Principles of Psychosocial Intervention

بسم ال الرحمن الرحيم

Nursing College

Master of community and mental health nursing

Psychosocial Intervention

Jan2010 Introduction

The Psychosocial Intervention is considered one of the important procedures in mental health field, particularly for nurses. It helps nurse who work in mental health field to involve a good services for mental patient. Now, the psychosocial intervention helps our to make multi- disciplinary team (Psychiatry-Nurse-Psychologist-Social worker,ect,,,,,,,).

The Psychosocial intervention consists (Stress vulnerability model, recovery, Assertive Community Treatment, Psychological Therapies, Early Intervention, Family Intervention, Crises Intervention, Training)

So,,, It is very important to know these parts to become a good psychosocial intervention for us particularly multi-disciplinary team .

I hope to involve this chapter in a good lecture for my teacher and my colleagues for useful from new information particularly in mental health.

1 Principles of psychosocial intervention : 1- Stress vulnerability model of serious mental illness. 2- Based on sound evidence. 3- A collaboration with the service user/patient. 4- Involved multi-disciplinary approach.

Stress vulnerability model . 1-Recognize factors or causes of stress which lead to illness. 2-Low stress versus high stress vulnerability. So,,,,,,,,,,,,,,,,,,,,, what causes the differences in people’s vulnerability?; and What makes one person more vulnerable than another ?

2 Genetics

Coping style

Thinking style

Environment

Social skills

Recovery.

People with schizophrenia, both with and without treatment, seemed to demonstrate recovery overtime (Warner 2003). The notion of recovery is now very helpful for providing a basis for care (Waldock 2006). The main element of recovery process has the experience of gaining a new and valued sense of self and purpose. Social support from friends, family and society for person with mental illness is very important for recovery to take place ( In eastern societies). In modern societies, stigma and social exclusion are seen as the main ways that recovery is compromised.

Recovery is now seen as central to mental health nursing

3 Assertive Community Treatment (ACT)

What Is Assertive Community Treatment?

Assertive Community Treatment (ACT) is a form of case management that is distinguished from more traditional case management by several important features.

First, rather than a case manager coordinating services, an ACT multi- disciplinary team provides services directly to an individual that are tailored to meet his/her specific needs.

An ACT team typically includes members from one of the fields of psychiatry, nursing, psychology, and social work with increasing involvement of substance abuse and vocational rehabilitation specialists.

Based on their various areas of expertise, the team members collaborate to deliver integrated services of the recipients' choice, monitor progress

4 towards goals, and adjust services over time to meet the recipient's changing needs.

The staff-to-recipient ratio is small (one clinician for every ten recipients versus one clinician for every 30 recipients in traditional case management), and services are provided 24-hours a day, seven days a week, for as long as they are needed.

ACT teams deliver comprehensive and flexible treatment, support, and rehabilitation services to individuals in their natural living settings. This means that interventions are carried out at the locations where problems occur and support is needed rather than in hospital or clinic settings. ACT teams share responsibility for the people they serve and use assertive engagement to proactively engage individuals in treatment.

Why Is Assertive Community Treatment Important?

 ACT improves recipient outcomes. Studies have shown that recipients who receive ACT services experience greater reductions in psychiatric hospitalization rates and a higher level of housing stability. Research has also shown that ACT is more satisfactory to recipients and their families and is no more expensive than other types of community-based care (Phillips et al., 2001).  Evidence of ACT's effectiveness has led mental health advocacy groups to endorse ACT as a key service with proven positive outcomes.

Distinguishing Features of Assertive Community Treatment (Phillips, et al. 2001) Multi-disciplinary team approach

ACT team consists of about six to eight staff members from the fields of psychiatry, nursing, and social work and professionals with other types of expertise, such as substance abuse treatment and vocational rehabilitation. Services are provided for as long as they are needed. The services are not brokered, rather the ACT team itself is the service delivery vehicle in the model.

Staff-to-recipient ratio of one to ten is recommended, although teams that serve populations that have particularly intensive needs may find that a lower ratio is necessary initially.

5 Sharing of caseloads

Team members share responsibility for the individuals served by the team.

Explicit admission criteria

Services are targeted to a specified group of individuals diagnosed with a severe mental illness. Treatment and support services are individualized.

Engagement measures

The team actively engages individuals in treatment and monitors their progress while respecting the recipient's right to choice and privacy.

Services are available on a 24-hour basis

Provision of services in recipients' natural living settings

Interventions are carried out at the locations where problems/issues occur and support is needed rather than in hospital or clinic settings.

Family, Recipient, Cultural Perspectives

The development of the descriptions for these OMH Priority Evidence- Based Practices included extensive involvement from clinical experts, recipients of mental health, family members, and people who represent culturally diverse viewpoints. Their perspectives are critical to the understanding of these important practices and programs in mental health.

Family Perspective

Historically, families of individuals diagnosed with a mental illness have served as de facto case managers, providing and coordinating care for their relatives when there are gaps in the system of services. This role often creates great strains on families who have to work; have responsibility for other family members; or who are elderly or disabled themselves. At local family support and education meetings, families often express their concerns about who will take care of their ill family member after they are gone. With ACT, families with a relative diagnosed with a mental illness have an easier time relating to one another as family members and have fewer concerns about the future.

Recipient Perspective

6 Research suggests that when people have adequate information regarding their options and are supported in their decision-making, they are likely to make healthier and more positive choices (Waller, 2001). The person who advocates for his/her choices in regards to services and/or course of treatment is likely to recovery more quickly (Waller, 2001). It is essential that ACT teams provide non-coercive services that are based on informed choice.

Cultural Perspective

Research has shown that minorities often receive their initial mental health treatment in the most restrictive environments or when help seeking has been delayed to a point of greater disability. With assertive community treatment, all aspects of the service from team development through individual discharge planning and program evaluation need be viewed through the lens of cultural competence and focused on building a strong family and community connection. Service effectiveness is tied to creating teams with the language capacity, community knowledge and connection to resources that will sustain skill-building efforts. In addition to assuring language access services, case managers need a working knowledge of the cultural considerations as well as the community and family norms to adapt and provide culturally relevant services.

Psychological Therapies.

Behavioral approach which developed by Ayllon and Azrin (1968). It was used for schizophrenia based on the use of reinforcement.

It focused on increasing socially desirable behaviors and improving daily living skills.

Social skills training(SST):

What is (SST)?

Social skills training is a type of psychotherapy that works to help people improve their social skills so they can become socially competent. SST is predominantly a behavioral therapy.

7 Who can benefit from SST?

SST is mainly used for individuals that are diagnosed with certain mental or psychological disorders and whose symptoms involve poor social functioning. However, anyone who wants to improve their social skills and social confidence can benefit from this psychotherapy.

The major disorders that are accompanied with social dysfunction are:

 Autism  Schizophrenia  Social anxiety disorder or social phobia

It is important to remember that, although SST can be very effective in helping people learn the necessary skills, it is very rare for SST to be a stand alone therapy. There are always underlying reasons why people are experiencing social difficulty and these too need to be treated, either with drugs or a combined psychotherapy.

The diagram below will help explain this. The arrows represent symptoms that negatively affect one another:

As you can see, there are many factors that contribute to worsening social skills, which in turn impair many other aspects of our lives. For example, social skill deficits cause social isolation, and social isolation worsens social skills. These are just some examples of the many vicious cycles that we see in psychology.

Treating only one aspect of the cycle without treating the other would be pointless; the condition will simply arise again and again. For example, there is no point learning the social skills if you are too anxious to use them!

8 What is involved in SST?

Social skills training will almost always be combined with some other type of psychotherapy, most often cognitive-behavioral therapy. The amount of time needed to complete an SST program varies depending on how well you are learning the techniques and how much confidence you have in using the skills in a social environment. Typically, eight one-hour sessions are standard.

Basic SST implementation structure

All social skills training follows the same basic structural and implementation outline:

Identifying the problem

Firstly, the major social problem needs to be identified. For example, are the problems with socializing predominantly a fear of large gatherings of people? Or speaking to people at work? In order to figure out the major problems, the patient and psychologist work together through discussion. Sometimes the psychologist may want to observe the patient's behaviour; this is mainly with inpatient settings or children in the classroom.

The underlying psychology behind the social problems also needs to be determined. Sometimes social problems are a result of a mental illness (e.g. schizophrenia), or they may have arisen from a past trauma. Once these problems and reasons have been determined, your psychologist can determine what skills need to be focused on, how best to teach the skills, and what other therapies are required to help with the underlying issues.

Setting the goals

As with any type of psychotherapy, your psychologist will help you develop specific goals for the therapy. This will include a broad overall goal as well as focused goals that may change from session to session. For SST, the broad overall goal may be the ability to socialize comfortably in the staffroom, whereas the individual goals will be skill- specific (e.g. learning how to greet someone, ask how they are and respond appropriately).

Once each goal or skill is mastered, the goal for the next session becomes more difficult. Keeping the overall goal in mind will help you overcome times when you feel like giving up on the therapy.

9 Modeling

Before you are expected to perform the skill, your psychologist will model the skill you are focusing on, so that you can see exactly what you need to do before attempting to do it yourself.

Role playing

After your psychologist has modeled the skill, you will be asked to role- play. This practice is a very important aspect of SST. It may feel odd to role-play, but until you have practiced the skill, it is hard to use it outside the safety and confinement that therapy sessions provide.

Feedback

Your psychologist will provide feedback at the end of each session. This feedback will help you to identify your strengths and weaknesses, and the things you especially need to work on and practice.

Homework!

In between sessions, your psychologist will set little “homework” challenges that you are required to do in your own time throughout the week. Usually the homework will carry on directly from the session, so that you practice the new skill you learnt. Depending on your success at meeting the challenge, you will focus on a new, more difficult skill in the next session.

Cognitive-Behavioral Therapy... is a form of psychotherapy that emphasizes the important role of thinking in how we feel and what we do.

Cognitive-behavioral therapy does not exist as a distinct therapeutic technique. The term "cognitive-behavioral therapy (CBT)" is a very general term for a classification of therapies with similarities. There are several approaches to cognitive-behavioral therapy, including Rational Emotive Behavior Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy.

However, most cognitive-behavioral therapies have the following

10 characteristics:

1. CBT is based on the Cognitive Model of Emotional Response. Cognitive-behavioral therapy is based on the idea that our thoughts cause our feelings and behaviors, not external things, like people, situations, and events. The benefit of this fact is that we can change the way we think to feel / act better even if the situation does not change.

2. CBT is Briefer and Time-Limited. Cognitive-behavioral therapy is considered among the most rapid in terms of results obtained. The average number of sessions clients receive (across all types of problems and approaches to CBT) is only 16. Other forms of therapy, like psychoanalysis, can take years. What enables CBT to be briefer is its highly instructive nature and the fact that it makes use of homework assignments. CBT is time-limited in that we help clients understand at the very beginning of the therapy process that there will be a point when the formal therapy will end. The ending of the formal therapy is a decision made by the therapist and client. Therefore, CBT is not an open-ended, never- ending process.

3. A sound therapeutic relationship is necessary for effective therapy, but not the focus. Some forms of therapy assume that the main reason people get better in therapy is because of the positive relationship between the therapist and client. Cognitive-behavioral therapists believe it is important to have a good, trusting relationship, but that is not enough. CBT therapists believe that the clients change because they learn how to think differently and they act on that learning. Therefore, CBT therapists focus on teaching rational self-

11 counseling skills.

4. CBT is a collaborative effort between the therapist and the client. Cognitive-behavioral therapists seek to learn what their clients want out of life (their goals) and then help their clients achieve those goals. The therapist's role is to listen, teach, and encourage, while the client's roles is to express concerns, learn, and implement that learning.

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5. CBT is based on aspects of stoic philosophy. Not all approaches to CBT emphasize stoicism. Rational Emotive Behavior Therapy, Rational Behavior Therapy, and Rational Living Therapy emphasize aspects of stoicism. Beck's Cognitive Therapy is not based on stoicism.

Cognitive-behavioral therapy does not tell people how they should feel. However, most people seeking therapy do not want to feel they way they have been feeling. The approaches that emphasize stoicism teach the benefits of feeling, at worst, calm when confronted with undesirable situations. They also emphasize the fact that we have our undesirable situations whether we are upset about them or not. If we are upset about our problems, we have two problems -- the problem, and our upset about it. Most people want to have the fewest number of problems possible. So when we learn how to more calmly accept a personal problem, not only do we feel better, but we usually put- knowledge, energy, and resources to resolve the problem.

12 6. CBT uses the Socratic Method. Cognitive-behavioral therapists want to gain a very good understanding of their clients' concerns. That's why they often ask questions. They also encourage their clients to ask questions of themselves, like, "How do I really know that those people are laughing at me?" "Could they be laughing about something else?"

7. CBT is structured and directive. Cognitive-behavioral therapists have a specific agenda for each session. Specific techniques / concepts are taught during each session. CBT focuses on the client's goals. We do not tell our clients what their goals "should" be, or what they "should" tolerate. We are directive in the sense that we show our clients how to think and behave in ways to obtain what they want. Therefore, CBT therapists do not tell their clients what to do -- rather, they teach their clients how to do.

8. CBT is based on an educational model. CBT is based on the scientifically supported assumption that most emotional and behavioral reactions are learned. Therefore, the goal of therapy is to help clients unlearn their unwanted reactions and to learn a new way of reacting.

Therefore, CBT has nothing to do with "just talking". People can "just talk" with anyone.

The educational emphasis of CBT has an additional benefit -- it leads to long term results. When people understand how and why they are doing well, they know what to do to continue doing well.

9. CBT theory and techniques rely on the Inductive Method. A central aspect of Rational thinking is that it is based on fact. Often, we

13 upset ourselves about things when, in fact, the situation isn't like we think it is. If we knew that, we would not waste our time upsetting ourselves.

Therefore, the inductive method encourages us to look at our thoughts as being hypotheses or guesses that can be questioned and tested. If we find that our hypotheses are incorrect (because we have new information), then we can change our thinking to be in line with how the situation really is.

10. Homework is a central feature of CBT. If when you attempted to learn your multiplication tables you spent only one hour per week studying them, you might still be wondering what 5 X 5 equals. You very likely spent a great deal of time at home studying your multiplication tables, maybe with flashcards.

The same is the case with psychotherapy. Goal achievement (if obtained) could take a very long time if all a person were only to think about the techniques and topics taught was for one hour per week. That's why CBT therapists assign reading assignments and encourage their clients to practice the techniques learned

Early Intervention (E.I).

What is EI.?

Early intervention means detection and treatment of psychosis during the critical early phase of illness. Delays cause unnecessary distress, increase

14 the risk of relapse and are potentially harmful for the person, their family and friends. Early treatment has been shown to improve the long-term course of psychosis. EI. Takes two forms:

Recognizing schizophrenia early and then initiating effective treatment.

Intervening early in the case of psychotic relapse.

Goals of EI.

Better short and long term outcomes.

Less need for hospitalization.

More rapid recovery.

Less family disruption.

Preservation of psychosocial skills, social and environmental supports, personal assets.

Less social and economic damage.

Reduced secondary morbidity (depression, cognitive impairments, substance abuse etc).

Reduced risk of relapse.

Reduced risk of homelessness.

Early warning signs.

Relapse is common in the early years after the first episode of psychosis.

50% (1 in 2) people are at risk of a further relapse of psychosis within the

15 first two years after their initial psychotic episode.

Most people who have had a psychotic episode are fearful of a relapse and the return of unpleasant psychotic experiences. Although some people will try and cope with this fear by trying to forget their experience of psychosis and hoping it will not recur, most people are keen to try to prevent it from returning.

There are a number of ways that you can cut down the risk of having a relapse:

 Continuing to take prescribed anti psychotic medication on a

regular basis after the first psychotic episode as this has been shown

to reduce relapse risk

 Learning how to reduce and manage stress and identifying coping

tools for dealing with stressful life events

 Seeking and developing relationships with family and friends

where you feel comfortable, happy and secure

 Avoiding using illicit drugs, particularly cannabis and

amphetamines which can trigger further episodes

16  Developing a life style which maintains your well being, which

you feel is meaningful and rewarding

 Knowing your early warning signs of relapse and having a relapse

prevention plan.

Family Intervention (FI)

 FI emerged when research began taking interest in the family and

the effects of the home environment on schizophrenia sufferers

after discharge from the psychiatric institutions .

 FI reflects a shift from viewing families as the cause of illness to a

source of support for the ill relative.

What is FI.?.

It is any strategy or programme, clinical or non-clinical, designed to

help and empower families to cope with the mental illness through

provision of support, education, skills training, family consultation,

family support and advocacy groups and other forms of assistance to

families (Solomon 2000).

17 Effects of FI.

Evidence-Based Medicine confirms that Family interventions reduce relapse rates, rehospitalisation, and costs of treatment and also increase compliance with medication (Tarrier et al 1988, Leff et al

1990, Falloon, 1993 ).

Furthermore, it decreases family burden, family stress, high expressed emotion (EE) and improve families’ coping skills (Leff & Vaughn

1985, Fadden et al 1987).

Cultural review.

Studies in different cultures found that the Western or standard model of family intervention was not suitable to their cultures and may be intrusive also, it failed to show positive treatment outcomes (Weisman

2006).

Culturally sensitive FI studies reported significant reduction in relapse rates and increase in patients and carers’ satisfaction with the service

(WHO, 1998).

Researches revealed that one of the most important explanations for the high drop-out rates and premature termination of the family work for ethnic minorities was the service inability to provide culturally responsive forms of treatment, and thus clients found the service strange, foreign and unhelpful (Castro, 2004

18 Crises Intervention.

Includes crises teams that are considered part of community mental health service.

The team should be available 24 hours a day, seven days a week, and includes social workers and nurses.

Some studies assured that crises intervention team increase hospital admission rates; on the other hand other studies indicated that team intervention decrease hospital admission rates.

19 Training.

Integrated and continuous training programs of psychiatric treatment and rehabilitation produce better outcomes for the care of individuals with severe and persistent mental health problems.

Until the early 1990 community psychiatric nurses had little skills- based training and it was only the advent of the Thorn training program in psychosocial interventions.

Thorn program was originally based on three modules:

Clinical case management.

Psychological interventions.

Family interventions.

20 On 1995 the program was developed and shared several common elements:

Focus on severe and enduring mental illness.

Use of biopsychosocial model of mental illness.

Focus on the evidence based.

Emphasis on skill acquisition.

Use of structured clinical supervision.

Use of valid and reliable measures of change.

Use of a cognitive behavioral model as a broad base intervention.

References

Ayllon T, Azrin N 1968 The token economy: a motivational system for therapy and rehabilitation.

Barraclough C, Tarrier N 1992 Families of schizophrenia patents.

Weisman 2006

Waller, 2001

Tarrier et al 1988, Leff et al 1990, Falloon, 1993.

WHO, 1998