Therapeutic Intervention
What is a nurse-client relationship?
-A series of interaction between the
nurse and the patient in which the nurse
assists the patient to achieve a positive
behavioral change
-Hildegard Peplau – introduced the
concept of the NPR in her book
Characteristics of the N –P
Relationship
-goal directed
-focused on the needs of the patient
-planned
-time limited
-professional
Elements of Therapeutic N-P relationship
Trust
Rapport
Unconditional positive regard
Setting limits
Therapeutic communication
to her parents. She might experience
intense feelings of rebellion or make
sarcastic remarks; these reactions are
actually based on her experiences with
her parents, not the nurse.
Counter transference
-transference as experienced by
the nurse
- occurs when the therapist
displaces onto the client attitudes or
feelings from his or her past. For
example, a female nurse who has
teenage children and who is experiencing
extreme frustration with an adolescent
client may respond by adopting a
parental or chastising tone. The nurse is
countertransfering her own attitudes and
feelings toward her children onto the
client.
Nurses
can
deal
with
countertransference by examining their
own feelings and responses, using selfawareness, and talking with colleagues.
INDIVIDUAL THERAPIES
Common
Problem
Encountered
while in a N-P Relationship
Transference
-the development of an emotional
attitude of the client either positive or
negative towards the nurse
- occurs when the client
displaces onto the therapist attitudes and
feelings
that the client originally experienced in
other relationships (Gabbard, 2000).
Transference patterns are automatic and
unconscious
in
the
therapeutic
relationship. For example, an adolescent
female client working with a nurse who is
about the same age as the teen’s parents
might react to the nurse like she reacts
1. Psychoanalysis
- Sigmund Freud (1856–1939; Fig.
3-1)
developed
psychoanalytic
theory,
several
other
noted
psychoanalysts and theorists
have contributed to this body of
knowledge, but Freud is its
undisputed founder. Many clinicians
and theorists did not agree with
much of Freud’s psychoanalytic
theory and later developed their
own theories and styles of
treatment.
-Psychoanalytic theory supports the
notion that all human behavior is caused
and can be explained (deterministic
theory). Freud believed that repressed
(driven from conscious awareness)
1
sexual impulses and desires motivated
much human behavior. He developed his
initial ideas and explanations of human
behavior from his experiences with a few
clients, all of them women who displayed
unusual behaviors such as disturbances
of sight and speech, inability to eat, and
paralysis of limbs. These symptoms had
no physiologic basis, so Freud considered
them to be the “hysterical” or neurotic
behavior of women.
-After several years of working with these
women, Freud concluded that many of
their problems resulted from childhood
trauma or failure to complete tasks of
psychosexual
development.
These
women repressed their unmet needs and
sexual feelings as well as traumatic
events. The “hysterical” or neurotic
behaviors resulted from these unresolved
conflicts.
-Personality Components: Id, Ego,
and Superego.
Freud
conceptualized
personality
structure as having three components:
id, ego, and superego. The id is the part
of one’s nature that reflects basic or
innate desires such as pleasure-seeking
behavior, aggression, and sexual
impulses. The
id seeks
instant
gratification;
causes
impulsive,
unthinking behavior; and has no regard
for rules or social convention. The
superego is the part of a person’s nature
that reflects moral and ethical concepts,
values, and parental and social
expectations; therefore, it is in direct
opposition to the id. The third
component, the ego, is the balancing or
mediating force between the id and the
superego. The ego represents mature
and adaptive behavior that allows a
person to function successfully in the
world.
-Freud believed that anxiety resulted
from the ego’s attempts to balance the
impulsive instincts of the id with the
stringent rules of the superego. The
accompanying drawing demonstrates the
relationship
of
these
personality
structures.
- Behavior Motivated by Subconscious
Thoughts and Feelings. Freud believed
that the human personality functions at
three levels of awareness: conscious,
preconscious,
and
unconscious
(Gabbard, 2000). Conscious refers to the
perceptions, thoughts, and emotions that
exist in the person’s awareness such as
being aware of happy feelings or thinking
about a loved one. Preconscious
thoughts and emotions are can recall
them with some effort—for example, an
adult remembering what he or she did,
thought, or felt as a child. The
unconscious is the realm of thoughts
and feelings that motivate a person, even
though he or she is totally unaware of
them. This realm includes most defense
mechanisms (see discussion below) and
some instinctual drives or motivations.
-According to Freud’s theories, the
person represses into the unconscious
the memory of traumatic events that are
too painful to remember. Freud believed
that much of what we do and say is
motivated by our subconscious thoughts
or feelings (those in the preconscious or
unconscious level of awareness). A
“Freudian slip” is a term we commonly
use to describe slips of the tongue—for
example, saying, “You look portly today”
to an overweight friend instead of, “You
look pretty today.” Freud believed these
“slips”
were
not
accidents
or
2
coincidences;
rather,
they
were
indications of subconscious feelings or
thoughts that accidentally emerged in
casual dayto- day conversation.
- Freud’s Dream Analysis. Freud believed
that a person’s dreams reflected his or
her subconscious and had significant
meaning, although sometimes the
meaning was hidden or symbolic
(Gabbard, 2000).
-Dream analysis, a primary method
used in psychoanalysis, involves
discussing a client’s dreams to
discover their true meaning and
significance. For example, a client
might report having recurrent,
frightening dreams about snakes
chasing her. Freud’s interpretation
might be that the woman fears
intimacy with men; he would view
the snake as a phallic symbol,
representing the penis.
-Another method used to gain
access to subconscious thoughts
and feelings is free association in
which the therapist tries to uncover
the client’s true thoughts and
feelings by saying a word and
asking
the client to respond quickly with
the first thing that comes to mind.
Freud believed that such quick
responses would be likely to
uncover subconscious or repressed
thoughts or feelings.
-Ego Defense Mechanisms. Freud
believed the self or ego used ego defense
mechanisms, which are methods of
attempting to protect the self and cope
with basic drives or emotionally painful
thoughts, feelings, or events. Defense
mechanisms are explained in Table 3-1.
For example, a person who has been
diagnosed with cancer and told he has 6
months to live but refuses to talk about
his illness is using the defense
mechanism of denial, or refusal to accept
the reality of the situation. If a person
dying of cancer exhibits continuously
cheerful behavior, he could be using the
defense mechanism of reaction formation
to protect his emotions. Most defense
mechanisms operate at the unconscious
level of awareness, so people are not
aware of what they are doing and often
need help to see the reality.
-Five
Stages
of
Psychosexual
Development. Freud’s based his theory of
childhood development on the belief that
sexual energy, termed libido, was the
driving force of human behavior. He
proposed that children progress through
five
stages
of
psychosexual
development: oral (birth to 18 months),
anal (18 to 36 months), phallic /oedipal
(3 to 5 years), latency (5 to 11 or 13
years), and genital (11 to 13 years).
-Psychopathology results when a person
has difficulty making the transition from
one stage to the next, or when a person
remains stalled at a particular stage or
regresses to an earlier stage. Freud’s
open discussion of sexual impulses,
particularly in children, was considered
shocking for his time (Gabbard, 2000).
- focuses on discovering the causes of
the client’s unconscious and repressed
thoughts, feelings, and conflicts believed
to cause anxiety and helping the client to
gain insight into and resolve these
conflicts and anxieties. The analytic
3
therapist uses the techniques of free
association, dream analysis, and
interpretation of behavior.
-Psychoanalysis is still practiced today
but on a very limited basis. Analysis is
lengthy with weekly or more frequent
sessions for several years. It is costly and
not covered by conventional health
insurance programs; thus, it has become
known as “therapy for the wealthy.”









Addiction
Relationship/Family/Work Conflicts
Sleep Disorders
Anxiety
Depression
Post-Traumatic
Stress
Disorder
(PTSD)
Grief and Loss of a Loved One
Cessation of Smoking
Weight Loss
The two main methods of hypnotherapy
are suggestion therapy and analysis.
Hypnotherapy
-a therapeutic modality which involves
various methods
and techniques to
induce a trance state where the patient
becomes submissive to instructions.
-Hypnotherapy, also referred to as
guided hypnosis, is a form of
psychotherapy that uses relaxation,
extreme concentration, and intense
attention to achieve a heightened state
of consciousness or mindfulness. In other
words, it places the individual into a
“trance” or altered state of awareness.
This form of therapy is considered
alternative medicine with the purpose of
utilizing one’s mind to help reduce or
alleviate a variety of issues, such as
psychological distress, phobias, and
unhealthy, destructive, or dangerous
habits (i.e. smoking and/or drinking).
The aim of hypnotherapy is to create a
positive change in an individual, while
he/she is in a state of unconsciousness or
slumber (sleep).
Hypnotherapy is used to treat a wide
range of conditions, issues, and
unwanted/unhealthy behaviors, such as:

Phobias
What is suggestion therapy?
Suggestion therapy relies on an
individual’s ability to respond to
suggestions and guidance from the
hypnotherapist or psychologist, while
he/she is in a “trance-like” or altered
state. This method is commonly used to
control or stop unwanted or unhealthy
behaviors like smoking, gambling, nailbiting,
and
excessive
eating. Studies have suggested that
it may also be beneficial for those with
chronic
pain.
Moreover, research indicates
that
suggestion
therapy may encourage
positive and healthy behaviors like selfmotivation and self-confidence.
Furthermore, this method may help
clients or patients “uncover” the
psychological root of a problem or
symptom, for instance, the root of one’s
social anxiety, depression, and/or past
trauma. It is important to understand
that feelings or memories associated with
trauma tend to “hide” in one’s
unconscious memory so that the
individual doesn’t remember (on a
conscious level) the trauma he/she
experienced.
4
What is analysis in hypnotherapy?
Analysis, on the other hand, has proven
extremely effective for “digging deep”
into the subconscious mind to retrieve
repressed memories or past trauma(s) –
all of which could be causing
psychological distress, mental health
conditions,
and/or
problematic
behaviors.
This method also referred to as
“regression therapy,” is more exploratory
in nature. In fact, the main goal of the
analysis is to determine the root cause,
issue, disorder, and/or symptom of an
individual’s distress.
During analysis, a psychologist first
hypnotizes the individual by putting
him/her into a relaxed state. Then,
he/she helps this individual explore past
event(s) in his/her life. The goal is to
probe the individual’s unconscious
memories of said event(s), so he/she can
move past them.
This method is not meant to cure or
directly
“change”
an
individual’s
behavior. Rather, the goal is to determine
the main cause of the individual’s distress
and treat it through psychotherapy.
Crisis Intervention
A crisis is a turning point in an individual’s
life that produces an overwhelming
emotional
response.
Individuals
experience a crisis when they confront
some life circumstance or stressor that
they cannot effectively manage through
use of their customary coping skills.
Caplan (1964) identified the stages of
crisis:
(1) the person is exposed to a stressor,
experiences anxiety, and tries to cope in
a customary fashion;
(2) anxiety increases when customary
coping skills are ineffective;
(3) the person makes all possible efforts
to deal with the stressor including
attempts at new methods of coping; and
(4) when coping attempts fail, the person
experiences
disequilibrium
and
significant distress.
Crises can occur in response to a variety
of life situations and events, and fall into
three categories:
• Maturational crises, sometimes called
developmental crises, are predictable
events in the normal course of life such
as leaving home for the first time, getting
married, having a baby, and beginning a
career.
• Situational crises are unanticipated or
sudden events that threaten the
individual’s integrity such as the death of
a loved one, loss of a job, and physical or
emotional illness in the individual of
family member.
• Adventitious crises, sometimes called
social crises, include natural disasters like
floods, earthquakes, or hurricanes; war;
terrorist attacks; riots; and violent crimes
such as rape or murder.
Note that not all events that result in
crisis are “negative” in nature. Events like
marriage, retirement, and childbirth are
often desirable for the individual but may
still present overwhelming challenges.
Aguilera (1998) identified three factors
that influence whether or not an
individual experiences a crisis: the
individual’s perception of the event; the
5
availability of emotional supports; and
the availability of adequate coping
mechanisms. When the person in crisis
seeks assistance, these three factors
represent a guide for effective
intervention. The person can be assisted
to view the event or issue from a
different perspective, for example, as an
opportunity for growth or change rather
than a threat. Assisting the person to use
existing supports or helping the individual
find new sources of support can decrease
the feelings of being alone or
overwhelmed. Finally, assisting the
person to learn new methods of coping
will help to resolve the current crisis and
give him or her new coping skills to use
in the future.
Crisis is described as self-limiting; that is,
the crisis does not last indefinitely but
usually exists for 4 to 6 weeks. At the end
of that time, the crisis is resolved in one
of three ways. In the first two, the person
either returns to his or her precrisis level
of functioning or begins to function at a
higher level; both are positive outcomes
for the individual.
The third resolution is that the person’s
functioning stabilizes at a level lower
than precrisis functioning, which is a
negative outcome for the individual.
Positive outcomes are more likely when
the problem (crisis response and
precipitating event or issue) is clearly and
thoroughly defined. Likewise, early
intervention is associated with better
outcomes. Persons experiencing a crisis
usually are distressed and likely to seek
help for their distress. They are ready to
learn and even eager to try new coping
skills as a way to relieve their distress.
This is an ideal time for intervention that
is likely to be successful. Hemingway,
Ashmore,
and
Askoorum
(2000)
identified two categories of crisis
intervention:
authoritative
and
facilitative.
Authoritative interventions are designed
to assess the person’s health status and
promote problem-solving such as
offering the person new information,
knowledge, or meaning; raising the
person’s self-awareness by providing
feedback about behavior; and directing
the person’s behavior by offering
suggestions or courses of action.
Facilitative interventions aim at dealing
with the person’s needs for empathetic
understanding such as encouraging the
person to identify and discuss feelings,
serving as a sounding board for the
person, and affirming the person’s selfworth. Techniques and strategies that
include a balance of these different types
of intervention are the most effective.
TREATMENT MODALITIES
Individual Psychotherapy
Individual psychotherapy is a method of
bringing about change in a person by
exploring his or her feelings, attitudes,
thinking, and behavior. It involves a oneto-one relationship between the therapist
and the client. People generally seek
this kind of therapy based on their
desire to understand themselves
and their behavior, to make
personal changes, to improve
interpersonal relationships, or to
get relief from emotional pain or
unhappiness. The relationship between
the client and the therapist proceeds
6
through stages similar to those of the
nurse–client relationship: introduction,
working,
and
termination.
Costcontainment measures mandated
by
health
maintenance
organizations and other insurers
may necessitate moving into the
working phase rapidly so the client
can get the maximum benefit
possible from therapy.
and area of specialization. State laws
regulate the practice and licensing of
therapists; thus, from state to state the
qualifications to practice psychotherapy,
the requirements for licensure, or even
the need for a license can vary. A few
therapists have little or no formal
education, credentials, or experience but
still practice entirely within the legal limits
of their state.
-The therapist–client relationship is key
to the success of this type of therapy.
The client and the therapist must be
compatible for therapy to be effective.
Therapists vary in their formal
credentials, experience, and model
of practice. Selecting a therapist is
extremely important in terms of
successful outcomes for the client. The
client must select a therapist whose
theoretical beliefs and style of therapy
are congruent with the client’s needs and
expectations of therapy. The client also
may have to try different therapists
to find a good match.
-A client can verify a therapist’s legal
credentials with the state licensing
board; state government listings are in
the local phone book. The Better
Business Bureau can inform consumers if
a particular therapist has been reported
to them for investigation. Calling the local
mental health services agency or
contacting the primary care provider is
another way for a client to check a
therapist’s credentials and ethical
practices.
-A therapist’s theoretical beliefs
strongly influence his or her style of
therapy (discussed earlier in this
chapter). For example, a therapist
grounded in interpersonal theory
emphasizes relationships, whereas
an existential therapist focuses on
the client’s self-responsibility.
-The nurse or other health care provider
who is familiar with the client may be in
a position to recommend a therapist or a
choice of therapists. He or she also may
help the client understand what different
therapists have to offer. The client should
select a therapist carefully and should ask
about the therapist’s treatment approach
GROUP THERAPY
In group therapy, clients participate in
sessions with a group of people. The
members share a common purpose and
are expected to contribute to the group
to benefit others and receive benefit from
others in return. Group rules are
established that all members must
observe. These rules vary according
to the type of group. Being a member
of a group allows the client to learn new
ways of looking at a problem or ways of
coping or solving problems and also helps
him or her to learn important
interpersonal skills. For example, by
interacting with other members,
clients often receive feedback on
how others perceive and react to
them and their behavior. This is
extremely important information
7
for many clients with mental
disorders, who often have difficulty
with interpersonal skills.
The therapeutic results of group therapy
(Yalom, 1995) include the following:
• Gaining new information or learning
• Gaining inspiration or hope
• Interacting with others
• Feeling acceptance and belonging
• Becoming aware that one is not alone
and that others share the same problems
• Gaining insight into one’s problems and
behaviors and how they affect others
• Giving of oneself for the benefit of
others (altruism)
Psychotherapy groups are often formal in
structure, with one or two therapists as
the group leaders. One task of the group
leader or the entire group is to establish
the rules for the group. These rules deal
with
confidentiality,
punctuality,
attendance, and social contact between
members outside of group time.
Therapy groups vary with different
purposes, degrees of formality, and
structures. Our discussion will include
psychotherapy groups, family therapy,
education groups, support groups, and
self-help groups.
There are two types of groups: open
groups and closed groups. Open
groups
are ongoing and run
indefinitely, allowing members to
join or leave the group as they need
to. Closed groups are structured to
keep the same members in the
group for a specified number of
sessions. If the group is closed, the
members decide how to handle
members who wish to leave the
group and the possible addition of
new group members (Yalom, 1995).
Psychotherapy Groups
Family Therapy
The goal of a psychotherapy group is for
members to learn about their behavior
and to make positive changes in their
behavior
by
interacting
and
communicating with others as a member
of a group. Groups may be organized
around a specific medical diagnosis,
such as depression, or a particular
issue
such
as
improving
interpersonal skills or managing
anxiety.
Group
techniques
and
processes are used to help group
members learn about their behavior with
other people and how it relates to core
personality traits. Members also learn
that they have responsibilities to others
and can help other members achieve
their goals (Alonso, 2000).
Family therapy is a form of group therapy
in which the client and his or her family
members participate. The goals include
understanding how family dynamics
contribute
to
the
client’s
psychopathology, mobilizing the family’s
inherent strengths and functional
resources, restructuring maladaptive
family
behavioral
styles,
and
strengthening family problem-solving
behaviors (Gurman & Lebow, 2000).
Family therapy can be used both to
assess and treat various psychiatric
disorders. Although one family
member usually is identified initially
as the one who has problems and
needs help, it often becomes
evident through the therapeutic
8
process that other family members
also have emotional problems
and difficulties.
therapist’s role, meaning that the
therapist both participates in and
observes the progress of the relationship.
Support Groups
The Therapeutic Community in 1953). In
the concept of therapeutic community or
milieu, the interaction among clients is
seen as beneficial, and treatment
emphasizes the role of this client-toclient interaction.
Support groups are organized to help
members who share a common problem
cope with it. The group leader
explores members’ thoughts and
feelings and creates an atmosphere
of acceptance so that members feel
comfortable expressing themselves.
Support groups often provide a safe
place for group members to express their
feelings of frustration, boredom, or
unhappiness and also to discuss common
problems and potential solutions. Rules
for support groups differ from those
in psychotherapy in that members
are allowed—in fact, encouraged—
to contact one another and socialize
outside the sessions. Confidentiality
may be a rule for some groups; the
members decide this. Support groups
tend to be open groups in which
members can join or leave as their needs
dictate. Common support groups include
those for cancer or stroke victims,
persons with AIDS, and family members
of someone who has committed suicide.
One national support group, Mothers
Against Drunk Driving (MADD), is for
family members of someone killed in a
car accident caused by a drunk driver.
Milieu Therapy
Sullivan envisioned the goal of treatment
as the establishment of satisfying
interpersonal relationships. The therapist
provides a corrective interpersonal
relationship for the client. Sullivan coined
the term participant observer for the
-Until this time, it was believed that the
interaction between the client and the
psychiatrist was the one essential
component to the client’s treatment.
Sullivan and later Jones observed
that interactions among clients in a
safe, therapeutic setting provided
great benefits to clients.
The concept of milieu therapy, originally
developed by Sullivan, involved clients’
interactions with one another; i.e.,
practicing interpersonal relationship
skills, giving one another feedback about
behavior, and working cooperatively as a
group to solve day-to-day problems.
-Milieu therapy was one of the
primary modes of treatment in the
acute hospital setting. In today’s
health care environment, however,
inpatient hospital stays are often
too short for clients to develop
meaningful relationships with one
another. Therefore, the concept of
milieu
therapy
receives
little
attention. Management of the
milieu or environment is still a
primary role for the nurse in terms
of providing safety and protection
for all clients and promoting social
interaction.
9
- Milieu therapy, meaning the total
environment and its effect on the client’s
treatment.
Individual
and
group
interactions focused on trust, selfdisclosure by clients to staff and one
another, and active participation in
groups. Effective milieu therapy
required long lengths of stay
because clients with more stable
conditions
helped
to
provide
structure and support for newly
admitted clients with more acute
conditions (McGihon, 1999).
PLAY THERAPY
Play therapy is a form of therapy
primarily geared toward children. In
this form of therapy, a therapist
encourages a child to explore life
events that may have an effect on
current circumstances, in a manner and
pace of the child's choosing, primarily
through play but also through
language.
Play therapy, can help individuals
communicate,
explore
repressed
thoughts and emotions, address
unresolved trauma, and experience
personal growth and is widely viewed
as an important, effective, and
developmentally
appropriate mental
health treatment.
HISTORY AND DEVELOPMENT OF
PLAY THERAPY
Though some of the earliest theories
and methods mentioned below are no
longer practiced and may not be
acceptable based on current research
and ethical standards, they did play a
part in advancing play therapy to the
extent that it is now regarded as an
established
therapeutic
approach.
Some
key
individuals
in
the
development of this therapy and their
contributions to the field include:
 Hermine Hug-Hellmuth, who
is widely regarded as the world’s
first psychoanalyst to specialize
in treating children and the first
person to use play as a form of
therapy. In 1921, she introduced
a formal play therapy process by
providing the children in her care
with the necessary materials to
express
themselves
and
advocated the use of play to
analyze children.
 Melanie Klein, who used play
as an analytic tool as well as a
means to attract the children she
worked
with
to
therapy. Klein believed
play
provided insight into a child’s
unconscious.
 David Levy, who developed a
therapeutic
approach
called
“release therapy” in 1938. This
was a structured approach that
encouraged a traumatized child
to engage in free play. The
therapist
then
gradually
introduced materials related to
the traumatic event, allowing the
child
to
re-experience
the stressful event and release
any
unresolved emotions or
actions.
 Joseph Soloman, who used an
approach called “active play” to
assist children who displayed
impulsivity and a tendency to act
out. The approach was based on
Soloman’s belief that expressing
emotions
such
as fear and anger in play would
result in more socially acceptable
behavior.
10
Anna Freud, who presented
theoretical arguments for the
use of play as a means to build a
positive relationship between the
child and therapist, thus allowing
the therapist better access to a
child’s inner thoughts and
emotions.
 Carl
Rogers,
who
developed person-centered
therapy during the 1940s and
1950s. This type of therapy
emphasizes the importance of
genuineness,
trust,
and
acceptance in the therapeutic
relationship.
 Virginia Axline, who developed
nondirective play therapy by
modifying Rogers’ approach into
a play therapy technique that
was more appropriate for
children.
 Roger Phillips, who posited the
idea
to
combine cognitive
therapy and play therapy in the
early 1980s. Cognitive behavioral
play therapy has been used to
treat children as young as two
years old.
THE NEUROSCIENCE BEHIND THE
IMPORTANCE OF PLAY
Though play is often regarded
simply as a way for individuals,
particularly children, to relax,
scientific research has proven that
play is a crucial factor in healthy
child development. Studies show
that newborn babies possess billions
of brain cells; however, these young
cells
lack
the
complex
neural
interconnectivity that is characteristic
of a mature, fully-functional human
brain. Neuroscience has revealed that
the majority of the brain’s growth takes

place within the first five years of a
child’s life, and the act of play
contributes significantly toward the
development
of
interconnections
between neurons. These neural links
play a major role in key areas of the
child’s life, such as learning, social
development, emotional development,
and memory.
Play is considered to be especially
important
for
the
healthy
development of children who have
experienced stressful events or
past trauma. While the effects of
trauma tend to reside in the
nonverbal areas of the brain—
the hippocampus, amygdala,
thalamus, and brain stem—a
person’s capacity to communicate
and process adverse issues resides
in the brain’s frontal lobes. As a
result, children affected by trauma
may find it difficult to let other
people know that they need help.
The physical and role-playing activities
associated with play therapy have
proven instrumental in helping to move
traumatic memories and sensations
from the nonverbal brain areas to the
frontal lobes.
HOW DOES PLAY THERAPY WORK?
When children are experiencing
adverse personal issues they will
often act out or engage in
inappropriate behavior. Parents
may be eager to help but may find
it difficult or impossible to offer
effective aid if a child is unable or
unwilling to discuss the problem.
Play therapy is thought to be one
of the most beneficial means of
helping
children
who
are
experiencing
emotional
or
11
behavioral challenges. Though the
approach may benefit people of all
ages, it is specially designed to treat
children under 12. A typical session
may last for 30-45 minutes and may be
conducted with one child only or
in groups.
During treatment, the therapist
creates
a
comfortable,
safe
environment in which the child is
allowed to play with as few limits
as possible. This counseling space
is often referred to as a playroom,
and it comes equipped with a
selection of specifically chosen
toys that are meant to encourage
the child to express his or her
feelings and develop healthier
behaviors. The child’s interactions
with these toys essentially serve
as the child’s symbolic words. This
allows the therapist to learn about
specific thoughts and emotions
that a child may find difficult or
impossible to express verbally.
Toys used in therapy may include a
sandbox with associated miniature
figurines, art materials, Legos or
other construction toys, costumes
or other clothing, stuffed animals,
dolls, a dollhouse with miniature
furniture, puppets, indoor sports
equipment, and other indoor
games. The therapist may also
incorporate the use of tools and
techniques
such
as
clay,
therapeutic storytelling, music,
dance and movement, drama/role
play, and creative visualization.
At first children in therapy are generally
allowed to play as they wish. As
treatment progresses, the therapist
may begin to introduce specific items or
play activities which are related to the
issues the child is facing. Play therapy
may benefit the child in a variety of
ways such as encouraging creativity,
promoting healing from traumatic
events, facilitating the expression of
emotions,
encouraging
the
development of positive decisionmaking skills, introducing new ways of
thinking and
behaving, learning
problem-solving
skills,
developing
better social skills, and facilitating the
communication of personal problems or
concerns.
Play therapy may be nondirective or
directive. Nondirective play therapy
is grounded in the idea that if
allowed
optimal
therapeutic
conditions and the freedom to
play, children in therapy will be
able to resolve issues on their own.
This approach is viewed as nonintrusive since there is minimal
instruction from the therapist
regarding how a child should
engage in play. Directed play
therapy involves much greater
input from the therapist and is
based on the belief that faster
therapeutic
results
may
be
obtained than in nondirective play
therapy sessions.
PLAY THERAPY FOR ADULTS
Play therapy can also be used to treat
issues faced by teenagers and adults.
By adulthood, most people have
lost their ability to playfully
explore
themselves.
Play
therapists are trained to help
adolescents, adults, and even the
elderly relearn the values of play.
Playful exploration has been proven to
enhance both cognitive and physical
behaviors, and there is a significant
12
amount of research from the fields of
neurophysiology and molecular biology
that supports play therapy as a valid
therapeutic technique for those past
childhood. A growing number of
organizations
and
experts
are
dedicated to play research and
advocacy, believing that play is
important for people of all ages.
Play has been shown to optimize
learning, enhance relationships, and
improve health and well-being. Adults
and children engaged in a
therapeutic alliance that focuses
on play have an opportunity to
choose from a variety of modalities
such
as
movement
(body
play), sand play, dream play,
nature play, social play, pretend
(fantasy) play, creative play,
storytelling, and vocal play. Play
therapy may be used to address a
variety
of
health
challenges
experienced by adults, especially if
incorporated with other treatment
modalities. One of the most
significant benefits is that play can
provide a comfortable and safe
environment that may prompt an adult
to approach more serious issues.
Play therapy can be used to treat (in
children or adults):
 Dementia
 Grief and loss
 Posttraumatic stress
 Obsessions and compulsions
 Attention deficit hyperactivity
 Mood issues
 Anxiety
 Depression
 Developmental issues
 Arrested emotional development
GUIDELINES FOR EFFECTIVE PLAY
THERAPY
Play therapy has proven to be an
effective therapeutic approach for
people from all age groups, though
minors respond particularly well to
this type of treatment. Therapists
may employ several general guidelines
and practices in treatment in order to
foster the greatest benefits for people
in their care.
When working with a child, a
therapist may provide adjunctive
therapy for adults who play key
roles in the child’s life. Throughout
therapy, the therapist will typically
place emphasis on the promotion of
mental
health
and
psychosocial
development, explaining treatment
plans to the person receiving treatment
and a child's legal guardians, if
necessary.
Therapists
may
also
coordinate treatment with doctors or
other health care professionals to
ensure that a child's welfare remains
the
treatment
priority.
If
inappropriately touched by a child in
treatment, the therapist may find it
best to explain that it is important that
each person’s body is respected,
document the event, then discuss the
situation with the child's legal
guardians at the earliest opportunity. A
therapist may also find it necessary to
make arrangements to prevent the
child, or any person they are treating,
from feeling abandoned, should there
be a break in treatment.
Attitude Therapy
Dr. Folsom says” There is no such thing
as hopelessly ill mental pt.
Kind firmness – for depressed pts.,
made to work and says no but therapist
is firm
Active friendliness- for avoidant
13
personality d/o, schizophrenia, schizoid,
socially withdrawn
Passive friendliness- for paranoid pts.,
let them do things for themselves
No demand – for violent patients
Matter of fact- concerned with facts
For antisocial personality disorders,
Narcissistic(self love)
Watchfulness- suicidal clients
Indulgence –severely depressed clients
Electroconvulsive Therapy
Psychiatrists may use electroconvulsive
therapy (ECT) to treat depression in
select groups such as clients who do not
respond to antidepressants or those who
experience intolerable side effects at
therapeutic doses (particularly true for
older adults). In addition, pregnant
women can safely have ECT with no
harm to the fetus. Clients who are
actively suicidal may be given ECT if
there is concern for their safety while
waiting weeks for the full effects of
antidepressant medication.
ECT involves application of electrodes to
the head of the client to deliver an
electrical impulse to the brain; this
causes a seizure. It is believed that
the
shock
stimulates
brain
chemistry to correct the chemical
imbalance
of
depression.
Historically clients did not receive
any anesthetic or other medication
prior to ECT, and they had fullblown grand mal seizures that often
resulted in injuries from biting the
tongue to broken bones (Challiner &
Griffiths, 2000). ECT fell into
disfavor for a period and was seen
as “barbaric.”
Today although ECT is administered
in a safe and humane way with
almost no injuries, there are still
critics of the treatment.
Clients usually are given a series of 6 to
15 treatments scheduled 3 times a week.
Generally a minimum of 6 treatments is
needed to see sustained improvement in
depressive
symptoms.
Maximum
benefit is achieved in 12 to 15
treatments.
Preparation of a client for ECT is similar
to preparation for any outpatient minor
surgical procedure. The client is NPO
after midnight, removes any fingernail
polish, and voids just prior to the
procedure.
An IV is started for the administration of
medication. Initially the client receives a
short-acting anesthetic so he or she is not
awake during the procedure. Next he or
she receives a muscle relaxant, usually
uccinylcholine, that relaxes all muscles
to reduce greatly the outward signs of
the seizure (e.g., clonic, tonic muscle
contractions). Electrodes are placed on
the client’s head: one on either side
(bilateral), or both on one side of the
head
(unilateral).
The
electrical
stimulation is delivered, which causes
seizure activity in the brain that is
monitored by an electroencephalogram
(EEG). The client receives oxygen and is
assisted to breathe with an ambu bag. He
or she generally be- gins to waken after
a few minutes. Vital signs are monitored,
and the client is assessed for the return
of a gag reflex.
Following ECT treatment, the client
may
be mildly
confused
or
14
disoriented briefly. He or she is very
tired and often has a headache. The
symptoms are just like those of
anyone who has had a grand mal
seizure. In addition, the client will
have some shortterm memory
impairment.
Following a treatment, the client
may eat as soon as he or she is
hungry and usually will sleep for a
period. Headaches are treated
symptomatically.
Unilateral ECT results in less
memory loss for the client, but more
treatments may be needed to see
sustained improvement. Bilateral
ECT
results
in
more
rapid
improvement but with increased
shortterm memory loss.
Studies regarding the efficacy of
ECT are as divided as the opinions
about its use. Some studies report
that ECT is as effective as
medication for depression, while
other studies report only short-term
improvement.
Likewise,
some
studies report that side effects of
ECT are short-lived, while others
report they are serious and longterm (Challiner, & Griffiths, 2000).
15