1/12/10 Lecture Notes

2. client chooses subject

3. therapeutic assistance

4. if they need help for example coping give them examples of coping mechanisms such as deep breathing

5. active listening by clinician

6. active listening includes giving good eye contact, repeating what they say so they know you are listening, etc

7. healthy boundaries maintained

8. don’t want to go into their room talking about things you shouldn’t etc. don’t want to be best friend, give phone number, or give out personal info. Etc

9. time limited

10. we have 5-15min to spend with you, what would you like to talk about?

11. Occurs at certain time

13. Sort of a peer peer relationship

14. Topics are at random

15. Each person can come up w/ a topic whereas in therapeutic communication the client comes up with a topic

16. Give and receive friendship

17. Opinions and advice given

18. Blurred boundaries

20. Intimate – 18inches

21. Personal – 18inches-4feet, 3feet when sitting down (important b/c this is where most therapeutic communication will be taking place)

22. Social – 4-12feet

23. Public – 12-25feet

25. How to establish boundaries w/ mentally ill pt: Say Hi my name is --- I will be your student nurse today – this sets relationship

26. Accept client’s uniqueness

27. Ppl don’t want to be treated all as the same person!

28. Be honest and direct

29. if you aren’t honest with them they will not trust you

30. Focus on therapeutic communication (see above for bulleted list)

31. Active listener

32. Facilitate expression

33. Allow them to express themselves – ask them open ended questions

34. Corrective, emotional experience

36. Fostering trust, starting a bond

37. Trust

38. Say what you mean, mean what you say

39. Congruence

40. Consistent

41. With boundaries, truth, relationship, facial expressions

42. Honesty

43. Uniqueness

44. Confidentiality

45. Especially important in psych

46. Blind trust

47. We expect them to trust us b/c we are in med profession. Some do but some have difficulties b/c of past relationships

48. Respect

49. Respect pts rights; don’t talk down to them; actively listen;

50. Genuineness

51. Be real

52. Not fake/phony

53. Congruent

54. Empathy Vs. Sympathy

55. Empathy is when you can see things f/ the clients perspective and understand the clients feelings

56. Sympathy is when you share that same feeling that the client is feeling

57. EXAMPLE: I can empathize w/ someone who has been on drugs who has had relapses but I can’t sympathize with them b/c I haven’t been there before.

59. GENERALIST – nurse who goes into nursing and decides to become psych nurse – other than nursing degree there is no special degree they have to have other than taking state boards

61. Where you obtain pt information, where you examine your own fears, feelings, and anxieties (when you 1st meet your pt)

62. Orientation phase (PHASE 2)

63. Where you establish trust and rapport, you also establish a contract for intervention like what are we going to do today, assess and formulate a nursing diagnosis here and establish goals, this phase is more nursing centered

64. Working phase (PHASE 3)

65. Action taking place here; The pt becomes actively involved in meeting goals (pt is doing most of the talking while nurse listens);

66. Use problems solving model

67. Termination (PHASE 4)

69. Patient needs to identify problem because pt is doing most of the talking

70. Discussion of desired changes

71. Have problem which changes do you want to make to that problem?

72. Identify realistic changes

73. What can’t be changed, adapt to

74. Ex: if living arrangements can’t be changed maybe you can adjust

75. Give Alternatives for changes

76. Ex: for a smoker who now can’t smoke in hospital maybe will chew on a straw etc

77. Give Benefits vs. consequences of each alternative (PROS VS CONS)

78. Assist with alternative selection

79. Sometimes they have all these alternatives and they don’t know where to begin

80. Encourage implementation of change (encourage their efforts in trying even if they weren’t successful)

81. Provide positive feedback

82. Assist in evaluating the outcomes and modify if necessary

84. Counter transference: When you transfer feelings onto the client

86. Rehabilitation uses the whole environment (the rooms, decorations, etc.)

87. Adaptive coping skills – such as learning your triggers such as anger, etc.

88. Interaction / relationship skills – teach them to talk to other people (they will be modeling you)

89. Multidisciplinary Therapies – different therapies

90. Occupational therapy

91. Recreation / Art / Music

92. Group therapy

93. Family therapy

94. Home-Life

95. Community Meetings – chance for pt to air grievances and a time for us to reinforce behaviors

96. Psychodrama – acting out behaviors; modeling a behavior through role play

97. Characteristics of therapeutic milieu

98. 24-hr environment – nurses are there 24hrs a day for the pt so nurses have a lot of say what goes on

99. Individualized treatment plan – EVERY pt has to have an individualized treatment plan

100. Self-governing / responsibility (for example: community meetings, wash own clothes, wear their own clothes

101. Structured activities – group is at a certain time, breakfast at certain time

102. Link with family – family group

103. Community involvement

104. Health team cooperation

105. Methodology/Rules of Therapeutic Milieu

106. Purposeful and planned

107. Behavior testing

108. Limit setting – set limits by while group is going on no phone calls, snack time at certain time, no smoke breaks, etc.

109. Participation in groups is expected

110. Respect / dignity – teaches them to respect the dignity of peers (can’t threaten other people)

111. Teaches them Acceptance / optimism

112. Pro communication

113. Effective management of milieu

114. Safety – freedom from danger or harm

115. Structure

116. Norms – expectations; rules that have been agreed upon; socially acceptable (ex: violence will not be tolerated)

117. Limit setting – related to the norms – the consequence! If you do this, this will happen.

118. Provide a Balance – as people get better want to give more freedoms

119. Environmental Modification – (ex: Noise level)

120. Team Members

121. Psychiatrist – a medical doctor who can prescribe medications and can provide therapy – in an inpatient facility there are too many pts so they often just prescribe

122. Psychologist – usually have a degree in psychology and may be called doctor; can provide therapy and conduct research; also administer and interpret psych testing (KNOW DIF BTWN PSYCHIATRIST AND PSYCHOLOGIST)

123. Social worker – master of science and social work; can be a therapist on unit providing group therapy and mobilize community support systems; can get a liaison to work with them to follow up with pt

124. Clinical nurse specialist / Nurse Practitioner- can provide therapy and prescribe meds in collaboration with physician (masters in nursing)

125. Staff Nurses – Any nurse (BSN, RN, LPN) These nurses assess the patient and look for side effects of medications; provide medication teaching; and structure meaningful activities

126. MHT – Mental Health Technician and Psych Tech – tend to do a lot of aide work but also do charting and groups

127. OT – Occupational Therapist – Help pts with ADL’s sometimes arts and crafts (distract and accomplishment);

128. RT – Recreational Therapist – Provides diversional activities use crafts games and hobbies to teach the balance between work and play

129. Music Therapist – music can play a role in your mood

130. Art Therapist – Explore moods through a project that they are doing and it can uncover repressed memories

131. Psychodramatist – person who role plays

132. Dietician – certain foods can alter moods such as sugar, caffeine, etc. Some medications they are on can cause massive weight gain and they need dietician. With weight gain can cause insulin resistance or diabetes. Pt can be bulimic or anorexic.

133. Chaplain – Spiritual needs

134. Client – determine the outcome of therapy; they are the only ones that can determine outcome therefore they are THE MOST IMPORTANT TEAM MEMBER

135. Case Manager – coordinate access to care – take them to dr. apt, shopping, etc. GOAL of the case manager is to keep the patient in the community and out of the hospital

137. Secondary prevention – occurs after a diagnosis has been made; want to limit the patients illness as much as possible (crisis hotline; medications)

138. Tertiary prevention – usually long term (rehab) (home health)

139. GOAL of community mental health

140. Keep optimal level of mental health for community

141. Must look at client wholistically (emotional, physical, spiritual, whole being)

142. Need for services are increasing

144. Nonverbal – how something is said can be nonverbal; expressions

146. Can:

147. Contradict/complement verbal communication

148. Emphasize emotions

149. Control the environment

150. Be communication of choice for some people

152. Facial expressions

153. Eye contact

154. Dress and physical appearance

155. Touch – therapeutic touch is important; you should not touch anyone unless they seem receptive to it, not even a tap on the shoulder because you don’t know who has been abused; and it may be against someone’s religion

156. Types of Touch

157. Functional touch – a professional touch – business like and impersonal (tailor, dressmaker, etc)

158. Social or polite touch – impersonal but affirming touch (shaking hands)

159. Friendship or warm touch – indicates a strong liking; (hand on shoulder)

160. Love and Intimacy touch – conveys a mutual attraction (strong and lasting embrace)

161. Sexual arousal – expresses physical attraction and involves sexual parts

163. Culture / religion

164. Social status

165. Gender

166. Age / Developmental Level

168. Self awareness (likes, dislikes, who am I? etc)

169. Self understanding (understand my own boundaries and abilities)

170. Philosophical beliefs (belief about life and death, do I believe there is anything after death? Is life valuable?)

171. Life

172. Death

173. Overall human condition (do I believe some people are just meant to be depressed?)

174. Attending behavior

175. SOLER

176. S – sit squarely facing the patient

177. O – open posture

178. L – lean in towards patient

179. E – eye contact

180. R – relax

181. Verbal – want to say some of the same things they’ve said (pt: I feel depressed you: you feel depressed?)

182. Don’t ask why questions to a psychiatric patient because sometimes they don’t know why and you are asking for a rationale that they may not be rationale about (instead of why are you sad; what makes you sad)

183. Positive regard – respecting the pt for who they are and their own uniqueness

184. Favorable Environment

185. You and pt in comfortable stance

186. Fair Eye contact (fair, appropriate, glaring to describe eye contact not good or poor or adequate)

187. Eye level

188. Client’s lead – therapeutic communication

190. Seating arrangement – want to have a seating arrangement that promotes therapeutic interaction and want all to be seen appropriate – usually circular fashion

191. Selective interacting – if it isn’t part of group process stop it

192. Notice nonverbal communication

193. Cohesiveness of the group – the togetherness of the group

194. Underlying tension – be aware of any

195. Yalom’s Factors

196. Group roles

197. Leader

198. Facilitator

199. Dictator

200. clown

202. Universality – seeing that you aren’t the only one with the same problem

203. Imparting information – when you get information or give information to each other

204. Altruism – Self growth by helping other people

205. Corrective Recapitulation of Family group – role playing the family roles

206. Development of socializing techniques –

207. Imitative behavior – role model to one another

208. Interpersonal learning – The benefit of interacting with others

209. Group cohesiveness – togetherness – sense of belonging

210. Catharsis – when they let all their feelings out – can be positive or negative (laughter, crying)

212. Someone who is actively psychotic (will be responding to voices in their head which will be impeding group improvement)

213. Antisocial personality disorder (don’t care about anyone else’s rights, rules, laws, etc)

214. In alcohol/drug withdrawal – will be physically ill and can’t concentrate

215. Under influence of drugs / alcohol – no information will be retained

216. All groups are reality based – here and now

217. Physical conditions that influence group process

218. Seating arrangement – circle

219. Size: ideally 7-10 clients in a group

220. Membership (close to same age and same gender)

222. Implementation

223. Health teaching

224. Community referrals

225. Evaluation

226. Goals: what you and the client want a client to achieve

227. Outcome criteria: an indication that the client is achieving the goalEx: Pt wants to be alcohol free (goal); Pt is attending AA meeting (outcome criteria) 25 questions – multiple choice TEST NEXT WEEK