Chapter III: Psychosocial Treatments
This chapter discusses the treatment of mood disorders through psychosocial means and evaluates the success of the treatment methods. Additionally, it recommends ways and means by which the stigma associated with mood disorders can be eliminated.
- The Treatment of Depressive Disorder
- The Treatment of Bipolar Disorder
- The Fight Against Stigmatization
Depressive Disorder and Psychosocial Treatments
Psychosocial treatment is often effective in combating the symptoms of an episode if a person has Depressive Disorder. However, it must be understood that medication and the prescription of drugs might also be a requirement in certain situations. As a subset of psychosocial therapy, counseling and family therapy methods are also useful in recovery. Family therapy is particularly important when it comes to the cases where children or adolescents have been affected with Depression (Donahue & Fristad, 2005).
Psychotherapy is a requirement in many cases because medical science has not yet advanced to a level where every mood disorder or mental ailment could be cured by a pill. Science has not fully identified the neurological or chemical basis of why certain individuals have feelings of love, courage, or compassion just as science has not identified why some people feel depressed, angry or lose control of their emotional state. However, therapy for patients suffering from a mood disorder is necessary and is often (Foltz, 2006).
The primary aim of psychosocial therapy is to provide assistance to the patient in understanding the disease, relieve symptoms and to try and alter behavior patterns in combination with efforts from the patient. After undergoing successful psychosocial therapy, a patient is able to communicate more effectively with others and can continue to improve until the disease becomes completely manageable. A large portion of the therapy provided to the patient looks at ways in which the patient can improve their outlook of the world as well as their own person. Since such methods seek to renew the cognitive behavior of the individual they are considered to be a part of Cognitive Behavior Therapy (CBT).
The success of CBT for depressed patients who are undergoing psychosocial treatments is limited because there is a high rate of relapse into an episode of depression once the therapy is stopped (Huxley et. al., 2000). This clearly suggests that the patient should have a social support group or an understanding family which continues to assist and monitor the patient. Psychosocial therapy coming in the shaper of interpersonal therapy centers can be quite helpful here because such centers help an individual cope with personal grief, drastic changes in life and other difficulties for patients with mood disorders.
Depending on the requirements of individual cases, psychosocial therapies for patients with Clinical Depression include elements from CBT, interpersonal supportive therapy, as well as social group/family support. The delivery of such therapies can be given in both inpatient and outpatient settings, depending on medical recommendations based on the psychosocial assessments of the patient. Modern research also suggests that patients with milder forms of depression can battle their mood disorder with self help sessions as well as therapy (Powell, 2001). A patient suffering from Clinical Depression may think that no one cares for them or that the individuals around him do not understand the state he is in. Psychosocial treatment in such cases is tremendously beneficial since it clearly shows that there are people who do care and are willing to sacrifice a lot to ensure that the patient gets better.
There might be a misconception about the depressed person that he is lazy and can easily snap out of his present state. Nurses and social workers have to do their part in psychosocial therapy to educate and inform the people around the patient that a mood disorder requires medical assistance as much as any other disease. Emotional support from the friends of the patient must continue to come with understanding, patience, love and supportive guidance. A depressed person needs to be listened to whenever he is willing to communicate and his feelings should not be belittled (Heru et. al., 2005). For example, remarks about suicide or thoughts/plans about committing suicide are red flags for both nurses and the people around the individual which should be reported to the physician/therapist handling the case (Jian et. al., 2005).
If possible, the depressed person should be taken for short walks in natural surroundings, taken to see a movie, or engaged in some activity which helps them take their mind off the disease. This must not be enforced on them, but rather they should be gently persuaded towards it (Ernst, 2006). Goals and milestones setup for a person with mood disorders can be monitored to see how much progress they have made and how they can help in improving their condition. However, a failure to meet goals can depress the person further; therefore, small goals should be set and met before larger ones can be given (Heru et. al., 2005). Finally, engagement in social groups, religious activities, sports and hobbies can also help a person suffering from depression.
Bipolar Disorder and Psychosocial Treatments
As per the case of Depressive Disorder, treatment with medicine alone is not always an effective method to control Bipolar Disorder. In fact, Craighead and Miklowitz (2000) report that patients may have a recurrence of the illness even when they maintain a dosage of common drugs for Bipolar Disorder like Lithium. Sajatovic (2002) examined several different types of evidence which show that some form of psychosocial therapy and intervention is required to enhance the effects of the medicine and to make the treatment last longer. Commonly accepted psychosocial therapies like interpersonal therapy, family oriented therapy and cognitive behavior therapy are therefore necessary for the treatment of Bipolar Disorder.
It was previously thought that patients with Bipolar Disorder could not benefit as much as patients with Depression since bouts of mania would greatly interfere with the therapy process (Winther, 1994). The latest research on the subject considers other factors like family support, CBT and monitoring of the patient as elements of psychosocial therapy which can act as effective counters to the impulsive behavior or uncooperative mood of a person suffering from BD. Additionally, it was found that patients (especially children) could continue learning, engage in active discussion, and make self-assessments if provided sufficient guidance from family members (Donahue & Fristad, 2005).
With Bipolar Disorder, family therapy becomes particularly important because, along with the individual, the whole family may suffer the effects of the disease since the social relationships of the patients are affected negatively. The role of the social worker or the nurse in such situations is to provide assistance, education and guidance as much as possible (Heru et. al., 2005). Nurses and social workers are often recruited by doctors to provide certain assistance in the course of such psychotherapies for monitoring progression in outpatient or inpatient settings. The cognitive therapy for Bipolar Disorder teaches the patient to recognize when they are going through one of their depressive or manic phases and how they can control their thoughts to control their behavior.
The process of education about the disease for the patient, as well as the family of the patient, helps them recognize patterns of behavior which can be adjusted over time. Additionally, the family members need to be watchful of any signs of relapse or fresh symptoms which show that the help being given is not sufficient (Heru et. al., 2005). In such situations, additional therapy could be recommended, or a change in medication might be ordered by the doctors to ensure that the fresh symptoms do not evolve into a full episode. Moreover, psychosocial therapy is often more cost effective than medical or surgical procedures for combating mood disorders (Huxley et. al., 2000).
Huxley et. al. (2000) are convinced that psychosocial therapy saves lives for patients suffering from mood disorders since they give a patient hope and understanding. The suicide rate for patients with mood disorders is quite high, and if the mood disorder is detected and cured, the therapist gets the credit for saving a valuable life as much as any doctor or nurse who saves a life in the emergency room or on an operating table. Additionally, psychotherapy for the treatment of Bipolar Disorder allows family members of the patient to play a part in the recovery process which reduces their feeling of helplessness and prevents the creation of guilt. Both Clinical Depression and the Bipolar Disorder can be helped with psychosocial treatments which include the following:
- Helping the patient as well as the family of the patient understand the disorder, its causes and symptoms.
- Monitoring the changes in the mood of the patient, the feelings of the patient and sleep patterns.
- Teaching the patient and concerned parties how to cope with the stress of the disease and reduce the effect of other stressors which can make the condition worse.
- Helping the patient manage his/her relationships to avoid/reduce the difficulties associated with decisions made or actions taken during a depressive or manic episode.
- Allowing patients to share experiences and offer helping hands in situations where group therapy is prescribed
- Offering an alternative to the patients for whom the side effects of pharmacological treatments are difficult to manage or for those who can not have pharmacological treatment at all.
Reducing the Stigma
An important role played by nurses and social workers in psychosocial therapy, as well as the treatment of other mental illnesses, is trying to reduce the social stigma associated with mood disorders. The main method with which the stigma can be reduced is through the creation of a therapeutic alliance. The concept of this sort of alliance between nurse and the patient is greatly appreciated by Safran and Segal (1990), and they recommend an educational/support system to be created between the patient and the other professionals involved in the care.
The concept of social support against the negative influences of mood disorders is certainly not a new thought since Cole (2006) reports that as early as 1912 Sigmund Freud considered a healthy relationship between the analyst and client to be positive. Freud called it a working alliance for mental health. The humanist therapist, Carl Rodgers took the concept to a higher level when he called it necessary as a support tool and essential for the growth and improvement of the client’s condition. The development of ethical principles for the bond between the caregiver and receiver were defined by the Association for the Advancement of Behaviour Therapy (AABT) and these rules safeguard the interests of both the client and the nurses involved in the treatment (Cole, 2006).
The role of the nurse in removing the stigmatisation and exclusion of the patient is not a static function since it changes dynamically based on the situation the nursing staff fined themselves to be in (Cole, 2006). For example, a nurse may have to gently ask a patient to come back to her room while the patient wishes to be outside. A social worker may have to explain to the children of the patient why their father or mother is behaving in a way which is clearly strange and hard for them to understand. Since it is not possible for a professional to be present and to handle the same patient round the clock, the relationship builds with time and it can also fall (Gelso & Carter, 1994). A person working with the patient might have limited time in which to make a connection, therefore the time spent with the patient should be utilized to learn from the patient and to understand how the patient deals with their situation, as well as what health care providers can do to help with the recovery process (Dewing, 2005).
While the idea of creating separate hospitals for the patients who have psychological or mental disorders is losing its appeal, mainstreaming is still not the singular system under which all mood disorders can be treated. Happell (2005) makes the recommendation that the same standards of treatment should be maintained for those individuals who seek mental care as the standards for those people who are physically ill.
While it is comparatively easy to change the policies involved in the delivery of health services, it is rather more difficult to change the attitudes and the beliefs of people about individuals who need assistance with mental health problems. Even close family members can react negatively to a patient having a relapse with statements that reflect their annoyance (Ostman, 2004). Going with the descriptions of mental health patients as presented in the general media, these attitudes might be even harder to change than previously thought (Harris, 2004).
The only way to overcome the fear, loathing and discrimination against people with mood disorders is to use the tool of education. Professionals must undertake the process of educating the patient’s relatives, hospital staff and even the general population about the problems and issues faced by those suffering from mood disorders and bring them out of the stigma given to them by society (Dewing, 2005). In absolute terms, these individuals are no different from those who have a physical disability or a medical condition such as diabetes, but while there are support networks and special interest groups looking out for the benefit of those who are physically ill, very few patients with mental disorders or disabilities can find support around them.
Nurses and others are in a special position to educate others as much as they can with regard to the care and treatment of patients with mood disorders. This might mean taking additional courses, attending seminars or even interacting with the patients when they are placed on rotation (Dewing, 2005). Working directly with such patients is a continual learning experience as well as a very rewarding experience that can only lead to the personal development and improvement of the individual nurse. Similarly, social workers can also help the cause for all patients with mood disorders if they can bring an understanding of the disease for themselves as well as others.
American Academy of Child & Adolescent Psychiatry. (2004). The Depressed Child. Retrieved October 15, 2006 from AACAP.org website: http://www.aacap.org/publications/factsfam/depressd.htm
Angst, J. and Cassano, G. (2005). The mood spectrum: improving the diagnosis of bipolar disorder. Bipolar Disorders, 4(7), 4-12.
Beers, M. et. al. (1999). The Merck Manual of Diagnosis and Therapy. Merck Research Laboratories.
Bland, R. (1997). Epidemiology of Affective Disorders: A Review. Canadian Journal of Psychiatry, 42(1), 367â€“377.
Cole, M. (2006). Power over therapy? Mental Health Practice, 9(9), 28-32.
Craighead, W. and Miklowitz, D. (2000). Psychosocial interventions for bipolar disorder. Journal of Clinical Psychiatry, 61(13), 58â€“64.
Dewing, J. (2005). Double skills, double knowledge. Mental Health Practice, 8(5), 46-47.
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). (2003). Mood Disorders. Retrieved October 12, 2006 from Heffner Media Group, Inc., website: http://allpsych.com/disorders/mood/index.html
Donahue, K. and Fristad, M. (2005). How to help parents and their children cope with depression and bipolar disorder. Brown University Child & Adolescent Behavior Letter, 21(10), 1-5.
Ernst, C. et. al. (2006). Antidepressant effects of exercise: Evidence for an adult-neurogenesis hypothesis? Journal of Psychiatry & Neuroscience, 31(2), 84-92.
Feirman, J. (2005). Bipolar Disorder. Retrieved October 11, 2006 from Psychology Today website: http://www.psychologytoday.com/conditions/bipolar.html
Foltz, R. (2006). The Mistreatment of Mood Disorders in Youth. Ethical Human Psychology & Psychiatry, 8(2), 147-155.
Foster, S. (2005). Introduction to Psychosocial Assessment. Retrieved October 15, 2006 from University of Texas Website: http://hcpc.uth.tmc.edu/procedures/volume2/chapter3/treatment_services-04.htm
Garcia, J. (1975). Psychofraud and Ethical Therapy. Retrieved October 12, 2006 from Society for Evolutionary Ethics website: http://www.see.org/e-pf-dex.htm>
Gelso, C. and Carter, J. (1994). Components of the psychotherapy relationship: their interaction and unfolding during treatment. Journal of Counseling Psychology, 41(2), 296-396.
Happell, B. (2005). Mental health nursing: challenging stigma and discrimination towards people experiencing a mental illness. International Journal of Mental Health Nursing, 14(1), 1-2.
Harris, R. (2004). Media representation of people with mental health problems, Nursing Times, 100(34), 33-5.
Heru, A. et.al. (2005). Psychoeducation for caregivers of patients with chronic mood disorders. Bulletin of the Menninger Clinic, 69(4), 331-340.
Huxley, N. et. al. (2000). Effectiveness of Psychosocial Treatments in Bipolar Disorder: State of the Evidence. Harvard Review of Psychiatry, 8(3), 126-141.
Jian, W. et. al. (2005). Help-Seeking Behaviours of Individuals With Mood Disorders. Canadian Journal of Psychiatry, 50(10), 652-659.
Leupo, K. and Birge, A. (2001). The History of Mental Illness. Retrieved October 12, 2006 from OhioU.edu. 2001. Website: http://www.ohiou.edu/~ridges/history.html
Licinio, J. (2005). The experience of bipolar disorder: a personal perspective on the impact of mood disorder symptoms. Molecular Psychiatry, 10(9), 827-830.
McIntyre, R. et. al. (2006). Obesity in Bipolar Disorder and Major Depressive Disorder: Results from a National Community Health Survey on Mental Health and Well-Being. Canadian Journal of Psychiatry, 51(5), 274-280.
National Center for Biotechnology Information (NCBI). (2006). Mood Disorders. Retrieved October 11, 2006 from U.S. National Library of Medicine website: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.30123
Ostman, J. (2004). Family burden and participation in care: differences between relatives of patients admitted to psychiatric care for the first time and relatives of re-admitted patients. Journal of Psychiatric and Mental Health Nursing, 11(1), 608â€“613.
Pelkonen, M. and Marttunen, M. (2003). Child and Adolescent Suicide: Epidemiology, Risk Factors, and Approaches to Prevention. Pediatric Drugs, 5(4), 243-265.
Powell, T. et. al. (2001). Predictors of psychosocial outcomes for patients with mood disorders. Psychiatric Rehabilitation Journal, 25(1), 3-14
Safran, J. and Segal, Z. (1990), Interpersonal Process in Cognitive Therapy. Basic Books.
Sajatovic, M. (2002). Treatment of bipolar disorder in older adults. International Journal of Geriatric Psychiatry, 17(9), 865-873.
Schulberg, H. and Burns, B. (1988). Mental disorders in primary care: epidemiologic, diagnostic, and treatment research directions. General Hospital Psychiatry, 10(2), 79-87.
Silove, D. et. al. (2006). Understanding community psychosocial needs after disasters: Implications for mental health services. Journal of Postgraduate Medicine, 52(2), 121-125.
The Nobel Foundation. (2005). Egas Moniz. Retrieved October 13, 2006 from NobelPrize.org website: http://nobelprize.org/medicine/laureates/1949/moniz-bio.html
Tyrka, A. et. al. (2006). Psychotic Major Depression: A Benefit-Risk Assessment of Treatment Options. Drug Safety, 29(6), 491-509.
Winther, G. (1994). Psychotherapy with manic-depressives: problems in interaction between patient and therapist. Group Analysis, 27(1), 467â€“74.