PSYCHOSOCIAL THERAPIES Introduction

Psychological therapies and psychosocial interventions have gained momentum in the treatment of psychiatric disorders over the past three decades. This can be attributed to at least two main factors. First, there has been growing recognition of the importance of psychological processes in psychosis, both as contributors to onset and persistence, and in terms of the negative psychological impact of a diagnosis of schizophrenia on the individuals well -being, psychosocial functioning and life opportunities. Psychological and psychosocial interventions for psychosis have been developed to address these needs. Secondly, although pharmacological interventions have been the mainstay of treatment since their introduction in the 1950s, they have a number of limitations. These include limited response of some people to antipsychotic medication, high incidence of disabling side-effects and poor adherence to treatment. Recognition of these limitations, has paved the way for acceptance of a more broadly based approach, combining different treatment options, tailored to the needs of individual service users and their families. Such treatment options include psychological therapies and psychosocial intervention

Definition:

A method of treatment based on the development of intimate(therapeutic) relationship between client/patient and therapist for the purpose of exploring and modifying the client/patients behaviour in a satisfying direction ( Lego. S) A process in which a person who wishes to relieve symptoms or resolve problems in living or is seeking personal growth enters in implicit or explicit contract to interact in a prescribed way with a psychotherapist ( A Psychiatrist Glossary)

Aims of psychosocial therapies

The goals of psychological and psychosocial interventions are numerous.

Particular treatments may be intended to improve one or more of the following outcomes: 1. To decrease the persons vulnerability

2. Reduce the impact of stressful events and situations

3. Decrease distress and disability

4. Minimise symptoms 5.Improve the quality of life 6.Reduce risk 7.Improve communication and coping skills 8. Enhance treatment adherence. 9.Changing maladaptive behaviour patterns 10.Reducing environmental conditions that causes such behaviour

11. Improving interpersonal and other competencies 12.Helping the patient to resolve inner conflicts 13.Helping him to develop a sense of self-identity

Types of psychosocial therapies

Individual psychotherapy Behavioral psychotherapy Interpersonal psychotherapy Group psychotherapy Family therapy Marital therapy Milieu therapy The therapeutic community Occupational therapy Recreational therapy Play therapy Music therapy Biofeedback

 Guided imagery Relaxation therapy INDIVIDUAL PSYCHOTHERAPY Psychotherapy conducted on a one-to-one basis. The therapist treats one person at a time. The effectiveness of such a therapy depends upon the patient therapist relationship. Individual psychotherapy involves regularly scheduled sessions between the patient and a mental health professional. The goal of this treatment is to help individuals understand why they are acting and thinking in ways that are troubling or dangerous to themselves (or others). This allows a person to have more control over their behaviors and to change these behaviors when possible. . Talk-therapy sessions may focus on a person's current or past problems, experiences, thoughts, feelings or relationships. By sharing their experiences with a trained, knowledgeable, and understanding person, individuals with mental illnesses may gradually understand more about themselves and the problems they are facing.

Individual psychotherapy is used successfully to treat emotional, behavioral, and social problems in people with Schizophrenia Bipolar disorder Attention deficit hyperactivity disorder Depression Eating disorder Anxiety disorder

Types of individual psychotherapy Types of individual psychotherapy include Psychoanalysis Hypnosis Abreaction Reality therapy Uncovering and Supportive psychotherapy

PSYCHOANALYSIS Psychoanalysis was first developed by Sigmund Freud at the end of 19 th century. The most important indication for psychoanalytic therapy is the presence of long standing mental conflicts, which may be unconscious but produce symptoms. In psychoanalysis the focus is on the cause of the problem, which is buried in the unconscious. The therapist tries to take the patient into the past in an effort to determine where the problem began. The aim of the therapy is to bring all repressed material to conscious awareness so that the patient can worktoward a healthy resolution of problems which are causing symptoms

HYPNOSIS Hypnosis is a superficial or deep trance ( a somnolent state / sleep like)resembling sleep.Hypnosis is an artificially induced state in which the person is relaxed and usually suggestible and concentrating attention on a single object. The patient become highly suggestible, submissive and abandons control and response to the therapists influence.He can be induced to recall the forgotten events, gains relief from tension, anxiety and psychological symptoms. Hypnosis is considered to be effective in

obesity hypertension asthma smoking peptic ulcer over eating and other addictive disorders ABREACTION It is a therapeutic technique in which the patient talks about repressed emotions by reviving and relieving painful experiences that have been buried in the unconscious. It is most useful in acute neurotic conditions caused by extreme stress Although abreaction is an integral part of psychoanalysis and hypnosis, it can also be used independently REALITY THERAPY This is a psychotherapeutic technique which focuses on the present behavior and development of a patients ability to cope with the stresses of reality and take a greater responsibility for the fulfillment of his needs.

To achieve these purposes the therapist become involved in an active relationship with the patient, rejects his unrealistic behaviour and teaches better ways to meet his needs in the real world UNCOVERING OR INSIGHT PSYCHOTHERAPY This technique is used to break through the patients repressed conflicts and traumatic experience to the surface. It helps the patient in gaining an insight. The patient explores different methods to cope with the problem, once he gains an insight into his conflict or problem It is a form of surface therapy. The therapist help the patient to relieve emotional distress and symptoms without probing into the past or attempting to change the basic personality of the individual SUPPORTIVE PSYCHOTHERAPY Types of supportive psychotherapy Ventillation It is a free expression of feelings or emotions . The patient is allowed to talk freely whatever comes to the mind. It is also described as mental ventilation

 Environmental modification or manipulation A method of improving the well being of mental patients by changing their living conditions Persuation Persuasion psychotherapy is used in which the therapist attempts to modify his faulty behaviour by using his power of reasoning, will and self criticism Reeducation The patient learns more effective ways of dealing with problems and relationship through therapist patient relationship Reassurance It is a supportive approach that encourages the patient to believe that there are possibilities of improvement. It is also used to diminish anxiety
BEHAVIORAL PSYCHOTHERAPY

Its a form of psychotherapy which focuses on modifying faulty behaviour rather than basic changes in personality. By applying basic learning techniques the behavior therapist tries to eliminate symptoms and modify ineffective symptoms.

BEHAVIOR TECHNIQUES

Behavior modification It is also called Simple Extinction. Learned behavior becomes a waste or disappears if it is not reinforced. To eliminate a maladaptive behaviour one has to remove the reinforcement for it. Rewards are also provided to reduce the maladaptive learning.
Systematic desensitization It is developed by J. Wolpe and others. The objective of the therapy is to reduce or eliminate the fear or anxiety in which

the patient is trained in deep muscle relaxation he has various anxiety provoking situations or specific phobias. These problems are placed from the strongest to the weakest order. That is the client is anxious about which one is causing anxiety the least. Each of these situations is presented in imagination or in reality by starting with the weakest. Once the patient relaxes while imagining, that means the anxiety is getting reduced gradually

Aversion therapy It is a form of behavior therapy in which the Patient is conditioned to avoid an undesirable behavior or symptom by associating them with painful or pleasant experience. This is used for alcoholism and socially unacceptable behavior such as homosexuality Assertiveness Training It is a behavior technique in which the patient is given training to bring about change in emotional and other behavior patterns by asserting himself. In other words one is encouraged not to be afraid of showing an appropriate response, negative or positive to an idea or suggestion. This training is given for mentally healthy and mentally ill patient Cognitive behavior therapy It is a psychotherapeutic approach based on the idea that emotional problems in an individual arise due to faulty ways of thinking and distorted attitude towards oneself and others. The therapist takes the role of a guide who helps the patient to correct and revise his perceptions and thoughts. Thus helps the patient to change his thoug hts, feelings and behavior about himself.

Implosive therapy It is abehavior therapy technique opposite to systematic desensitization. It is also called FLOODING. In this therapy, an individual is exposed directly to maximum intensity fear producing situation either in imagination or in real life. The patient is gradually feels no actual danger in the situation Positive Reinforcement It is a stimulus or a stimulus situation which is given to the patient or individual after the response Positive reinforcement can be done by Response shaping Modelling Token economy

Response shaping Positive reinforcement is used in response shaping or incorporating or establishing a response which is not existing in an individuals behavior. This technique is used in behavior problem or mental retardation

Modelling Modelling is abehaviour therapy technique in which learning occurs through observation. The client watches someone else perform a particular action such as answering the telephone. Models are often parents or other adults and children Token economy It is a behavior therapy programme usually conducted in a hospital or classroom setting. In token economy the desired behavior is reinforced by offering tokens that can be exchanged for special foods, games, comics or other rewards

INTERPERSONAL PSYCHOTHERAPY

Interpersonal psychotherapy is a term used by J.L Morena for a type of psychotherapy in which there is emphasis on the interpersonal relationship of the various persons involved, such as husband, wife and one or more other parties The therapist actively teaches individuals to evaluate their interactions with others and to become aware of self-isolation and difficulties getting along with, relating to, or understanding others. He or she also offers advice and helps individuals make decisions about the best way to deal with other people.

Coleman J.C included marital therapy and family therapy and transaction analysis in interpersonal psychotherapy Marital Therapy This psychotherapy is aimed at improving a disturbed marital relationship. It is centred on efforts to change the psychodynamics and behaviour of the partners. The sessions are usually conjoint. Here insight is shared by the couple which may help them in a satisfactory marital relationship

Family therapy It is a type of group psychotherapy in which the family is a therapeutic unit. The objective of family therapy is not merely to modify home influences that contribute to the disorder of one or more family members. The therapist also encourages the members to communicate more meaningfully and handle their difficulties in a constructive manner. Changes in the individual behavior can only occur if there is a change in all the members of the family Transactional Analysis It is a form of interpersonal psychotherapy developed by Eric Berne. In a transactional analyses the interaction among group members and help the

participants understand the ego state in which they are communicating with each other. This provides an opportunity to an individual to reveal how we often unknowingly manipulate and harm other other people as well as ourselves. Interpersonal therapy is a psychosocial treatment used most frequently to help people with Bipolar disorder, ADHD, Depression, Eating disorders and Generalized anxiety disorder. It is often expected to last for approximately 3-4 months and to target specific symptoms over this time period.

GROUP THERAPY
Group psychotherapy is a treatment of psychological problems in which two or more patients interact with each other on both an emotional and cognitive levels in presence of one or more psychotherapies who serve as catalyst , facilitators or interpreters.

Three major kinds of group are : Group Therapy, Therapeutic groups and Adjunctive Groups Therapeutic group : Therapeutic group is a group of patients who meet under the leadership of a therapist to work together to improve mental and emotional health. Examplegroup of expectant mothers, group of people with a chronic illness. Adjunctive Groups : Adjunctive Groups deal with selected needs of a group. For example, for sensory stimulation allow them to have music therapy, for expression of feelings and emotions through dance therapy Group psychotherapy: Group psychotherapy members gain a personal insight improve their interpersonal relationship, change destructive behaviour and make necessary alteration in their behaviour. Types of psychotherapy groups Psychotherapy groups can be classified in various ways such as

1. Traditional groups 2. Encounter groups 3. Homogenous or heterogenous groups 4. Open or closed groups Group according to mental illness Traditional groups Traditional groups include the patient with mental illness and are from the hospital inpatient department. In the didactic group therapy, lecture is given to the patient along with some film show, like in the case of excessive drinking or use of drugs. Encounter Groups Encounter group is a form of small group in which the individual learns how his feelings and behavior affect him and others. This group is not necessarily a group with mental illness. The individual may have some coping difficulty which he would like to resolve at right time. Homogenous and Heterogenous Groups Homogenous groups are composed of patients of the same age, race, sex, socioeconomic level and similar category of illness. Heterogenous groups vary on all these aspect

Open Groups and Closed Groups In open groups members may join and leave the group at anytime. Closed groups have a specific number of people, specific time to start and close the group sessions; the duration is three to four weeks. Inpatients and outpatients both are included in this group

Group according to Mental illness Neurotic group or patients suffering from psychotic illnesses come under this category Steps of Group Therapy The steps of group therapy can differ from an individual group therapist to therapist. Some of the common steps are Selecting the members in a group Developing contact in a group Selection of group leader

Selecting the members in a group It is very important function of group therapist. She has to decide based on the condition of the patient who all can be included in the group Developing contact It is a very significant factor The purpose should be made clear to all the members in the group Time, length and place of the meeting should be announced Starting and ending time and how frequently the group sessions will be conducted Attendence of the members Confidentiality should be maintained within the group Role of members is : to report punctually, maintain confidentiality and interact freely Selection of Group Leaders Role of the therapist- therapist acts as a facilitator and helper. The goals of the nurse therapist as identified by De Mocker(1981) are : 1) To provide information to the group 2) Allow emotional catharsis

3) Share members perception 4) Share feelings of fear, lonliness and frustration 5) Improve communication skills 6) Provide a role model 7) Set limits for some patients

OTHER PSYCHOSOCIAL THERAPIES In other psychosocial therapies the major concepts included are milieu therapy/ therapeutic community and attitude therapy. MILEU THERAPY Mileu is derived from a French word, Mi means middle and lieu means place. So mileu means environment or setting. Therapeutic mileu mens providing a healthy environment which helps in the recovery of a patient. Most of the psychiatric illnesses occur because of an unhealthy environment. So therapeutic environment helps the patient to become socially productive individuals. Definition Mileu therapy or Therapeutic Community maximum use of approach attempts to make the

the social system and its constituents, personnel and the

hospital community to modify the patient behaviour so that he may manage his life and personal relationship in a more constructive manner.

Goals or purposes of therapeutic community To minimize antitherapeutic environment for the patient in the ward To minimize prolongation of hospitalization by helping in early recovery To minimize maladaptive behaviour To provide a free and favourable climate To help the patient to improve his self esteem

Principles of Milieu Therapy The essential principles of milieu therapy are 1) Therapeutic community is an approach used for the care of mentally ill patients through group activity 2) Democracy is observed in a hospital setting 3) The patient is involved in his own therapy which help him in decision making 4) Decision making ability improves the self confidence of patients

5) It provides an environment of free communication 6) Milieu therapy reduces social isolation 7) The patient feels of approaching the doctor 8) Continuous assessment should be made to evaluate the progress of a patient

Important aspects of therapeutic community Governing system Communication is open and free The patient and staff get frequent opportunities to participate in hospital administration Emphasis is upon social and group interaction with an individual, patient and staff A successful therapeutic community requires both the staff and the patient become fully aware of their roles The hospital units remain in close contact with outside agencies so that the patient can be provided with required information

Administrative Organization Therapeutic and antitherapeutic effect of milieu therapy will depend on the hospital setting. If the hospital organization believes in this type of approach for mentally ill patients, the effect can be achieved. Otherwise it is difficult for a unit to achieve the goals Advantages for the patient Milieu therapy creates a different type of attitude and behaviour in mthe patient because the environment is like home. Instead of adopting a sick role the patient makes decisions in the ward management and cares for other patients The patient learns to adopt a behaviour which is acceptable in the therapeutic environment The patient learns to make a decision which improves the self confidence Types of staff The types of staff are professional i.e Psychiatrist, nurse psychologist, technical staff, support personnel Role of Nurse Authoritarian role : when she controls the group and sets a limit

Social role : the nurse encourages support in various ways. Therapeutic role : By giving medication, maintaining therapeutic relationship

ATTITUDE THERAPY Definition Attitude therapy is a form of milieu therapy in which all staff members assume a consistent, prescribed attitude designed to be therapeutic towards patients Criteria for planning attitude therapy Attitude therapy is planned : When the patient is in the hospital for a long time The patient is interviewed to assess his emotional state and activity level Family members are interviewed to acquaint them with attitude therapy which will be used for the patient After this , a staff meeting is held in which all team members are present A clinical diagnosis is made by the psychiatrist A plan of attitude to be adopted for particular patients is discussed with purpose

 One principal line of approach at a time is used by all the team members Advantages of attitude therapy for patients Key and Hoffling have described the advantages of attitude therapy The patient start feeling that an organized approach is being used for his/her treatment Guesswork and haphazard plans by individual members of the team are reduced The patients problems or conflicts are solved in less time This approach also provides an opportunity for the members to explore, test and change the therapeutic attitude which will bring best results in patients It brings members of the team together to plan, work and evaluate each others efforts and to discover new ways of helping the patient

Cognitive behaviour therapy

Cognitive Behavioural Therapy is based on the premise that there is a relationship between thoughts, feelings and behaviour. Although Albert Ellis developed the first Cognitive Behavioural Therapy in the 1960s which he called Rational Emotive Behaviour Therapy, most Cognitive Therapy practiced in the present day

has its origins in the work of Aaron T Beck. Beck developed CBT for the treatment of depression in the 1970s. As with other psychological interventions, CBT depends upon the effective development of a positive therapeutic alliance . On the whole, the aim is to help the individual normalise and make sense of their psychotic experiences and to reduce the associated distress and impact on functioning. Definition Cognitive-behavioural therapy was defined as a discrete psychological intervention where:

recipients establish links between their thoughts, feelings or actions with respect to the current or past symptoms, and/or functioning; and

the re-evaluation of their perceptions, beliefs or reasoning relate to the target symptoms.

In addition, a further component of the intervention should involve the following:

recipients monitor their own thoughts, feelings or behaviours with respect to the symptom or recurrence of symptoms; and/or

the promotion of alternative ways of coping with the target symptom; and/or

the reduction of distress; and/or the improvement of functioning.

A CBT therapist will try to explore the links between the thoughts and emotions that occur prior to disruptive behaviors in people with mental illness. By establishing these connections, individuals learn to identify and change inappropriate or negative thought patterns and as a consequence, can address the behaviors associated with their illness. A common goal is to recognize negative thoughts or mind-sets (mental processes such as perceiving, remembering, reasoning, decision making, and problem solving) and to replace them with positive thoughts, which will lead to more appropriate and beneficial behavior. For instance, CBT tries to replace thoughts that lead to low self-esteem ("I can't do anything right") with positive expectations ("I can do this correctly"). This can often times involve homework to help an individual practice their skills in between treatment sessions. CBT is often thought of as a first-line treatment in many anxiety disorders (including OCD, Panic Disorder, and PTSD). Along with medication treatment, CBT can successfully help people with schizophrenia, bipolar disorder, ADHD,

depression, eating disorders, generalized anxiety disorder, panic disorder, OCD, substance abuse problems and other mental illnesses. PLAY THERAPY Play therapy is a form of counseling or psychotherapy that uses play to communicate with and help people, especially children, to prevent or resolve psychosocial challenges. This is thought to help them towards better social integration, growth and development Play therapy can also be used as a tool of diagnosis. A play therapist observes a client playing with toys (play-houses, pets, dolls, etc.) to determine the cause of the disturbed behavior. The objects and patterns of play, as well as the willingness to interact with the therapist, can be used to understand the underlying rationale for behavior both inside and outside the session.. Play therapy is generally employed with children aged 3 through 11 and provides a way for them to express their experiences and feelings through a natural, selfguided, self-healing process. As childrens experiences and knowledge are often communicated through play, it becomes an important vehicle for them to know and accept themselves and others.

History Play has been recognized as important since the time of Plato (429-347 B.C.) who reportedly observed, you can discover more about a person in an hour of play than in a year of conversation. In the eighteenth century Rousseau (1762/1930), in his book Emile wrote about the importance of observing play as a vehicle to learn about and understand children. Friedrich Frbel, in his book The Education of Man (1903), emphasized the importance of symbolism in play. He observed, play is the highest development in childhood, for it alone is the free expression of what is in the childs soul. childrens play is not mere sport. It is full of meaning and import. Hermine HugHellmuth (1921) formalized the play therapy process by providing children with play materials to express themselves and emphasize the use of the play to analyze the child. In 1919, Melanie Klein (1955) began to implement the technique of using play as a means of analyzing children under the age of six. Models of play therapy Play therapy can be divided into two basic types: Nondirective and Directive.

Nondirective play therapy is a non-intrusive method in which children are encouraged to work toward their own solutions to problems through play. It is typically classified as a psychodynamic therapy. In contrast, directive play therapy is a method that includes more structure and guidance by the therapist as children work through emotional and behavioral difficulties through play. It often contains a behavioral component and the process includes more prompting by the therapist. Directive play therapy is more likely to be classified as a type of cognitive behavioral therapy Nondirective play therapy Nondirective play therapy, also called client-centered and unstructured play therapy, is guided by the notion that if given the chance to speak and play freely under optimal therapeutic conditions, troubled children and young people will be able to resolve their own problems and work toward their own solutions. In other words, nondirective play therapy is regarded as non-intrusive. The hallmark of nondirective play therapy is that it has few boundary conditions and thus can be used at any age This therapy originates from Carl Rogers's non-directive psychotherapy and in his characterization of the optimal therapeutic conditions

Directive play therapy Directive play therapy is guided by the notion that using directives to guide the child through play will cause a faster change than is generated by nondirective play therapy. The therapist plays a much bigger role in directive play therapy. Therapists may use several techniques to engage the child, such as engaging in play with the child themselves or suggesting new topics instead of letting the child direct the conversation himself. Stories read by directive therapists are more likely to have an underlying purpose, and therapists are more likely to create interpretations of stories that children tell. In directive therapy games are generally chosen for the child, and children are given themes and character profiles when engaging in doll or puppet activities. This therapy still leaves room for free expression by the child, but it is more structured than nondirective play therapy. There are also different established techniques that are used in directive play therapy, including directed sandtray therapy and cognitive behavioral play therapy. OCCUPATIONAL THERAPY
Occupational therapy is a client-centered practice that places a premium on the progress towards the clients goals.[2] Occupational therapy interventions focus on adapting the environment, modifying the task, te

History

The earliest evidence of using occupations as a method of therapy can be found in ancient times. In c. 100 BCE, Greek physician Asclepiades initiated humane treatment of patients with mental illness using therapeutic baths, massage, exercise, and music. Later, the Roman Celsus prescribed music, travel, conversation and exercise to his patients. However by medieval times the use of these strategies with people considered to be insane was rare, if not nonexistent.[3] In 18th-century Europe, revolutionaries such as Philippe Pinel and Johann Christian Reil reformed the hospital system. Instead of the use of metal chains and restraints, their institutions utilized rigorous work and leisure activities in the late 18th century. This was the era of Moral Treatment, developed in Europe during the Age of Enlightenment, where the roots of occupational therapy lie.[4] Although it was thriving abroad, interest in the reform movement waxed and waned in the United States throughout the 19th century. It re-emerged in the early decades of the 20th century as Occupational Therapy.
aching the skill, and educating the client/family in order to increase participation in and performance of daily activities, particularly those that are meaningful to the clie

occupational therapy Toy making in psychiatric hospital worldwar1 era