STRATEGIES USED IN DEALING WITH PSYCHIATRIC CLIENTS
Kenn S. Nuyda, RNAquinas University
MAN 2008
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1) WORKING WITH THE AGGRESSIVE PATIENT
2) WORKING WITH GROUPS OF CLIENTS
3) WORKING WITH THE FAMILY
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WORKING WITH THE AGGRESSIVE PATIENT
ANGER– Is it normal?– Does it result to problem solving and change?– Is it destructive and life threatening?
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ANGER
What is ANGER?– Normal human emotion crucial for growth
– When handled properly, it is a + force that leads to px solving and change
– When handled aggressively it is destructive and life threatening – assault, battery and violence
– PHYSICAL AGGRESSION
– PASSIVE AGGRESSION
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HOW IS ANGER MANIFESTED?
AGGRESSION– Aggressive person: verbal expression (assault),
may carry out the verbal threat (battery)– Recipient: fear. Frustration and avoidance of
that person, helplessness, defensive, guilty or angry, may retaliate, revenge or hold grudge towards the person
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Questions:
1) What if two competent clients are heard arguing by the nurse, would you intervene? Why?
2) What if the other one is less competent, as a nurse would you act stopping the argument? Why?
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VERBAL AGGRESSION– Serves as warning signs of assault or
impending battery– May provoke counteractions = fighting /
violence
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VERBAL AGGRESSION
Passive-aggressive = expression of anger in subtle and evasive ways, denies its source > coz afraid of punishment and rejection> inefficient to accomplish task
Passive – inward manifestations of anger> may damage, destroy or avoid relationship and intimacy > may lead to low self-esteem, depression, substance abuse, somatoform, suicide attempts
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ASSERTIVENESS– Accepted: HEALTHY ASSERTIVENESS
• Respecting the rights of others and the self while expressing emotions
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EXPRESSIONS OF ANGER
TURNED OUTWARD OVERT ANGER PASSIVE AGGRESSION
TURNED INWARD SUBJECTIVE OBJECTIVE
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OUTWARD EXPRESSION
OVERT ANGER PASSIVE AGGRESSION
Verbalization of angerPacing with agitation
HostilityContempt
Clenching of fistsInsulting remarks
Provoking behaviorsSadistic acts
Temper tantrumsScreamingDeviance
RageDamage to property
Threats: words and weaponsRape, assault, homicide
ImpatiencePouting
Tensed facial expressionAnnoyancePessimism
ComplainingStubbornness
SarcasmManipulation
NoncomplianceResistanceBitterness
ProcrastinationUnfair teasing
domination
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INWARD EXPRESSION
SUBJECTIVE OBJECTIVE
Feeling upsetTension
UnhappinessFeeling hurt
GuiltDisappointmentLow self-esteem
EnvyPowerlessnessSomatization
InferiorityDepression
HopelessnessDesperationHumiliation
CryingSelf-destructive behaviors
Self-mutilationSubstance abuse
Suicide
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THE DEVELOPMENT OF AGGRESSION BY AGE
Infancy: Uncontrollable crying and screaming, profuse perspuration, DOB, flailing of arms and legs
Toddlerhood: temper tantrums SAC: hitting one another Preadolescents: hitting each other competitive
sports, “tsimis”, practical/sarcastic jokes, fighting is controlled and purposeful, gangs
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22 – 45 y/o: aggression and fightingAfter 45 y/o: stopped fighting70 y/o: diminished impulse control and
cognitive impairment decreased expression of anger
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INDIVIDUAL MODELS
Violence – quality of being human and use biologically based expressions of aggression– Neuroanatomy
• Limbic system, frontal and temporal lobe
– Neurophysiology• Neurotransmitters (sero, GABA, dopa)
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Common Problems r/t aggression
Bifrontal injuries Damage to limbic system
AD Inc. dopamine
Dec. serotonin, GABA, Ach
Alcohol/drug abuse / withdrawal
Imbalance hormones Nutritional deficiencies
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Social – Psychological – interaction with the environment and
the frustrations met
Socio – Cultural– Social structures, norms, values
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STRESS MODEL (GAS)
Hans SelyeStress – wear and tearStressors - + / - stimuli that
requires a response
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STAGES (A, R, E)
ALARM RESISTANCE EXHAUSTION
F or F responseAlertness to focus immediately with the px+1 to +2 anxiety
Coping / defense mechanisms initiatedPsychosomatic begins+2 to +3 anxiety
Stress that lasts too long leading to inability to cope
>+ 3
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Smith’s Stress ModelSmith’s Stress Model
According to Smith, According to Smith, patients who are patients who are repeatedly assaultive repeatedly assaultive exhibit behavior exhibit behavior patterns that are:patterns that are: RitualisticRitualistic StereotypicalStereotypical AutomaticAutomatic
As the acuity of the As the acuity of the aggressive response aggressive response increases:increases:
Dec. px solving Dec. px solving abilities, creativity, abilities, creativity, spontaneity and spontaneity and behavioral optionsbehavioral options
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1)1) TRIGERRING PHASETRIGERRING PHASE- Stress- producing eventsStress- producing events
2)2) ESCALATION PHASEESCALATION PHASE- Escalating behaviors leading to loss of controlEscalating behaviors leading to loss of control
3)3) CRISIS PHASECRISIS PHASE- Emotional and physical crisis, loss of controlEmotional and physical crisis, loss of control
4)4) RECOVERY PHASERECOVERY PHASE- Cooling down, slowing down and return to normal Cooling down, slowing down and return to normal
responsesresponses
5)5) POST CRISIS DEPRESSION PHASEPOST CRISIS DEPRESSION PHASE- - Attempts to be reconciled with othersAttempts to be reconciled with others
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The Assault CycleThe Assault Cycle
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WHAT WILL THE NURSE FEEL WHAT WILL THE NURSE FEEL IF PTS. BECOME IF PTS. BECOME
AGGRESSIVE TO THEM?AGGRESSIVE TO THEM?
FRUSTATIONFRUSTATION PROFESSIONAL INADEQUACYPROFESSIONAL INADEQUACY SENSE OF FAILURESENSE OF FAILURE STIMULATE POWER STRUGGLES W/ STIMULATE POWER STRUGGLES W/
PTSPTS
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HOW WILL THE NURSE CONTROL PATIENT’S AGGRESSION?
N must be know the factors that may contribute to the escalation of aggression of the pt.
1) Env’t that HAS EXCESSIVE STIMULI2) Env’t that is OVERCROWDED3) Facility that has NO OUTLET FOR ENERGY –
DRAINING4) Pt’s perceived lack of CONTROL OF LIFE
AND FREEDOM5) BOREDOM d/t lack of STRUCTURED
ACTIVITIES
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Staffing must be sufficientStaff must have fair philosophies and
policies – Over-controlled env’t : aggression and
rebellion– Reasonable, flexible: reduce risk for power
– ESTABLISH THERAPEUTIC MILIEU
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Nurses must be able to recognize when the patient would most likely become
aggressive or assaultive:
ADMISSION CHANGE OF
SHIFTS MEALTIMES VISITING HOURS
EVENING ELEVATORS DURING
TRANSPORTATION PERIODS OF
CHANGE
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Hospitalization is a stress-producing situation.
NURSES' ROLES:
1) Explain rules and policies - the searches, the removal/restriction of personal items, physical examinations
2) Introduce unfamiliar professionals and other patients
3) Integrate pt slowly to the unit
4) Decrease the stimuli if possible
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5) Explain all medications/treatments in advance
6) Assess history – family violence/abuse, previous history of assault, destruction of property
7) Render documentation
NURSING INTERVENTIONS NURSING INTERVENTIONS in ANGER AND in ANGER AND NONVIOLENT NONVIOLENT AGGRESSIONAGGRESSION
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FACTORS TO CONSIDER IN FACTORS TO CONSIDER IN INTERVENING WITH ANGER AND INTERVENING WITH ANGER AND
NONVIOLENT AGGRESSIONNONVIOLENT AGGRESSION
• SOURCE SOURCE – manifests inwardly– manifests inwardly• TARGETTARGET – may aim at no one in – may aim at no one in
particularparticular• LIKELIHOOD OF ESCALATIONLIKELIHOOD OF ESCALATION – –
may be defused if dealt may be defused if dealt appropriatelyappropriately
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• Assess at safe Assess at safe distancedistance
• Warmth and Warmth and empathy, but be empathy, but be firm in setting firm in setting limitslimits
• If patient is less If patient is less verbal, take an verbal, take an active, supportive active, supportive and directive roleand directive role
• Ask pts to Ask pts to ventilate their ventilate their feelings, feelings, thoughts, thoughts, situationssituations
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Forget these things Forget these things not!!!not!!!
• CHOOSE THE LEAST RESTRICTIVE CHOOSE THE LEAST RESTRICTIVE MEASURES BEFORE MEASURES BEFORE RESTRAINTS/SECLUSIONRESTRAINTS/SECLUSION
• DOCUMENT PT’S RESPONSESDOCUMENT PT’S RESPONSES• APPROACH THE PT IN CALM, APPROACH THE PT IN CALM,
POSITIVE MANNERPOSITIVE MANNER
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NI BASED ON THE NI BASED ON THE ASSAULT CYCLE … ASSAULT CYCLE …
TRIGGERING PHASETRIGGERING PHASEBEHAVIORSBEHAVIORS NINI
Muscle tension, changes in Muscle tension, changes in voice quality, readiness to voice quality, readiness to
retaliate, tapping of fingers, retaliate, tapping of fingers, pacing, repeated pacing, repeated
verbalization, noncompliance, verbalization, noncompliance, restlessness, irritability, restlessness, irritability, anxiety, suspiciousness, anxiety, suspiciousness,
perspiration, tremors, glaring, perspiration, tremors, glaring, changes in breathingchanges in breathing
1)1) EMPHATIC, EMPHATIC, NONDIRECTIVE, NONDIRECTIVE, CONCERNED TECHNIQUECONCERNED TECHNIQUE
2)2) ENCOURAGE VENTILATIONENCOURAGE VENTILATION
3)3) PROVIDE QUIETER PROVIDE QUIETER ENVIRONMENTENVIRONMENT
4)4) USE RELAXATION USE RELAXATION TECHNIQUESTECHNIQUES
5)5) FACILITATE PROBLEM FACILITATE PROBLEM SOLVING BY DISCUSSING SOLVING BY DISCUSSING ALTERNATIVE SOLUTIONSALTERNATIVE SOLUTIONS
6)6) PRN ORAL MEDSPRN ORAL MEDS
7)7) EMPIRICAL SUPPORTEMPIRICAL SUPPORT
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NI BASED ON THE NI BASED ON THE ASSAULT CYCLE … ASSAULT CYCLE …
ESCALATION PHASEESCALATION PHASEBEHAVIORSBEHAVIORS NINI
Pallor, screaming, anger, Pallor, screaming, anger, agitation, hypersensitivity, agitation, hypersensitivity, threats, demands, loss of threats, demands, loss of
reasoning ability, provocative reasoning ability, provocative behaviors, clenched fistsbehaviors, clenched fists
1)1) TAKE CHARGE WITH TAKE CHARGE WITH CALM, FIRM DIRECTIONS, CALM, FIRM DIRECTIONS, DON’T PUNISH/THREATEN, DON’T PUNISH/THREATEN, AVOID LOUD SOUNDSAVOID LOUD SOUNDS
2)2) DIRECT CLIENT TO A DIRECT CLIENT TO A QUIET ROOM FOR A “TIME QUIET ROOM FOR A “TIME OUT”OUT”
3)3) ASK ANOTHER STAFF TO ASK ANOTHER STAFF TO BE ON STANDBY AT A BE ON STANDBY AT A DISTANCEDISTANCE
4)4) PRN MEDSPRN MEDS
5)5) PREPARE FOR A “SHOW PREPARE FOR A “SHOW OFF DETERMINATION” – 4-6 OFF DETERMINATION” – 4-6 STAFF WITHIN THE SIGHT STAFF WITHIN THE SIGHT OF CT.OF CT.
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NI BASED ON THE NI BASED ON THE ASSAULT CYCLE … ASSAULT CYCLE … CRISIS CRISIS
PHASEPHASEBEHAVIORSBEHAVIORS NINI
Loss of self control, fighting, Loss of self control, fighting, hitting, rage, kicking, hitting, rage, kicking,
scratching, throwing thingsscratching, throwing things
1)1) INVOLUNTARY INVOLUNTARY SECLUSION, SECLUSION, RESTRAINTSRESTRAINTS
2)2) IM MEDSIM MEDS
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NI BASED ON THE NI BASED ON THE ASSAULT CYCLE … ASSAULT CYCLE … RECOVERY PHASERECOVERY PHASE
BEHAVIORSBEHAVIORS NINIAccusations, lowering of Accusations, lowering of
voice, decreased body voice, decreased body tension, change in tension, change in
conversational content, more conversational content, more normal responses, relaxationnormal responses, relaxation
1)1) CONTINUE NURSING CARE, CONTINUE NURSING CARE, ALLOW CLIENT TO RELAX ALLOW CLIENT TO RELAX AND SLEEP AND SLEEP
2)2) PROCESS THE INCIDENT PROCESS THE INCIDENT WITH THE STAFF AND WITH THE STAFF AND OTHER PATIENTSOTHER PATIENTS
3)3) ASSESS PATIENT, STAFFASSESS PATIENT, STAFF
4)4) EVALUATE PT’S PROGRESS EVALUATE PT’S PROGRESS TOWARD SELF-CONTROLTOWARD SELF-CONTROL
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NICE TO KNOW!!!NICE TO KNOW!!!
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SECLUSIONSECLUSION
• Principle of containmentPrinciple of containment• Placing of ct alone in a lockable room Placing of ct alone in a lockable room
designed with window and cameradesigned with window and camera• Minimize violence of aggressive Minimize violence of aggressive
client to himself, othersclient to himself, others• To reduce stimuliTo reduce stimuli• To increase nursing care to To increase nursing care to
agitated/violent/aggressive ptagitated/violent/aggressive pt
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Reasons for SeclusionsReasons for Seclusions
• AgitationAgitation
• Disruptive behaviorDisruptive behavior
• Inappropriate sexual behaviorsInappropriate sexual behaviors
• To avoid aggressive assaults and To avoid aggressive assaults and have a responsive actionhave a responsive action
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• ““TIME OUT”TIME OUT”
• BED, MATTRESS, WINDOW, SECURITY BED, MATTRESS, WINDOW, SECURITY CAMERACAMERA
• REMOVE DANGEROUS ARTICLES REMOVE DANGEROUS ARTICLES FROM THE PT.FROM THE PT.
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RESTRAINTRESTRAINT
• Protective devices used to limit the Protective devices used to limit the physical activity of a ct or to physical activity of a ct or to immobilize a ct. or an extremityimmobilize a ct. or an extremity
• To safely control the ct and assure To safely control the ct and assure that there’ll be no injuries to himself, that there’ll be no injuries to himself, other cts and the staffother cts and the staff
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INDICATIONSINDICATIONS
• Falling out of a bed/chairFalling out of a bed/chair
• Pulling out IV lines, NGT, catheterPulling out IV lines, NGT, catheter
• Breaking open suturesBreaking open sutures
• Unsafe ambulationUnsafe ambulation
• Wandering and entering an unsafe Wandering and entering an unsafe placeplace
• Causing harm to others, self, staffCausing harm to others, self, staff
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TYPES OF RESTRAINTTYPES OF RESTRAINT
1.1. PHYSICAL PHYSICAL
2.2. CHEMICAL CHEMICAL
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CHOOSING THE RESTRAINTCHOOSING THE RESTRAINT
• It restricts the ct's mov’t as little as It restricts the ct's mov’t as little as possiblepossible
• It is the least obvious to othersIt is the least obvious to others
• Does not interfere with the ct's tx Does not interfere with the ct's tx and health pxand health px
• It is readily changeableIt is readily changeable
• It is safe for a particular ctIt is safe for a particular ct
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Is there any alternative before Is there any alternative before the use of restraint?the use of restraint?• Orient ct and family to surroundingsOrient ct and family to surroundings• Explain all procedures and tx Explain all procedures and tx • Encourage family and friends to stay with the clientEncourage family and friends to stay with the client• Assign confused cts and disoriented ct's to rooms near Assign confused cts and disoriented ct's to rooms near
the nurses' stationthe nurses' station• Visual and auditory stimuli - clocks, calendarsVisual and auditory stimuli - clocks, calendars• Place familiar items - pictures near client's bedsidePlace familiar items - pictures near client's bedside• Maintain toileting routinesMaintain toileting routines• Eliminate bothersome tx - tube feedings ASAP Eliminate bothersome tx - tube feedings ASAP • Evaluate all medications that the ct is receivingEvaluate all medications that the ct is receiving• Relaxation techniquesRelaxation techniques• Ambulation and exercise schedule as the client's Ambulation and exercise schedule as the client's
condition allowscondition allows
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WHAT EVERY NURSE SHOULD KNOW IN WHAT EVERY NURSE SHOULD KNOW IN THE IMPLEMENTATION OF THE IMPLEMENTATION OF
RESTRAINT?RESTRAINT?
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• Never be used as a a punishment or for the Never be used as a a punishment or for the convenience of the staffconvenience of the staff
• The least restrictive means of restraint for the The least restrictive means of restraint for the shortest duration should be usedshortest duration should be used
• Used when physically harmful to the client or Used when physically harmful to the client or to othersto others
• Used when disruptive behavior presents a Used when disruptive behavior presents a danger to the facilitydanger to the facility
• Used when alternative or less restrictive Used when alternative or less restrictive measures are insufficient in protecting the ct measures are insufficient in protecting the ct or others from harmor others from harm
• Used when the ct anticipates that a controlled Used when the ct anticipates that a controlled env’t would be helpful and requests seclusionenv’t would be helpful and requests seclusion
• Requires a written order, reviewed, renewed q Requires a written order, reviewed, renewed q 24hrs, specify type of restraint24hrs, specify type of restraint
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• In an emergency, the charge nurse may In an emergency, the charge nurse may place a ct in restraint/seclusion and obtain a place a ct in restraint/seclusion and obtain a written or verbal order ASAP thereafterwritten or verbal order ASAP thereafter
• Laws require the of the ct unless an Laws require the of the ct unless an emergency situation exists and can be emergency situation exists and can be documenteddocumented
• The ct must be removed from restraint or The ct must be removed from restraint or seclusion when safer and quieter behavior is seclusion when safer and quieter behavior is observedobserved
• While in restraint/seclusion, the client must While in restraint/seclusion, the client must be protected from all sources of harmbe protected from all sources of harm
• Documentation - behavior, time, releaseDocumentation - behavior, time, release• Assessment q 15-30 min for physical needs, Assessment q 15-30 min for physical needs,
safety comfort = documentsafety comfort = document
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~End~ ~End~
WORKING WITH GROUPS OF PATIENTS
Kenn S. Nuyda, RN
WORKING WITH GROUPS OF PATIENTS
Kenn S. Nuyda, RN
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NURSING CARE in Psych Cts
24/7 responsibilityManpower to provide therapeutic
interventionConcern with how our clients solve their
problems, conflicts and interpersonal relationships in order for them to learn and cope
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TYPES OF GROUPS
1. INPATIENT- Open membership – adding and losing
members- 3 – 5 x a week- Short term
2. OUTPATIENT- Longer duration- Once a week- Closed membership
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SIGNIFICANCE OF GROUPS
Deals with “here and now” Provides awareness and knowledge about the
ct’s behavior Teaches ct to be aware of the alternatives in
decision making and making choices Teaches the ct/family about their mental illness
and make them cope up with it
Considered as MILIEU therapy
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BENEFITS OF THE GROUP
Ct gains knowledge about how to relate and how to relate and communicate w/ otherscommunicate w/ others
Ct gains acceptance, reassurance and support from peers and group leader
Ct gains feelings of hopefulness, sense of power Ct tests out new behaviors Ct shares feelings, problems, concerns and ideas w/
others Ct’s self- esteem is enhanced and affirmed and
developed Ct feels sense of importance and worthiness
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11 THERAPEUTIC FACTORS- Dr. Irvin Yalom -
INSTILLATION OF HOPE Observe others in the group
UNIVERSALITY Unique individual and not alone having that problem
IMPARTING OF INFORMATION Gaining info r/t their needs
ALTRUISM Helpful to others
CORRECTIVE RECAPITULATION Review of previous dysfunctional family patterns and learning how to change them
SOCIALIZATION
IMITATIVE BEHAVIOR
CATHARSIS Expression of feelings appropriately
EXISTENTIAL FACTORS Acceptance of ultimate concerns – death, isolation
COHESIVENESS Sense of being values and accepted in a group
INTERPERSONAL LEARNING Learning of how their behavior affects others, and try out new ways of relating to others
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1. SUPPORT GROUP
2. ACTIVITY GROUP
3. EDUCATION OR PROBLEM SOLVING GROUPS
4. THERAPY GROUPS
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SUPPORT GROUPS
Nursing is supporting To support = to accept, emphatize, show
concern while cts talk Nurse’s presence, interest and
encouragement = ct’s ease of expressing his/her feelings and concerns
Support groups enable the ct to cope w/ feelings and situations
Reinforces or maintains the existing strengths/behaviors of cts
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a) REALITY – ORIENTATION GRP- deals with psychopathology, confusion and short attention span
NI: > safe env’t> reality testing> orientation to time, place, person> setting limits
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ACTIVITY GROUPS
Facilitate communication and interaction
- INDICATIONS - For withdrawn, depressed, regressed patients To increase self – esteem, provide openness
and expression of feelings to decrease isolation
Used to facilitate self – expression and patient interaction
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EXAMPLES
TYPE PURPOSE/RN’S ROLE EXAMPLES
Recreation Fun, relief of tensionCt experiences sense of participation, acceptance and accomplishment
Indoor/outdoor sports, field trips, exercise groups and games
Creative Expression
Expression of feelings, a form of communication with others and socializationAllow for creativity, self-expression and praise for accomplishments
Arts and crafts, ADL, poetry, music, dance and pet therapy
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EDUCATION / PROBLEM SOLVING GROUPS
Teaches ct and family about:Medication Dynamics and management of illnessProblem solving Stress managementSocial skills Interpersonal skills Relapse prevention
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The nurse’s expertise, empathy and support help the ct to learn = ct cares for themselves/illness
Benefits to family: improved relationships with family members
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EXAMPLESTYPE PURPOSE/RN’S ROLE EXAMPLES
Psychoeducation Dynamics of illness, mgt of illness, crises
Addiction processes, coping with sx, mood mgt, relapse prevention, community resources
Medication Dispensing of med, s/sx of SE, purpose of med, dosage, and therapeutic effects, support to prevent relapse
Problem Solving Identify and describe current px, develop solutions, its alternatives
Conflict resolutions, job concerns, relationship issues
Stress Mgt Teach and facilitate coping behaviors
Lifestyle balance and mgt, relaxation training, tension-reducing strategies, anger mgt
Social Skills Teach, develop and practice skills, focus on realistic day-to-day needs
Social interactions
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THERAPY GROUPS
Develops insight, understanding of feelings, behaviors and roles in relationships in ct
Changes behaviors and healthier responses to other people
Motivates members : exposed to other members who share the same feeling
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EXAMPLESTYPE PURPOSE/RN’S ROLE EXAMPLES
Insight – oriented
Understanding how individuals affect and be affected by othersDeals with healthier ways on how to handle feelings to others
self-esteem groups
Psychodrama Intense emotional release are achieved through intrapersonal and interpersonal conflictsImprove their roles using a script
Psychodrama
Sociodrama Focus insights on role communication, roles are reenacted/role played
> Psychodrama
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CHARACTERISTICS THAT THE NURSE MUST POSSESS IN LEADING
A GROUP
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Group Leadership Model as a leader Communication skills - reinforcement Must be aware of the environment that affects the
clinical setting Assessment skills of the mental status of the ct Must be able to gain the trust of his patient Confidentiality Must be able to document
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Coleadership Useful when the primary nurse is on “off” or “on
leave” They are the ones who collaborate/share
responsibility for the group Teaches ct how to relate to others with respect
Active Structured/goal-directed Empathetic
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PHYSICAL SETTING
Adequate space / private room
Adequate lighting, comfortable temp, seating and equipment
CIRCLE, SEMICIRCLE
MEMBERS: 7 – 10 more members will
make the group subdivide, create acting out behaviors
Audio Video, handouts
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FORMAL GROUPS… guidelines
N must be goal directed and focus on the here and now in each inpatient and outpatient group session
N assesses the needs of the pt and formulates plans Timeframe: one hour (lower functioning), 1 ½ (higher
functioning) Participants are expected to arrive ON TIME NO SMOKING/REFRESHMENT will be served One person speaks at a time May be allowed to pace/leave if pt has inability to sit
still No hitting or throwing is allowed “What you see, what you here leave it here”
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At the start, the N states the purpose of the group
Then working phaseThen before the end of the session,
summarize and close the session for 5-10 mins.
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GROUP MEMBER ROLES accdg TO FUNCTION
ENCOURAGER – praises others, agrees and accepts ideas of others
HARMONIZER – mediates and reconciles intragroup differences
COMPROMISER –resolve conflicts
INITIATOR – offers new ideas, suggestions
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ELABORATOR – gives examples
EVALUATOR – relates the group standards to any problem
COORDINATOR – clarifies relationships among ideas and activities of the group
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ANNOYING MEMBERS
AGGRESSOR – acts negatively with hostility toward others, jokes aggressively, attacks the group/members
RECOGNITION SEEKER – calls attention to own activities, boasts achievements
HELP SEEKER / CONFESSOR – uses the group to gain sympathy, expresses insecurity and self – depreciation
DOMINATOR – asserts authority and manipulates individuals and the group as a whole
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EXCLUSION FROM JOINING THE GROUP
MANICDISORIENTEDTOO PSYCHOTICHOSTILEVERBALLY THREATENING
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STAGES… KELTNER
1. INITIAL
2. WORKING
3. TERMINATION
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INITIAL WORKING TERMINATIONInvolves superficial rather than open and trusting communicationMember acquainted w/ each other, searching for similarities b/w themselvesMember still unclear about the purpose of goals of the groupNorms, roles and responsibilities takes place
Members are familiar w/ each other, the group leader and the group roles and they feel free to approach their problems and to attempt to solve their problemsConflict and cooperation surface
Group evaluates the experience and explores member's feelings about it and the impending separationProvides an opportunity for members who have difficulty w/ termination to learn to deal more realistically and comfortably with this normal part of human experience
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STAGES OF GROUP DEV’T… MOSBY
1. PREGROUP
2. INITIAL
3. WORKING
4. TERMINATION
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PREGROUP
Forming of the groupTime period before people knew each
other in the group setting
Select group membersDecide length of meetingDecide composition of members
HomogenousHeterogenous
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Leader Responsibilities
Establish purpose Secures physical
space Selects members Screens
interviewees
Determine member motivation
Describes norms Educates about the
group Secures commitment
of the group Begins
leader/member rel.
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INITIAL STAGE
Group members have anxiety about being accepted
TASKS:Setting of normsCasting of roles
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Member Behaviors
Concerned with acceptanceFear of rejectionFear of self-disclosureDependent on leader – look to leader for
structure, approval, acceptance
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Leader Behaviors
DirectiveActiveGroup contract dev’tEncourages interaction b/w membersFacilitates approach/avoidanceSuggests how members might be helpful
to one another
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CONFLICT STAGE within INITIAL STAGE… member
Members concerned with status in groupDependency conflictIndependent members attempt to make
leader’s rolesSubgroups formHostility toward leader or other members
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CONFLICT STAGE within INITIAL STAGE… leader
Allows expression of - / + feelingsHelps group understandPrevents scapegoatingDirects expression of hostility
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COHESIVE STAGE within INITIAL STAGE… member
Form attachment to group+ feelings toward the group/membersSelf-disclosureSuppress hostilityLimited problem solving
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COHESIVE STAGE within INITIAL STAGE… leader
Encourages problem solvingDemonstrates that differing opinions are
acceptable
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WORKING STAGE
Group becomes team, complete tasks, shares responsibilities, group is stable
Anxiety is decreased
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Member Behaviors: Explore goals and tasks Serious work occurs Explore feelings Explore new coping
mechanisms
Group Behaviors: Decreases activity Serves as consultant Fosters cohesion Maintains boundaries Encourages work on
tasks Solving the problem/s of
the group
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TERMINATION STAGE
Types:
1. whole group ends
2. Individual member leaves
Involves grieving and sense of loss
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Member Behaviors
Anger Regression
Dependency, competition Avoidance
Do not come to the group, do not talk about the termination
Devalue group Discuss other feelings (separations, death,
aging) Sense of resolution
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Leader Behaviors
Reminisces about the group’s activities Evaluates group goals Discusses the member’s contribution to each
other Encourages full discussion of termination for
several sessions Shares own experience and feelings r/t the
group Discourages premature termination of
individual group members
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COMMUNICATION SKILLS THAT THE NURSE MUST POSSESS IN
LEADING A GROUP
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Giving informationSeeking clarification Encouraging description and explorationPresenting realitySeeking consensual validationFocusingEncouraging comparisonMaking observationsGiving recognition/acknowledgementAccepting Encouraging evaluationSummarizing
INTERVENTIONSINTERVENTIONSINTERVENTIONSINTERVENTIONS
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DOMINANT CLIENTDOMINANT CLIENT
• Monopolizes the group discussion, other members feel that they do not have the opportunity to participate
• “Mr. Antonio, you are doing well today in our session, but I would like to hear what others are thinking about at this time.”
• Don’t put down the feelings of the pt
• Monopolizes the group discussion, other members feel that they do not have the opportunity to participate
• “Mr. Antonio, you are doing well today in our session, but I would like to hear what others are thinking about at this time.”
• Don’t put down the feelings of the pt
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UNINVOLVED CLIENTUNINVOLVED CLIENT
• Tend to be quiet d/t anxiety or fear• Should be comfortable to the group
• “It is hard to talk about ourselves in group, but I know that everyone here has something to share that can help someone else.”
• The N recognizes that ct is mistrustful and anxious about initiating the group sharing.
• Respect, recognition
• Tend to be quiet d/t anxiety or fear• Should be comfortable to the group
• “It is hard to talk about ourselves in group, but I know that everyone here has something to share that can help someone else.”
• The N recognizes that ct is mistrustful and anxious about initiating the group sharing.
• Respect, recognition
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HOSTILE CLIENTHOSTILE CLIENT
• Masks patient’s fear, self-anger and unresolved anger toward others
• “Mr. Antonio, tila galit ka ata ngayon. Ano ba nangyari? Gusto mo bang i-share iyan sa grupo?”
• N is confrontational in a sense that he is still supportive in dealing with the client’s feelings
• Masks patient’s fear, self-anger and unresolved anger toward others
• “Mr. Antonio, tila galit ka ata ngayon. Ano ba nangyari? Gusto mo bang i-share iyan sa grupo?”
• N is confrontational in a sense that he is still supportive in dealing with the client’s feelings
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• N should not allow hostility in any manner – verbal, nonverbal because it endangers the group
• Members would feel:– Uneasy– Uncomfortable– Impairs group work– Would feel that anger of one ct is directed
to them
• N should not allow hostility in any manner – verbal, nonverbal because it endangers the group
• Members would feel:– Uneasy– Uncomfortable– Impairs group work– Would feel that anger of one ct is directed
to them
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• But, NURSES should be:– Empathic– Understanding– Respectful for each ct
• To increase their sense of worth
• But, NURSES should be:– Empathic– Understanding– Respectful for each ct
• To increase their sense of worth
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EXAMPLES OF GROUPSEXAMPLES OF GROUPS
• PYSCHODRAMA GROUP– explore truth through dramatic methods– individual produces a topic to be explored– therapists directs individual through role
playing– audience experiences the feelings and
identifies with the action on the stage– change occurs
• PYSCHODRAMA GROUP– explore truth through dramatic methods– individual produces a topic to be explored– therapists directs individual through role
playing– audience experiences the feelings and
identifies with the action on the stage– change occurs
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COMMUNITY SUPPORT GROUPSCOMMUNITY SUPPORT GROUPS
• promote identification, clarification, understanding, role modeling, feelings of togetherness and group cohesion
• prevent the individual member from feelings lonely and isolated
• help members decrease levels of stress and increase levels of self-acceptance
• members are able to deal with the problems that they brought to the group
• dev’t of new or more effective patterns of behavior• some groups evolve into educational models that enhance
communication, self-image, body language, px-solving, decision making and growth processes
• promote identification, clarification, understanding, role modeling, feelings of togetherness and group cohesion
• prevent the individual member from feelings lonely and isolated
• help members decrease levels of stress and increase levels of self-acceptance
• members are able to deal with the problems that they brought to the group
• dev’t of new or more effective patterns of behavior• some groups evolve into educational models that enhance
communication, self-image, body language, px-solving, decision making and growth processes
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Ex: Alcoholics anonymousEx: Alcoholics anonymous
• Alcoholics Anonymous is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism.
• The only requirement for membership is a desire to stop drinking.
• There are no dues or fees for AA membership
• Alcoholics Anonymous is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism.
• The only requirement for membership is a desire to stop drinking.
• There are no dues or fees for AA membership
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• Fellowship of relatives and friends of alcoholics who share their experience, strength, and hope in order to solve their common problems
• Believe alcoholism is a family illness and that changed attitudes can aid recovery
• Fellowship of relatives and friends of alcoholics who share their experience, strength, and hope in order to solve their common problems
• Believe alcoholism is a family illness and that changed attitudes can aid recovery
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NARCONONNARCONON
• Means “no drug”
• Drug-free rehab program in RP
• Uses nutrition, assists, objective exercises, and training routines
• Means “no drug”
• Drug-free rehab program in RP
• Uses nutrition, assists, objective exercises, and training routines
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Other ExamplesOther Examples
• Overeater’s Anonymous
• Women’s Groups
• Men’s Groups
• Overeater’s Anonymous
• Women’s Groups
• Men’s Groups
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GESTALT THERAPY GROUPGESTALT THERAPY GROUP
• "here and now"• emphasizes self-expression, self-
exploration and self-awareness in the present
• everyday problems and try to solve them• individual becomes aware of the total self
and the surrounding env’t, renders the ct. capable of change
ROLE: help the members express their feelings and grow from their experiences
• "here and now"• emphasizes self-expression, self-
exploration and self-awareness in the present
• everyday problems and try to solve them• individual becomes aware of the total self
and the surrounding env’t, renders the ct. capable of change
ROLE: help the members express their feelings and grow from their experiences
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FAMILY THERAPYFAMILY THERAPY
• therapist works to assist the family members to identify and express their thoughts and feelings, define family roles and rules, try new, more productive styles of relating and restore strength to the family
• therapist works to assist the family members to identify and express their thoughts and feelings, define family roles and rules, try new, more productive styles of relating and restore strength to the family
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INTERPERSONAL GROUP THERAPY
INTERPERSONAL GROUP THERAPY
• Promotes the individual’s comfort with others in the group, which then transfers to other relationships
• Promotes the individual’s comfort with others in the group, which then transfers to other relationships
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~ END ~~ END ~
SALAMAT!SALAMAT!