Therapeutic Recreation Processes and Techniques 6th Edition

1
Therapeutic Recreation Processes and
Techniques6th Edition

• David R. Austin

2
Table 2-1Five Major Theories of Helping
3
Table 2-1Five Major Theories of Helping (Cont.)
4
Table 2-1Five Major Theories of Helping (Cont.)
5
Table 2-1Five Major Theories of Helping (Cont.)
6
Table 2-1Five Major Theories of Helping (Cont.)
7
Table 2-2Freuds Stages of Psychosexual
Development

• Oral Stage
• Anal Stage
• Phallic Stage
• Latency Stage
• Genital Stage

Sources Murray Huelskoetter (1991)
Okun (2002) Rawlins, Williams, Beck (1993)
Rowe Mink (1993) Townsend (2000).
8
Table 2-3Common Defenses

• Denial. The source of distress is not
  acknowledged or perceived because it is too
  threatening. The person refuses to admit being
  frightened by an event or action of another
  individual.
• Repression. Unacceptable or anxiety-provoking
  thoughts or feelings are blotted out of
  consciousness. People forget threatening
  occurrences.
• Displacement. Emotions are transferred from the
  original person or object to a less formidable,
  or safer, target. It is the kick the cat
  defense.

9
Table 2-3Common Defenses (Cont.)

• Projection. Rejecting an unacceptable thought or
  feeling by blaming it on another person. By
  attributing it to someone else, the unacceptable
  thought or feeling is removed from the person.
• Sublimation. Directing a socially unacceptable
  desire or activity into a socially acceptable
  one. For example, releasing sexual urges though
  dance.
• Rationalization. A socially acceptable reason is
  given to avoid having to face a nonacceptable
  belief about oneself.
• Intellectualization. Painful emotions or feelings
  associated with an event are explained away by
  the use of a rational explanation.

10
Table 2-4Six Conditions for Change

• The client and helper must be in psychological
  contact. A therapeutic relationship or emotional
  connection between the helper and client is
  essential.
• The client must be in a state of incongruenceIf
  a client feels no anxiety, she or he is unlikely
  to be motivated enough to engage in the helping
  process.
• The helper must be congruent (genuine) or
  integrated in the relationshipThe helper cannot
  be phony in the helping relationship.

Source Hill, C.E., OBrien, K.M.
(1999). Helping skills Facilitating,
exploration, insight, and action. Washington,
D.C. American Psychological Association, pp.68,
69.
11
Table 2-4Six Conditions for Change (Cont.)

• The helper must feel unconditional positive
  regard for the clientEssentially, a helper is
  trying to understand a clients feelings and
  experience but is not trying to judge whether the
  person should or should not have the feelings
  or whether the feelings are right or wrong.
• The helper must experience empathy for the
  clientWe can distinguish empathy from sympathy,
  in which the helper feels pity for the client and
  often acts from a one-up power position rather
  than as an equal.
• The client must experience the helpers
  congruence, unconditional positive regard, and
  empathy. If the client does not experience the
  facilitative conditions, for all practical
  purposes they do not exist for the client and the
  sessions are not likely to be helpful.

12
Table 3-1McDowells Levels of Counseling

• Leisure-Related Behavioral Problems Orientation
• Leisure Lifestyle Awareness Orientation
• Leisure Resource Guidance Orientation
• Leisure-Related Skills-Development Orientation

Source McDowell, C.F. (1984). Leisure
Consciousness, well-being, and counseling. In
E.T. Dowd (Ed.), Leisure counseling Concepts and
applications. Springfield, IL Charles C. Thomas.
13
Table 3-1McDowells Levels of Counseling (Cont.)

• Leisure-Related Behavioral Problems Orientation.
  To help clients resolve behavioral concerns.
  Clients develop effective coping skills and
  problem-solving abilities to deal with chronic or
  excessively expressed leisure-related behavioral
  concerns (e.g., boredom, TR watching, etc.).
• Leisure Lifestyle Awareness Orientation. To help
  clients improve self-knowledge and understanding
  pertaining to leisure values, beliefs, and
  attitudes. Clients develop understanding
  regarding leisure and issues such as personal
  lifestyle, family relations, and transitions
  (e.g., aging retirement, relocation, divorce).

14
Table 3-1McDowells Levels of Counseling (Cont.)

• Leisure Resource Guidance Orientation. To help
  clients match leisure interests with community
  resources. Clients need to identify leisure
  interests, or what to do in their free time and
  information regarding opportunities needs to be
  provided to them.
• Leisure-Related Skills-Development Orientation.
  To help clients develop the leisure-related
  skills and abilities that they lack. Clients
  develop skills in areas such as assertiveness,
  social skills, grooming, motor abilities,
  effective use of transportation, and recreation
  activities.

15
Figure 4-1Illness-Wellness Continuum
Illness
Wellness
Peak health
Death
(Concern with growth)
(Concern with disease)
16
Table 4-1Health Protection Health Promotion
Model
Health Protection
Health Promotion
Wellness oriented

• Treatment or rehabilitation due to illness or
  disability

Motivation to enhance health
Motivation to restore health
17
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18
Table 4-2Characteristics of the TR Process

• It is client centered to meet the unique needs of
  the client.
• It is cyclical. All phases interrelate.
• It is goal directed.
• It is collaborative in that it requires the
  therapist to communicate with the client to meet
  his or her needs.
• It emphasizes feedback to reassess the problem or
  revise the intervention plan.
• It is applicable as a framework in all TR
  settings.

Adapted from Table 4.1 Characteristics of
the Nursing Process in Ramont, R.P., Maldonado
Niedringhaus, D. (2004) Fundamental nursing care.
Upper Saddle River, NJ Pearson Education, Inc.,
p. 51.
19
Figure 4-3Cyclical Nature of the Therapeutic
Recreation Process
20
Table 4-3Guidelines for Using Standardized
Assessments

• Guidelines for Selection of Assessment
  Procedures
• The assessment measures what you intend to
  measure.
• The assessment instrument rests on a strong
  theory base.
• The assessment should provide evidence of
  validity.
• The assessment should be validated on a
  representative sample of sufficient size.
• The assessment should be valid for its intended
  use.
• There should be evidence of the relationship of
  subscores to total scores of those measure which
  produce subscores.

Sources Dunn., J.D. (1989). Guidelines
for using published assessment procedures.
Therapeutic Recreation Journal, 23(2), 59-69.
Zabriskie, R.B. (2003). Measurements basics A
must for TR professionals today. Therapeutic
Recreation Journal, 37(4), 330-338.
21
Table 4-3Guidelines for Using Standardized
Assessments

• Guidelines for Selection of Assessment
  Procedures (Cont.)
• The assessment must provide evidence of
  reliability.
• The manual and test materials should be complete
  and or appropriate quality.
• A test user should demonstrate relevance for the
  assessment selection.
• The assessment should be relevant to the clients
  served by the agency.
• The assessment should be relevant to the
  decisions made based on assessment results (i.e.,
  It measures the specific behaviors or constructs
  you hope to influence).

Sources Dunn., J.D. (1989). Guidelines
for using published assessment procedures.
Therapeutic Recreation Journal, 23(2), 59-69.
Zabriskie, R.B. (2003). Measurements basics A
must for TR professionals today. Therapeutic
Recreation Journal, 37(4), 330-338.
22
Table 4-3Guidelines for Using Standardized
Assessments

• Guidelines for Assessment Use
• An assessment should be revalidated when any
  changes are made in procedures, or materials, or
  when it is used for a purpose or with a
  population group for which it has not been
  validated.
• The assessment should be selected and used by
  qualified individuals.
• The assessment should be used in the intended
  way.
• Published assessments should be used in
  combination w/other methods.
• The assessment should be usable with your
  population in your situation (e.g., It is not too
  difficult for your clients. It may be completed
  in the time available).

Sources Dunn., J.D. (1989). Guidelines
for using published assessment procedures.
Therapeutic Recreation Journal, 23(2), 59-69.
Zabriskie, R.B. (2003). Measurements basics A
must for TR professionals today. Therapeutic
Recreation Journal, 37(4), 330-338.
23
Table 4-3Guidelines for Using Standardized
Assessments

• Guidelines for Administering, Scoring, and
  Reporting
• The administration and scoring of an assessment
  should follow standardized procedures.
• During the administration of an assessment, care
  should be taken in providing a comfortable
  environment with minimal distractions.
• During the administration of assessments, the
  administrator should be aware of the importance
  and effect of rapport with the client.
• It is the responsibility of the test user to
  protect the security of materials.

Sources Dunn., J.D. (1989). Guidelines
for using published assessment procedures.
Therapeutic Recreation Journal, 23(2), 59-69.
Zabriskie, R.B. (2003). Measurements basics A
must for TR professionals today. Therapeutic
Recreation Journal, 37(4), 330-338.
24
Table 4-3Guidelines for Using Standardized
Assessments

• Guidelines for Protecting the Rights of
  Clients
• Test results should not be released without
  informed consent.
• Data regarding a clients assessment results
  should be kept in a designated clients file.

Sources Dunn., J.D. (1989). Guidelines
for using published assessment procedures.
Therapeutic Recreation Journal, 23(2), 59-69.
Zabriskie, R.B. (2003). Measurements basics A
must for TR professionals today. Therapeutic
Recreation Journal, 37(4), 330-338.
25
Figure 4-4Examples of Verbs for Specific
Behavioral Objectives
Accepts Cooperates Describes Demonstrates Disclose
s Displays Expresses Explains
Identifies Informs Initiates Lists Participates Pe
rforms Shares States
26
Gronlunds RulesforStating Objectives

• Begin with an action verb.
• State the objective to reflect client behavior
• Only state one terminal behavior per objective.
• Aim the objective at the appropriate level of
  specificity.

27
Magers CharacteristicsofUseful Objectives

• Performance What the learner is expected to be
  able to do.
• Conditions The conditions under which the
  performance is expected to occur.
• Criterion The level of competence that must be
  reached or surpassed.

28
SMART

• Specific
• Measurable
• Attainable
• Realistic
• Timelined

29
Figure 4-5Outline for program protocols

• Program Title
• Time and Place of Program
• Target Population/ Size of Group
• Client Referral Criteria
• Contraindicated Criteria
• General Program Purpose
• Program Description
• Problems or deficits the Program Might Address

Sources Cole, M. B. (1993). Group
dynamics in occupational therapy The theoretical
basis and practice application of group
treatment. Thorofare, NJ SLACK Incorporated
Kelland, J. (Editor) (1995). Protocols for
recreation therapy program. State College, PA
Venture Publishing OMorrow, G.S. Carter, M.
J. (1997). Effective management in therapeutic
creation service. State College, PA Venture
Publishing, Inc. Stumbo, N.J. Perterson, C.A.
(2009). Therapeutic recreation program design
(5th ed.). San Francisco Pearson Education, Inc.
30
Table 4-5Outline for program protocols (Cont.)

• Interventions or Facilitation Techniques to be
  Employed
• Staff Program Responsibilities
• Training Requirements for Staff
• Risk Management Considerations
• Expected Program Outcomes
• Program Evaluation Methods/ Frequency

Sources Cole, M. B. (1993). Group
dynamics in occupational therapy The theoretical
basis and practice application of group
treatment. Thorofare, NJ SLACK Incorporated
Kelland, J. (Editor) (1995). Protocols for
recreation therapy program. State College, PA
Venture Publishing OMorrow, G.S. Carter, M.
J. (1997). Effective management in therapeutic
creation service. State College, PA Venture
Publishing, Inc. Stumbo, N.J. Perterson, C.A.
(2009). Therapeutic recreation program design
(5th ed.). San Francisco Pearson Education, Inc.
31
Figure 5-1Examples of the Professional Values of
Recreational Therapists

• Health and Well-Being. Recreational therapists
  value assisting persons to achieve their optimal
  levels of health whether these persons are in
  normal health, or having an illness, disorder, or
  disability. All possess the potential for change.
• Control and Choice. Recreational therapists
  respect and promote the autonomy of clients so
  they may maintain control over their lives to the
  greatest degree possible and make informed
  choices.
• Client-Therapist Relationship. The
  client-therapist relationship is valued as a
  critical element in therapeutic recreation. The
  essential role of the recreational therapist is
  that of a catalyst who works in partnership with
  clients in order to help them be as self-directed
  as possible.

32
Figure 5-1Examples of the Professional Values of
Recreational Therapists (Cont.)

• Client Abilities and Strengths. Each client is
  seen as possessing abilities and intact strengths
  that may be used to meet client challenges.
  Clients can build strengths and abilities through
  participation in therapeutic recreation.
• Fun and Enjoyment. Fun and enjoyment are valued
  as motivators for client participation. People
  are motivated to take part in activities that are
  fun or enjoyable. Fun and enjoyment are positive
  emotions that open clients up to try new
  behaviors.
• Emphasis on Client. Therapeutic recreation is
  action oriented but the emphasis is always on the
  client as a person and not on the activity.

33
Figure 5-1Examples of the Professional Values of
Recreational Therapists (Cont.)

• Goal-Directed. Therapeutic recreation is valued
  for being purposeful and goal-directed. Being
  purposeful means having a plan, which implies
  choice making on the part of clients.
• Intrinsic Worth. Every client is valued as an
  individual possessing intrinsic worth who should
  be treated with dignity.
• Competent and Ethical Care. Recreational
  therapists value the ability to offer competent
  and ethical care and therefore meet their
  professional obligations to clients.

34
Table 5-1Ethical Principles

• Autonomy- Self-governing
• Confidentiality- Right to control access to
  information
• Social-sexual Relations- Need to avoid
  social/sexual involvements with clients
• Professional Competence- Do not exceed levels of
  competence
• Nonmaleficence- Obligations not to harm others
• Beneficence- Promote well-being
• Veracity-Telling the truth
• Fidelity- Faithfulness keeping promises
• Justice- Fairness in distributing services

35
Table 6-1Attentive Listening Using Acronym
SOLER

• S - Sit squarely facing the clients.
• O - Observe an open posture.
• L - Lean forward toward the client.
• E - Establish eye contact.
• R - Relax.

Source Adapted from Egan, G. (2002). The
skilled helper A problem management approach to
helping (7th edition). Pacific Grove, CA Brooks/
Cole Publishing Company Townsend, M. C. (2000).
Psychiatric mental health nursing Concepts of
care (3rd edition). Philadelphia F. A. Davis
Company.
36
Table 6-2Verbal Techniques

• Informing
• Summarizing
• Self-disclosing
• Focusing
• Making observations
• Suggesting
• Closed questions
• Facilitative questions and statements

• Minimal verbal responses
• Paraphrasing
• Checking out
• Clarifying
• Probing
• Reflecting
• Interpreting
• Confronting

37
Table 6-3General Guidelines for Using Major
Verbal Techniques

• Phrase your response in the same vocabulary that
  the client uses.
• Speak slowly enough that the client will
  understand each word.
• Use concise rather than rambling statements.
• Relate the topic introduced by the client to the
  identified cognitive theme that is of most
  importance.
• Talk directly to the client, not about him or
  her.
• Send I statements to own your feelings, and
  allow the client to reject, accept, or modify
  your messages.
• Encourage the client to talk about his or her
  feelings.
• Time your responses to facilitate, not block,
  communication.

Adapted from Okun, B.F. (2002/ Effective
helping Interviewing and counseling techniques
(6th ed.). Pacific Grove, CA Brooks/Cole.
38
Table 6-4Facilitative Questions and Statements
Type Observeto notice what went on or what goes
on.
Example Tell me about yourself. Tell me every
detail from the beginning. To what degree do
you feel that way?

Adapted from Haber, J. (1997). Therapeutic
communication. In J. Haber, B. Krainovich-Miller,
A.L. McMahon P. Price-Hoskins (Eds.),
Comprehensive Psychiatric Nursing (5th ed.). St.
Louis Mosby (pp. 121-142).
39
Table 6-4Facilitative Questions and Statements
(Cont.)
Type Describeto stimulate recall and details of
a specific event or experience.
Example What did you feel at the time? What
happened just before? How did he respond to
your comment?

Adapted from Haber, J. (1997). Therapeutic
communication. In J. Haber, B. Krainovich-Miller,
A.L. McMahon P. Price-Hoskins (Eds.),
Comprehensive Psychiatric Nursing (5th ed.). St.
Louis Mosby (pp. 121-142).
40
Table 6-4Facilitative Questions and Statements
(Cont.)
Example What is the importance of event? What
do you see as the reason? What was your part in
it?
Type Analyzeto review that information for
greater understanding.
Adapted from Haber, J. (1997). Therapeutic
communication. In J. Haber, B. Krainovich-Miller,
A.L. McMahon P. Price-Hoskins (Eds.),
Comprehensive Psychiatric Nursing (5th ed.). St.
Louis Mosby (pp. 121-142).
41
Table 6-4Facilitative Questions and Statements
(Cont.)
Type Formulateto restate in a clear, direct way
the relationship between thoughts, feelings, and
experiences.
Example Tell me again. What would you say was
the problem? Can you tell me the essence of it?
Adapted from Haber, J. (1997). Therapeutic
communication. In J. Haber, B. Krainovich-Miller,
A.L. McMahon P. Price-Hoskins (Eds.),
Comprehensive Psychiatric Nursing (5th ed.). St.
Louis Mosby (pp. 121-142).
42
Table 6-4Facilitative Questions and Statements
(Cont.)
Type Testto try out new thoughts, feelings, or
behaviors.
Example What would you do if a situation like
that came up again? In what way will this
understanding help you in the future?
Adapted from Haber, J. (1997). Therapeutic
communication. In J. Haber, B. Krainovich-Miller,
A.L. McMahon P. Price-Hoskins (Eds.),
Comprehensive Psychiatric Nursing (5th ed.). St.
Louis Mosby (pp. 121-142).
43
Table 6-5Barriers to Therapeutic Communication
Non-Therapeutic Examples If I were you Dont
worryeverything will be OK. Lets wait on that
and talk about Hold it, hold it!
Barriers Giving advice Giving false
reassurance Topic jumping (changing the
subject) Interrupting
Adapted from Haber, J. (1997). Therapeutic
communication. In J. Haber, B. Krainovich-Miller,
A.L. McMahon P. Price-Hoskins (Eds.),
Comprehensive Psychiatric Nursing (5th ed.). St.
Louis Mosby (pp. 121-142).
44
Table 6-5Barriers to Therapeutic Communication
(Cont.)
Barriers Being judgmental Blaming Giving
directions Excessive questioning Challenging
Non-Therapeutic Examples Youre wrong. It is
all your fault. Just do what I say. What is
the real reason? You cant really hear the
devil speaking.
Adapted from Haber, J. (1997). Therapeutic
communication. In J. Haber, B. Krainovich-Miller,
A.L. McMahon P. Price-Hoskins (Eds.),
Comprehensive Psychiatric Nursing (5th ed.). St.
Louis Mosby (pp. 121-142).
45
Table 6-5Barriers to Therapeutic Communication
(Cont.)
Barriers Expressing disapproval Hurried
approaches Closed-mindedness, Stereotyped
responses
Non-Therapeutic Examples I dont approve of
that. (or frowning) Will you please hurry
up. Thats the only way to see it. Keep your
chin up it wont be much longer.
Adapted from Haber, J. (1997). Therapeutic
communication. In J. Haber, B. Krainovich-Miller,
A.L. McMahon P. Price-Hoskins (Eds.),
Comprehensive Psychiatric Nursing (5th ed.). St.
Louis Mosby (pp. 121-142).
46
Table 6-5Barriers to Therapeutic Communication
(Cont.)
Barriers Double messages Defending or defensive
responses Self-preoccupation or
daydreaming Patronizing
Non-Therapeutic Examples Tell me more. (While
non-verbals show lack of interest.) Dont blame
me youre the one with problems. Oh, excuse
me could you repeat that? I didnt hear what you
said. Now, Honey, it will work out.
Adapted from Haber, J. (1997). Therapeutic
communication. In J. Haber, B. Krainovich-Miller,
A.L. McMahon P. Price-Hoskins (Eds.),
Comprehensive Psychiatric Nursing (5th ed.). St.
Louis Mosby (pp. 121-142).
47
Table 6-6Communication with Clients with Special
Needs

• Clients Who Are Visually Impaired
• Clients Who Are Hearing Impaired
• Clients Who Use Wheelchairs
• Clients Who Speak a Foreign Language

48
Table 6-7Techniques for the Productive Interview

• Establish rapport
• Control the external environment
• Wear clothing that conveys the image of a
  professional and is appropriate for the
  situation.
• Begin by stating and validating with the client
  the purpose of the interview.
• Use a vocabulary on the level of awareness or
  understanding of the person.

Source Murray, R.B., Huelskoetter, M.M.W.
(1991). Psychiatric/mental health nursing (3rd
ed.). Norwalk, CT Appleton Lange pp.139.
49
Table 6-7Techniques for the Productive Interview
(Cont.)

• Avoid preconceived ideas, prejudices, or biases.
  
• Be precise in what you say, so the meaning is
  understood.
• Avoid asking questions in ways that get only
  socially acceptable answers.
• Be gentle and tactful when asking questions about
  home like or personal matters.
• Be an attentive listener.

Source Murray, R.B., Huelskoetter, M.M.W.
(1991). Psychiatric/mental health nursing (3rd
ed.). Norwalk, CT Appleton Lange pp.139.
50
Table 6-7Techniques for the Productive Interview
(Cont.)

• Carefully observe nonverbal messages for signs of
  anxiety, frustration, anger, loneliness, or
  guilt.
• Encourage spontaneity.
• Ask questions beginning with What? Where?
  Who? and When?
• Keep data obtained in the interview confidential
  and share this information only with the
  appropriate and necessary health team members.
• Evaluate the interview.

Source Murray, R.B., Huelskoetter, M.M.W.
(1991). Psychiatric/mental health nursing (3rd
ed.). Norwalk, CT Appleton Lange pp.139.
51
Table 7-1Developing Closeness by Achieving Trust

• Communicating clearly in a way a layperson can
  understand
• Keeping promises
• Protecting confidentiality
• Avoiding negative communications (e.g. blocking,
  false reassurance)
• Being available to the client

52
Figure 7-1Factors Influencing Choices of
Leadership Style
Leader (ability and personality)
53
Figure 7-2Continuum of Leadership Styles
Autocratic
Laissez-faire
Democratic
(Leader centered)
(Client centered)
Dependency
Independency
54
Table 7-2Advantages of Therapeutic Recreation
Groups

• Advantages for Clients
• Group identity
• Socialization
• Empathetic understanding
• Social support
• Hope
• Control
• Vicarious learning
• Modeling coping
• Role-Modeling
• Practice new behaviors

• Feedback
• Share thoughts
• Self-confidence
• Give and take
• Transcendence
• Validation
• Self-awareness
• Helping others
• Recreation skills
• Cost savings

55
Table 7-2Advantages of Therapeutic Recreation
Groups

• Advantages for Group Leaders
• Cost savings
• Provide added support
• Resources of the group
• Stimulating

56
Stages of Group Development

• Forming
• Storming
• Norming
• Performing

57
Table 7-3Guidelines for Giving Feedback

• Be sensitive
• Do not avalanche
• Do not overpraise the group
• Try not to punish, preach, or judge
• Feedback should be immediate
• Use confrontive feedback carefully
• Act as a role model for giving and receiving
  feedback.

58
Processing Techniques

• No Loading
• Frontloading (aka framing, briefing,
  prebriefing)
• Feedback (including stop-action reframing)
• Metaphors
• Debriefing

59
General Frameworks for Debriefing

• What? So What? Now What?
• The 5 Question Model
• Experiential Learning Model

60
What? So What? Now What? Model

• What Phase - review of what happened
• So What Phase - Express what they have learned
• Now What Phase - what they will do with learning

61
The 5 Question Model

• Did you notice?
• Why did that happen?
• Does that happen in life?
• Why does that happen?
• How can you use that?

62
The Experimental Learning Cycle

• Experiencing
• Publishing
• Processing
• Generalizing
• Applying

63
Table 8-1Reasons for Charting

• It is a vital tool for communication among health
  care team members.
• It is a legal document admissible as evidence
  that can protect you.
• It establishes therapeutic recreations
  professional accountability.
• It is a document for evaluation of changes in a
  clients condition.
• It is used to develop improvements in the quality
  of care.
• It aids in accreditation, licensing, and
  reimbursement.
• It serves an educational purpose as students read
  notes.
• It is used in research to identify researchable
  problems.

64
Table 8-2Effective Documentation Must Be

• Clear, concise, and comprehensive
• accurate
• relevant
• objective
• permanent
• legible
• chronological time

Source College of Respiratory Therapists of
Ontario (2005). Professional Practice Guidelines
Documentation. Retreived 6/4/2008 from
http//www.crto.on.ca./pdf/documentation-ppg.pdf.
65
Table 8-3Stages of Transtheoretical Model (TTM)

• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance

Not planning any changes in foreseeable
future. Having acknowledged problem. Is
considering change. Planning steps in the near
future. May be starting to make small changes.
Plans are put into action. Actively involved in
changing. Engaging in new behaviors. Working to
maintain change over time. Preventing relapse,
consolidating gains, integrating new behaviors
into lifestyle.
Adapted from Berman, A., Snyder, S.J., Kozier,
B, Erb, G. (2008). Fundamental of nursing (8th
ed.). Upper Saddle River, NJ Pearson Prentice
Hall, p. 281 Niven, N. (2006). The psychology of
nursing care (2nd ed.). New York Palgrave
MacMillan, 368.
66
Table 9-1Characteristics of Clinical Supervision

• supportive
• safe, because of clear, negotiated agreements by
  all parties with regard to the extent of limits
  of confidentiality
• brave, because practitioners are encouraged to
  talk about the realities of their practice
• a chance to talk about difficult areas of work in
  an environment where the person attempts to
  understand
• an opportunity to ventilate emotion without
  comeback
• the opportunity to deal with material and issues
  that practitioners may have been carrying for
  many years (the chance to talk about issues which
  cannot easily be talked about elsewhere and that
  may have been previously unexplored)

Adapted from Cutcliffe, J.R., Butterworth, T.,
Proctor, B. (2001). Fundamental themes in
clinical supervision. New York Routledge, pp. 3,
4.
67
Table 9-1Characteristics of Clinical Supervision
(Cont.)

• not to be confused with or amalgamated with
  managerial supervision
• not to be confused with or amalgamated with
  personal therapy/counseling
• regular
• protected time
• offered equally to all practitioners
• a committed relationship from those involved
• separate and distinct from mentorship
• a facilitative relationship
• challenging
• an invitation to be self-monitoring and
  self-accountable
• at times hard work and at others enjoyable
• the supervisee learning to become a reflective
  practitioner
• an activity that continues throughout ones
  professional life.

Adapted from Cutcliffe, J.R., Butterworth, T.,
Proctor, B. (2001). Fundamental themes in
clinical supervision. New York Routledge, pp. 3,
4.
68
Table 9-2Benefits of Clinical Supervision

• Reduced emotional exhaustion
• Reduced occupational stress
• Reduced sick leave
• Reduced burnout
• Reduced feelings of professional isolation
• Increased feelings of support
• Increased job satisfaction
• Enhanced feelings of accomplishment
• Improved recruitment
• Improved retention

Sources Bishop, V. (2007) Literature review
Clinical supervision evaluation studies. In V.
Bishop (editor). Clinical supervision in practice
(2nd ed.). New York Palgrave McMillan (pp.
151-152) Driscoll, J. OSullivan, J. (2007).
The place of clinical supervision in modern
healthcare. In J. Driscoll (editor). Practicing
clinical supervision (2nd ed.). New York
Bailliere Tndall Elsevier, p. 20.
69
Table 9-3Clinical Supervision is NOT

• A management activity allowing for the overseeing
  of subordinates
• Linked to the disciplinary process
• Exclusively concerned with time-keeping, ranges
  of pay, and hours of duty
• About having the supervisees work controlled,
  directed, or managerially evaluated
• A punitive or gratuitously negative experience
  for the supervisor
• A continuous discussion of mistakes, falling, or
  errors on the part of supervisee, without being
  balanced by a discussion or the supervisees
  professional strengths and the positive aspects
  of his (or her) work.

Adapted from Bishop, V. (2007). Clinical
supervision What is it? Why do we need it? In V.
Bishop (editor). Clinical Supervision in Practice
(2nd ed.). New York Palgrav MacMillian, pp.
14-15.
70
Models of Supervision

• The Skill Development Model
• The Personal Growth Model
• The Integrative Model

71
Roles of Clinical Supervision

• The Teaching Role
• The Counselor Role
• The Consulting Role

72
Clinical Supervision Stages

• Initial State
• Growth Stage
• Maturity Stage

73
Table 10-3Anticonvulsant Drugs (Standard Agents)

• Carbamazepine (Tegretol)
• Possible side effects sedation, unsteady gain,
  anemia, infections.
• Ethosuximide (Zarontin)
• Possible side effects nausea, lethargy,
  dizziness, weight loss, headache, skin rashes.
• Phenobarbital (Luminal, Mysoline)
• Possible side effects sedation, lethargy,
  mental dullness, hyperactivity, skin rash.
• Phenytoin (Dilantin)
• Possible side effects unsteady gain, slurred
  speech, drowsiness, fatigue, gum swelling, skin
  rash, hair growth, anemia, infections.
• Valproic acid (Depakote)
• Possible side effects nausea and vomiting,
  decreased liver function, decreased platelets,
  unsteady gait, weight gain.

Sources Pellock (1998) Browne Homes(2004)
74
Table 10-3Anticonvulsant Drugs (New Agents)

• Gabapentin (Neurontin)
• Possible side effects sedation, lethargy,
  hyperactivity, irritability, dizziness, headache.
• Lamotrigine (Lamictal)
• Possible side effects skin rash, lethargy,
  stomach upset, unsteady gait, respiratory
  infections.
• Levetiracetam (Keppra)
• Possible side effects drowsiness, behavioral
  changes.
• Oxcarbazepine (Trileptal)
• Possible side effects headache, stomachache,
  dizziness, rash.
• Tiagabine (Gabitril)
• Possible side effects dizziness, lethargy,
  nervousness, tremor, stomach upset.
• Topiramate (Topamax)
• Possible side effects sedation, psychomotor
  slowing, slow speech, memory troubles, dizziness,
  unsteadiness, nausea, numbness.
• Zonisamide (Zonegran)
• Possible side effects unsteadiness, depression,
  renal stones.

Sources Pellock (1998) Browne Homes(2004)
75
Table 10-4Antipsychotic Drugs

• Typical antipsychotics
• 1. Chlorpromazine (Thorazine)
• 2. Thioridazine (Mellaril)
• 3. Fluphenazine (Prolixin)
• 4. Thiothixene (Navane)
• 5. Haloperidol (Haldol)
• 6. Primozide (Orap)

• Atypical antipsychotics
• 1. Clozapine (Clozaril)
• 2. Risperidone (Risperdal)
• 3. Olanzapine (Zypreza)
• 4. Quetiapine (Seroquel)
• 5. Ziprasidone (Geodon)
• 6. Aripiprazole (Abilify)

Source Schatzberg Nemeroff (1998)
Findling (2008)
76
Table 10-4Antipsychotic Drugs (Cont.)

• Desired Effects
• Major actions include the reduction of symptoms
  of psychosis (i.e., hallucinations, delusions,
  disordered thinking processes, and social
  withdrawal). The antipsychotic drugs have been
  used in the pervasive developmental disorders for
  reducing hyperactivity, emotional quieting, and
  decreased anxiety, and in Tourettes syndrome to
  decrease tics.

Source Schatzberg Nemeroff (1998)
Findling (2008)
77
Table 10-5Antipsychotic Drug Side Effects

• Extrapyramidal Side Effects (EPS)
• Motor restlessness where the client cannot spot
  moving (akathisia).
• Involuntary jerking and bizarre movements of
  muscles in the face, neck, tongue, eyes, arms,
  and legs.
• Tremors, muscle weakness, and fatigue.
• Parkinson-like symptoms such as rigidity,
  drooling, difficulty in speaking, slow movement,
  and an unusual gait when walking, where the
  client has trouble slowing down.

Source Appleton (1998) Newton et al. (1978)
Schatzberg Nemeroff (1988)
78
Table 10-5Antipsychotic Drug Side Effects (Cont.)

• Tardive Dyskinesia (TD)
• Abnormal mouth motion such as lip smacking,
  chewing, sucking, moving the tongue in and out of
  the mouth quickly, and pushing out the cheeks.
• Involuntary movements of the jaw, increase
  blinking, and spasms of muscles in the face,
  neck, back, eyes, arms, and legs.

Source Appleton (1998) Newton et al. (1978)
Schatzberg Nemeroff (1988)
79
Table 10-5Antipsychotic Drug Side Effects (Cont.)
Other Side Effects

• Drowsiness
• Low blood pressure
• Nausea
• Vomiting
• Rash
• Dry mouth
• Urinary retention
• Blood destruction
• Photosensitivity
• (especially with Thorazine)

• Edema
• Weight gain
• Feminizing effects
• Menstrual irregularities
• Blurred vision
• Constipation
• Seizures
• Skin discoloration
• Fever
• Drop in blood cell count (especially with
  Clozapine)

Source Appleton (1998) Newton et al.
(1978) Schatzberg Nemeroff (1988)
80
Table 10-6Antidepressant Drugs

• Tricyclic antidepressants
• Imipramine (Tofranil)
• Amitriptyline (Elavil)
• Desipramine (Norpramin)
• Nortriptyline (Pamelor)
• Heterocyclic antidepressants
• Trazadone (Desyrel)
• Nefazadone (Serzone)

• Serotonin reuptake inhibitors
• Fluoxetine (Prozac)
• Sertraline (Zoloft)
• Paroxetine (Paxil)
• Fluvoxamine (Luvox)
• Citalopram (Celexa)
• Escitalopram (Lexapro)
• Others
• Buproprion (Wellbutrin)
• Venlafaxine (Effexor)
• Mirtazapine (Remeron)
• Duloxetine (Cymbalta)

Source Appleton (1988) Schatzberg
Nemeroff (1998) Findling (2008)
81
Table 10-6Antidepressants

• Desired Effects
• Relief of feelings such as hopelessness,
  sadness, helplessness, anxiety, worthlessness,
  and fatigue that are associated with depression.

Source Appleton (1988) Schatzberg
Nemeroff (1998) Findling (2008)
82
Table 10-7 Antianxiety Drugs

• Benzodiazepines
• Alprazolam (Xanax)
• Clonazepam (Klonopin)
• Lorazepam (Ativan)
• Serotonin reuptake inhibitors
• Tricyclic antidepressants

• Azapirone
• Buspirone (BuSpar)

Source Appleton (1988) Schatzberg
Nemeroff (1998) Findling (2008)
83
Table 10-7 (cont.)Antianxiety Drugs

• Desired Effects
• Reduction of anxiety, relaxation of skeletal
  muscles, relief of symptoms of tension and
  insomnia, and anticonvulsant properties.

Source Appleton (1988) Schatzberg
Nemeroff (1998) Findling (2008)
84
Figure 10-1Transferring a Client from a
Wheelchair to a Bed
85
Figure 10-2Transferring a Client from a Bed to a
Wheelchair