I.

LEARNING CONTENT

TREATMENT MODALITIES
A treatment modality is a title given to the variety of different treatment types for helping those with mental health
issues. Treatment modality is interchangeable with "treatment approach" or "treatment type".

Mental illness treatment can take place in a variety of settings and typically involves a multidisciplinary team of
providers such as counselors, psychologists, psychiatrists, nurses, mental health aides, and peer support professionals.
Recent changes in health care and reimbursement have affected mental health treatment, as they have all areas of
medicine, nursing, and related health disciplines. Inpatient treatment is often the last, rather than the first, mode of
treatment for mental illness. Current treatment reflects the belief that it is more beneficial and certainly more cost
effective for clients to remain in the community and receive outpatient treatment whenever possible. The client can
often continue to work and can stay connected to family, friends, and other support systems while participating in
therapy. Outpatient therapy also takes into account that a person’s personality or behavior patterns, such as coping
skills, styles of communication, and level of self-esteem, gradually develop over the course of a lifetime and cannot be
changed in a relatively short inpatient course of treatment. Hospital admission is indicated when the person is severely
depressed and suicidal, severely psychotic, experiencing alcohol or drug withdrawal, or exhibiting behaviors that require
close supervision in a safe, supportive environment.

A. 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 one-to-one relationship between the therapist and the client. Individual therapy is a
form of talk therapy where an individual works one on one with a therapist to address unresolved feelings, traumas,
and mental health problems using a variety of different strategies and approaches. 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 through stages similar to those of the nurse–client relationship: introduction, working, and
termination. Cost-containment 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.
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 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 and area of specialization.

Groups
A group is a number of persons who gather in a face-to-face setting to accomplish tasks that require cooperation,
collaboration, or working together. Group therapy is typically led by a therapist and consists of a various number of
participants. Group therapy is usually focused on specific topics that everyone in the group is working on. For example,
a therapist may lead a group therapy session on anger management, postpartum depression, or suicide. Each person in
a group is in a position to influence and to be influenced by other group members. Group content refers to what is said
in the context of the group, including educational material, feelings and emotions, or discussions of the project to be
completed. Group process refers to the behavior of the group and its individual members, including seating
arrangements, tone of voice, who speaks to whom, who is quiet, and so forth. Content and process occur continuously
throughout the life of the group.
Stages of Group Development
A group may be established to serve a particular purpose in a specified period such as a work group to complete an
assigned project or a therapy group that meets with the same members to explore ways to deal with depression. These
groups develop in observable stages. In the pregroup stages, members are selected, the purpose or work of the group is
identified, and group structure is addressed. Group structure includes where and how often the group will meet,
identification of a group leader, and the rules of the group—for example, whether individuals can join the group after it
begins, how to handle absences, and expectations for group members.

The beginning stage of group development, or the initial stage, commences as soon as the group begins to meet.
Members introduce themselves, a leader can be selected (if not done previously), the group purpose is discussed, and
rules and expectations for group participation are reviewed. Group members begin to “check out” one another and the
leader as they determine their levels of comfort in the group setting.

The working stage of group development begins as members begin to focus their attention on the purpose or task the
group is trying to accomplish. This may happen relatively quickly in a work group with a specific assigned project but
may take two or three sessions in a therapy group because members must develop some level of trust before sharing
personal feelings or difficult situations. During this phase, several group characteristics may be seen. Group
cohesiveness is the degree to which members work together cooperatively to accomplish the purpose. Cohesiveness is
a desirable group characteristic and is associated with positive group outcomes. It is evidenced when members value
one another’s contributions to the group; members think of themselves as “we” and share responsibility for the work of
the group. When a group is cohesive, members feel free to express all opinions, positive and negative, with little fear of
rejection or retribution. If a group is “overly cohesive,” in that uniformity and agreement become the group’s implicit
goals, there may be a negative effect on the group outcome. In a therapy group, members do not give one another
needed feedback if the group is overly cohesive. In a work group, critical thinking and creative problem-solving are
unlikely, which may make the work of the group less meaningful.

Some groups exhibit competition, or rivalry, among group members. This may positively affect the outcome of the
group if the competition leads to compromise, improved group performance, and growth for individual members. Many
times, however, competition can be destructive for the group; when conflicts are not resolved, members become
hostile, or the group’s energy is diverted from accomplishing its purpose to bickering and power struggles.

The final stage, or termination, of the group occurs before the group disbands. The work of the group is reviewed, with
the focus on group accomplishments or growth of group members or both, depending on the purpose of the group.

Observing the stages of group development in groups that are ongoing is difficult with members joining and leaving the
group at various times. Rather, the group involvement of new members as they join the group evolves as they feel
accepted by the group, take a more active role, and join in the work of the group. An example of this type of group
would be Alcoholics Anonymous(AA), a self-help group with stated purposes. Members may attend Alcoholics
Anonymous meetings as often or infrequently as they choose; group cohesiveness or competition can still be observed
in ongoing groups.

Group Leadership
Groups often have an identified or formal leader— someone designated to lead the group. In therapy groups and
education groups, a formal leader is usually identified based on his or her education, qualifications, and experience.
Some work groups have formal leaders appointed in advance, whereas other work groups select a leader at the initial
meeting. Support groups and self-help groups usually do not have identified formal leaders; all members are seen as
equals. An informal leader may emerge from a “leaderless” group or from a group that has an identified formal leader.
Informal leaders are generally members recognized by others as having the knowledge, experience, or characteristics
that members admire and value.

Effective group leaders focus on group process as well as on group content. Tasks of the group leader include giving
feedback and suggestions; encouraging participation from all members (eliciting responses from quiet members and
placing limits on members who may monopolize the group’s time); clarifying thoughts, feelings, and ideas; summarizing
progress and accomplishments; and facilitating progress through the stages of group development.

Group Roles
Roles are the parts that members play within the group. Not all members are aware of their “role behavior,” and
changes in members’ behavior may be a topic that the group will need to address. Some roles facilitate the work of the
group, whereas others can negatively affect the process or outcome of the group. Growth-producing roles include the
information seeker, opinion seeker, information giver, energizer, coordinator, harmonizer, encourager, and elaborator.
Growth-inhibiting roles include the monopolizer, aggressor, dominator, critic, recognition seeker, and passive follower.

B. 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, which 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 with 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
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).

Therapy groups vary with different purposes, degrees of formality, and structures. Our discussion includes
psychotherapy groups, family therapy, family education, education groups, support groups, and self-help groups.

1. Psychotherapy Groups
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
they have responsibilities to others and can help other members achieve their goals.

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.
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).
2. Family Therapy
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 (Sadock & Sadock, 2008). Family therapy can be used both to
assess and to 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 process that other
 family members also have emotional problems and difficulties. Family therapy is a form of psychotherapy
where family members meet with a therapist to resolve issues. Family therapy is often conducted by a licensed
marriage and family therapist (MFT) who specializes in family therapy.
3. Family Education
The National Alliance for the Mentally Ill (NAMI) developed a unique 12-week Family-to-Family Education
Course taught by trained family members. The curriculum focuses on schizophrenia, bipolar disorder, clinical
depression, panic disorder, and obsessive–compulsive disorder. The course discusses the clinical treatment of
these illnesses and teaches the knowledge and skills that family members need to cope more effectively. The
specific features of this education program include emphasis on emotional understanding and healing in the
personal realm and on power and action in the social realm. NAMI also conducts Provider Education Programs
taught by two consumers, two family members, and a mental health professional who is also a family member
or consumer. This course is designed to help providers realize the hardships that families and consumers endure
and to appreciate the courage and persistence it takes to live with and recover from mental illness (NAMI,
2008).
4. Education Groups
The goal of an education group is to provide information to members on a specific issue—for instance, stress
management, medication management, or assertiveness training. The group leader has expertise in the subject
area and may be a nurse, therapist, or other health professional. Education groups usually are scheduled for
specific number of sessions and retain the same members for the duration of the group. Typically, the leader
presents the information and then members can ask questions or practice new techniques. In a medication
management group, the leader may discuss medication regimens and possible side effects, screen clients for
side effects, and in some instances, actually administer the medication (e.g., depot injections of haloperidol
[Haldol] decanoate or fluphenazine [Prolixin] decanoate).
5. Support Groups
Support groups are organized to help members who share a common problem to 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.
6. Self-Help Groups
In a self-help group, members share a common experience, but the group is not a formal or structured therapy
group. Although professionals organize some self-help groups, many are run by members and do not have a
formally identified leader. Various self-help groups are available. Some are locally organized and announce their
meetings in local newspapers. Others are nationally organized, such as Alcoholics Anonymous, Parents Without
Partners, Gamblers Anonymous, and Al-Anon (a group for spouses and partners of alcoholics), and have
national headquarters and Internet websites. Most self-help groups have a rule of confidentiality: whoever is
seen and whatever is said at the meetings cannot be divulged to others or discussed outside the group. In many
12-step programs, such as Alcoholics Anonymous and Gamblers Anonymous, people use only their first names
so their identities are not divulged (although in some settings, group members do know one another’s names).
OTHER TREATMENT MODALITIES:

1. Remotivation Therapy
Remotivation is a small group therapeutic modality objective in nature, designed to help clients by promoting
self-esteem, awareness, and socialization. It is a technique of simple group therapy of an objective nature, used
with a group of patients in an effort to reach the ‘unwounded’ areas of the patients’ personality and to get
them thinking about reality in relation to themselves.

Goal of Remotivation Therapy:

5 Steps:
a. Climate Acceptance
Greet each client with a handshake. Do not be offended if they do not take your hand. Verbally say
something positive about the client: “What a nice smile you have today” “That color brings out the roses in
your cheeks”. “What a nice handshake, thank you”. This puts your resident at ease – they know you are
friendly and will not embarrass them or hurt them in any way. You must establish a trust factor. The
remotivator introduces himself/herself and welcomes each person on his or her arrival in a warm, friendly
manner and assists in finding a seat or wheelchair space in the circle. Acknowledging members by name and
giving attention to any aspect of their uniqueness (such as the clothing or haircut) must be guaranteed. It
could also allude to aspects related with the weather or other trivial but relevant subjects in order to
establish contact with participants. These observations must be pleasant and objective and serve to create
an atmosphere free of formality and tension.
b. Creating of bridge to reality
This is where you develop your bounce questions to eventually have the client state what the topic of the
session is. Also you select (or write) a poem/story/song to be shared with the group. The remotivator
introduces a general topic that would be relevant to the group. In the original technique, the linkages with
reality were promoted through the lecture of poetry about objective themes, following the assumptions of
bibliotherapy. Also texts from magazines and newspapers as well as citations can be used. The texts must
be simple, rhythmic, and related to the topic under exploration. Along with reading and analyzing a text,
visual aids, pictures, and other objects that are related to the topic can be used. It is important to ensure
that all participants have contact with the materials
c. Sharing the world we live in
This is where you begin to ask questions related to the topic. The remotivator must stimulate the group
members to think about the topic in relation to themselves and their realities. Here, the questions must call
for subjective aspects of the topic, such as the participants’ past experiences and reminiscences, personal
opinions, and points of view.
d. Appreciation for the work of the world
The remotivator develops the topic through planned, open-ended, factual, and objective questions,
promoting discussion and interaction between participants. In order to keep the debate alive and to avoid
dispersion, questions must be successively placed. In line with the previous step, also at this one materials
appealing to the group members should be used.
 e. Climate of appreciation
The remotivator provides a brief summary of the session emphasizing the most important ideas exchanged
between participants. It is also time to express appreciation for the participants’ attendance and
contributions. The remotivator ends with information on the following session, inviting the group members,
and transmitting a sense of continuity. During the sessions the remotivator must not assume the role of a
lecturer. Instead, the remotivator must speak in a nonthreatening and nonjudgmental manner, regardless
of the participants’ response to the presented topic. An individual acknowledgement of each group
member’s contribution must take place (Sullivan et al. 2001). Along with the use of open-ended questions,
the remotivator seeks active listening, verbalizing appropriately in discussions, attentiveness to the activity,
ability to remain on task, responding to reality cues, accepting redirection, making an effort to
communicate with other group members, and demonstrating or expressing positive feelings in group (Erwin
2013).

2. Play Therapy- treatment modality which enables patient to experience intense emotions in a safe environment
with the use of play. Play therapy is a type of therapy that utilizes play as the method for communication
instead of the traditional talk therapy. It is most often used with children, but it can also be used with adults
regardless of age, ethnicity, or background. Play allows people to experiment with different roles, learn and try
new skills, and create or recreate events from life. Play therapy has been adapted to fit different theoretical
orientations and multicultural considerations, and it can be demonstrated through a variety of mediums and
formats. There is a lack of adequate information and research concerning play therapy. The purpose of this
paper is to review the current literature concerning play therapy with adults and provide further
recommendations.
3. Music Therapy- involves the use of music to facilitate relaxation, expression of feelings and outlet of tension. A
music therapy session may incorporate different elements, such as making music, writing songs, or listening to
music.
4. Milieu Therapy- manipulating the environment so that all aspects of the client’s hospital experience are
considered therapeutic.
5. Psychoanalysis – a method of psychotherapy which focuses on the exploration of the unconscious, to facilitate
identification of the patient’s defenses
6. Hypnotherapy- involves various methods and techniques to induce a trance state where the patient becomes
submissive to instructions
7. Humor Therapy- involve the use of humor to facilitate expression of feelings and to enhance interactions
8. Behavioral Modification- involves application of learning principles in order to change maladaptive behavior
Aversion Therapy- an example of behavior modification in which a painful stimulus is introduced to bring about
an avoidance of another stimulus with the end view of facilitating about behavioral change
9. Token-economy- a behavior modification technique which utilizes the principle of rewarding desired behavior
to facilitate change
10. Desensitization – periodic exposure of the individual to a feared object, until the undesirable behavior
disappears or is lessened
11. Cognitive Therapy- short-term structured therapy between the patient and the therapist oriented towards
present problems and solutions. The main focus of this therapy is a depressive disorder. Cognitive behavioral
therapy is the most common psychotherapeutic approach. It can be used on the individual, group, or family
level. CBT therapists help clients address unhealthy thoughts and behaviors by replacing them with realistic
self-talk and constructive behaviors.
12. Electroconvulsive Therapy (ECT)- is a medical treatment most commonly used in patients with severe major
depression or bipolar disorder that has not responded to other treatments. ECT involves a brief electrical
stimulation of the brain while the patient is under anesthesia. It is typically administered by a team of trained
medical professionals that includes a psychiatrist, an anesthesiologist, and a nurse or physician assistant.
Extensive research has found ECT to be highly effective for the relief of major depression. Clinical evidence
indicates that for individuals with uncomplicated, but severe major depression, ECT will produce substantial
improvement in approximately 80 percent of patients. It is also used for other severe mental illnesses, such as
bipolar disorder and schizophrenia. ECT is sometimes used in treating individuals with catatonia, a condition in
which a person can become increasingly agitated and unresponsive. A person with catatonia can seriously injure
themselves or develop severe dehydration from not eating or drinking. ECT is typically used when other
treatments, including medications and psychotherapy, haven’t worked. ECT is also used for people who require
a rapid treatment response because of the severity of their condition, such as being at risk for suicide. ECT’s
effectiveness in treating severe mental illnesses is recognized by the American Psychiatric Association, the
American Medical Association, the National Institute of Mental Health, and similar organizations in Canada,
Great Britain and many other countries. Although ECT can be very effective for many individuals with serious
mental illness, it is not a cure. To prevent a return of the illness, most people treated with ECT need to continue
with some type of maintenance treatment. This typically means psychotherapy and/or medication or, in some
circumstances, ongoing ECT treatments.

Indications:
o Patients who require rapid response
o Patients who cannot tolerate pharmacotherapy or cannot be exposed to pharmacotherapy
o Patients who are depressed but have not responded to multiple and adequate trials of medication
o Manic
o Catatonic schizophrenia
Contraindications:
o Fever
o Increased intracranial tumor
o Cardiac problems
o TB with history of hemorrhage
o Recent fracture
o Retinal detachment
o pregnancy
Complications:
o Loss of memory
o confusion
o Headache
o Apnea
o Fracture
o Respiratory depression
Preparations for ECT:
o Pretreatment evaluation and clearance
o Consent
o NPO from midnight until after the treatment
o Atropine Sulfate-to decrease secretions
o Succinylcholine (Anectine)- to promote muscle relaxation
o Methohexital Sodium(Brevital)- anesthethic agent
o Empty bladder
o Remove jewelry, hairpins, dentures and other accessories
o Check vital signs
o Attempt to decrease patient’s anxiety
Care after ECT:
o O2 therapy of 100% until patient can breathe unassisted
o Monitor for respiratory problems, gag reflex
o Reorient patient
o Observe until stable
o Careful documentation
o Monitor for male erectile dysfunction