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Course: Mental Health Nursing

Topic: Non-Pharmacological Management

of Mental Illness - Part I

The Nurses International Community

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COPYRIGHT

NI Privacy Policy and Terms of Use.

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Module Goals

Learners will be able to:

Describe the non-pharmacological management therapies used in psychiatric treatment.
Describe the indications for non-pharmacological treatments of various conditions.
Describe the nurse’s role in the use of nonpharmacological treatment methods.

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Treatment and Management of Mental Illness

Alternative management of the mental illness apart from pharmacotherapy

Psychotherapies
Family intervention
Support groups
Biofeedback therapy
Eye movement desensitization and reprocessing (EMDR)
Arts and creative therapies
Guided imagery

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Psychotherapy

American Psychological Association (APA) defines psychotherapy as

“..any psychological service provided by a trained professional that primarily uses forms of communication and interaction to assess, diagnose, and treat dysfunctional emotional reactions, ways of thinking, and behavior patterns..”

Psychotherapist uses talk therapies to help clients with:

Difficulties coping with daily life
Impact of trauma, medical illness or loss
Psychotic symptoms of mental illness

APA, n.d.a

Parekh & Givon, 2019

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Psychotherapy

Parekh & Givon, 2019

Medication combined with psychotherapy found to be most effective treatment for many mental illnesses.
Conducted with individual, couple, family, or group setting.
Short term sessions (few sessions) deal with immediate issues, while long-term sessions deal with longstanding/complex issues.
Relationship of trust is vital between therapist and client.

Client confidentiality is basic requirement.
Intimate physical contact is never appropriate, acceptable, or useful.

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Psychotherapy

Desired outcomes for psychotherapy

Symptom relief
Better functioning in life
Improved emotions and behaviours
Positive changes in brain and body
Fewer sick days and medical problems, less disability, and increased work satisfaction.

Psychotherapy can be provided by psychiatrists, psychologists, licensed social workers, licensed marriage and family therapists, psychiatric nurses, and others with specialized training.

Parekh & Givon, 2019

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Psychotherapy Types

Behavioral Psychotherapy (BT)
Cognitive Behavioral Therapy (CBT)
Psychodynamic psychotherapy
Interpersonal therapy

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Behavioural Psychotherapy (BT)

APA Dictionary of Psychology defines it as

“a form of psychotherapy that applies the principles of learning, operant conditioning, and classical conditioning to eliminate symptoms and modify ineffective or maladaptive patterns of behavior. The focus of this therapy is upon the behavior itself and the contingencies and environmental factors that reinforce it, rather than exploration of the underlying psychological causes of the behavior. A wide variety of techniques are used in behavior therapy, such as behavior rehearsal, biofeedback, modeling, and systematic desensitization.”

APA, n.d.b

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Two Key Principles of BT

Classical Conditioning

Based on idea that repeated association between neutral stimuli and the stimuli that elicit a response, will eventually result in neutral stimuli eliciting same response without pairing with other stimuli.

Operant Conditioning

Uses reinforcement and punishment to change behaviour.
Based on the idea that behaviours followed by desirable consequences are more likely to occur again, while behaviours followed by negative consequences are less likely to occur.

Gans, 2021a

Spielman et al., 2020

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Classical Conditioning

Aversion Therapy

Change undesirable behavior by associating it with unpleasant experiences.
Treat obsessive-compulsive disorders, drug/alcohol addiction.

Exposure Therapy

Flooding technique: Direct exposure to maximum-intensity anxiety-producing situation/stimulus.

Stimulus can be described or real
Treat phobias, anxiety disorders

Systematic desensitization: Gradual exposure to feared situation/stimulus (least feared to highest) while attempting throughout to maintain non-anxious state.

APA, n.d.c

APA, n.d.d

APA, n.d.e

Spielman et al., 2020

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Operant Conditioning

Contingency Management

Positive behavioural change is reinforced through rewards.
Highly effective for treatment of substance use disorder.

Extinction

Stop reinforcing behavior in order to eliminate the response.

Behaviour Modeling

Learning occurs through observation and imitation of desired behaviors of others, without comment or reinforcement by the therapist.
To treat phobias, anxiety disorders, post-traumatic stress disorder, attention deficit disorders, eating disorders.

Petry, 2011

Gans, 2021a

APA, n.d.f

Block, 2021

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Critical Thinking Question

A mother is concerned about her child’s temper tantrums t”o get what he wants”.

After consultation with a nurse therapist, the mother decided to ignore the child’s temper tantrums in the future.

Which type of operant behavior technique did the nurse recommend?

Contingency management
Extinction
Behavior modeling
Non-tolerance

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Cognitive Behavioural Therapy (CBT)

APA Dictionary of Psychology defines it as

“...form of psychotherapy that integrates theories of cognition and learning with treatment techniques derived from cognitive therapy and behavior therapy…aimed at identifying and modifying the client’s maladaptive thought processes and problematic behaviors through cognitive restructuring and behavioral techniques to achieve change..”

Concept that emotions and behavioral problems, at least in part, are result of maladaptive or faulty ways of thinking (cognition)

APA, n.d.g

APA, n.d.h

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Glossary:
Cognitive Therapy:

“a form of psychotherapy based on the concept that emotional and behavioral problems in an individual are, at least in part, the result of maladaptive or faulty ways of thinking and distorted attitudes toward oneself and others. The objective of the therapy is to identify these faulty cognitions and replace them with more adaptive ones, a process known as cognitive restructuring. The therapist takes the role of an active guide who attempts to make the client aware of these distorted thinking patterns and who helps the client correct and revise his or her perceptions and attitudes by citing evidence to the contrary or by eliciting it from the client.” (APA, n.d.h)

Cognitive restructuring:

“a technique used in cognitive therapy and cognitive behavior therapy to help the client identify his or her self-defeating beliefs or cognitive distortions, refute them, and then modify them so that they are adaptive and reasonable.” (APA, n.d.i)

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CBT (Continued)

Fenn & Byrne, 2013

Most widely researched and empirically supported psychotherapeutic method.

Aims to change how a person thinks (‘cognitive’) and what they do (‘behaviour’).

Therapist-client relationship of trust, understanding and empathy is vital for effective interventions and treatment.

Focused on present, ‘here and now’ problems, structured, and time-limited.

Cognition/thoughts

Behavior

Emotions/Feelings

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CBT (Continued): Cognitive Technique

Uses concept of ‘guided discovery’

Process of understanding client’s view of things, expanding client’s thinking to bring self-awareness of their underlying assumptions, and discover alternative perspectives and solutions for them.

Therapist asks questions to:

Probe assumptions
Question the reasons
Find evidence for their beliefs
Highlight other perspectives and probe other implications

Fenn & Byrne, 2013

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CBT (Continued): Cognitive Technique

Clients may be asked to:

Keep positive log of their new, adaptive behaviors (e.g I am useful to people).
Provide evidence that supports/does not support, their assumptions.
Keep record of their thoughts (thought record)

Helps makes client aware of their NATs, distinguish thoughts from facts, and see how they impact their mood.
Used to develop alternative rational response and a rerating of mood.

Fenn & Byrne, 2013

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CBT (Continued): Behavioral Technique

Therapist and client schedule daily activity to:

Reduce the mass of tasks to a manageable list.
Remove the need for repeated decision making.

Graded task assignment may be used to bring changes in daily/weekly activities to ensure sense of enjoyment in life, or change in pattern of isolation or procrastination.

Progressive relaxation training and breathing exercises used to reduce levels of autonomic arousal related to anxiety.

Fenn & Byrne, 2013

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CBT (Continued): Behavioral Technique

Behavior experiments may be performed

Clients makes prediction prior to an activity, and notes if their predictions came true after activity completion.

Helps develop evidence against:

Catastrophic predictions (e.g. ‘If I leave the house, something terrible will happen’).
And/or avoidance and escape behaviors (e.g avoiding public transport due to belief something bad will happen).

Progressive relaxation training and breathing exercises to manage anxiety disorders.

Fenn & Byrne, 2013

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Critical Thinking Question

Which of the following are true of Cognitive Behavior Therapy? (Select all that apply)

It is designed to change how a person thinks
Focuses on the present
May take a long time to see permanent results
It involves behavioral and cognitive techniques
Behavioral experiments may be performed

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Psychoanalytic Psychotherapy

Gans, 2021b

Talk therapy based on the Sigmund Freud’s theories of psychoanalysis.

Freud believed that unconscious reservoir of desires, thoughts, and memories may often lead to psychological distress and disturbances.

Makes client self-aware of disruptive contents of unconscious mind, to make a change in the pattern so client takes charge of their life.

Client meets with therapist a few times a week for intensive sessions.

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Psychoanalytic Psychotherapy: Techniques Used

Dream interpretation:

Freud referred to dreams as "the royal road to the unconscious".
Dream are interpreted to gain insight into the client’s unconscious mind.

Free association

Clients are encouraged to freely share their thoughts which may lead to unexpected connections and memories.

Transference:

Clients are asked to project their feelings about another person onto the therapist.
Provides therapist insight on how a client interacts with others.

Gans, 2021b

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Psychoanalytic Psychotherapy Approaches

Explores full range of client’s emotions.
Explores feelings, thoughts, and situations client is avoiding to understanding why it is happening.
Makes client self-aware of self-destructive patterns.
Explores past and present relationships with others.
Unlike other therapies that are structured and goal-oriented, clients are able to explore freely about their fantasies, desires, fears, and dreams.

Gans, 2021b

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Interpersonal Therapy (IPT)

Rajhans et al., 2020

Based on assumption that interpersonal (IP) relationships of a person either in the past or in the present, play a role in the origin and maintenance of psychopathology.

Focuses on interpersonal context and related factors.

Goal; Either help improve client’s IP relationships or change their expectations about them and focus on improvements in their social support networks.

Time-limited and diagnosis-targeted intervention.

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Focus Areas of IPT

Four problem areas are identified for IPT:

Grief defined as loss of relationships or loss of healthy self.
IP role disputes with significant others such as friends, parents, and siblings.
IP role transitions including difficulties in adjusting to life changes, which is undesired, unexpected, or for which the client is not psychologically and emotionally ready.
IP skill deficits such as maintaining relationships and communicating about feelings.

Rajhans et al., 2020

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Elements of IPT

Non-specific elements:

Nonjudgmental approach, empathic listening, confidentiality, expressing warmth, and engaging client in the therapy.

Specific elements:

Providing clients a sick role, applying IP inventory, and making a formulation that links clients’ IP problem areas with their psychiatric diagnosis.

Suitability for IPT is assessed prior to its initiation

The ego strengths, motivation to change, social support network, focus of distress, ability to relate to coherent IP formulation.

Rajhans et al., 2020

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Phases of IPT

Initial Phase

Therapeutic alliance formed between therapist and client
Symptoms assessed, diagnosis made, review for pharmacotherapy
Exploration of client’s present and past relationships
Identification of IP problem, therapy goals/strategies planned

Middle Phase

Solutions for IP problem is developed jointly, client applies it between therapy sessions

End/Termination Phase

Client is credited for successful treatment,
Avoid shame if there still are unresolved issues; collaborate with clients on additional treatment

Rajhans et al., 2020

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Critical Thinking Question

Elements of interpersonal therapy (IPT) include which of the following? (Select all that apply)

Non-judgemental approach
Empathetic listening
Escape behaviors
Motivation for change

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Nurse’s Role in Non-Pharmacological

Management of Mental Illness

As frontline care providers have the opportunity for early. identification of sign/symptoms indicative of mental disorders in clients.

Make early and appropriate referral to specialist.

Be knowledgeable about current evidence-based non-pharmacological management/interventions for mental disorders.
Build nurse-client therapeutic relationships.
Provide client education about non-pharmacological therapies.

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Nurse’s Role in Non-Pharmacological

Management of Mental Illness

Provide client information

Assist in referral to available resources for non-pharmacological therapies in the community.

Based on role and expertise of the nurse in the client care team, nurse might need to undertake the following activities:

Coordinate appointments for therapy sessions of the clients
Accompany clients to the therapist
Monitor client’s adherence to the therapy

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References:

American Psychological Association. (n.d.a). APA Dictionary of Psychology: psychotherapy. Retrieved on December 22, 2021 from https://dictionary.apa.org/psychotherapy

American Psychological Association. (n.d.b). APA Dictionary of Psychology: behaviour therapy . Retrieved on December 22, 2021 from https://dictionary.apa.org/behavior-therapy

American Psychological Association. (n.d.c). APA Dictionary of Psychology: aversion therapy. Retrieved on December 22, 2021 from https://dictionary.apa.org/aversion-therapy

American Psychological Association. (n.d.d). APA Dictionary of Psychology: flooding. Retrieved on December 22, 2021 from https://dictionary.apa.org/flooding

American Psychological Association. (n.d.e). APA Dictionary of Psychology: systematic desensitization. Retrieved on December 22, 2021 from https://dictionary.apa.org/systematic-desensitization

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References

American Psychological Association. (n.d.f). APA Dictionary of Psychology: modeling. Retrieved on December 22, 2021 from https://dictionary.apa.org/modeling

American Psychological Association. (n.d.g). APA Dictionary of Psychology: cognitive behaviour therapy. Retrieved on December 22, 2021 from https://dictionary.apa.org/cognitive-behavior-therapy

American Psychological Association. (n.d.h). APA Dictionary of Psychology: cognitive therapy . Retrieved on December 22, 2021 from https://dictionary.apa.org/cognitive-therapy

American Psychological Association. (n.d.i). APA Dictionary of Psychology: cognitive restructuring . Retrieved on December 22, 2021 from https://dictionary.apa.org/cognitive-restructuring

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References:

Block, D.B. (2021, October 11). Behavior modeling for the treatment of phobias. [Review of article Behavior modeling for the treatment of phobias, by Fritscher, L.]. Verywellmind. https://www.verywellmind.com/behavior-modeling-2671528

Fenn, K. & Byrne, M. (2013). The key principles of cognitive behavioural therapy. InnovAiT, 6(9). https://journals.sagepub.com/doi/full/10.1177/1755738012471029

Gans, S. (2021a, August 31). What is behavioural therapy?. [Review of article What is behavioural therapy? by cherry, K.]. Verywell Mind. https://www.verywellmind.com/what-is-behavioral-therapy-2795998

Gans, S. (2021b, July 13). What is psychoanalytic therapy?. [Review of article What is psychoanalytic therapy? by Cherry, K.]. Verywell Mind. https://www.verywellmind.com/what-is-psychoanalytic-therapy-2795467

Contact info: info@nursesinternational.org

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References:

Parekh, R. & Givon, L. (2019, January). What is psychotherapy?. American Psychiatric Association. Retrieved on December 22, 2021 from https://www.psychiatry.org/patients-families/psychotherapy

Petry N. M. (2011). Contingency management: what it is and why psychiatrists should want to use it. The psychiatrist, 35(5), 161–163. https://doi.org/10.1192/pb.bp.110.031831

Rajhans, P., Hans, G., Kumar, V., & Chadda, R. K. (2020). Interpersonal Psychotherapy for Patients with Mental Disorders. Indian journal of psychiatry, 62(Suppl 2), S201–S212. https://journals.lww.com/indianjpsychiatry/Fulltext/2020/62002/Interpersonal_Psychotherapy_for_Patients_with.9.aspx

Spielman, R.M., Jenkins, W.J., & Lovett, M.D. (2020). Psychology 2e. Rice University, OpenStax. https://assets.openstax.org/oscms-prodcms/media/documents/Psychology2e-WEB_0eRvAre.pdf

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