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. 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:

o Improve cognitive, social and physical skills
o Decrease isolation
o Monitor decline in functionality
o Provide self-esteem goals
o Enhance engagement programs
o Increase program attendance

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.
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