Therapeutic communication skills and treatment modalities THERAPEUTIC COMMUNICATION Therapeutic communication is the basic tool used to construct

the nurse-client relationship. It's the major intervention modality of psychiatric nursing. To become an effective communicator, the nurse must be aware of the client's nonverbal as well as verbal messages. Being able to focus on both the content and the context of the message enables the nurse to assist clients to speak openly about their feelings. In all interactions, the client must be able to trust the nurse and feel safe and respected if inner thoughts, emotions, and personal difficulties are to be revealed and explored. A trust relationship with the client is built in an environment in which acceptance, consistency, empathy, and positive regard by the nurse can be nurtured. The client must perceive that the nurse is sensitive, interested, and caring about the client as an individual. The nurse must demonstrate predictable behavior during each encounter. It is the therapeutic relationship that establishes the foundation for the client to feel understood, to be comfortable discussing problems, to explore ways of appropriately meeting emotional needs, and to develop satisfying relationships. Caring, the root of the nurse-client relationship, is essential for humanity's survival. A caring relationship forms the basis for assisting another person. The elements of caring are universal and expressed in various ways in different cultures. Nursing is considered by Jean Watson to be a science of caring. All nursing interventions apply knowledge of human caring within the cultural context of the client's particular situation. The therapeutic nurse-client relationship is based on Watson's Carative Factors. (For further information, see Watson's Carative Factors.} WATSON'S CARATIVE FACTORS

Humanistic-altruistic system of values Faith-hope Sensitivity to self and others Helping-trusting, human care relationship Expressing positive and negative feelings Creative problem-solving caring process Transpersonal teaching-learning Supportive, protective, and/or corrective mental, physical, societal, and spiritual environment

Human needs assistance Existential-phenomenological-spiritual focus

From Watson, J. Nursing: Human Science and Human Care - A Theory of Nursing. New York: National League of Nursing, 1988. Therapeutic Communication Skills In therapeutic communication, the nurse forms a relationship with a client through the use of verbal and nonverbal messages. The interaction concentrates on the client's specific needs. Clients will discuss problems and painful situations with the nurse by sharing personal stories about their lives and feelings. In a therapeutic interaction, the nurse assists clients to focus primarily on feelings, thoughts, actions, and consequences of behavior to develop insight and see that they can manage their lives. Clients are directed toward resolving issues of concern by discovering and implementing alternative ways of handling stressors. The nurse uses communication principles to establish the foundation for a relationship that promotes the client's health and well-being. (For further information, see VariablesThat Influence Communication.) VARIABLES THAT INFLUENCE COMMUNICATION

Many factors in the client's background influence the communication pro-cess and affect the outcome of each nurse-client Interaction. Some ot the most common factors are:

culture values (the beliefs and rules people live by) social status emotional state (feelings that affect patterns of communication) spiritual orientation internal experiences (such as the biological and psychological Impact on how a person interprets life situations) external events family socialization about communication relationships current context of relationship

content of message (such as sensitive or emotionally charged topics).

Principles of Communication To establish a therapeutic relationship, the nurse must be attentive to all the client's verbal and nonverbal communication. To actually listen to another person requires the nurse to be both physically and emotionally present. Therapeutic communication includes the use of two types of skills: attending skills and responding skills. Attending skills enable the nurse to perceive the client's feelings. Selfawareness and sensitivity to the person's unique situation are essential to establish communication. Responding skills are the verbal and nonverbal tools that build the therapeutic relationship between nurse and client. An interpersonal relationship is the mechanism the nurse uses to facilitate the problem solving and behavioral changes necessary for the client's adaptive functioning. (For further information, see Attending Skills, page 4, and Principles That Enhance Communication, page 5.) Communication Techniques Communication techniques enable a nurse to build a trust relationship with the client. The main purposes for using these skills are to create a nurse-client alliance and to identify and explore ways to construct healthy relationships. At each encounter, the nurse speaks in a clear, direct, nonthreatening manner. The client is given the opportunity to work on issues of concern while receiving support and assistance as the process of change evolves. During interactions, the nurse requests information by using open-ended questions. Never does the nurse pose questions or statements that imply the correct way to answer. Questions are asked one at a time to ascertain information and encourage description of thoughts and feelings. In modeling appropriate ways to communicate with another person, the nurse is promoting self-respect while simultaneously teaching the client how to be interpersonally effective with others. Communication techniques establish the foundation for goal-directed nursing interventions. ATTENDING SKILLS

PHYSICAL Open, relaxed posture Face-to-face stance Eye contact Body position leaning forward

PSYCHOSOCIAL Validate congruency of verbal and nonverbal information Verify nonverbal massages conveyed Verify nonverbal massages conveyed Determine verbal messages conveyed

Comfortable environment Listen for process (feelings and relationships)

Privacy

Listen for content (client story) Identify repetitive life themes Determine patterns of Noughts, feelings, and behaviors Sumrnarize content and process

Therapeutic Responding Strategies The nurse uses particular ways of responding to the client's verbal and nonverbal behaviors. These responding strategies enable the nurse to talk with clients for the purpose of exploring their needs and encouraging personal growth. (For further information, see Therapeutic Communication Techniques, page 6.) TREATMENT MODALITIES Various treatment modalities are used by psychiatric-mental health nurses as frameworks for nursing assessments, interventions, and outcome criteria. Nurses may prefer to use a specific treatment approach or a combination of approaches to guide their client care. An overview of these common modalities is presented. PRINCIPLES THAT ENHANCE COMMUNICATION

PRINCIPLE Acceptance

EXAMPLE I don't agree with your decision, but I accept that you need more time before you can discuss it with your wife. listening When your parents argue like that, you feel helpless and choked up; It seems as. if something terrible win happen to you. While you're In the hospital, I'll meet with you daily from 10a.rn.to1l a.m. to work with you on treatment goals. Please feel free to seek me out at other times If you need anything.

Active

Assistance

Concreteness Go back to the beginning and describe In detail the way you were feeling after being verbally attacked by your father. Empathy Honesty You're in a painful situation. Try to stare with me what you're feeling. I disagree with what you said. I feel that if you're going to ask your husband to perform that task, then you need to allow him to do it in a way that is comfortable for him.

Immediacy

Let's stop for a minute and took at what is happening between us. Is it just me, or do you feel that we're stuck right now? It sounds to me like you want to stop volunteering to take care of your son's problems. Maybe you could be on standby and let him have a chance to handle things himself. I know you're frightened that your mother will severely criticize you about this issue. Let's plan some strategies to deal with that situation. Remember, whether or not you get a promotion, you're a valuable, competent person with a right to ask for what you want.

Permission

Protection

Respect

Individual Therapy Individual therapy is the establishment of a structured relationship between nurse and client to achieve change in the client. On a one-to-one basis, the nurse works with the client to develop a unique approach to resolve conflict, decrease emotional pain, and develop appropriate ways of meeting the client's needs. A therapeutic relationship is created in three overlapping phases: orientation, working, and termination. In the orientation phase, the nurse builds a connection with the client by establishing a rapport and sense of trust. The client's background is discussed and issues and concerns are identified. Together the nurse and client formulate goals and mutually determine the practical components of the therapy relationship, such as scheduling and cost. In the working phase, the client becomes increasingly more involved in self-exploration. Here the nurse works with both the content (or story) and the process (or feelings) associated with the client's pain. It's difficult for people to reveal and examine the thoughts, feelings, and behaviors that cause their distress. During this phase, the client is assisted to develop self-understanding and encouraged to take risks in terms of changing dysfunctional behavior. The termination phase occurs when client and nurse determine that closure of the relationship is appropriate. Usually both parties agree that the problem that initiated the therapeutic relationship is alleviated or has become more manageable from the client's perspective and that the specified goals have been accomplished. Clients begin to feel better about themselves and often report improvement in personal, social, or occupational functioning. Overall, the major goals of therapy, such as alleviation of emotional distress, alteration of detrimental behaviors, promotion of the client's growth and development, and increased life satisfaction, have been met. THERAPEUTIC COMMUNICATION TECHNIQUES

TECHNIQUE

EXAMPLE

Attempting to translate into feelings Encouraging comparison Encouraging description of perceptions Encouraging evaluation

What you described makes me think that you content might feel....

Was this experience similar to... ? Let me know when you're feeling over whelmed.

What are your feelings about this problem?

Encouraging formulation of a plan What could you do the next time you're accused of... ? of action Exploring Focusing Giving broad openings Giving information Giving recognition Making observations Offering general leads Offering self Placing events in time or in sequence Presenting reality Reflecting After that occurred, what did you do next? Let's go back to what we were just talking about. Is there something that you would like to talk about? I want to orient you to the unit and explain the rules. Good morning, Linda. I notice you're wearing new shoes. You seem to be nervous today. Tell me about.... I'll stay here with you for a while. Did this happen before or after... ?

That noise was the squeaking of the door. You're worried about what to do, but you're not sure if you want to get involved. You're feeling angry and you think it's because of the way your spouse treated you last night. I'm not sure I understood what you just said. Tell me if my perception of what happened agrees with yours.

Restating

Seeking clarification Seeking consensual validation

Silence

The nurse nonverbalty encourages the client to answer by remaining silent. Perhaps we can meet with your parents to discuss.... In the past hour, you and I agreed to.... Do you feel that no one cares about you? Isn't that an unusual experience?

Suggesting collaboration Summarizing Verbalizing the implied Voicing doubt Milieu Therapy

In milieu therapy, the nurse uses all facets of the hospital environment in a therapeutic manner. Specifically, nurses establish opportunities for growth and behavioral change by focusing on the therapeutic value of every activity and interaction. Examples of creating an environment in which the client receives support, understanding, and opportunities to develop as a responsible person are community meetings, physical exercise, and other activity groups. Clients are exposed to rules, unit expectations, peer pressure, and social interactions. Nurses encourage communication and decision making and provide opportunities for enhancing self-esteem and learning new skills and behaviors. It's essential to promote the client's sense of responsibility and competence in working with others. The incorporation of work-related events, such as meal preparation and life skills workshops, into the client's day fosters feelings of value in the community. By participating in milieu therapy, clients can learn appropriate behaviors, methods for managing self-care, and the social and emotional skills necessary for interacting with others. The goal of this therapy is to enable the client to live outside the institutional setting through the acquisition of competence necessary for a smooth transition to the community. Crisis Intervention Crisis intervention is a systematic process of short-term therapy in which the nurse works with a client, family, or group that is experiencing an overwhelming or unbearable situation. When a person is in crisis, it becomes apparent that the strategies that once worked to handle problems are no longer effective. Clients may demonstrate severe personal disorganization, in that they can't handle the activities of daily living and become obsessively preoccupied with the crisis situation. In extreme cases, some clients respond to a crisis with disturbed or psychotic behavior. The nurse plans for successful intervention of the crisis by obtaining an accurate assessment of the situation, staying focused on the immediate problem, and working collaboratively with the client. It is essential to clarify what motivated the client to seek assistance, to develop a clear understanding of past coping behaviors and current dependency needs, and to determine the availability of social support and other resources. The nurse initiates actions that decrease the client's sense of personal danger and facilitate the client's ability to control the situation. These interventions must complement the client's usual level of functioning, culture, and lifestyle.

Client crises can be developmental or situational. They tend to be self-limiting, typically lasting 4 to 6 weeks. A crisis is successfully resolved when the client returns to a level of functioning that's equal to or greater than the pre-crisis level. Typical outcomes for clients may be an enhanced sense of selfcompetence, identification of the potential for growth, or the development of a plan for the future, which may include accessing short-or long-term therapy or even hospitalization. Biological Therapies Biological therapies are based on the medical model that views emotional and behavioral disturbances as specific disorders or illnesses. The emphasis is placed on systematically assessing the client's condition and clustering the symptoms into specific syndromes. Abnormal behavior is believed to be attributable to disease causing organisms that are external to the body or to a biochemical change within the body. Nurses frequently engage in caring for clients who are participating in biological therapies. Monitoring the client's responses to somatic therapies, providing instructions and guidance on proper use of medications, and managing client symptoms are some of the clinical duties nurses perform. The focus of care is to assess, interpret, advocate for, and evaluate client needs. The nurse needs to have a strong background in physiology as well as knowledge of the brain, central nervous system, endocrine functions, and immune system. Examples of biological therapies are psychoactive medications, nutritional interventions, phototherapy, electroconvulsive therapy, nonconvulsive electrical stimulation, and psychosurgery Cognitive Therapy Cognitive therapy uses strategies to modify the beliefs and attitudes that influence a client's feelings and behaviors. When people have negative views of themselves, the world, and the future, they tend to formulate irrational beliefs about their abilities and relationships with others. The results of these faulty perceptions and distortions are evidenced by unrealistic expectations of self and others, ineffective coping methods, and viewing one's self as incompetent. To work with a client from the cognitive perspective, the nurse is active and directive in helping the client reconsider stressors and identify patterns of inaccurate thinking and beliefs. Care focuses on reevaluating ideas, values, and expectations and initiating steps to make the necessary cognitive changes. The main goals of the therapy are to assist clients to develop more rational thinking, engage in reality testing, and reconstruct behavior by altering internal messages. Basic interventions include teaching thought substitution, problem solving, and ways to modify negative self-talk as well as initiating role playing and modeling coping strategies. Family Therapy In family therapy, the entire family is considered the treatment unit. All difficulties in the family are viewed from a perspective that explores how each member contributes to the problem being experienced. The nurse assesses the family structure and functioning by focusing on the relationships between significant members. Differentiation of the generations and the presence or absence of clear boundaries are noted. The nurse determines if parents act like parents and children behave as children.

According to family theorists, symptoms in any family member are reflections of dysfunctional behaviors and relationships and unhealthy communication patterns. Behavior extremes can be seen, such as the overinvolvement or underinvolvement of family members. Enmeshment may be seen, in which there is overinvolvement or excess of communication between family members. At the opposite extreme, families may be so disengaged or underinvolved that communication is severely limited or almost nonexistent. In working with a family, the nurse progresses through three phases of the therapeutic relationship. The first phase, which family therapists call the engagement period, is characterized by the development of connections between family members and the therapist. At this point, issues are identified and goals established. The second, or working, phase consists of changing interaction patterns, promoting the competency of individuals, and exploring new ways of behaving. Members are involved in clarifying boundaries, rules, and expectations. In the termination phase, the family reviews progress made toward achieving their goals, ways to deal with the reappearance of issues, and maintenance of follow-up care. The principal goal of therapy is to improve the functioning of the family. Techniques often used include prescribing the symptom, reframing the behavior, and giving homework assignments. In prescribing the symptom, paradoxical communication is used to change the undesirable behavior by allowing it to occur. The meaning of the unacceptable behavior diminishes when it becomes an intentional act. To reframe behavior is to relabel it in a way that emphasizes the positive aspects of the situation. Homework assignments are given for the purpose of meeting goals between scheduled meetings. The types of clients that can benefit most from family therapy are those that are involved in marital issues, intergenerational conflicts, sibling concerns, and family crises, such as death and divorce. Group Therapy In this treatment method, an advanced practice nurse therapist and six to eight persons meet regularly for the purpose of increasing self-awareness, improving interpersonal relationships and changing maladaptive behavior patterns. The nurse works with the group members to facilitate their interpersonal learning and to encourage them to seek out peer feedback and support. In many circumstances, the group functions as a microcosm of the family, enabling clients to understand and change behavior learned in their family of origin. Within the group setting, the nurse therapist suggests alternative ways of handling stressful situations. Clients learn how to develop appropriate expression of feelings and explore ways re enhance personal growth and change. During the group experience, clients can develop new coping strategies and strengthen their problem solving skills. The group process typically occurs in three stages. In the beginning stage, the orientation period, the members are oriented to what therapy entails. Many people depend on the nurse therapist for direction and approval as they seek to be accepted as part of the group. During this time, the therapist serves as a role model for behavior by offering structure, decreasing anxiety, and facilitating interactions.

The second stage, the working phase, is characterized by conflicts related to autonomy and control. The therapist assists clients to explore issues and focus on the here and now. Supper:is given to the members as they struggle with conflicts related to intimacy, cooperation, and productivity. In the third, or termination, stage, the group is connected and engaged in interpersonal interactions. These interactions provide feedback, support, and tolerance of differences: they also encourage problem solving. Clients must work through their feelings and concerns related to group termination as they evaluate personal change and goal achievement. Successful groups can modify aspects of personality, help change dysfunctional behavior patterns, and promote insight and understanding of problems. The techniques used for group therapy are similar to those used for individual therapy, with modifications based on the type of clients and theoretical orientation of the therapist. The nurse group therapist has highly developed interpersonal skills plus an extensive knowledge of human behavior and group process theory. The goals of group therapy are to assist clients to develop effective behaviors, to establish realistic alternatives handling conflicts and stressors, and to promote personal growth. Hypnosis Hypnosis is used to induce deep relaxation by altering the client's state of consciousness. The result of hypnotic induction is a trancelike state in which clients use their memories, mental associations, and concentration to discover major life events and experiences that are connected to their current level of distress. Hypnosis can be performed by a nurse therapist who has been educated in clinical hypnotherapy. The nurse may also be able to teach clients the method for self-induced hypnosis. The major purposes of hypnosis are to enable clients to relax, to formulate a different perspective on problems, to uncover repressed feelings and thoughts, and to facilitate behavioral changes. Hypnosis is useful for dealing with anxiety disorders, some types of pain, repressed traumatic events, and addictive disorders, such as overeating and smoking. Thought Field Therapy Thought field therapy (TFT) was formulated by Dr. Roger Callahan, a cognitive psychologist. This therapy aims to eliminate disruptions of the body's energy system that create physiologic health problems, addictions, and negative emotions stemming from distressing thoughts. TFT integrates scientific principles, traditional Chinese medicine, and the body's energy system. Eastern medicine postulates that the body's energy flows along pathways called meridians. Meridians channel a person's energy for healing and growth. When an energy path is blocked, the person experiences emotional disturbances, which Callahan calls perturbations. Releasing a blocked energy path dissipates the negative feelings created by the upsetting thought pattern. A nurse trained in TFT uses sequences of touching, or body taps called algorithms applied to specific meridian points on the client's body Different algorithms treat specific clinical conditions. In a

typical TFT procedure, the therapist asks the client to think about the disturbing issue (perturbation): asks the client to quantify feelings about the perturbation on a scale of 1 to 10 (10 representing maximum distress); instructs the client to tap on specific energy points in a prescribed pattern; then asks the client again to quantify feelings about the perturbation on a scale of I to 10. After treatment, many clients report that the distress has virtually disappeared or lost the emotional power that it once held over them. Callahan claims that in most clients, these benefits are permanent. He also acknowledges that it's hard to understand how TFT can work so well. Research on the effects of TFT on the central nervous system is ongoing. Callahan has also developed a variant, Voice TechnologyTM, in which TFT treatments can be given over the phone. TFT is noninvasive and safe to use with both adults and children; no adverse effects have been reported. The therapy has been successful in adults who have experienced trauma as well as those with phobias, anxiety, panic attacks, obsessive-compulsive behavior, intense anger, depression, and alcohol, food, drug and tobacco addictions. In children, TFT has been effective in treating anxiety, school phobia, fears, anger, and trauma. Instead of tapping meridian points, children are instructed to use drawings effaces or their hands to communicate the level of distress associated with their problem. TFT may be useful when traditional therapeutic approaches are ineffective or in cases where the client is intimidated by talk therapy. Eye Movement Desensitization Reprocessing Eye movement desensitization reprocessing (EMDR) was developed by Dr. Francine Shapiro as part of a comprehensive therapeutic approach for clients who have experienced severe abuse or recent emotional trauma. The premise of EMDR is that it somehow restructures neurologic links in the brain that store a person's traumatic experiences. Eye movements can be used re stimulate the brain's ability to process information and heal psychological problems. When properly directed by a therapist, me eye movements release and process the disturbing thoughts, overwhelming feelings, and bodily sensations that are trapped within the person as a result of the trauma. By using EMDR with other therapeutic techniques, negative thoughts and feelings can be healed and overall self-care and wellness can be achieved. Appropriate training is required for the nurse therapist planning to integrate EMDR into clinical practice. In an EMDR session, the client is asked to remember the disturbing event along with any bodily sensations and negative thoughts and feelings associated with it. Then the client is asked to rate the level of distress on a scale of 1 to 10 (where 10 is maximum distress) and to describe where in the body the feelings are stored. The client next watches a series of finger movements performed by the therapist and describes the response and any change in distress level. During a session, clients typically reveal intense images, memories, thoughts, and feelings that begin to race through the mind. After EMDR, many clients report that their original problem changed in a way that makes it less threatening. With each series of EMDR sessions, the level of distress diminishes. Often, as the primary problem changes or decreases in emotional intensity, other problems emerge, and they are likewise treated with EMDR. Because each person experiences traumatic situations in unique ways, it's essential to remember that the healing process is highly individualized.

EMDR has been used successfully to treat such traumatic events as rape, domestic violence, criminal victimization, combat (posttraumatic stress disorder), terrorism, accidents, and natural disasters. EMDR has also shown promising clinical results with other distressing conditions, such as depression, eating disorders, obsessive compulsive behaviors, sleeping difficulties, inability to concentrate, grief and stresses of chronic illness, particularly cancer. Behavioral Therapy Behavioral therapy is based on the premise that because behaviors are learned, healthy behaviors can be learned and substituted for unhealthy behaviors. The nurse therapist works with the client to identify problems and defines certain goals as the focus of treatment. Interventions are based on the principles of classical and operant conditioning and follow a precise format. There are five basic techniques of behavioral therapy. In role modeling, the therapist or another appropriate person models the desired behavior and the client learns through practice and imitation. Role modeling is often used with operant conditioning and desensitization. In operant conditioning, also called positive reinforcement, the therapist rewards the client for making a positive behavioral change. Behavior modification occurs when the client reaches a predetermined behavioral goal; this behavior is systematically reinforced by positive feedback or the receiving of rewards. Over time, the desired behavior is increased and ultimately sustained. In systematic desensitization, a client suffering from a phobia is repeatedly introduced to the phobic stimulus while in a relaxed state. As the therapist gradually increases exposure to the stimulus, the person learns to handle the anxiety and, eventually, the fear ceases. In self-control therapy, clients are coached by the therapist to learn how to alter negative self-talk and guide themselves toward gaining control over their actions. The outcome is a reduction in their level of distress. The final technique, aversion or conditioned reflex therapy, is based on the principle of negative reinforcement. The selected abnormal behavior is paired with an uncomfortable experience, and the client soon learns to avoid the behavior in order to avoid the negative consequences of that behavior. An example of aversion therapy is giving disulfiram (Antabuse) to the client with a drinking problem. (For more about Antabuse, see chapter 5, Suo-stance-Related Disorders.} Behavioral therapy has long been a treatment modality for children with autistic disorder, and for adolescents with conduct disorder, attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder. Success is also reported when this modality is used with adult clients who are struggling with anxiety, depression, schizophrenia, alcoholism, and phobias, especially agoraphobia. Brief Therapy Brief therapy (short-term dynamic psychotherapy) evolved from the work of Drs. Franz Alexander and Thomas French, who treated psychosomatic illness by helping clients resolve psychological problems

that trigger physiologic effects. In contrast with traditional talk therapies, brief therapy aims to solve a client's specific problems without delving into underlying personality dynamics. It also emphasizes treating the client in as short a time as possible typically, in 15 sessions or less. The therapist has specific treatment goals and uses various therapeutic techniques such as homework assignments, incorporation of supports outside of therapy, and emphasis on the client's strengths. The client is viewed as needing help in learning how to cope with current life problems. Treatment emphasizes having the client work on identified goals outside the therapy session. Brief therapy is most effective with clients who are intelligent, articulate, motivated, able to problem-solve, and relatively well functioning. It should not be used with clients who are severely depressed, suicidal, or schizophrenic or have personality disorders. Play Therapy Play therapy allows children to express their feelings and concerns through play activities the "language of childhood." The premise of play therapy is that children communicate better through play than with their verbal skills. It's important to recognize that children externalize their internal struggles in order to work on their pain and distress. With play therapy, a nurse therapist can assess a child's developmental status and emotional state, make diagnostic hypotheses, and establish therapeutic interventions. By using nondirective play, a therapist can observe themes and symbols that provide diagnostic information. In1947. Dr. Virginia Axline established the guiding principles of play therapy She encouraged therapists to develop a warm relationship with each child and to follow the child's lead during the play session. For this therapy to be effective, the therapist must be able to reflect the child's feelings and believe in the child's ability to solve problems. Reflection provides feedback to the child about what is happening in the play. As rapport is established, the therapist makes interpretations of the child's behavior. The only limits set during play therapy concern maintenance of safety, security, and reality for the child. Nurse therapists must be specially trained to practice play therapy. Playrooms are equipped with art supplies (including clay or other modeling compound), puppets, multigenerational families of dolls of various ethnic backgrounds, dollhouses, toy soldiers and policemen, soft balls, play tools, kitchen sets, building blocks, cars, trucks, and airplanes. Play therapy is useful for pediatric clients who are depressed, anxious, disruptive, and abused. It has also been used successfully in adults who are suffering from posttraumatic stress disorder, dissociative identity disorders, and various forms of abuse. Mind-Body-Spirit Therapies Mind-body-spirit therapies (also called alternative or complementary therapies) are a combination of various Eastern and Western medical traditions. Often clients are guided to mind-body-spirit therapies as an adjunct to traditional care or when conventional therapies seem ineffective. A major Eastern perspective is that we are "all one with nature" and that each person harbors a life force, called qi or ch'/, which must be respected and nurtured to promote internal harmony and well-being. A two-part life force known as yin and yang represents the balance between the opposite (positive and negative) forces in the universe.

The overall goal of Eastern medical practices is to establish order out of disorder and to promote harmony, which leads to health. These practices address health problems through the integration of the client's mind, body, and spirit. Healing occurs through a compassionate, evolutionary process and is viewed as spirit-centered. Mind-body-spirit therapies include acupuncture, acupressure, herbs, guided imagery, therapeutic touch, meditation, diet interventions, exercises, and manipulation of bones and muscle groups. Emphasis is also placed on balancing a person's relationships with other people, Nature, emotions, and spiritual forces. Several Western mind-body-spirit therapies used to treat psychiatric clients have been major influences in the promotion of the healing process. Examples include nutritional interventions, exercise prescriptions, "doing good works," and prayer and other religious practices. Often clients are guided to alternative therapies as an adjunct to traditional "toolbox medicine" when the latter fails to give relief The future of health care lies in the integration of Eastern and Western modalities.