Behavioral Therapy

1

• Behavioral Therapy
• Behavioral therapy is based on the assumption
  that changes in maladaptive behavior can occur
  without insight into the underlying cause
• It works best when it is directed at specific
  problems the goals are well defined
• Modeling
• The therapist provides a role model for specific
  identified behaviors, the cl learns through
  imitation.
• They demonstrate to cl patterns of behaving that
  might prove more effective than those the cl
  usually engage in then have the cl practice
  these new behaviors
• Operant Conditioning
• Is the basis for behavior modification uses
  () reinforcement to increase desired behaviors.
• Systematic Desensitization
• Systematic desensitization is another form of
  behavior modification therapy that involves the
  development of behavioral tasks customized to the
  cls specific fears these tasks are presented to
  the cl while he or she is using learned
  relaxation techniques.
• The cls fear is broken down into its components
  by exploring the particular stimulus cues to
  which the cl reacts.
• Pairing of a maladaptive behavior with a noxious
  stimulus, so that anxiety or fear becomes
  associated with the once-pleasurable stimulus
• Punishment
• Avoidance training
• Biofeedback, which is also a form of behavioral
  therapy is successfully used today, especially
  for controlling the bodys physiological response
  to stress anxiety.
• Milieu
• To describe his use of the total environment to
  treat disturbed children.
• Is sometimes a difficult concept to grasp
• It is an all-inclusive term that recognizes the
  people, setting structure, emotional climate as
  all important to healing

2

• Psychiatric Mental Health Nursing Managed Care
  Issues
• What is psychiatric mental health nursing
• Psychiatric mental health nurses work with
  children, adolescents, adults, the elderly.
• Psychiatric nurses work with individuals,
  couples, families, groups
• They work with cls in hospitals, in their homes,
  in halfway houses, in shelters, in clinics, in
  storefronts, on the streetvirtually everywhere.
• Phenomena of concern because of the diversity of
  cls.
• Psychiatric nursing as the diagnosis and t/ of
  human responses to actual or potential mental
  health problems.
• Nursing outcomes classification (NOC) is one
  reference that provides a comprehensive list of
  standardized outcomes, definitions, measures to
  describe cl outcomes influenced by nursing
  practice.
• Nursing interventions Classification (NIC) is
  another tool to define measure nursing care
• A clinical judgment knowledge, that a nurse
  performs to enhance cl outcomes, including
  direct and indirect care through a series of
  nursing activities.
• Evidence-based practice that is, care based on
  the collection, interpretation integration of
  valid, important, applicable cli-observed,
  research-derived evidence.
• Levels of psychiatric mental health clinical
  nursing practice
• Basic Level
• The nurse at the basic level has completed a
  nursing program passed the state licensure
  examination.
• Basic level registered nurse is a baccalaureate
  RN may take a basic certification examination
  sponsored by the ANA through its credentialing
  center to demonstrate clinical competence
• Counseling, Milieu therapy, promotion of
  self-care activities, psychobiological
  interventions, health teaching, case management,
  health promotion health maintenance
• Advanced Level
• Advanced practice RNpsychiatric mental health
  (APRN-PMH) is a licensed RN with a masters
  degree in psychiatric nursing
• this clinician is eligible to take an advanced
  certification examination, which adds another
  credential to the nurses title

3

• Mental Health Managed Care
• Managed care is the dominant form of health care
• The goal of managed care is to provide
  coordination of all health services at the
  appropriate level of care, with an emphasis on
  preventive care, to control costs.
• Health maintenance organization provide
  comprehensive services to members only within a
  defined provider network for a fixed yearly rate,
  usually a primary care physician as the
  gatekeeper for specialty care
• Preferred provider organizations give members a
  choice of using providers in a defined network
  for a fixed copayment or using providers outside
  the network for a higher copayment.
• Managed behavioral health care organizations
  (MBHOs) were developed separately, or carved
  out, from medical services
• Hospital stays were shortened or admission
  denied, outpatient options were enhanced
• Partial hospitalization programs, intensive
  outpatient t/, assertive community t/,
  psychiatric home care, school-based services.
• The quality of nursing documentation plays a
  direct role in ensuring that clients receive
  necessary care.
• Future Challenges Roles for Nurses
• Case Management is an integral part of
  psychiatric home care for the elderly, in-home
  services for children adolescents, long-term
  t/ of the chronically mentally ill.
• Community nursing centers will hopefully survive
  to serve low-income uninsured people as long as
  they can secure funding.
• Three more significant trends will affect the
  future of psychiatric nursing the aging of the
  population, increasing cultural diversity,
  ever-expanding technology.
• Nurse as client advocate must continue to
  evolve.
• Nurse has the responsibility to communicate to
  the cl to uphold the cls rights.

4

• Mental Health Nursing in Acute Care Settings
• Although lengths of stay have decreased from
  weeks to days since 1980s, the inpatient setting
  provides intensive effective t/ for the
  acutely ill cl.
• Admission therefore is commonly reserved for
  those conditions that require immediate
  assessment, stabilization, s/ management
• Most inpatient t/ today takes place in private
  general hospitals or psychiatric hospitals
• State psychiatric hospitals that exist as a
  resource for the uninsured and for specialty
  populations, such as forensic cls referred for
  evaluation or t/ by the court system.
• Admission Goals
• Admission may be planned, it is common for a cl
  to enter t/ through a psychiatric crisis center
  that is located in the admissions area or is part
  of emergency department services.
• Most managed behavioral health care organization
  (MBHOs) other third-party payers require that
  at least one of the following criteria be met to
  justify admission
• Clear risk of the cls danger to self or others
• Dangerous decomposition of a cl under long-term
  t/
• Failure of community-based t/ with a clearly
  demonstrable need for more intensive structured
  t/ to avoid harmful consequences.
• Mental need, either unassociated with
  psychiatric t/ or associated with t/
• Goals for acute psychiatric hospitalization
• Prevention of self-harm to the cl
• Prevention of crisis with a return to
  community-based services
• Initiation or modification of a psychotropic
  medication regimen for cls requiring careful
  titration or observation
• Brief, specific problem solving that is designed
  to enable the cl to gain or regain a state of
  compensation
• Rapid establishment of a plan for outpatient
  therapy, especially referral to a partial
  hospitalization program that provides intensive
  daily services.
• Rights of the Hospitalized Client

5

• Interdisciplinary Teamwork Care Management
• Cls care is planned implemented by a team
  composed of nurses, social workers, counselors,
  psychologists, occupational activity
  therapists, psychiatrists, medical physicians,
  mental health workers, pharmacists, other
  members of the hospitals health care team,
  according to the cls needs
• Members of each discipline are responsible for
  gathering data participating in the planning of
  care.
• medical problems are usually referred to a
  primary care physician or specialist, who assess
  the cl consults with the unit physicians
• Members of the various disciplines meet within
  72 hrs to formulate or select a plan of care that
  reflects the consensus of the team.
• Multidisciplinary t/ plan or a clinical pathway
  used by some organizations, seek to standardize
  the daily expected outcomes for cl
• The reduction of overt s/ development of an
  adequate outpatient plan signal that discharge is
  imminent.
• Psychiatric Case Management
• Has been defined as any systematic program that
  coordinates individual patient care throughout
  the organizationally defined continuum of
  services settings
• Inpatient setting, case managers on the hospital
  team communicate daily or weekly
• In the community, ideally, psychiatric case
  managers establish enduring relationships with
  cl, facilitate their involvement in outpatient
  settings, access resources, thereby helping to
  avoid the crises that result in readmission to
  the acute care hospital
• Nursing on the inpatient unit
• Management
• Nurses assume the bulk of the management of the
  daily functioning of the inpatient mental health
  unit.
• Program staff may provide social services,
  activities, occupational therapy, specialized
  counseling services.
• Nurse manager is responsible for an awareness of
  the safety of the unit, its effectiveness in the
  delivery of services, the degree to which the
  components of the health care team are
  integrating their services well.
• Therapeutic Strategies
• Informal contacts can be viewed as more
  significant than the formal ones, because they
  occur during natural activities of daily social
  living are therefore based on reality.
• Nurses are prepared educationally with
  psychosocial communication skills to help cls
  feel heard supported, develop trust increased
  feelings of safety, receive feedback, learn
  more adaptive coping skills

6

• Milieu
• Group Activities
• Experienced mental health nurses conduct
  specific, structured activities involving the
  therapeutic community, special groups, or
  families on most mental health units.
• Community meetings may be held daily or at other
  scheduled times of the week.
• Group therapy addresses communication sharing,
  helps cls explore life problems decrease their
  isolation anxiety, engages cls in the
  recovery process
• Management of Milieu
• On an inpatient unit, nursing is the discipline
  primarily responsible for maintenance of a
  therapeutic milieu
• Reports from shift to shift provide info on the
  emotional climate level of tension on the unit.
• To maintain an atmosphere in which healing
  growth can take place, nurses strive to keep
  communitively honest
• Verbal messages must be clear or must also be
  congruent with verbal messages
• therapeutic milieu operates on the understanding
  that the community can serve as a real-life
  training ground for learning about self for
  practicing communication coping skills in
  preparation for a return to the community outside
  the hospital.
• Safety
• Psychiatric mental health nurse assumes a
  responsibility for ongoing vigilance regarding
  safety hazards
• The nurse must supervise the units systems for
  tracking which cl are on or off the unit for
  tracking which cls are on or off the unit for
  performing periodic or constant checks on those
  cls at risk of harming themselves or others
• Violence disruption must be minimized while
  maintaining an atmosphere that promotes healthy
  appropriate expression of anger other feelings
• Elopement (escape) of cls must be prevented, but
  in a way that avoids an atmosphere of
  imprisonment.
• Documentation
• Documentation of cl progress is the
  responsibility of the entire mental health team.
• Although communication among team members
  coordination of services are the primary goals.

7

• Psychopharmacological Responsibilities
• Nurses on the inpatient acute care unit.
• Both detection prevention of medical illnesses
  are compromised by cls reluctance to seek t/,
  poor communication skills, denial lack of
  awareness of health status
• Anxiety, lack of trust, or thought impairment
  may cause cls to resist procedures such as
  measurement of VS.
• As the therapeutic relationship develops, cls
  become more tolerant of physical interventions,
  the nurse may begin to address physical health
  status
• Safe administration of medications monitoring
  of their effects is a 24-hr responsibility of the
  nurse
• Detailed knowledge of psychoactive medications
  of the interactions psychological side effects
  of others medications is expected of mental
  nurses
• Nurses observations of the expected adverse
  effects of medications provide data necessary for
  daily medication decisions by the psychiatrist
  t/ team.
• Documentation for administering each prn
  medication must include the rationale for its use
  the effects.
• Crisis Management
• Nurses anticipate, prevent, manage emergencies
  crises on the unit.
• These crises may be of a medical or behavioral
  nature.
• Nurses must maintain their cardiopulmonary
  resuscitation skills be able to use basic
  emergency equipment
• Behavioral crises can lead to cl violence toward
  self or others
• Crisis prevention management techniques are
  practiced by staff in most mental health
  facilities
• To psychiatric emergencies called codes. Each
  member of the team takes part in the team effort
  to defuse a crisis in its early stages.
• The nurse also advocates for cls by ensuring
  that their legal rights are preserved, no matter
  how difficult their behavior may be for the staff
  to manage.
• Preparation for Discharge to the community
• Nurses assist cls their families to prepare
  for independent or assisted living in the
  community.

8

• Mental Health Nursing in Community Settings
• Context for psychiatric nursing in the community
• In 1963, Community Mental Health Centers Act,
  thus solidifying the shift of mental health care
  from the institution to the community heralding
  the era of deinstitutionalization
• Policy-makers believed that community care would
  be more humane less expensive than the historic
  hospital-based care.
• Caring for seriously mentally ill (also called
  chronically mentally ill) cls in the community,
  however presented many challenges.
• With advances in psychopharmacology
  psychosocial ts/, levels of psychiatric care in
  the community have multiplied into a continuum
  with many choices.
• Aspects of Community Nursing
• Community setting requires flexibility on the
  part of the psychiatric nurse knowledge about a
  broad array of community resources.
• Setting is the realm of the cl rather than of
  the health care provider.
• T/ in the community permits cls those involved
  in their support to learn new ways of coping w/
  s/ or situational difficulites.
• Psychiatric Nursing Assessment Strategies
• Assessment of the biopsychosocial needs
  capacities of cls living in the community
  requires expansion of the general psychiatric
  nursing assessment.
• Four key elements of this assessment are
  strongly related to the probability that the cl
  will experience successful outcomes in the
  community.
• Problems in any of these areas require immediate
  attention before other t/ goals are pursued
• housing adequacy stability income source of
  income, Substance abuse history current use
• Individual cultural characteristics of cls are
  also very important to assess.
• Psychiatric Nursing Intervention Strategies
• In the hospital setting, the focus of care is on
  stabilization, as defined by staff
• In the community setting, t/ goals
  interventions are negotiated rather than imposed
  on the cl

9

• Biopsychosocial Care Manager
• Role of the community psychiatric RN includes
  the coordination of mental health, physical
  health, spiritual health, social service,
  educational service, vocational realms of care
  for the mental health cl.
• Case management includes the following
  functions assessing cl needs developing a plan
  for service linking the cl with necessary
  services advocating for the cl, as needed.
• Nurses are in a position to help the cl to
  manage medication, recognize side effects, be
  aware of the interactions among drugs prescribed
  for physical illness mental illness.
• Community Settings
• Nurses are providing primary mental health care
  at therapeutic day care centers, schools, partial
  hospitalization programs, shelters.
• Basic Practice Counseling, promotion of
  self-care activities, psychobiological
  interventions, health teaching, case management.
• Continuum of psychiatric mental health t/
• Movement along the continuum is fluid, from
  higher to lower levels of intensity, changes
  are not necessarily step by step.
• It is also notable that cls may pass through the
  continuum of t/ in the reverse direction that
  is, if s/ exacerbate, a lower intensity service
  may refer the cl temporarily to a higher level of
  care in an attempt to prevent total
  decompensation hospitalization.
• Partial Hospital Program
• Partial hospitalization programs (PHPs) offer
  intensive, short-term t/ similar to an inpatient
  level of care, except that the cl is able to
  return home each day.
• Criteria for referral to a PHP include the need
  for prevention of hospitalization for serious
  s/or step-down from acute inpatient t/ the
  presence of a responsible relative or caregiver
  who can assure the cls safety.
• Referrals come from inpatient or outpatient
  providers.
• Psychiatric Home Care
• Requiring 4 elements 1) home-bound status of
  the cl, 2) presence of a psychiatric diagnosis,
  3) need for the skills of a psychiatric RN , 4)
  development of a plan of care under orders of a
  physician.
• Homebound refers to the cls inability to leave
  home independently to access community mental
  health care because of physical or mental
  conditions/
• Cls are referred to psychiatric home care
  following an acute inpatient episode, either
  psychiatric or somatic, or to prevent
  hospitalization.
• Psychiatric RN visits the cl 1 to 2 mo,
  usually sees 5 or 6 cls daily.

10

• Assertive Community Treatment
• Teams or mobile t/ units have sprung up in
  various area throughout the US to respond to
  those mentally ill cls who cannot effectively use
  traditional pursue woo cls support t/ in
  whatever settings cls find themselves inat home
  or in a public place
• Creative problem solving interventions are
  hallmarks of care provided by mobile teams
• Cls are referred to ACT teams by inpatient or
  outpatient providers because of a pattern of
  repeated hospitalizations with severe s/, along
  with an inability to participate in traditional
  t/.
• Length of t/ may extend to yrs, until the cl is
  ready to accept transfer to a more structured
  site for care
• There is a 24-hr on-call system.
• Community Mental Health Center
• For those who have no access to private care.
• Generally they provide emergency services,
  childrens services
• T/ include medication administration, individual
  therapy, psychoeducational therapy groups,
  family therapy, dual-diagnosis t/
• A clinic may also be aligned with a psychosocial
  rehabilitation program that offers a structured
  day program, vocational services, residential
  services
• Multidisciplinary team sees one to four times
  per month
• Referred to the clinic for long-term follow-up
  by inpatient units or other providers of
  outpatient care at higher intensity levels.
• Cls may attend the clinic for years or be
  discharged when they improve reach desired
  goals.
• Ethical Issues
• Ethical dilemmas are common in disciplines
  specialties that care for the vulnerable
  disenfranchised.
• Role of the nurse is to act in the best
  interests of the cl society, to the degree that
  this is possible
• In most organization, there is a designated
  resource for consultation regarding ethical
  dilemmas
• Future Issues

11

• Legal Ethical Guidelines for Safe Practice
• Ethical dilemma (a situation that requires a
  choice between morally conflicting alternatives)
• The fundamental goal in resolving any legal or
  ethical issue confronting the nurse in a
  psychiatric setting is striking a balance between
  the rights of the individual cl and the rights of
  society at large.
• Ethical Concepts
• Ethics is the study of philosophical beliefs
  about what is considered right or wrong in a
  society
• term bioethics is used in relation to ethical
  dilemmas surrounding cl care.
• Five principles of bioethics are
• Beneficence is the duty to act so as to benefit
  or promote the good of others
• Autonomy is the right to make ones own
  decisions
• Justice is treating others fairly equally
• Fidelity (nonmaleficence) is maintaining loyalty
  commitment to the cl doing no wrong to the cl
• Veracity refers to ones duty always to tell the
  truth
• Its important to respect protect the cls
  autonomy the cls right to be the ultimate
  decision maker about decisions that affect his or
  her life
• You must avoid trying to impose personal values
  on the cl
• Resources
• Legal advice, nurse practice acts, hospital
  organizational polices, pts Bill of Rights,
  Colleagues, Clergy, examination of ones own
  ideals morals, code of ethics for nurses with
  interpretive statements of American nurses
  association
• Ethical standards, although lacking the clarity
  power of law, do serve as a field guide for
  decision making.
• You are bound to comply with the laws, even
  though you may feel morally obligated to follow
  ethical guidelines, these guidelines should not
  override laws.
• Laws override ethical principles, which do not
  have the same legal strength

12

• Mental Illness the Social Norm
• Social norms are known to every society, most
  members of society conform to these norms
• What constitutes desirable or acceptable
  behavior of the individual is decided by the
  group (society) that establishes the norms
• Freedom of expression is a fundamental value of
  our society, a right embodied in the U.S.
  Constitution.
• Responsibilities of the Therapeutic Relationship
• Nurses clinicians also have a legal ethical
  obligation to the cl to society not to abuse
  the power that can exist when a cl relies on them
• Protection of the cl when he or she is in a
  vulnerable state of mind must be considered.
• This misuse of the therapeutic relationship
  constitutes grounds for losing a license
  violates the ethical duty of fidelity to the cl
• Protection of the confidentiality privacy of
  the cls disclosures during therapeutic
  communication is also vitally important
• Without self-awareness, nurses risk imposing
  their own value system upon the cl
• Mental Health Laws
• Laws have been enacted in each state to regulate
  the care t/ of the mentally ill.
• Outpatient t/ is less expensive than
  hospitalization provides a less restrictive t/
  setting
• With this shift in emphasis has come the more
  widespread use of psychotropic drugs in the t/ of
  mental illnesswhich has enabled many people to
  integrate more readily into the larger
  community-- an increasing awareness of the need
  to provide the mentally ill with humane care that
  respects their civil rights.
• Civil Rights
• Persons with mental illness are guaranteed the
  same rights under federal state laws any other
  citizen
• Psychiatric cls rights include the right to
  humane care t/
• Mentally ill in prisons jails are afforded the
  same protections.

13

• Specific Client Rights
• Client Consent
• Proper orders for specific therapies t/ are
  required must be documented in the cls chart.
• Consent for surgery, electroconvulsive t/, or the
  use of experimental drugs or procedures must be
  obtained.
• Cl have the right to refuse participation.
• Without fear of punishment or reprisal.
• Communication
• Cls have the right to communicate fully
  privately with those outside the facility,
  receive visitors, access to phones and mail
• Rules regulations of the hospital need to be
  explained to the cl
• Freedom from Harm
• Right to be free from harm, which includes
  freedom from unnecessary or excessive physical
  restraint, isolation, medication, as well as
  freedom from abuse or neglect
• Dignity Respect
• Right to be treated with dignity respect
• Right to be free from discrimination on the
  basis of ethnic origin, gender, age, disability,
  or religion
• Confidentiality
• Of care t/ is also an important right for all
  cls, particularly psychiatric cls
• Photographs may not be taken without written
  consent
• The cls privacy is protected
• The cls permission must be obtained to share
  information with persons who are not directly
  involved in his or her care

14

• Admission, Commitment, Discharge Procedures
• Due process in Civil Commitment
• Writ of habeas corpus, meaning a writ to free
  the person
• the writ of habeas corpus the least
  restrictive alternative doctrine are two of the
  most important concepts applicable to civic
  commitment cases
• Admission to the Hospital
• Involuntarily committed cl is considered to be
  capable of consenting to t/, unless a judicial
  determination has been made or the cl lacks the
  capacity to understand the implications of his or
  her decision
• Cl retain freedom from unreasonable bodily
  restraints the right to refuse medications,
  including psychotropic or antipsychotic
  medications
• A medical standard or justification for
  admission should exist
• A well-defined psychiatric problem must be
  established.
• Voluntary Admission
• Is sought by the cl or the cls guardian through
  a written application to the facility
• Right to demand obtain release
• Involuntary Admission (Commitment)
• Is made without the cls consent
• Is necessary when a person is in need of
  psychiatric t/, presents a danger to self or
  others, or is unable to meet his or her own basic
  needs
• Judicial determination, administration, agency
  determination
• It may be emergency, observational or temporary,
  or indeterminate or extended
• Emergency Involuntary Hospitalization
• Commitment for a specified period (1 to 10 days
  on average) to prevent dangerous behavior that is
  likely to cause harm to self or others

15

• Release from the Hospital
• Release from hospitalization depends on the cls
  admission status
• Informal or voluntary admission, right to
  request receive release
• Conditional release of voluntary cls, which
  enables the treating physician or administrator
  to order continued t/ on an outpatient basis if
  the clinical needs of the cl warrant further care
• Conditional Release
• Usually requires outpatient t/ for a specified
  period to determine the cls compliance with
  medication protocols, ability to meet basic
  needs, ability to reintegrate into the
  community
• Discharge
• Discharge, or unconditional release, is the
  termination of a cl-institution relationship.
• Cls Right Under the Law
• Right to T/
• Statue requires that medical psychiatric care
  t/ be provided to all persons admitted to a
  public hospital
• Right to T/
• Environment must be humane
• Staff must be qualified sufficient to provide
  adequate t/. Plan of care must be
  individualized.
• state cannot constitutionally confine a
  nondangerous individual who is capable of
  surviving safely in freedom by himself or with
  the help of willing responsible family members
  or friends
• Right to Refuse Treatment
• Withdraw consent at any time
• Retraction of consent previously given must be
  honored, whether it is a verbal or written
  retraction
• Right to refuse t/ with psychotropic drugs has
  been debated in the courts, based partly on the
  issue of metal cls competency to give or withhold
  consent to t/ their status under the civil
  commitment statues