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BAPTIST HEALTH SCHOOL OF NURSING
NSG 3036A: PSYCHIATRIC-MENTAL HEALTH
HEALTH TEACHING: EMPOW ERING PEOPLE W ITH MENTAL HEALTH NEEDS
LECTURE OBJECTIVES:
1.
Identify conditions for which relaxation is appropriate therapy
2.
Discuss various methods of achieving relaxation
3.
Describe the role of the nurse in relaxation therapy
4.
Discuss basic human rights
5.
Differentiate among nonassertive, assertive, aggressive, and passive-aggressive behavior
6.
Describe techniques that promote assertive behavior
7.
Discuss thought-stopping techniques
8.
Discuss the principles of classical and operant conditioning as foundations for behavior threrapy
9.
Identify various techniques used in the modification of client behavior
10.
Implement the principles of behavior therapy using the steps of the nursing process
11.
Identify various indications for cognitive therapy
12.
Describe goals, principles, and basic concepts of cognitive therapy
13.
Discuss a variety of cognitive therapy techniques
READING ASSIGNM ENT:
Townsend, Chapters 14, 15,19 and 20
LECTURE OUTLINE:
I.
II.
Assertive Communication
A.
Definition: Behavior that enables individuals to act in their own best interests, to stand up for
themselves without undue anxiety , to express their honest feelings comfortably, or to exercise
their own rights without denying the rights of others.
B.
How is this accomplished?
Basic Human Rights
A.
B.
C.
D.
Treated with respect
Express feelings, opinions, and beliefs
Say “no” without feeling guilty
Make mistakes and accept the responsibility for them
E.
F.
G.
H.
I.
J.
III.
Be listened to and taken seriously
Change your mind
Ask for what you want
Put yourself first, sometimes
Set your own priorities
Refuse justification for your feelings or behavior
Response Patterns
A.
Individuals develop patterns of response by:
1.
2.
3.
4.
5.
6.
B.
IV.
V.
W atching other people (role modeling)
Being positively reinforced or punished for a certain response
Inventing a response
Not being able to think of a better way to respond
Not developing the proper skills for a better response
Consciously choosing a response style
Common Response Patterns
1.
Nonassertive behavior-
2.
Assertive behavior-
3.
Aggressive behavior-
4.
Passive-aggressive behavior-
Behavioral Components of Assertive Behavior
A.
Eye contact-
B.
Body posture-
C.
Distance/physical contact-
D.
Gestures-
E.
Facial expressions-
F.
Voice-
G.
Fluency-
H.
Timing-
I.
Listening-
J.
Thoughts-
K.
Content-
Techniques That Promote Assertive Behavior
A.
Standing up for one’s basic rights
B.
Assuming responsibility for one’s own statements
C.
Responding as a “broken record”
D.
Agreeing assertively
E.
Inquiring assertively
F.
Shifting from content to process
G.
Clouding/fogging
H.
Defusing
I.
Delaying assertively
J.
Responding assertively with irony
VI.
Thought-Stopping Techniques
VII.
Role of the Nurse
VIII.
A.
Recognize their own behavioral responses
B.
Assist clients who wish to effect behavioral change in an effort to increase self-esteem and improve
interpersonal relationship
C.
Teach clients the techniques to use to increase their assertive responses
Behavior Therapy
A.
B.
C.
Introduction
1.
Maladaptive behavior is age-inappropriate, interferes with adaptive functioning or is
misunderstood by others in terms of cultural inappropriateness
2.
People have become what they are through the interaction of the environment with their
genic endowment
3.
Basic assumption: problematic behaviors occur when there has been inadequate learning
and therefore can be corrected through the provision of appropriate learning experiences
Classical Conditioning
1.
Pavlov introduced this process of learning using his experiences with dogs.
2.
He identified conditioned verses unconditioned responses and stimuli.
3.
He also documented classical conditioning and stimulus generalization using a 6 month
old baby
Operant Conditioning
1.
Introduced by Skinner, whose work was influenced by Thorndike’s law of effect (the
connection between a stimulus and a response is strengthened or weakened by the
consequences of the response.
2.
Stimuli- environmental events that interact with and influence an individual’s behavior.
They may precede or follow a behavior
3.
Reinforcer- stimulus that follows a behavior (or response)
a.
b.
D.
Positive reinforcement- reinforcing stimulus increases the probability that the
behavior will recur
Negative reinforcement- increasing the probability that a behavior will recur by
removal of an undesirable reinforcing stimulus
4.
Aversive stimulus or punisher- a stimulus that follows a behavioral response and
decreases the probability that the behavior will recur
5.
Discriminative stimuli- precedes behavioral response and predict that a particular
reinforcement will occur
Techniques for Modifying Client Behavior
1.
Shaping- reinforcements are given for increasingly closer approximations to the desired
response
2.
Modeling- learning new behaviors by imitating the behavior of others
3.
Premack Principle- a frequently occurring response can serve as a positive reinforcement
for a response that occurs less frequently
4.
Extinction- the gradual decrease in frequency or disappearance of a response when the
positive reinforcement is withheld
5.
Contingency contracting- a contract drawn up specifying the desired behavioral change
and the reinforcers to be given for performing the desired behavior
6.
Token economy- a type if contingency contract in which the reinforcers for desired
behavior are presented in the form of tokens
7.
Time out- aversive stimulus or punishment during which the client is removed from the
environment where the unacceptable behavior is being exhibited
8.
Reciprocal inhibition- (counterconditioning) decreases or eliminates a behavior by
introducing a more adaptive behavior, but one that is incompatible with the unacceptable
behavior
9.
Overt sensitization- type of aversion therapy that produces unpleasant consequences for
undesirable behavior
10.
Covert sensitization- aversion technique that relies on the individual’s imagination to
produce unpleasant symptoms rather than on medication
11.
Systematic desensitization- a techniques for assisting individuals to overcome fear of a
phobic stimulus by gradually increasing the exposure to a stimulus in hierarchy format
12.
Flooding- (implosive therapy) a technique used to assist individuals overcome phobic
stimuli by “flooding” the individual with continuous presentation (through mental
imagery) of the phobic stimulus until it no longer elicits anxiety
E.
IX.
Role of the Nurse
1.
Assessment of behaviors that are unacceptable for age and cultural inappropriateness
2.
Formulate nursing diagnosis
3.
Plan for behavior modification. Consistency in implementation is the key.
4.
All team members must be aware of the plan
5.
Evaluate the achievement of outcome criteria.
Cognitive Therapy- directed towards modifying distorted cognition about a situation
A.
B.
C.
Indications
1.
Developed as treatment for depression
2.
Today it is used for a broad range of disorders, such as panic D/O, OCD, substance abuse,
Goals of Therapy
1.
The client will monitor negative and automatic thoughts
2.
Recognize the connection between cognition, affect, and behavior
3.
Examine evidence for and against distorted automatic thoughts
4.
Substitute more realistic interpretations for these biased cognitions
5.
Learn to identify and alter the dysfunctional beliefs that predispose him or to distort
experiences
6.
Therapy is short term lasting 12-16 weeks, and patient should improve within 25 weeks or
diagnosis should be reevaluated
Principles of Therapy
1.
Based on ever-evolving formation of the client and his or her problem in cognitive terms
2.
Requires a sound therapeutic alliance
3.
Emphasizes collaboration and active participation
4.
Goal oriented and problem focused
5.
Initially emphasizes the present
6.
Educative, aims to teach the client to be his or her own therapist, and emphasize relapse
prevention
7.
Aims to be time limited
D.
8.
Sessions are structured
9.
Teaches clients to identify, evaluate, and respond to their dysfunctional thoughts and
beliefs
10.
Uses a variety of techniques to change thinking, mood and behavior
Basic Concepts- “...emotional responses are largely dependent on cognitive appraisals of the
significance of environmental cues”
1.
Automatic Thoughts- occur rapidly in response to a situation and without rational analysis
a.
b.
c.
d.
e.
f.
g.
h.
2.
E.
Arbitrary inference- conclusion drawn without facts
Overgeneralization (Absolutistic thinking)- sweeping conclusions based on one
incident
Dichotomous thinking- viewing situations in terms that are all-or-nothing, blackor-white, or good-or-bad
Selective abstraction (mental filter)- conclusion based on only a selected portion
of the evidence
Magnification- exaggerates the negative significance of an event
Minimization- overevaluates the positive significance of an event
Catastrophic thinking- always thinking the worst will occur
Personalization- taking responsibility for situations without considering other
circumstances may have contributed to the outcome
Schemas (core beliefs)- individual’s fundamental beliefs and assumptions, which
developed early in life from personal experiences and identification with significant
others
Techniques of Cognitive Therapy
1.
Didactic (Educational) Aspects
a.
b.
c.
2.
Client prepared to become own cognitive therapist
Client given information about cognitive therapy
Explanations given about expectations of both client and therapist
Cognitive Techniques
a.
b.
Recognizing automatic thoughts and schemas
(1)Socratic questioning (guided discovery)- client is questioned about his/her
situation
(2)Imagery- client asked to relive the situation by imagining the setting in which
it occurred; and role play- therapist assumes the role of an individual within a
situation that produces a maladaptive response
(3)Thought recording- assigned as homework to client. Client asked to keep a
written record of situations that occur and the automatic thoughts elicited
Modifying automatic thoughts and schemas
(1)Generating alternatives- consider broader range of possibilities
(2)Examining the evidence- automatic thought set as hypothesis and evidence
studied for and against
(3)Decatastrophizing- validity of negative automatic thought examined
(4) Reattribution- aimed at helping decrease the tendency of attributing adverse
life events to themselves
(5)Daily record of dysfunctional thoughts (DRDT)- tool used to modify
automatic thoughts. Client asked to rate intensity of automatic thought,
(6)Cognitive rehearsal- mental imagery used to uncover potential automatic
thoughts in advance of their occurrence
3.
Behavioral Interventions (Cognition affects behavior and behavior influences cognition)
a.
b.
c.
d.
e.
F.
X.
Activity scheduling- client keep daily log of activities on hourly basis and asked
to rate each for mastery and pleasure
Graded test assignment- overwhelming tasks are broken down into subtasks with
a time interval attached. Completion increases self-esteem
Behavioral rehearsal- uses role play to “rehearse” a modification of maladaptive
behaviors that may contribute to dysfunctional cognitions
Distraction- activity used to divert client from intrusive thoughts
Miscellaneous techniques- relaxation exercises, assertiveness training, etc
Role of the Nurse
1.
Apply cognitive therapy
2.
Understand the basic concepts of cognitive therapy
Relaxation Therapy
A.
B.
C.
The Stress Epidemic
1.
Normal human response is “fight-or-flight”. However inappropriate if the stress is
prolonged over long periods of time
2.
Health issues from prolonged stress: coronary heart disease ,cancer, lung ailments,
accidental injuries, cirrhosis of the liver, and suicide
3.
Genetic influences, past experiences and existing conditions influence the degree of
severity to which one perceives or responds to stress.
Physiological, Cognitive, and Behavioral Manifestations of Stress
1.
Physiological- increase in heart rate, respirations, blood pressure, blood sugar and
metabolism
2.
Behavioral- restlessness, irritability, insomnia and anorexia
3.
Cognitive- confusion, forgetfulness, difficulty in concentration, problem solving and
learning
4.
Relaxation can counteract these symptoms
Methods of Achieving Relaxation
1.
Deep breathing- breath through the nose, hold a few seconds and then release slowly
through the nose
a.
b.
2.
Reduces anxiety, depression, irritability, muscular tension, and fatigue.
Advantage: Can be done anywhere, any time
Progressive Relaxation- tense each muscle group for 5 - 7 seconds, then relax for 20 -30
seconds while concentrating on the difference in the two sensations. W ork from head to
feet.
Treatment: muscular tension, anxiety, insomnia, depression, fatigue, irritable
bowel syndrome, muscle spasms, neck and back pain, high blood pressure, mild
phobias, and stuttering
b.
Caution: assessment for individuals on hypertensive medication. Could lower
blood pressure too much.
3.
Modified (passive) Progressive Relaxation- achieved by concentrating on the feeling of
relaxation within the muscle groups. W ork from feet to head.
4.
Meditation- achievement of inner peace and harmony (deep rest)
5.
6.
7.
D.
a.
a.
2000 years old; goal: to gain “mastery over attention”
b.
Achieved through extreme concentration solely on one thought or object. Some
use Mantra: “um” = I am, “so hum” = I am he; and “sa-hum” = I am she.
c.
Treatment: cardiovascular disease, obsessive thinking, anxiety, depression and
hostility
Mental Imagery- employs the imagination to reduce the body’s response to stress
a.
Select an environment that is considered to be relaxing and concentrate on it
b.
Soft background music enhances the effect.
Biofeedback- use of instrumentation to become aware of processes of the body that go
unnoticed, bringing them under control
a.
Involuntary functions to control- heart rate, B/P, muscle tension, and skin
temperature
b.
Traetment: spastic colon, hypertension, tension/migraine headaches, muscles
spasms/pain, anxiety, phobias, stuttering, and teeth grinding
Physical Exercise- natural outlet for tension in the body in its state of “fight-or-flight”
a.
Restores equilibrium, feel relaxed and revitalized. Stimulates production of
endorphin
b.
Aerobic exercises- strengthen cardiovascular system
c.
Low-intensity physical exercise- help prevent obesity, relieve muscular tension,
and prevent muscle spasms.
Role of the Nurse
1.
Assist client to recognize source of stress
2.
Identify methods of adaptive coping
3.
Teach methods for achieving relaxation
4.
Provide rationale for importance of implementing relaxation techniques
5.
Analyze the usefulness of various relaxation techniques in the management of stress in
their own lives
BAPTIST HEALTH SCHOOL OF NURSING
NSG 3036A: PSYCHIATRIC-MENTAL HEALTH
SELF INVENTORY/DISCOVERY
NAM E:_____________________________________________
I.
W hat are your stressors?
II.
How do you deal with stress?
W hat role/responsibilities stress you most?
(List the things you do to deal with stress)
A.
B.
C.
D.
E.
F.
III.
W hat is it you would like to get out of this course?
A.
B.
C.
IV.
How do you feel about going through this course?
(W hat do you hope to learn in the next 6 weeks?)
V.
List 5 positive aspects about yourself.
A.
B.
C.
D.
E.
VI.
List the 5 BAPTIST HEALTH system values and discuss how you think you will use each value in caring
for the Psychiatric-Mental health patient.
A.
Honesty
B.
Respect
C.
Performance
D.
Service
E.
Stewardship
VII.
W ho do you nurture? (List)
VIII.
W ho nurtures You?