MENTAL HEALTH NURSING

SEMINAR ON

PSYCHOSOCIAL THERAPIES

-MILIEU THERAPY

-RECREATIONAL THERAPY

-OCCUPATIONAL THERAPY

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INTRODUCTION

The word milieu is French for “middle.” The English translation of the word is

“surroundings, or environment.” In psychiatry, therapy involving the milieu, or environment, may

be called milieu therapy, therapeutic community, or therapeutic environment.

MILIEU THERAPY

A scientific structuring of the environment in order to effect behavioural changes and to improve

the psychological health and functioning of the individual (Skinner, 1979).

CONCEPT OF MILIEU THERAPY

A therapeutic milieu is a 24 hour environment designed to provide a secure retreat for

individuals whose capacities for coping with reality have deteriorated. The therapeutic milieu gives

them opportunities to acquire adaptive coping skills. By offering secure, comfortable physical

facilities for sleeping, dinning, bathing, and engaging in recreational, occupational, social,

psychiatric and medical therapies.

GOALORE CONCEPT

The goal of milieu therapy is to manipulate the environment so that all aspects of the client’s

hospital experience are considered therapeutic. Within this therapeutic community setting the client

is expected to learn adaptive coping, interaction, and relationship skills that can be generalized to

other aspects of his or her life.

FUNCTIONS OF MILIEU THERAPY

1. Shelters clients physically from what they perceive as painful, terrifying stressors.

2. Protects clients physically from discharges of their own and others maladaptive behaviours

3. Supports the physiological existence of clients.

4. Provides pleasant, attractive, sensory stimulation to clients.

5. Educates clients and their families about adaptive, effective coping.

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CHARACTERISTICS OF A THERAPEUTIC MILIEU/ ELEMENTS OF

MILIEU THERAPY

1. INDIVIDUAL TREATMENT PROGRAM

A therapeutic milieu is tailored to the client’s individual needs without infringing on the

needs and rights of other clients. A definite structure, schedule, overall guidelines and social

controls are set forth to provide organization and predictability.

2. SELF-GOVERANCE

To avoid the cultivation of dependence and regression, the clients are encouraged to

participate in decision making regarding milieu issues. Structured community meetings client-team

meetings and client-team committee meetings held at regular scheduled intervals to help the client

to find opportunities to develop decision making skills.

3. PROGRESSIVE LEVELS OF RESPONSIBILITY

Clients are expected to assume a responsible role in the maintenance of the environment.

The degree of responsibility expected of clients is depending upon their capabilities. This approach

is a form of behaviour modification in that it rewards and reinforces adaptive behaviour.

4. A VARIETY OF MEANINGFUL ACTIVITIES

To minimize social withdrawal and regression, therapeutic milieu must provide each client

with an individual activity schedule. Such activities may include structured exercise classes,

jogging, training, arts, crafts, relaxation training and stress management classes and occupational

therapies.

5. LINKS WITH THE CLIENT’S FAMILY

Therapeutic milieu provides opportunities for clients to re-enter the mainstream of family

life at their own pace. Links with the family is accomplished in several ways. Family visits and

family counselling are carried out.

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 6. LINKS WITH COMMUNITY

Activities occurring outside the structured milieu such as shopping, trips, picnics, camping trips,

attending movies and plays serve to link clients to community.

7. EFFECTIVE WORKING RELATIONSHIPS AMONG MENTAL HEALTH TEAM

MEMBERS

Interpersonal conflict occasionally occurs in any group of people. When mental health team

members can engage in effective conflicts resolution, they are more likely to trust other and to act

an interact as a mental health team.

8. HUMANISTIC MENTAL HEALTH TEAM MEMBERS

They should possess;

 Optimistic attitudes toward people in general

 The ability to inspire hopefulness in clients.

 Creativity in working toward more effective ways of involving clients in the environment

 Lack of fear or prejudice

 Ability to set limits

 Willingness to share control and decision making

COMPONENTS OF A THERAPEUTIC MILIEU

Comfortable, secure physical facilities, the mental health team and the therapeutic milieu

program are the three essential components of a therapeutic milieu.

MILIEU THERAPY APPROACH

It is a group therapy approach that uses a total living experience- recreational, occupational,

psychosocial, psychiatric, nursing, plus mental health team-client relationships-to accomplish

therapeutic objectives, which includes;

 Correct or re-define their perceptions of stressors

 Correct maladaptive coping behavioural patterns

 Develop adaptive coping behavioural patterns

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  Acquire interpersonal and stress management skills in order to conduct themselves more

effectively in the environment and strengthen or correct their coping abilities.

THERAPEUTIC COMMUNITY

DEFINITION - Therapeutic community is one of the psychiatric nursing approach where in,

the patient’s social environment would be used to provide a therapeutic experience for him by

involving him as an active participant in his own care and the daily problems of his community.

BASIC ASSUMPTIONS

Skinner (1979) outlined seven basic assumptions on which a therapeutic community is based:

1. The Health in Each Individual Is to Be Realized and Encouraged to Grow;

All individuals are considered to have strengths as well as limitations. These healthy aspects

of the individual are identified and serve as a foundation for growth in the personality and in the

ability to function more adaptively and productively in all aspects of life.

2. Every Interaction Is an Opportunity for Therapeutic Intervention.;

Within this structured setting, it is virtually impossible to avoid interpersonal interaction.

The ideal situation exists for clients to improve communication and relationship development skills.

Learning occurs from immediate feedback of personal perceptions.

3. The Client Owns His or Her Own Environment;

Clients make decisions and solve problems related to government of the unit. In this way,

personal needs for autonomy as well as needs that pertain to the group as a whole are fulfilled.

4. Each Client Owns His or Her Behavior; Each individual within the therapeutic community is

expected to take responsibility for his or her own behavior.

5. Peer Pressure Is a Useful and a Powerful Tool;

Behavioral group norms are established through peer pressure. Feedback is direct and

frequent, so that behaving in a manner acceptable to the other members of the community becomes

essential.

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6. Inappropriate Behaviors Are Dealt with as They Occur;

Individuals examine the significance of their behaviour, look at how it affects other people,

and discuss more appropriate ways of behaving in certain situations.

7. Restrictions and Punishment Are to Be Avoided;

Destructive behaviors can usually be controlled with group discussion. However, if an

individual requires external controls, temporary isolation is preferred over lengthy restriction or

other harsh punishment.

CONDITIONS THAT PROMOTE A THERAPEUTIC COMMUNITY

In a therapeutic community setting, everything that happens to the client, or within the

client’s environment, is considered to be part of the treatment program. The community setting is

the foundation for the program of treatment. Community factors such as social interactions, the

physical structure of the treatment setting, and schedule of activities may generate negative

responses from some clients. These stressful experiences are used as examples to help the client

learn how to manage stress more adaptively in real-life situations.

1. Basic Physiological Needs Are Fulfilled. As Maslow (1968) has suggested, individuals do not

move to higher levels of functioning until the basic biological needs for food, water, air, sleep,

exercise, elimination, shelter, and sexual expression have been met.

2. The Physical Facilities Are Conducive to Achievement of the Goals of Therapy. Space is

provided so that each client has sufficient privacy, as well as physical space, for therapeutic

interaction with others. Furnishings are arranged to present a homelike atmosphere—usually in

spaces that accommodate communal living, dining, and activity areas for facilitation of

interpersonal interaction and communication.

3. A Democratic Form of Self-Government Exists. In the therapeutic community, clients

participate in the decision making and problem solving that affect the management of the treatment

setting. This is accomplished through regularly scheduled community meetings. These meetings are

attended by staff and clients, and all individuals have equal input into the discussions. At these

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meetings, the norms and rules and behavioral limits of the treatment setting are set forth. This

reinforces the democratic posture of the treatment setting, because these are expectations that affect

all clients on an equal basis. Some therapeutic communities elect officers (usually a president and a

secretary) who serve for a specified time. The president calls the meeting to order, conducts the

business of discussing old and new issues, and asks for volunteers (or makes appointments,

alternately, so that all clients have a turn) to accomplish the daily tasks associated with community

living; for example, cleaning the tables after each meal and watering plants in the treatment facility.

New assignments are made at each meeting.

4. Responsibilities Are Assigned According to Client Capabilities. Increasing self-esteem is an

ultimate goal of the therapeutic community. Therefore, a client should not be set up for failure by

being assigned a responsibility that is beyond his or her level of ability. By assigning clients

responsibilities that promote achievement, self-esteem is enhanced. Consideration must also be

given to times during which the client will show some regression in the treatment regimen.

Adjustments in assignments should be made in a way that preserves self-esteem and provides for

progression to greater degrees of responsibility as the client returns to previous level of functioning.

5. A Structured Program of Social and Work-Related Activities Is Scheduled as Part of the

Treatment Program.

Each client’s therapeutic program consists of group activities in which interpersonal

interaction and communication with other individuals are emphasized. Time is also devoted to

personal problems. Various group activities may be selected for clients with specific needs (e.g., an

exercise group for a person who expresses anger inappropriately, assertiveness

group for a person who is passive-aggressive, or a stress-management group for a person who is

anxious). A structured schedule of activities is the major focus of a therapeutic community.

Through these activities, change in the client’s personality and behavior can be achieved. New

coping strategies are learned and social skills are developed. In the group situation, the client is able

to practice what he or she has learned to prepare for transition to the general community.

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6. Community and Family Are Included in the Program of Therapy in an Effort to Facilitate

Discharge from Treatment.

An attempt is made to include family members, as well as certain aspects of the community

that affect the client, in the treatment program. It is important to keep as many links to the client’s

life outside of therapy as possible.Family members are invited to participate in specific therapy

groups and, in some instances, to share meals with the client in the communal dining room.

Connection with community life may be maintained through client group activities, such as

shopping, picnicking, attending movies, bowling, and visiting the zoo. Inpatient clients may be

awarded passes to visit family or may participate in work-related activities, the length of time being

determined by the activity and the client’s condition. These connections with family and community

facilitate the discharge process and may help to prevent the client from

becoming too dependent on the therapy.

THE PROGRAM OF THERAPEUTIC COMMUNITY

Care for clients in the therapeutic community is directed by an interdisciplinary treatment

(IDT) team. An initial assessment is made by the admitting psychiatrist, nurse, or other designated

admitting agent who establishes a priority of care. The IDT team determines a comprehensive

treatment plan and goals of therapy and assigns intervention responsibilities. All members sign

the treatment plan and meet regularly to update the plan as needed. Depending on the size of the

treatment facility and scope of the therapy program, members representing a variety of disciplines

may participate in the promotion of a therapeutic community. For example, an IDT team may

include a psychiatrist, clinical psychologist, psychiatric clinical nurse specialist, psychiatric nurse,

mental health technician, psychiatric social worker, occupational therapist, recreational therapist, art

therapist, music therapist, psychodramatist, dietician, and chaplain.

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TYPES

 Genuine Therapeutic Community of Democratic/Analytic ; In these TC, all the material

and human resources in the hospital are actively engaged in a therapeutic program.Usually

in residential buildings, the resident collaborate with staff in a day to day decision making

and running of the organization.

 Therapeutic Milieu of Institutional; These are wads or small units, where patients and

staff ha less control over the domestic and administrative decision-making of the

organization.

 Social therapy or Concept based therapy ; social relationships and social environment are

the focus of care.The residents have less control over the values, which permeate the

organization than the previous two.

THE TC APPROACH

TC’s are stratified communities composed of peer groups that hold memberships in wider

aggregate and that are led by individual staff. The preparation of the community itself i the task of

the residents, working under staff supervision, work assignments, called job functions, are arranged

in hierarchy, according to seniority, individual progress and productivity. The new client enters a

setting of upward mobility. Job assignments begins with the most menial tasks and lead vertically to

levels of coordination and management.

 The fundamental aspects of rehabilitative approach are ; mutual self group [residents

conduct self care activities] – work as education and therapy – peer as role model – staff as

rational authorities.

 The induction [60 days] – assimilate the individual into the community through full

participation and involvement in all of its activities and observation to identify special

problems in their adaptation to the TC.

 Primary treatment [2-12 months]; socialization, personal growth and psychological

awareness are followed through all the activities.

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  Re-entry [13-24 months] ; client strengthens skills for autonomous decision making and the

capacity for self management with less reliance and the capacity for self management with

less reliance on rational authorities of a well-informed peer network.

SALIENT FEATURES

 Free communication both within and between staff and patient group

 Communications are directed towards the modification of patients attitude, behaviour and

role performance

 Atmosphere in the community will be democratic as opposed to hierarchical, rehabilitative

rather than custodial, permissive instead of limited and controlled

 Nurses will be more communal with the patient instead of displaying all the time therapeutic

role.

 Environment will be essentially permissive and flexible.

 Patient’s activities are individualised and the role of patients are unspecified and their

participation is completely voluntary

 A compulsory daily community meeting that all staff members have to attend and all

patients are encouraged to attend.

 Group responsibility is emphasized and opportunities for corrective learning experience are

deliberately provided.

 The primary role of staff is to help the patients gain new insights and test new behavioural

patterns.

 Problems of the patients are discussed and the solutions are sought in the small group

therapy sessions following each community meeting.

 Patient government or ward council is to deal with practical unit details such as privileges

and housekeeping rosters.

 Staff meeting or review is essential to on the ward training

 Living learning opportunities are provided to the patient within the social milieu.
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ROLE OF NURSE IN MILIEU THERAPY

 Use nursing process to provide comprehensive care

 Provide direct client care

 Manages the day to day care of individual clients

 Assists the client for re-entry into the community

 Administer medication and give medication teaching

 Provides psychosocial care

 Uses informal group interventions such as community meetings

 Conduct brief ‘ on the spot’ counselling with clients and families.

 Set limits to deal with behaviours destructive to the self , others or the environment

 Help the clients use their time productively for leisure an work

 Involves withdrawn patients in the milieu

 Encourages client who have low self esteem to value themselves

 Serve as the role model

 Provide mental health teaching.

 Encourages clients to help and support each other individually and as a group

 Assists to understand each other’s feelings

 Conduct community meetings

 Participate freely in milieu activities

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THE ROLE OF THE NURSE THERAPEUTIC COMMUNITY
In the hospital, nurses are generally the only members of the IDT team who spend time with

the clients on a 24-hour basis, and they assume responsibility for management of the therapeutic

milieu. In all settings, the nursing process is used for the delivery of nursing care. Ongoing

assessment, diagnosis, outcome identification, planning, implementation, and evaluation of the

environment are necessary for the successful management of a therapeutic milieu.

Nurses are involved in all day-to-day activities that pertain to client care. Suggestions and

opinions of nursing staff are given serious consideration in the planning of care for individual

clients. Information from the initial nursing assessment is used to create the IDT plan. Nurses have

input into therapy goals and participate in the regular updates and modification of treatment plans.

In some treatment facilities, a separate nursing care plan is required in addition to the IDT plan.

When this is the case, the nursing care plan must reflect diagnoses that are specific to nursing and

include problems and interventions from the IDT plan that have been assigned specifically to the

discipline of nursing. In the therapeutic milieu, nurses are responsible for ensuring that clients’

physiological needs are met. Clients must be encouraged to perform as independently as possible in

fulfilling activities of daily living. However, the nurse must make ongoing assessments to provide

assistance for those who require it. Assessing physical status is an important nursing responsibility

that must not be overlooked in a psychiatric setting that emphasizes holistic care. Reality orientation

for clients who have disorganized thinking or who are disoriented or confused is important in the

therapeutic milieu. Clocks with large hands and numbers, calendars that give the day and date in

large print, and orientation boards that discuss daily activities and news happenings can help keep

clients oriented to reality.

Nurses should ensure that clients have written schedules of activities to which they are

assigned and that they arrive at those activities on schedule. Nurses are responsible for the

management of medication administration on inpatient psychiatric units. In some treatment

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programs, clients are expected to accept the responsibility and request their medication at the

appropriate time. Although ultimate responsibility lies with the nurse, he or she must encourage

clients to be self-reliant.

Nurses must work with the clients to determine methods that result in achievement and

provide positive feedback for successes. The nurse is responsible for setting limits on unacceptable

behavior in the therapeutic milieu. This requires stating to the client in understandable terminology

what behaviors are not acceptable and what the consequences will be should the limits be violated.

These limits must be established, written, and carried out by all staff. Nurses must be able to assess

learning readiness in individual clients.

RECREATIONAL THERAPY
Recreation is a form of activity therapy used in most psychiatric settings. It is a planned

therapeutic activity that enables pople with limitations to engage in recreational experiences.

AIMS

 To encourage social interaction

 To decrease withdrawal tendencies

 To provide outlet for feelings

 To promote socially acceptable behaviour

 To develop skills , talents and abilities

 To increase physical confidence and a feeling of self-worth

POINTS TO BE KEPT IN MIND

 Provide a non-threatening and non-demanding behaviour

 Provide activities that are relaxing and without rigid guidelines and time-frames

 Provide that are enjoyable and self-satisfying

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TYPES OF RECREATIONAL ACTIVITIES

1. Motor forms : this can be further divided into fundamental and accessory; among the

fundamental forms are such games as hockey and football , while the accessory forms are

exemplified by play activity and dancing

2. Sensory forms : his can be either visual, eg;looking at motion picturs,play etc,or auditory

such as listening to a concert

3. Intellectual forms: these include reading, debating and so on.

RECREATIONAL THERAPY INTERVENTIONS

Within behavioral health, recreational therapists provide a range of psychosocial interventions and s

upports to assist individuals and families to achieve recovery and community integration goals. The

se include:

• Psychoeducational groups (e.g., stress management; coping skills; managing free time);

•Leisure education (Self awareness, resource knowledge, leisure skills, affiliation)

‐ Awareness of lifestyle and leisure‐related values, attitudes, interests and aspirations

‐ Leisure activity skills needed to engage in preferred activities

‐ Knowledge of community resources that support participation

‐ Social interaction skills needed to form and maintain relationships;

•Community Integration skills. Assisting individuals to identify, locate and use community

resources that support physically, socially, spiritually and culturally active community participation;

•Wellness. Attitudes, knowledge and abilities to pursue holistic health, and the role of self‐

determined recreation and leisure engagement in all aspects of health;

•Adventure challenge/adventure based counselling. Individual and group problem‐

solving activities that challenge one’s sense of confidence and competence to act, and the group’s c

ommunication and cooperation. (e.g., a “maze” of obstacles through which partners –

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one blindfolded, or a whole group must navigate. The maze is a metaphor for obstacles in

the journey of recovery, decision making processes, and social interdependence).

THE RECREATIONAL THERAPY PROCESS

A recreational therapist utilizes a systematic process of assessing, planning, implementing

and evaluating interventions. Intervention plans are co‐created, and the entire working relationship

reflects a partnership of shared responsibility. An important part of this change process involves

helping the individual to reflect on their experiences in order to understand (“process”) and

appreciate the dynamic interplay of thoughts, feelings, and behavior. For example, previous

experiences with social rejection or stigma when trying to use a public library or an Internet café

can leave one unmotivated to be more active in the community. Similarly, previous success and

pleasure that was experienced during a recreational activity may have been forgotten or is not used

to reinforce continued healthy and adaptive choices.

THEORETICAL FRAMEWORK

Recreational therapy practice is an applied social science that upon several interrelated theories.

These include:

• Self Determination theory (competence, relatedness, autonomy)

• Stress‐Coping theory

• Social Cognition theory (self efficacy)

‐ Stages of Change (change readiness)

‐ Cognitive‐Behavioral Therapy (self efficacy)

• Resiliency theory (problem solving, positive attitudes, managing feelings, coping, hope)

• Positive Psychology

• Leisure Sciences (theoretical research related to determinants and benefits of leisure behavior)

Recreational therapists fit within many aspects of behavioral health services, including:

• Inpatient psychiatric facilities (short and intermediate stay, including Veterans hospitals)

• Intensive outpatient and partial hospital programs

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• Residential Services

• Behavioral Health Rehabilitation Services

• And other aspects of CBH/psychiatric rehabilitation such as Clubhouse and Drop‐ in centers

SUGGESTED RECREATIONAL ACTIVITIES FOR PSYCHIATRIC

DISORDERS

 Anxiety disorders ; aerobic activities like walking , jogging, etc

 Depressive disorders :Non-competitive sports, which provide outlet for anger , like jogging,

walking, running etc.

 Maniac disorders: one to one basis individual games like shuttle, badminton etc

 Schizophrenia: Activities requiring concentration

 Dementia: Concrete , repetitious crafts and projects that breed familiarization and comfort

ROLE OF NURSE

 Assessment of strengths and needs

 Plan for treatment designed to address individual needs

 Implementation of therapeutic activities to address objectives

 Evaluation of individual goals at the end of the program

 Increase strength and function while reducing pain and physical limitations

 Build physical strength and awareness

 Encourage lifestyle behaviours that promote wellness and longevity

 Decrease anxiety

 Restore daily activities

 Maximize potential to perform daily living activities and encourage the normalcy of the

patient’s current condition. This will assist in providing a balance of not onlythe physical,

but the mental and emotional well-being.

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  To demonstrate effective communication skills with users and carers, team members and

other professionals to provide support and reassurance following diagnosis of physical or

mental illness where there may be a poor or limited prognosis.

 To produce written Recreational Therapy reports for other professions and agencies and

to contribute to multidisciplinary records.

 To gain consent from clients for the sharing of information across disciplines and their

participation in R.T activities and programmes. To establish robust communication

networks with clients

 To instruct and coach clients in activities and techniques to meet their specific physical or

psychological needs.

 To communicate in a way that nurtures inclusion with respect to personal beliefs,

religious and cultural differences.

 To maintain an empathetic and supportive role towards clients with complex and

cognitively challenged needs, their carers and relatives.

 To advocate on behalf of the client. To promote and develop awareness of Recreational

Therapy and facilitate effective working relationships.

 Use knowledge of R.T to inform the multidisciplinary team regarding the best use of the

service resources.

OCCUPATIONAL THERAPY
Occupation is variously defined as ‘any activity which engages a person’s resource of time

and energy and is composed of skills and values (Lalitha: 1995). Occupational therapy is a potent

and uniquely valuable approach to health care that enables people to take control of their own lives

and overcome their own disabilities. The essence of occupational therapy lies in the use of activities

of every description as the treatment medium, with a minimum aim of improving the quality of life

and a maximum aim of complete rehabilitation.

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DEFINITION

Occupational therapy is the application of goal oriented, purposeful activity in the

assessment and treatment of individuals with psychological, physical or developmental disabilities.

AIMS

 Promotion of recovery

 Mobilization of total assets of the patient

 Prevention of hospitalisation

 Creation of good habits of work and leisure

GOAL

The main goal is to enable the patient to achieve a healthy balance of occupations through

the development of skills that will allow him to function at a level satisfactory to himself and others.

SUBGOALS

 Assess the patient’s needs in terms of the occupational role required of him.

 To identify the skills needed to support those roles.

 To remove or minimize behaviours that interfers with occupational performance.

 To improve role performance

 To assist the patient to develop, relearn or maintain skills to a level of competence

that will allow satisfactory performance of occupational role.

THE OCCUPATIONAL THERAPY PROCESS

The occupational therapy process fall into three main stages

 Assessment

 Treatment/intervention

 Evaluation

Selecting a model is also an integral step that must occur at the beginning of the process.

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 1. SELECTING A MODEL

A model is selected to translate the occupational therapy paradigm into practice in a particular

work setting or with an individual client.

Each stage of assessment and treatment is related to the chosen model, but its appropriateness

can only be judged by valuating the outcome of the process

Selection of an appropriate model is the first stage of occupational therapy process. Many

factors influence the choice of model used in particular area of practice. The four models with in

each frame of reference are briefly mentioned here;

a) Activity therapy – It is from the adaptive performance frame of reference. This model,

first presented by Mosey in the early 1970’s was one of the first attempt to bring

together theories , goals of intervention and methods in a unifying framework

b) Occupational therapy as a communication process – It is from the psychodynamic

frame of reference, this model was developed by Fiddler and Fiddler in the 1960’s.

When individual and group psychotherapy were being widely used for the treatment of

all types of psychological dysfunction.

c) Facilitating growth and development from the development frame of reference;

This model is based on the theories of human development aspect of development theory

which are drawn for most occupational therapy models.

d) A model of human occupation- it is from the occupational behaviour frame of

reference. This model , first presented by Kielhofner, Burke and Igli in 1980 , is based

on general system theory, theories of motivation and role therapy.

2. ASSESSMENT

Assessment is the basis for all intervention and must be both thorough and valid in order to

ensure that treatment is appropriate.

a) Initial assessment

b) Detailed assessment

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Initial assessment is a screening process to determine the main problem area of the client and

whether or not occupational therapy can be of any value in this case. Effective assessment will, lead

directly to settling long term , intermediate and short term goals.

3. TREATMENT

Treatment in 3 stages which may be repeated as necessary, depending on the clients progress

 Formulation of treatment plan

 Treatment implementation

 Treatment review

4. EVALUATION

The circular process of occupational therapy is completed by the 3 stages of evaluation

 Final treatment review

 Evaluation of process

 Review of model

The final review of the client’s progress is used to reach decisions about discharge or referral to

other agencies.

OCCUPATIONAL THERAPY SERVICES

Assessment and treatment service may include;

i. Independent living skills

ii. Task oriented treatment using creative expressive modalities, crafts, education, leisure time,

play.

iii. Prevocational and work adjustment programs

iv. Sensorimotor including neuromuscular and sensory integrative assessment and treatment

v. Design fabrication and application of orthotic devices

vi. Adaptation to physical environment and guidance

vii. Therapeutic exercises

viii. Discharge planning and community re-entry

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 ix. Patient or family education

OCCUPATIONAL THERAPY IN A PATIENT UNIT

Usually consists of a wide range of both individual and group experience designed to meet

the patient’s social, emotional and occupational needs based on the abilities of the patients.

Beyond this, these programs offer assertiveness training, daily living skills groups and

current event groups. Art range activities, including music, art and clay work, providing ways of

training people together and exploring the self. For chronic long stay psychiatric patients, the

therapeutic interventions are training for physical well bing, daily living skills, social activities,

social skill training.

SETTINGS

Occupational therapy is provided to children, adolescents, adults and elderly patients. These

programs are offered in psychiatric hospitals, nursing home, rehabilitation centres, special schools,

community group homes, community mental health centres, day care centres, halfway homes and

de-addiction centres.

POINTS TO BE KEPT IN MIND INCLUDE THE IMPORTANCE OF:

- Selecting an activity that interests the client

- Starting at the point the client is at and progress slowly

- Providing ample in enforcement for even shall achievements.

- If possible, the selected activity should provide some new experience for the patient

-The activity should be of short duration to foster a feeling of accomplishment

-The activity should utilize the patient’s strengths and abilities.

PROCESS OF INTERVENTION

It consists of 6 steps

1. Initial evaluation of what patient can do and cannot do in a variety of situations over

a period of time

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 2. Development of immediate and long term goals y the patient and therapist together.

Goals should be concrete and measurable so that it is easy to see when they have

been attained.

3. Development of therapy plan with planned intervention.

4. Implementation of the plan and monitoring the progress. The plan is followed until

the first evaluation. If found satisfactory it is continued and altered, if not.

5. Review meetings with patient and all the staff involved in treatment.

6. Setting further goals when immediate goals have been achieved; modifying the

treatment program as relevant.

TYPES OF ACTIVITIES

Diversional Activities: These activities are used to divert one’s thoughts from stresses or to fill

time. E.g.: organized games.

Therapeutic Activities; These are used to attain a specific care plan or goal. Eg; basket making,

carpentry.

OCCUPATIONAL THERAPY TO PROMOTE PHYSICAL FITNESS

i. Relaxation training – to turn off tensions, includes meditative and hypnotic techniques

ii. Dance

iii. Swimming – to enable the physically handicapped to participate as frely as the able-bodied

iv. Yoga – to increase concentration, stimulate interest and improve body awareness

v. Keep fit

vi. Walking, jogging and running

Aims of occupational therapy through physical mode

 To improve co-ordination and spatial awareness

 To improve general physical condition

 To develop strength and suppleness and to improve posture and gait

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  To improve mood and reduce anxiety

 To provide an outlet for aggressive impulses

 To improve confident and to encourage independent personal care

OCCUPATIONAL THERAPY FOR DEVELOPING COGNITIVE SKILLS

Aims

 To restore the lost skills

 To use remaining skills

 To make adjustments

Treatment activities

 Crafts, which are useful for developing concentration, creative thinking and planning

 Quizzes and table games

 Art and poetry

 Play-reading or discussion

 Creative writing

 Reality orientation

Activity as treatment

The process of activity and its products have the following values;

 Play and social value

 Stimulates, activates and energizes

 Allows exploration and expession of feelings

 Work value, meets the needs

 Develop skills and knowledge

OCCUPATIONAL THERAPY TO ENHANCE SENSORY INTEGRATION

Aims

 To normalize sensory integration and therefore normalize motor and perceptual responses.

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Technique

 Non- competitive pleasurable activities are used

Treatment activities

 Kicking and throwing balls

 Rolling

 Crawling

 Scooter board

 Hopping

 Skipping

 Jumping

RANGE OFF OCCUPATIONAL THERAPY ACTIVITIES

Task activities

To improve the daily living work or task performance skills

Social activities`

To promoting enjoyment and leisure time pursuits

Activities involving communication and sharing

Used exclusively in activity or can form an important part of nearly any activity which

involves group work

Social skill education

Psychotherapy activities

SUGGESTED ACTIVITIES FOR PSYCHIATRIC DISORDERS

1. Anxiety disorders- simple concrete tasks with not more than 3 or 4 steps that can be learnt

quickly.eg; kitchen tasks, washing, sweeping, mopping, weeding gardens

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 2. Depressive disorders; simple concrete tasks which are achievable, it is important to

experience success by patient.eg; crafts, weeding gardens.

3. Maniac disorders; Non-competitive activities that allow the use of energy and expression

of feelings. Activities should be limited and changed frequently. Patient needs to work in an

area away from distractions.eg; raking grass, sweeping etc.

4. Schizophrenia (paranoid); non-competitive , solitary meaningful tasks that require some

degree of concentration so that less time is available to focus on delusions eg; puzzles,

scrabble

5. Schizophrenia (catatonic); simple concrete tasks nin which patient is actively involved.

Patient needs continuous supervision.eg; molding clay

6. Antisocial behaviour; activities that enhance self-esteem and are expressive and creative,

but not too complicated. Patient needs supervision to make sure each task is completed. Eg;

leather work, painting

7. Dementia; group activities to increase feeling of belonging and self-worth. Provid those

activities which promote familiar individual hobbies. Activities need to be structured,

requiring little time for completion and not much concentration. Explain and demonstrate

each task

8. Substance abuse; group activities in which patient uses his talents.

ADVANTAGES:

- It helps to build a healthier and integrated ego - It helps to express and deal with needs and

feelings

- It assists in a gratification of frustrated basic needs.

- It may strengthen ego defences

- It may reverse psychopathology

- It facilitates personality integration

- It offers opportunities to explore and see valuate self concepts and object concepts

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 - It develops a more realistic view of the self in relation to action and others.

ROLE OF NURSE

 Co-ordinates with other therapeutic team members in diagnosing the abilities ,

strengths, and talents, interests IQ levels of the clint and in slecting the activity for a

specific client.

 Provides a series of graded experiences to the client

 Educates the client to develop specific new skills

 Encourage socialization and exhibits positive interest to the client

 Guides the client in formulation of new hobbies by strengthening the abilities of the

client

 Appreciates if the clint performs any approved behaviour

 Offers tokens for each accomplishment of the work, based on the principle of

positive reinforcement

 Helps the client t develop independent living skills

 Approaches community agencies for job placement of the clients in approvesd social

activities

 Assists in developing good social interaction and relationship

CONCLUSION

There is a dearth of good, reliable studies investigating psychosocial interventions in

substance misuse especially looking at comparative effects of different treatments. However, there

is evidence that some form of counselling is better than none, and that whatever the form of

psychosocial intervention it should be a subject of training within the agency and be adequately

supervised.

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 BIBLIOGAPHY

1. Mary C Townsend,Psychiatric Mental Health Nursing,6th dition,Davis company,2009,p

2. Sreevani, A Guide to Mental Health and Psychiatric Nursing, 3rd edition, Jaypee

Brothers Publishers, P

3. Dr.K Lalitha, MentalHealth Nursing, 2nd edition, Jaypee Brothers publishers,p186-

190,p257-273

4. www.tr.com

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