CHOITHRAM COLLEGE OF

NURSING
SUBJECT: PSYCHIATRIC NURSING

TOPIC:
TEACHING ON PLAY THERAPY, MUSIC THERAPY, LIGHT
THERAPY, RECREATIONAL THERAPY, PSYCHO DRAME,
DANCE THERAPY

SUBMITTED TO: MRS. BLESSY ANTONY

ASSO. PROFESSOR

SUBMITTED BY: MS. DEEPIKA PATHAK

M.Sc NURSING PREVIOUS

DATE OF SUBMISSION: NOV 2009

 MUSIC THERAPY

INTRODUCTION
Music is a moral law. It gives soul to the universe, wings to the mind, flight to the imagination, a charm
to sadness gaiety and life to everything. It is the essence of order, and leads to all that is good and
beautiful.

DEFINITION:
The national association of music therapy has defined music therapy as the therapeutic tool for the
restoration, maintenance and improvement of mental and physical health. It is the systemic application
of music, as directed by the music therapist in a therapeutic environment to bring about desirable
changes in behavior. S such changes enable the individual undergoing therapy to experience a greater
understanding of himself and the concepts about him, there by achieving a more appropriate
adjustment to the society.

GOAL:
The goal of music therapy is to reduce psycho- physiological stress, pain, and anxiety. Music therapy
leads to slower heart rate, respiration rate and blood pressure.

MECHANISM:
Even though the exact mechanism by which the music works out is not fully understood but it is
assumed to is an effective therapy because it stimulates peptides, endomorphism and natural
opiates secreted by the hypothalamus that produces pleasurable feelings and reduces the
unwanted stimuli.
The music therapy has the potential to synchronize body rhythms with rhythm of the music.
The synchronization and entertainment is thought to decrease the sympathetic nervous system
activity leading to relaxation response. The pitch also affects the autonomic nervous system,
increasing tension when high and relaxing it when low, therefore music with slow, steady
relaxing rhythm and low pitch orchestral effects would be appropriate for the patient.

EFFECTS OF MUSIC THERAPY:

 Music has distinct effects on the human organism. Soothing music can be used to achieve an
alpha wave brain state which initiates a state of relaxed awareness.
 Soothing music with a flowing, lyrical, melody, single, harmony and soft tone helps to stimulate
the relaxation response.
 Music can stimulate the release of endorphins from the brain, reduce the levels of
adrenocorticalcotrophic hormone and increase phenylethlamine secretion. Neural impulses
triggered by soothing music can trigger autonomic nervous system and produce relaxation in
muscle tone, brain wave frequency, galvanic skin response and papillary reflexes. Music also
facilitates emotional homeostasis.
 Barbara Crowe(1982), the former president of association of music therapy, said that music
makes the difference between isolation and interaction, between chronic pain and comfort,
between demoralization and dignity.
 Music therapy influence the physiological variables lick blood pressure, heart rate, respiration,
EEG measurements, body temperature and galvanic skin response.
 Alleviates pain, anxiety, nausea, fatigue and depression.
  Lowers apical heart rates and raises peripheral temperature.
 Reduces stress and anxiety, decreases blood pressure and heart rate during music therapy.

GERONTOLOGICAL CONSIDERTIONS:
 Music therapy provides comfort to the elderly
 Music relieves the stress and anxiety
 Music therapy minimize the pain
 Enhances sleep, minimizes the pain
 Improves the heart rate, respiratory rate and oxygen saturation.

MUSIC THERAPY MAKES A DIFFERENCE WITH ELDERLY :

 Music stimulates all the senses and involves the elderly at many levels. The multi model
approach facilitates many skills related to activities of daily living.
 Quality relearning and maximum participation occurs, when the elderly is permitted to
experience the joy of activity with music. The medium of music therapy allows his/ her activity
to occur naturally and frequently.
 Music is highly motivating, yet it can also have relaxing effect. Enjoyable music activities are
designed to be success oriented and elderly to feel better about them.
 Music is can encourage socialization, self expression, communication and motor development.
 Because the brain processes music, in both hemispheres, music can stimulate cognitive
functioning and may be used for recommendation of some speech and language skills.
 LIGHT THERAPY

MEANING OF LIGHT THERAPY:

Light therapy involves exposure to intense light under specified conditions. The recommended light
therapy system consists of a set fluorescent bulbs installed in a box with a plastic diffusing screen and
set up on a table or desk top at which one can sit comfortably for the treatment session.

PROCESS OF LIGHT THERAPY:

 Treatment procedure consists simply of sitting close to the light box, with lights on and eyes
open. Looking at the lights is not necessary or recommended; rather, one is free to engage in
such activities as reading, and writing, or eating meals.
 What is important is to orient the head and body toward the lights, concentrating on activities
on the surfaces illuminated by lights and not on the light themselves.
 Treatment sessions can last from 15 min to 2 hrs, usually once a day, but sometimes split into
separate sessions, depending on individual needs and equipments used.
 The amount of light reaching the eyes and the duration of light treatments may need to be
adjusted to achieve the best possible effect.
 It may be possible to shorten the duration of exposure by using a light source that gives off more
light, or by sitting closer to the lights.

LIGHT THERAPY IN TREATING MENTAL DISORDERS:

 People suffering from seasonal affective disorder experience feeling down, having less energy,
putting on a few pounds, and having difficulty getting up in the morning though out the dark,
short days of winter. They often feel chronically depressed and fatigued, and want to withdraw
from the world and to avoid social contact. They become less productive at work and complain
that the world and to avoid social contact.
 They become less productive at work and complain that their quality of life has gone. In the
extreme, they may increase their sleep by as four hours or more per day; have greatly increased
appetitive – sometimes accompanied by irresistible cravings for sweet and starchy foods and
gain a substantial amount of weight. Women frequently report worsening of premenstrual
symptoms.

MECHANISM OF LIGHT THERAPY:

 The therapeutic level of illumination has several known physiological effects, though its
mechanism of effect is still unclear. Blood levels of the hormone melatonin, which may be
abnormally high at certain times of day, are rapidly reduced by light exposure.
 Depending on when bright light is presented, the body’s internal clock which controls daily
rhythms of body’s internal clock which controls daily, rhythms of body temperature, hormone
secretions and sleep patterns shifts ahead or is delayed when stimulated by light. These
physiological time shifts may be the basis of the therapeutic response.
 On the other hand, the antidepressant effect may not involve rhythm shifts, but rather overall
changes in neurotransmitter activity such as serotonin and dopamine.

SIDE EFFECTS:
 Side effects have been minimal. People occasionally report eye irritation and redness that can
be alleviated by sitting farther from the lights or for shorter periods.
  Some complaint of nausea or agitation when beginning light treatment, but passes off quickly as
one accommodates to the high intensity. Antidepressants and light therapy combined for SAD
patients are found to be most effective.

USE OF LIGHT THERAPY FOR OTHER THAN SAD:

Light therapy is useful for non seasonal, bulimia nervosa and pre- menstrual syndrome.

CONCLUSION:
Although the first demonstration of clinical effect of light therapy was in the early 1980’s but compared
to drug treatment or psychotherapy, the method is not yet in widespread use.
 PLAY THERAPY
INTRODUCTION:
To understand play therapy, it is necessary to consider how children learn. “A child play is his
work”, the old saying goes. Infants first learn about object and people in their environment by
touching and exploring. Later in creative play, children reveal their understanding of the world
and their relationship to it. Children are unable to verbalize many of their thoughts, feelings,
wishes and fears. In play therapy toys became medium of communication between child and
therapist.

GOALS OF PLAY THERAPY:

I. Helping the child better understand feelings, and how feeling relate to behavior.
II. Helping the child find more appropriate ways of expressing feelings.
III. Helping the child find ways to solve personal problems.

PHASE OF PLAY THERAPY:

I. Introductory phase:
The first task of the therapist is to gain child’s trust. This may happen in 5 min or in 5
months, depending on the personality and prior experience of the child. Until trust has been
firmly established and the child is able to reveal inner thoughts and feelings it is difficult to
accomplish other goals.

II. Honeymoon phase:

Children, like adults in therapy, usually go through a honeymoon period when the relief
from finally being able to express some of their anxieties is so great that their demeanor at
home and school improves dramatically.

III. Rebellious phase:

At this point the child often voices strong anger about having to attend therapy sessions.
Usually the child is voicing strong anger about almost everything else as well, and parents
begin to wonder whether therapy is constructive or destructive endeavor. This sudden
rebellion, the constant venting of anger is actually a positive sign. It indicates that a
repressed feeling that has resulted in much anxiety or depression is beginning to surface. In
the therapy the child is encouraged to express feelings. Temper tantrum are more likely to
appear.

IV. The working through phase:

Becoming aware of what one is feeling, learning more productive methods of expressing
feelings, and developing healthier defense are some of the tasks achieved in this phase.
Occasionally the behavior may actually deteriorate or symptoms may intensify. Such period
is relatively short. Such regressive episode may indicate that old defense is weakening.
The old defense that served to ward off feelings of insecurity is no longer operative.
While this may increase the child’s distress, it provides an opportunity for an examination of
 the underlying feelings of worthlessness the child has harbored all along, so the healthier
defense against external threats to his self confidence can be developed.

V. Termination phase:
The longer and more intense the sessions have been, the more difficult termination will be
for the child. Many of the child original symptoms do reappear. This due to the stress
ceased by the termination; it may be child way of convincing everyone that the therapy is
still needed. If proper time is not allowed to work through the emotions generated by the
separation, therapeutic gains may not be maintained.
The therapist must help the parents be as realistic as possible in setting goals for
the child. I the end the therapy is like a education, the condition for learning are provide
but it is up to the child to accept or reject the available possibilities for growth and change.

ADVANTAGES OF PLAY THERAPY:

The non directive play therapy offers the child an opportunity to experience growth under
the most favorable conditions. Because play is the child’s natural medium for self
expression, he uses the therapy time to play out his accumulated feelings of fear, tension,
frustration and aggression.
When the child plays out his feelings, he allows them to surface, faces them and learns
to control, accept and abandon them. Through this process the child gradually realize that
he is an individual in his own right and is capable of thinking and marking decision for him.
 PSYCHODRAMA THERAPY
Introduction:
Psychodrama is a therapeutic discipline, which uses action methods, sociometry, and role
playing and group dynamics to facilitate constructive change in the lives of the participants.
Psycho dramatist provides service to diverse group of children to the elderly, and from
chronically mentally ill to those seeking understanding and learning in their work settings.
By closely approximating life situation in a structured environment, the participant is
able to recreate and enact scenes in a way, which allows both insight and opportunity to
practice new life skills. The client focuses on a specific situation to be enacted. Other
member of the group act as a auxiliaries, supporting and protagonist in his or her work, by
taking the parts or roles in significant others in scenes. The trained director helps to
recreate which might otherwise not possible. The psychodrama then becomes an
opportunity to practice new or more appropriate behavior, and evaluate its effectiveness
within the supportive atmospheres of the group.

Meaning of psychodrama:
Psycho drama is special form of group therapy which provides the patient with an additional
opportunity to gain self insight. It uses structured, directed dramatization of the patient
emotional problems and experiences. Members are encouraged to act out immediate or
past life situations, conflicts or problems.

Aims:
To develop greater awareness to patient about his thoughts, feelings and actions of how
they affect others.

Principles:
i. Action principle: Is that just as life is not limited to a single verbal dimension, so psycho
dramatic action overcomes the linguistic restrictions placed on understanding one self. It
is considered to be the most integrative vehicle for social learning and has the most
cathartic impact.
ii. Social atom principle: It states that each person is the center of his “structure of primary
interpersonal relationship”. The interpersonal network is filled with incomplete
perception and distortion. Psychodrama allows for the recreation of the social atom and
the exploration of role function in an immediate feedback system that is conducive to
learning.
iii. Spontaneity: It is an ability to response to a new situation with some “degree of
adequacy” and to an old situation with a “degree of novelty”. Psychodrama provides
plenty of opportunity to demonstrate these skills while enacting the role.
iv. Potentiality to grow: The human being is not over determined by his past. At any
moment in the time the human is in a “state of great growth potential”.
v. Catharsis: In psychodrama, catharsis is used to mean a bursting through of a personal or
cultural conserve.
vi. Tele: Is a word used to describe a two way feeling that cements and hold a relationship
together. The underlying principle in this human being is in constant interaction to
strengthen the relationship between the people in the environment.
vii. Surplus reality: It refers to the act of going beyond reality. In psychodrama, a group
member may represent a dead person and also speak.

Elements involved in psychodrama:

1. A stage to play the drama. It should be round and should have two or three step like
levels. Since psychodrama is primarily a group process, the psycho dramatist efforts is to
mobilize the group to work together. The response to the action on the stage may be
greater in the group than it is with the people on the stage.
2. Protagonist: the patient is selected to be the major subject for the specific enactment.
He is the star; he best typifies the concern of the group.
3. Auxiliary egos: the therapeutic actor to whom the protagonist is responding or reacting.
4. Director: the therapist who directs the actors.
5. Producer: psychodrama techniques
6. Role reversal: in the role reversal, the star exchanges his role for that of a significant
other. As the script is acted out, the patient would gain further understanding of himself
and behavior during the disagreement. This understanding would also increase when
other members (audience) give feed back to the patient. At another time his roles of the
patient and the auxiliary ego might be reversed. The role reversal would facilitate the
patient understanding of auxiliary, egos predicament and how the patient might
communicate more effectively.
7. Use of double feed back: In psychodrama the therapeutic actors, an auxiliary ego who
gets behind the protagonist and attempts to express thoughts and feelings with which
the protagonist is having difficulty.

Phase of psychodrama:
There are three phases:
1. The first phase is the warm up. During the warm up, the psycho dramatist involves
the group in a discussion of issues deemed important to explore for that session.
Once a group concern emerges, a protagonist is supported and encouraged to come
forth.
2. The second phase is composed of the shaping and presentation of drama. If this
stage is conducted properly, the entire group may be benefit from the action.
3. The final phase is post action group sharing. In this phase the group members
express what events in their own lives were touched on by the action. The psycho
dramatist attempts to draw from the group some identification with the protagonist.

Advantages:
1. It helps the patient to define his problems clearly.
 2. To explore the patient adaptive and maladaptive coping response to his
problem.
3. To identify misperception, unrealistic goals and distortion of reality.

RECREATIONAL THERAPY
INTRODUCTION
Recreation is a form of activity therapy used in most psychiatric settings. Therapeutic recreation
can occur as informal ping pong and card games, structured soft ball, basket ball or volley ball
games, as trips outside the hospital, attending sport event and so on. Recreation or play
activities provide patients with the opportunity for fun and for feeling good. It tends balance to
their daily schedule and helps in treating the whole patient.
Play is one kind of recreation therapy. It is considered as a variety of occupations that
constitute a pleasurable way of passing time and are also the medium through wide range of
skills can be learned and rehearsed.
Nurses can use a recreational activity as a foothold for establishing a therapeutic
relationship with patients or as a platform for therapeutic encounters with patients who are
frightened, withdrawn or reluctant to participate. Some patients view games as being non-
threatening and are able to tolerate informal interaction during a game of pool, ping pong or
soft ball. Patients who play games with each other experience predictability, security, order and
success they can see, feel and acceptance by a group. Nurse can be role models of healthy
behaviors for patients if they can display a sense of humor while engaging in therapeutic
recreation. It helps the patient to discharge tension and anxiety. It can be scheduled in the
morning to help patients feel better physically as they start their day and give them a sense of
accomplishment and participation. It is beneficial for hyperactive patients because it channels
their energy constructively within a specific framework.
The chief emphasis of recreational therapy is on the social re education of the
patient, and the basic objective may be described as the restoration of some function e.g.
power of attention is previously learned but for the time being inhibited or temporarily lost
because of some personality change due to mental illness. The principle of “learning by doing”
is more used in recreational therapy.

CLASSIFICATION OF RECREATIONAL ACTIVITIES

The various forms of play or activity used in recreational therapy are….
1. Motor forms: These can be further divided into fundamental and accessory, based on
whether the motor element is the main purpose of the activity or merely incidental to it.
Among the fundamental forms are such games as hockey and football, while the
accessory forms are exemplified by play activity and dancing.
2. The sensory forms: May be either visual e.g. looking at motion pictures, play, etc or
auditory, such as listening to a concert.
3. The intellectual forms: Include such activities as reading, debating etc.
In recreational therapy, recreation is regarded in its every sphere, and the following
shows the wide range in which it is used:
 a)Goal games, e.g hide and seek
b) Team games, e.g. hockey and football
c) Country sports, e.g. shooting, fishing
d) Combats, e.g. wrestling, boxing
e) Curiosity play, e.g. crossword puzzles
f) Creative play, e.g. play-acting
g) Vicarious play, e.g. viewing at motion pictures
h) Imitative play, e.g . follow the leader in folk dancing
i) Social play, e.g. party games
j) Aesthetic play,e.g. painting and clay modeling
k) Acquisition play, e.g. collecting antiques or stamps

AIM OF RECREATIONAL THERAPY

i. To train memory and concentration
ii. To re- educate mentally, physically and socially
iii. To give a sense of responsibility, e.g. by giving an opportunity to organize or lead
a game
iv. To stimulate interest
v. To stimulate or recreate self confidence
vi. To arouse an develop attention
vii. To give and opportunity for self expression
viii. To replace unhealthy trends by healthy ones
ix. To substitute encouragement for discouragement
x. To improve the circulation
xi. To improve the appetite
xii. To improve respiration
xiii. To strengthen the tone of the muscle
xiv. To develop a sense of rhythm
xv. To develop a good posture

Conclusion: Recreational therapy may also use community resources to help patients identify
socialization activities that they can become involve with after discharge from the hospital.
Movement or dance therapy is a specific example of how the body can be used as a medium for
change. Since body and mind cannot be separated, through dance, nurses work toward
integrating the muscular and cognitive expressions of the patient’s feelings and thoughts.
 ART THERAPY

Through history, art has been an important means of expression. Art was also recognized as
a bridge between the client’s inside and outside world when, in 1933, Sigmund Freud
described the unconscious and it’s expression in imaginary, especially in dreams. Elinor
wilmas expanded the scope of art therapy for psychotic patients increasing directiveness
and focusing more on building defenses against unconscious material. Wilam saw art
therapy as ‘a way to bring order out of chaos. Chaotic feelings and impulses withing art
therapy is defined as the use of the creative art process for psychotherapy and
rehabilitation.

The primary goal of art therapy are as follows:

1. Provide a safe environment free of judgement and censorship for the expression felling ,
cognition and unconscious material.
2. Select a media that will promote the therapeutic balance between regression and use of
healthy defenses.
3. Encourage clients to verbally share their art work with the therapist, individually or with
a group , to increase insight and promote a connection with others.
4. Provide a creative experience as an outlet for emotion and perception.
5. Expose clients to art materials so that they may benefit from the curative effects of
colour and design.

The nurse’s role includes observing client’s use of the art media, encouraging their
verbal responses to their verbal responses to the work, and nothing the specific content
of the art work, as it relates to clients individual issues.
 INTERVENTIONS FOR CHILDHOOD DISORDERS
1. REMOVAL AND RESTRAINT
a) Seclusion: Controversy over the use of seclusion in dealing with children continues,
there being no clear evidence that it is therapeutic (Walsh and Rendell 1955). Child
and adolescent units may have a seclusion room, but its use is limited because
youths who are out of control can become self-destructive seclusion is most
frequently used for non-compliant behavior that might have been managed in other
ways before the behavior escalated. The persistent use of seclusion reflects the
staff’s lack of confidence in their ability to handle behaviors and their adherence to
traditional practices.
The child or adolescent will always perceives seclusion as punishment, and
the experience of being overpowered by adults is terrifying for one who has been abused.

b) Quiet Room: Instead of seclusion, a unit may have an unlocked quiet room for a
child who needs to be removed from the situation for either self-control or control
by the staff (Joshi et al. 1988) Other approaches include the feeling room, which is
carpeted and supplied with soft objects that can be punched and thrown (Sevenfold
1991), and the freedom room, which contains a large ball for throwing and kicking.
The child is encouraged to express freely and work through feeling of anger,
frustration, and sadness in private and with staff support.

c) Time out: time out from the group or unit activity is another method for
intervening in disruptive or inappropriate behaviors. Time put procedures are
designed so that staff can be consistent in their interventions. Time out may require
going to a designated room or sitting to a periphery of an activity until the child gain
self control or reviews the episode with the staff member. The child’s individual
behavioral goals are considered in sitting limits of a behavior and using time out
periods.

d) Therapeutic holdings: at times child behavior is so destructive that physical restraint

is needed. Although a mechanical restraint such as helmet for head banging may be
used, therapeutic holdings is a long establish practice for the control of destructive
behaviors. One technique the basket hold is involves, one nurse holding the child
from the behind by the wrist, while the child arms are crossed over the torso. The
nurse can immobilize the child legs if necessary by sitting and crossing one or both
legs over the Childs legs.
Throughout the episode, the nurse talks to the child in a reassuring manner,
providing comfort and keeping the child self esteem intact. To make each restraint
situation therapeutic, the nurse review the event with the child after restraint is
released. This review of the event and a discussion of alternative ways of coping foster
learning and self control.
2. THERAPEUTIC GAMES
 Children enjoy games, so this treatment modality is ideal for children who have
difficulty talking about their feelings and problems. Playing a game with the child
facilitates the development of a therapeutic alliance and provides an opportunity for
conversation. The game might be as simple as checkers but the therapeutic games
are most effective in eliciting children’s fear and fantasies.

3. BIBLIOTHERAPY
Bibliotherapy involves using children’s literature to help the child express feelings in
a supportive environment, gain insight into feelings and behavior and learn new
ways to cope up with difficult situations.
The books selected by the nurse should reflect the situations or feelings the
child is experiencing. It is important to assess not only the needs of the child but also
the Childs level of understanding. A children’s librarian has access to a large
collection of stories and knows which books are written specifically to help children
deal with the particular subjects. Whenever possible the nurse consults with family
to make sure the books do not violate the family belief system. A choice of several
books is offered, and the book is never forced upon the child.

4. THERAPEUTIC DRAWINGS
Children love to draw and paint and will spontaneously express themselves in
artwork. The drawing capture the thoughts, feelings and tensions children may not
be able to express verbally are aware of or are denying. Children do not have to
draw themselves. In drawing any human figure, children leave an imprint of the
inner self, revealing personality traits, relationship with others, attitudes and values
of the family and culture group, behavioral characteristics and perceived strength
and weakness.
Therapeutic drawing may be used in play therapy with individuals or group. The
use of this modality involves observing children while they draw, asking question
about pictures and looking for message in what has been drawn. Often children
draw or asked draw human figures. The following characteristics of human figure are
general indicators of children’s emotions and are not necessarively indicative of
psychopathology.
 Size of figures: very large (aggression ,poor impulse control), very
small( shyness, insecurity)
 Emphasis on and exaggeration of body parts: large heads (desire to be
smarter), large mouth( speech problems), large arms( desire for strength and
power)
 Omission of body parts: hands (trauma, insecurity), arms (inadequacy), legs
(lack of support), feet (insecure, helplessness), mouth (difficulty relating to
others).
 Facial expressions: mood and affect
 Integration of body parts: scattered or disorganized parts indicate cognitive
or psychological problems or both
Drawing can be used in working with children and families.
 BIBLIOGRAPHY

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banglore , p.p 224-234

Neerja . K.P, (2008 ) “essentials of mental health and psychiatric nursing” , (edn 1 st )
volume 1 , jaypee brothers, New Delhi, p.p 337-342

Sreewani R (2008) “ mental health and psychiatric nursing” (edn 2 nd ), Jaypee brothers,
New delhi, p.p 186

Townscend . C .M (2007) “ psychiatric mental health nursing” (edn 1st ), Jaypee brothers ,
New delhi, p.p 156,

Varcolis M. Elizabeth (2002) “Foundation of psychiatric mental health nursing, a clinical

approach” (edn 4th ), W.B. Saunders Company, Philadelphia, p.p 479, 876 -79