NURS 3524

Week 6:
Therapeutic
Approaches to
Illness
Management
and Recovery

Course Director: Dr. Crystal

Garvey
Discuss and analyze the
prevention and
management of aggression

Discuss models and Class

approaches to care of the
mental health population
Objectives

Discuss pharmacological
intervention to illness
management
  Effect of caffeine on therapeutic levels
 Effect of nicotine

Points to  Effect on liver function and metabolic

rates
Consider When
 Photosensitivity
Administrating
Psychotropic  GI upset
Medications  Weight gain
 Food intolerances
 Side effects
 Awareness of:
 Tardive dyskinesia
 Neuroleptic Malignant syndrome Nursing
 Agitation and sedation
Implications for
Psychotropic
 Class of psychotropics
Administration
 toxicity
Pharmacological
Treatment
Modalities/Interventions
Special Populations: Older Adults
 Higher risk for toxicity due to:
 Increased proportion of adipose tissue
 Decreased rate of excretion of medications
in the liver
 Decreased renal filtration rate

 Greater risk of antipsychotic side effects:

sedation, orthostatic hypotension, EPS,
especially tardive dyskinesia
Pregnant Women
 Goal of medication therapy: effect a balance
between the risk to the fetus and the risk of
mental illness to the mother
Pharmacological
Interventions
Pregnant Women:
 Avoid initiation during first trimester,
particularly in gestational weeks 6 to 10
 Avoid multiple psychotropic intervention
 Lowest dose for the shortest period of
time
 Lower the dose before delivery
 Increase the dose after delivery
 Start the medication immediately after
breastfeeding is finished
Children:
 Most psychotropic medications are not well
studied in children
 Risk of atypical antipsychotics
 Antidepressants may instigate suicidal risks; Pharmacological
increase in risk during the initial days of
treatment
Interventions
 Doses are given in multiple, smaller amounts
during the day
Severely and Persistently Mentally Ill:
 Assess ability to learn
 may have an impaired capacity to learn
and retain information
 Availability of family supports
 Availability of community support and
resources.
Medically Complex Clients:
 Hospitalized clients may develop
psychiatric symptoms due to the underlying
pathology, medication toxicity, or
environmental causes: delirium
 Clients with medical illness and psychiatric
symptoms: monitor for drug interactions

Special
Populations
 THE RIGHT TO REFUSE GOALS MUTUALLY AGREED
TREATMENT UPON BETWEEN CLIENT
AND NURSE

Medication
Management

ASSESS FOR CLIENT’S REASONS FOR CLIENT

CONTINUED NEED FOR REFUSAL TO TAKE
SELF-EDUCATION MEDICATIONS AS ORDERED
Mental health Care
models
Holistic care modalities
  Differing conceptual views of family
theory and therapy exist
 Structural framework
 Minuchin – family as a social system
with structure and organization in
which the individual lives and
responds
Family  Maladaptation is noted in the
transactional patterns
Approach in  Goal of therapy is to initiate change
Mental in the family structure by clarifying
boundaries, rules, and expectations
Health Care
 Interactional framework – Satir & Haley
 Therapy directed toward change in
individual interaction patterns within
the family system and/or change in
the structure or transaction pattern
Family as a System

 General System Theory – Bertanlanffy:

 Notions of linear cause and effect are not
helpful in understanding systems ,it’s more
complex with relationships and causations
 Behaviors can be understood either as cause
or consequence
 Incompatible with a disease view
 Genograms
 Focus is on helping the
caregivers support the sick
member.

Supportive
Family
Management
Psycho-education

Aligned treatment plan / care

plan
Family Therapy

 Assumes that:
 treated as a unit and the focus is on family dynamics
 Families function as complex organic social systems
 Some aspect of system functioning is inadequate and are
disabling
 Most vulnerable member becomes symptomatic
 The whole is more than a sum of the parts
Family Therapy

 Strategic Family Therapy – Milan Model

 psychotherapy
 Paradoxical intervention
 Nursing
 1975 – Smoyak “The Psychiatric Nurse as a Family
Therapist
 “Historically, nurses recognized the
relevance of families, even when a
particular person in the family was
designated as “The Patient.” Nurses knew
that, in order to understand and to
intervene therapeutically, in a pathological
situation, the variable of family dynamics
was a crucial one.”
 Overall goals
 Develop better parenting and
nurturing skills
 Reinstate generational boundaries Family
 Improve family communication Approach to

•
Teach the family problem-solving
Preferred approach for children or
Care
adolescent clients
Nursing
King
Models
congruent
with Rogers
Family as
Focus
Neuman – a
systems model
 Foundations in basic education
program
 Post basic education is recommended
 How does family therapy compare to
family-sensitive care?

Nurse as
Family
Therapist
Stages of the Nurse-Family
Relationship
 Naïve Trust = trust is assumed
 Disenchantment: trust is questioned
 Guarded Alliance: trust is earned or
reconstructed
 Trust facilitated by “tell be about…” not
“why” & concern for/ concretely meeting
immediate needs
 Previous experience and perceptions of
individuals and systems impacts on the
development of trust
Thorne and Robinson,1988a, sited in Lynn-
McHale & Deatrick, 2000
Nurse’s Role in Groups

 Help cohesiveness
 Establish code of behavior
 Technical expert
 Model-setter
 Establish type of group
 Serve as therapist/co-therapist
 Help members relate
 Encourage members to remain
 People are seen in groups or individually which
can include:
 Psychotherapy Group, Art Therapy Group, Stress
Management Group, Assertiveness Group,
Awareness Group, Psycho-education Group,
Medication Group to name a few

Goals include: Psychotherapy

– Clarifying perceptions
– Identifying feelings
– Making connections
– Gaining insight
– Problem-solving
– Modifying problematic behaviour
PACT, ACT, and Case Management

 Program of Assertive Community Treatment and Assertive

Community Treatment
 US models of care
 Multidisciplinary team
 Care provided 24/7
 Community is the site, but the intensity is that of inpatient care
 As expensive as inpatient care
 Effective in care of persons with Schizophrenia
Peer Support
 Part of PACT/ACT Model but often not implemented in
Ontario, although this is beginning to change
 Available through OPDI (Ontario Peer Development
Initiative) funded programs
 Peer Specialists/Supporters are trained and supervised
 Former clients of the mental health care system who
promote friendship, provide understanding, teach
community living skills, and encourage current clients
in making a transition from psychiatric hospital to
community
 Recruitment/ Training of Volunteers
 Screening procedures
 Manuals developed
 Geographic and system differences

 Support of buddy matches

 Regular checks by the coordinator
 Statistical gathering for research
 Matching continues post-project
 Often the model of choice in CMHA
Branches

One person has a caseload, and connects

the client with necessary services
Case
Management Visits occur in the community, scheduled
according to acuity and need

Counseling is part of the role,

psychotherapy is not
Individuals
with severe Destructive criticism
mental illness
often benefit Special training
from social
skills training. Modeling the skill through role playing
Teaching
social skills Constant reinforcement
requires:
“Bridge to Discharge”

 Follow up from “Pilot Study” – Bridges to Discharge-

Preparation to Community Living 1992- 1995
 Developed in Hamilton
 Participatory Action Research
 Development of a transitional program for clients
involving discharge planning and community
integration
 Uses 2 primary interventions : overlapping
professional services and peer support
 Reduced service consumption by $500,000
 Extends Peplau’s theory to look at therapeutic
relationships broadly

Transitional
Discharge Includes Peer Support
Model of
Care

Overlap of in-patient and community staff in which the in-

patient staff continue to treat clients until the clients have
a working relationship with a community care provider
Prevention
and
Management
of Aggression
Safety
Class Discussion - Personal
Triggers
 When or how do you know you have been
triggered?
 What strategies have you developed to
successfully manage your own triggers?
  How do you define crisis?
 What are the factors that influence crisis ?
A Mental Health or
Psychiatric “EMERGENCY”
is …..

 “a relatively unpredictable,
acute situation that demands
an immediate response. If no
response is forthcoming,
physical harm or serious
biopsychosocial deterioration,
with a poorer prognosis, may
result” (Callahan, 1994, p. 167)
 Developmental or
Maturational; Situational or
Social; Adventitious or
Psychopathological
Anger

What are some observable characteristics of

anger?
 Physiological arousal
 Cognitive arousal
 Behavioural arousal
ANGER: The process

 An appropriate expression of feeling

 Sense of injustice
 Core values in conflict
 A displaced expression of feeling
 Projection
 Transference
 A confused expression of feeling
 Fear
 Illness
 Reframe the problem
 Don’t personalize the trigger
 Seek supervision for support
 Seek to understand the meaning of the
Anger and behaviour
Triggers  Keep stress levels lower on a daily basis – self-
care – e.g. regular exercise, meditation,
 Disengage from the encounter – give both
people time and space when possible
 Reflection - Know what triggers you and why
 Thinking before speaking
 Listen – Empathically and Actively
 Identify your “triggers” and try to “own them”
vs. blaming the client or yourself
 Count in your head
 Turn away; breathing; talk to myself; talk to
the client; name and own your feelings Personal
 Knowing in advance your sensitivities,
boundaries and limits.
Management
of
Anger and
Triggers
 What is the difference between anger and
aggression?
 Anger – Immediate emotional arousal Anger vs.
 Aggression – Enduring negative attitude Aggression
Anger or
aggression may
lead to violence
when:
 An immoveable threat is perceived
 a strong sense of powerlessness
occurs
 communication fails
 the system is felt to be profoundly
unresponsive to individual needs
 Violence Risk Assessment
(tools/rating scales)
 Aggression management
has cognitive, behavioural
and social components
 Body Language is non-
Personal Space is
threatening and An “interviewers”
respectful and does not
demonstrates support stance
violate the others space
and confidence

Support / Mindful Breathing

Managing Anger Responsiveness to
verbal and non-verbal
Soft eye contact
• Stacking
• Box Breathing
– Non-Verbal cues, critical distance,
and balance
Communication
Bio-feedback
• Shake-it-out
• Body Scan
Holistic Mind (How I
think)
Body (What I do
to my body)
Behaviour (How
I act)

Intervention • Rigid thinking • Headache • Clamming up

• Discounting • Muscle tension • Avoiding
• Attacking • Heat Rate • Attacking

and Self- thoughts

Management
Mind Body Behavior

• Validating • Centering • Defusing

• Assessing • Relaxing • Disengaging
• Coping • Positive • Problem
Activity Solving
 When clients are angry, prevent escalation,
intervene early
 Remain assertive and unhurried
 Medication may be necessary to help client Dealing with
regain control
Aggression
 Seclusion and restraints should be used
rarely—only in dangerous situations
Principles  Act – don’t react

of De-  What are some common mistakes?

Escalation
  Defuse Yourself first (Centre or Ground)
 Consider Trauma
 Observe, prepare and be Proactive
 Deal With Person's Feelings First
Defusing  Look To What You Can Agree With, and What You Can
Hostility Say “Yes” To
 Be Assertive, Not Manipulative, Passive, or Aggressive
 Focus on “Being Effective” vs. “Being Right
 Be mindful of your body language, facial expression,
distance and the environment
 A dynamic and responsive resource for:
The Crisis De-  Assessing the level of escalation based on
observed behaviours and clinical intuition
Escalation Spiral  Self-management strategies and skills
 Matching interventions appropriate and effective
at the corresponding levels of escalation
The Crisis De-
Escalation Spiral
  Ensure safety in the milieu
 Review with all staff
 To discover what happened prior to and
during the episode
 To explore staff behavior
 To explore client treatment
Critical  To learn from mistakes

Incident  Review with client

 To help client gain awareness
Review  To understand it was not punishment or
revenge
 To maintain trust and feelings of
security
Self Care

 What strategies do you

currently use to maintain
your vitality, resiliency and
zest, in working with
people in crisis?
 What resources and/or
supports do you use?