals ages 17 and younger 10/03/2024 Ahmad M. Al Sayeh 136  Victims of Abuse Cycle of Battering Phase I. Tension Building - Anger with little provocation; minor battering and excuses. Tension mounts and victim tries to placate. Phase Il. Acute Battering - Most violent, up to 24 hours. Beating may be severe and threatening or fear for children. victim may provoke to get it over. Minimized by abuser. Help sought by victim if life 10/03/2024 Ahmad M. Al Sayeh 137 Victims of Abuse Cycle of Battering Phase III. Calm, Loving, Respite - Batterer is loving, kind, contrite. Fear of victim. leaving. Lesson taught and now batterer believes victim "understands. ▪ Victim believes batterer can change and batterer uses guilt. Victim believes this (calm/loving in phase III) is what batterer is really like. Victim hopes the previous phases will not repeat themselves. ▪ Victim stays because of fear for life (batterer threatens more and self-esteem lowers), society values marriage, divorce is viewed negatively, financial dependence. Starts all over again - dangerous, and victim often killed. (Walker 1979). 10/03/2024 Ahmad M. Al Sayeh 138 Electroconvulsive Therapy Electroconvulsive therapy (ECT) is the induction of a grand mal (generalized) seizure through the application of electrical current to the brain. ECT is effective with clients who are acutely suicidal and in the treatment of severe depression, particularly in those clients who are also experiencing psychotic symptoms and those with psychomotor retardation and neurovegetative changes, such as disturbances in sleep, appetite, and energy. It is often considered for treatment only after a trial of therapy with antidepressant medication has proved ineffective. 10/03/2024 Ahmad M. Al Sayeh 139 The most common indications for ECT are major depressive disorder and Bipolar II Disorder, depressed. It is indicated for clients in the following situations : 1. Failure to respond to medications. 2. Severe symptoms, such as severe psychosis or dangerously suicidal or homicidal behaviors. 3. Adverse reactions to psychotropic medications. 4. Medical conditions, such as heart disease or glaucoma that could be worsened by psychotropic medications. 5. Previous successful response to ECT client preference. 10/03/2024 Ahmad M. Al Sayeh 140 Client Preparations for ECT: 1. The client should ingest NPO for at least 8 hours prior to the treatment. 2. Medications Used With ECT a) (1) mg atropine sulfate or glycopyrrolate (Robinul), is administered intramuscularly approximately 30 minutes before the treatment. Either of these medications may be ordered to decrease secretions and counteract the effects of vagal stimulation induced by the ECT B) thiopental sodium (Pentothal) or methohexital sodium (Brevital). The anesthesiologist administers intravenously a short-acting anesthetic. 10/03/2024 Ahmad M. Al Sayeh 141 Client Preparations for ECT: C. a muscle relaxant, usually succinylcholine chloride (Anectin), is given intravenously to prevent severe muscle contractions during the seizure, thereby reducing the possibility of fractured or dislocated bones. Because succinylcholine paralyzes respiratory muscles as well, the client is oxygenated with pure oxygen during and after the treatment, except for the brief interval of electrical stimulation, until spontaneous respirations return. 3. Electrodes are placed on either one side of the temple or on both sides, through which the current is delivered 10/03/2024 Ahmad M. Al Sayeh 142 Mechanism of Action The exact mechanism by which ECT effects a therapeutic response is unknown. Several theories exist, but the one to which the most credibility has been given is the biochemical theory (Wahlund & von Rosen, 2003). These neurotransmitters include serotonin, norepinephrine, and dopamine, the same biogenic amines that are affected by antidepressant drugs. Additional evidence suggests that ECT may also result in increases in glutamate and gamma-aminobutyric acid (Grover, Mattoo, & Gupta, 2005). The results of studies relating to the mechanism underlying the effectiveness of ECT are still ongoing and continue to be controversial. 10/03/2024 Ahmad M. Al Sayeh 143 Side Effects The most common side effects of ECT are temporary memory loss and confusion. Critics of the therapy argue that these changes represent irreversible brain damage. Marangell, Silver, and Yudofsky (2003) state, "To date, no reliable data have shown permanent memory loss caused by modern ECT." Other researchers have suggested that varying degrees of memory loss may be evident in some clients up to 6 to 7 months following ECT (Hall & Bensing, 2009; Popolos, 2009). The controversy continues regarding the choice of unilateral versus bilateral ECT. Studies have shown that unilateral placement of the electrodes decreases the amount of memory disturbance 10/03/2024 Ahmad M. Al Sayeh 144