BAPTIST HEALTH SCHOOL OF NURSING NSG3037: PSYCHIATRIC MENTAL HEALTH. Health Teaching: Empowering People with Mental Health Needs

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1 BAPTIST HEALTH SCHOOL OF NURSING NSG3037: PSYCHIATRIC MENTAL HEALTH K 1 Health Teaching: Empowering People with Mental Health Needs Objectives: 1. Define cognitive, behavioral, empowerment, and cognitive behavioral interventions. 2. Discuss aspects of behavioral therapy. 3. Explain cognitive therapy. 4. List and discuss Basic Human Rights and the Behavioral styles of passive, aggressive, passive-aggressive, and assertiveness. 5. Teach principles upon which stress management techniques are effective. 6. Describe 12 stress management techniques. 7. Apply stress management techniques to enhance personal and professional functioning. Reading Assignment: Townsend Chapter 19 Behavior Therapy Chapter 20 Cognitive Therapy Chapter 15 Assertiveness Training Chapter 14 Relaxation Therapy Lecture Outline: This lecture builds on the Anxiety and Stress lectures and is about How to cope with stress. In the Crisis Lecture, the word stress is commonly used to describe external events and our internal responses to the event or stressor. It is not the stress or the situation, but how we interpret and respond to the stress or situation. I. Self-Inventory. Learning how to manage stress facilitates personal and professional growth. Stress reduction interventions and strategies help us to reduce our stress. The first step in practicing mental health care is to take a personal inventory (self assessment). A Self inventory is based on one s capacity to reflect as objectively as possible on Thoughts - Feelings - Behavior. This process of knowing one s thought, feelings and behaviors is called Introspection. II. Definitions A. Cognitive - The mental processes of knowing, thinking, learning, and judging.

2 K 2 B. Behavioral - Any recordable, observable, and measurable act, movement or response of the individual. Learning theorist say: All behavior has meaning. It is our job to figure out the meaning. C. Empowerment - is a process by which people are supported and valued as they learn about themselves, make decisions, mobilize resources and accept power, control and direction of their lives. In a holistic model of Behavioral Health, empowerment is one of the conceptual outgrowths of facilitating well being and healing. Providing opportunities for empowerment through health teaching is challenging and rewarding. Cognitive Behavioral Therapies - are directed toward teaching stress reduction and teaching people to think Rationally.. The underlying basis of Cognitive Therapy is that the negative event is not the problem, but rather how the person thinks about the problem event. Cognitive approaches help people to make decisions, take control and direction of their lives. III. Behavioral Therapy A. Definition - The behavioral approach to therapy is that people have become what they are through:1. learning 2. environmental experiences and 3. genetic endowment. Problematic behaviors occur when there has been inadequate learning, which can be corrected through the provision of appropriate learning experiences. B. Principles of behavior therapy 1. Classical conditioning - Russian physiologist Pavlou experimented with dogs. 2. Operant conditioning - American psychologist, B.F. Skinner. C. Techniques for Modifying Behavior 1. Shaping - to shape behavior, reinforcements are given for increasingly closer approximations to the desired response. 2. Modeling - learning new behaviors by imitating behavior of others. 3. Premack Principle - a frequently occurring response can serve as positive reinforcement for a response. Example: homework and telephone. 4. Extinction - gradual increase in frequency or disappearance of a response when reinforcement is withheld. Example = temper tantrums 5. Contingency Contracting - a contract for behavioral change is developed. positive and negative reinforcers for performing the desired behaviors, as well as aversive reinforcers for failure to perform are stated explicitly in the contract. 6. Token Economy - reinforcers for desired behaviors are presented in the

3 K 3 form of tokens. Tokens may be exchanged for designated privileges. 7. Time Out - aversive stimulus or punishment where the patient is removed from an environment where unacceptable behavior is being exhibited. 8. Reciprocal Inhibition - also called counter-conditioning, a technique that serves to decrease or eliminate a behavior by introducing a more adaptive behavior. 9. Overt Sensitization - aversive therapy that produces unpleasant consequences for undesirable behavior. Anatabuse (difulsaram) 10. Covert Sensitization - aversive technique relies on the patient s imagination to produce unpleasant consequences for undesirable behavior. 11. Systematic Desensitization - gradually desensitize the phobia. IV. Cognitive Therapy - short term, highly structured and goal directed therapy. Men are disturbed not by things, but the views they take of them Townsend Chapter 20. Our thoughts are a controlling factor in our emotional lives. This belief forms the base upon which the Cognitive Model was established. A. History - Depression - Aaron Beck 's - Depression is anger turned inward, and cognitive therapy is aimed at modifying distorted cognition. B. C. Indications for Cognitive Therapy 1. Originally depression. 2. Today a variety of emotional disorders: a. Panic b. Generalized Anxiety Disorder c. Social phobia d. Post Traumatic Stress Syndrom e. Eating Disorders f. Substance Abuse g. Personality Disorders h. Schizophrenia i. Couple s Problems j. Bipolar k. Hypochondriasis l. Somatoform disorders

4 C. Goals and Principles K 4 1. Goals are aimed at modifying distorted cognition about a situation. 2. Overall goal is to identify and alter the distorted/dysfunctional beliefs a. Monitor negative automatic thoughts b. Recognize connections between cognition, affect, and behavior c. Examine evidence for and against distorted automatic thoughts d. Substitute more realistic interpretations for the biased cognition e. Learn to identify and alter the dysfunctional beliefs that predispose them to distort experience(s). 2. Principles a. Cognitive therapy is based on an ever-evolving formulation of the patient and his problems in cognitive terms. Cognitive Therapy: b. requires a sound therapeutic alliance. c. emphasizes collaboration and active participation. d. is goal-oriented and problem-focused. e. initially emphasizes the present. f. is educative, the aim is to teach the patient to be his own therapist, and emphasizes relapse prevention. g. aims to be time-limited. h. sessions are structured. i. teaches patients to identify, evaluate, and respond to their distorted thoughts and beliefs. j. uses a variety of techniques to change thinking, mood, and behavior. D. Basic Concepts - the general thrust of cognitive therapy is that emotional responses are largely dependent on cognitive appraisals of the significance of environmental cues Townsend, page 281. There are two basic concepts; E. 1. Automatic thoughts - thoughts that occur rapidly in response to a situation without rational analysis - usually negative a. b. Over generalization (Absolutistic Thinking) - sweeping conclusions are made based on one incident - a type of all or nothing thinking.

5 c. Dichotomous Thinking - situations are viewed as all or nothing thinking. No in between d. Selective Abstraction - also called mental filter. A conclusion is drawn based only on selected portion of facts e. Magnification- exaggerating the negative significance of event f. Minimization - undervaluing the positive significance of event g. Catastrophic Thinking - always thinking that the worst will occur without considering the possibility of other outcomes h. Personalization - taking complete responsibility for situations without considering that other circumstances may have contributed to the outcome. Do not always personalize everything! 2. Schema - core belief Cognitive structures that consist of the individual s fundamental beliefs and assumptions, which develop early in life from personal experiences and identification with significant others. These concepts are reinforced by further learning experiences and, in turn, influence the formation of other beliefs, values, and attitudes Townsend, pg 283. Most variations of dysfunctional automatic thoughts can be traced back to core beliefs of Helplessness and Unlovability. See table 20.8 page 283 a. Helplessness b. Un-lovability c. F. Techniques of Cognitive Therapy G. 1. Didactic (educational) Aspects 2. Cognitive Techniques a. Recognizing automatic thoughts and schemas i. Socratic questioning (guided discovery) - person is asked to describe feelings associated with specific situations. Questions are stated in such a way that they may stimulate recognition of possible dysfunctional thinking. ii. Imagery and role play - the patient is asked to relive the iii. stressful situation. Thought recording - asked to keep a record of situations that occur and the automatic thoughts they have with the situation b. Modifying Automatic Thoughts and Schemas i. Generating alternatives - helping to see a broader range of possibilities to the situation. ii. Examining evidence - use automatic thought as a tool.

6 K 6 iii. Decatastrophizing - help to examine the validity of the negative automatic thought. iv.. Reattribution - technique aimed at helping to decrease the tendency of attributing adverse life events to them. v. Daily record of dysfunctional thoughts (see table 20.3 pg common tool used in cognitive therapy to modify automatic thoughts. vi. Cognitive rehearsal 3. Behavioral Interventions a. Activity scheduling b. Graded task assignments c. Behavioral rehearsal - used with cognitive rehearsal, use role play to rehearse a modification of maladaptive behaviors that may be contributing to the dysfunctional cognition. d. Distraction - use of activities to distract the person from the intrusive thoughts or depressive ruminations that are contributing to the maladaptive responses. e. Miscellaneous Techniques i. Relaxation Exercises ii. Assertiveness Training V. Basic Human Rights and Behavioral Approaches/Styles (chapter 15, Townsend) A. 10 Basic Human Rights see page 220 B. Passive - non-assertive 1. Seeks to please others at the expense of denying their own basic rights. 2. Strives to avoid conflict. 3. Discounts own feelings and attempts to meet other s needs. Justifies this as necessary to avoid hurting others and be pleasant. 4. Lacks self confidence. 5. Usually gets hurt...why? C. Aggressive 1. Defend their own basic rights by violating basic rights of others. 2. Ignores rights of others consciously or unconsciously. 3. Want to increase their feeling of power by dominating or humiliating. D. Passive- Aggressive (indirect aggression) 1. Most common 2. Most irritating but easiest to change! 3. Lacks courage or information to be assertive

7 4. Tends to let others infringe upon their rights and will not speak up to express feelings directly. 5. Becomes sulky, irritable or argumentative when asked to do something they do not want to do. 6. Devious, manipulative, sly and undermines others by expressing the opposite of what they really feel. Highly critical and sarcastic. 7. Again, probably the most irritating style for others to deal with, but once recognized can be fairly readily changed to assertiveness. E. Assertiveness Training is based on the theory that much of our social behavior is learned. So, maladaptive behavior can be unlearned and replaced by more rewarding and constructive. behavior 1. Stand up for their own rights as well as rights of others. 2. Feelings are expressed openly and honestly. 3. Assume responsibility for own choices and allows others to choose for themselves. 4. Maintain self respect and respect for others by treating everyone equally and with human dignity. 5. Communicate using I statements. 6. Voices are warm, expressive and eye contact is intermittent, and direct. 7. Through Assertiveness Behavior, people begin to take responsibility for the nature and quality of their lives. The goal of assertiveness is to balance power between yourself and others. K 7 VI. Techniques that promote assertive behavior 1. Standing up for one s basic human rights. What are your basic human rights? 2. Assuming responsibility for one s own statements. 3. Responding as a broken record. 4. Agreeing assertively. 5. Inquiring assertively. 6. Shifting from content to process. 7. Clouding and or fogging. 8. Defusing. 9. Delaying assertively Responding assertively with irony. 11. Stress Management Selecting and Utilizing A. Principles of utilizing stress management skills a. Mind and body are interrelated

8 b. Relaxed = NOT anxious c. If the body is relaxed, the mind will feel relaxed as well. K 8 B. Requirements of stress management technique a. Motivation b. Ability to concentrate c. Follow directions C. Important to assess patient before any relaxation techniques are used to determine if there are any medical problems. D. Purpose of stress management? VII. Creative Stress Management What do you do to relax? What relaxes you? Relaxation is personal. Why do people criticize stress management techniques? Some think that commitment to daily practices and follow through is unrealistic. When actually, it shows acceptance of responsibility for one s life A. Stress Awareness Log/Diary - Purpose? 1. Identifies particular stressors in predictable symptoms B. Breathing Exercises (page 212) Purpose: Keeps blood well oxygenated and purified, removes waste materials from the blood and clears thinking. Poorly oxygenated blood contributes to fatigue, mental confusion, anxiety, tight muscles, and feelings of hopelessness and helplessness (depression) 1. Technique a. First step = awareness of breathing Do you breathe properly? Move the diaphragm downward and fill the lower part of the lungs with air. b. Do 10-1 count Deep Breathing (simple and quick) I. Inhale, taking a deep breath while saying #10 to yourself, then exhale slowly letting out air from lungs. Now inhale saying the #9, then exhale telling yourself I feel more relaxed than I did at 10". Continue counting down experiencing increasing calmness as you approach #1. Or, you can do an abbreviated version of 5 to 1. c. Alternate Nostril Breathing - helps decrease tension and sinus headache. C. Progressive Relaxation - Edmund Jackson (1929), page 213, Townsend Premise = muscle tension is the body s physiological response to anxiety provoking thoughts. Deep muscle relaxation decreases physiological tension and blocks anxiety. What happens physiologically? Pulse decreases, respirations

9 decrease, B/P and anxiety decrease. D. Mental Imagery Used with cancer patient and chronic pain patients. Uses person s own imagination and positive thinking to create powerful mental picture or images to reduce stress and promote healing. E. Meditation- Requires self discipline and helps to achieve Inner Harmony. 1. Procedure - practice 15 minutes a day every day, avoid after heavy meal a. Quiet place b. Comfortable position c. Object to focus on or Mantra - peace, love, calm, om (I am) d. Passive attitude e. F. Hypnosis -Milton Erickson Goal = to achieve relaxation and make positive suggestions for change. Contraindicated in psychosis G. Thought Stopping - Joseph Wolpe (1991) Technique used to eliminate intrusive, unwanted thoughts Procedure = interrupt the thought and empty the mind. Negative thoughts precede negative emotions. Therefore, STOP the thinking and reduce the feeling and stress. Command-----STOP, then thought substitution. People who are fearful of heights This is a gorgeous view from up here K 9. H. Biofeedback 's - use of instrumentation to become aware of processes in body that usually do not notice and to being under voluntary control I. Physical Exercise -page 215 J. Problem Solving K. Humor VIII. Relaxation Time Revised and prepared by: Sandra Kahler,MS R.N. from original outline and

10 th Townsend 4 edition April, 2006 K 10 MANAGING STRESS TOP 9 WAYS #1. Do I feel helpless? Why do these things happen to me? What can I do to change the situation? #2. Do I express anger appropriately? #3. Take care of your health. #4. Leisure time - How do I spend it? #5. Simplify your world. #6. How flexible am I? #7. Do I worry too much? #8. Do I nurture my spirituality? #9. Do I accept that which I cannot change?

11 K 11 Basic Assertive Skills Passive Assertive Aggressive Passive Aggressive Whimp Superman Bully Sneaky Snake Does not stand up Does stand up for Stands up for Does not stand up for rights. rights while respect- rights even if for rights. But goes ing the rights of hurts others. about getting own others. way thru manipulation 1. Conning 2. Lying Others walk over them Often gets what Often gets what 3. Messes things up they want they want 4. Silent treatment 5. Withholds love or Does not express Expresses own Expresses feelings attention own feelings directly feelings directly at expense of others 6. Crying Avoids Conflicts Compromises Intimidates others Does not express true Gains respect feelings Low Self Esteem Good Self Esteem Uncompromising Feelings: Feelings: Feelings: Feelings: depressed happy anger resentment frustrated confident guild