Depression Treatment Options


However the client should be aware of the treatment options so that he /she can discuss with the consultant. Broadly speaking, the treatment of depression rests on two factors Medication, and Psychotherapy or Counselling.

  • Medication is required for moderate and severe depressive disorder cases.
  • Counseling and psychotherapy serves as an edge in treating depression and need to be started simultaneously along with medicines.
  • You should continue the full course of psychotherapy even if you are feeling better to prevent a relapse.
  • Suddenly stopping antidepressants can precipitate a relapse. Medication needs be tapered gradually under your doctor’s supervision.

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USING PLAY THERAPY TO DEAL WITH ENURESIS (BED WETTING) & ENCOPRESIS (SOILING OF CLOTHES)


Rahul was 12 years old when he was referred for bed wetting (enuresis) and passing stools (encopresis). He was referred by the family doctor who found a non medication approach to his bedwetting and encopresis a better solution, especially considering the long term side effects of the medicines and the fact that there were no physiological causes to his problem.
His problem had escalated soon after they had shifted into this new house. Parents didn’t think that shifting house could have been the reason for the same as he always wanted to shift back to this house. In fact he had many friends here and would initially quickly finish off his homework to go down to play. But soon he started wetting his bed in the night more often and the ‘accidents’ at school too increased.
By the time he started with play therapy, he was regularly wetting his bed in the night and the soiling his pants at least once a month. Rahul was so unsure of his own bowel movements that he refused to go for school trips or for a sleep over at his friends or cousins house. Off late he was fearful of going to school too, as he was now teased for being a sissy boy. At home too, he would play with his play station for hours on end and would be generally. His parents had tried every thing from making him visit the toilet at bed time and before going to school to more frequent visits when outside, but to no vain. Normally an active boy was now unsure and irritated most of the times.
During the case history on enquiring about any traumatic history the parents recalled that just before they had shifted the house he lost his grand mother and around that time the van in which the school children traveled had met with an accident. Although no one was injured Rahul had recounted the incident in great detail. They found it difficult to believe that these could again be the reasons as it was not the first time he was dealing with a loss of a grand parent or meeting with an accident. In fact he had lost his grand father the previous year, to whom he was more attached. Since his grandmother suffered from Alzheimer he hardly ever interacted with her over the years.
Bedwetting is considered to be problematic for children only above 6 years of age. Till about 5 it is considered normal if the child occasionally wets the bed. Usually children have considerable bowel control by the age of 4 and do not soil their clothes. Enuresis can be primary (the child did not grow out of using diapers) or secondary (child stopped wetting beds but suddenly after a period of time started wetting them again, as in Rahul’s case).
It is often connected to psychological issues of emotional stress / anxiety. Often the causes remain unknown to both the child and the therapist. Therefore using cognitive or reasoning approach is difficult with these children and it is not in their awareness or consciousness. Also emotions of shame and guilt are quite complex for the children to express verbally. This coupled with threats or punishment from parents (who feel an extreme sense of concern and frustration dealing with this problem) can become quite traumatic for the child. Play therapy, being dynamic, non directive and symbolic allows the child to reenact and work out his emotional issues leading to the problem in a safe and trusting environment without having to get into verbal communication. This is further supported by some parenting sessions where parents are usually asked to bring about certain changes in the child’s routine to support the sessions proves extremely effective.
The following are some of the changes that parents are requested to introduce:
• Having liquids at least 4 – 5 hours before the bed time.
• Setting up alarms at regular intervals and encouraging Rahul to visit the toilet.
• Keeping an extra pair of clothes and bed sheets so that Rahul need not wake his parents every time he had an accident.
• Not humiliating / threatening / asking too many questions to the child to rectify his behaviours .

Rahul began his play sessions. Initially he found it quite boring to play with toys that were around and often asked if he could carry his video games or whether there was access to computers. But slowly as the sessions progressed he started playing with animals, clay and balls. The therapist noticed that in most of his sessions he would give instructions to the therapist to follow. He would make loud noises and fight with the wild animals. With the clay he would often make snakes and then turn them into turbans which the therapist was instructed to wear and become the care taker of the animals. Some times he used the ball to knock down the animals. After many such sessions, he moved on to drawing. He initially drew only symmetric drawings but soon moved on to draw themes. Most of the themes again reflected anger, punishment and morality issues.
Around the 8th session, the mother mentioned that Rahul had wetted his bed only once and had soon woken up to change his clothes and the bedsheet. The therapist had given a list of instructions to the parents to follow. Soon after that Rahul showed greater interest in his play and also in the sessions.
After his summer break when he returned for the first session, he sent a message containing smiley face and to inform the therapist that they were on their way to the clinic. He seemed to have settled down with not a single mishap of soiling his clothes or wetting the bed. He had returned to his original confident self and seemed less tentative about things. Although he was apprehensive on the first day of school, he settled into his new routine pretty soon. On the follow up terminating sessions, the bedwetting and soiling behaviours had consistently shown improvement with no further accidents. His academic marks also returned to their earlier levels.

USING PLAY THERAPY AS A TREATMENT FOR AN AUTISTIC CHILD



Rima was a 5.5 year old ASD child when on gentle persuasion by a day care teacher her parents approached us for play therapy. Rima’s parents although both were paramedics, struggled to accept that their child was not normal. Initially they blamed themselves for the lack of time and hoped that their love and attention would reverse her ‘odd’ behaviours. The mother especially blamed her work hours or their decision to have another child (a normal 3 year old son) so soon for Rimas developmental issues.
When they first came to discuss Rima, they thought that the only issue with the child was that she was not very verbal. They claimed that although she was better than before after the day care center teacher spent extra time with her, they were worried how she would react to the big school which she would join in the 1st grade, next year. But as they talked they realized that the problem was far more complex and interlinked. They were able to identify other issues such as her hyperactivity, non communicative behaviour, usually preferring to play on her own, petrified of loud noises and animals, asocial by nature and find it difficult to share things. She also was easily irritated and was often teased and bullied by her cousins to whom she reacted by either crying or reacting violently. She loved to play in sand and go to the beach but didn’t much play with other toys. She was also at times mean and violent with the younger brother. She didn’t demand much, even in food and would be quite passive most of the times. She enjoyed watching television ads, and listened to religious mantras. She seemed to have an unusually bright memory in remembering lyrics of the songs / advertisement / mantras. Her favourite game with her father was to climb on him holding his hand and then throw herself backward head down. Although she does this regularly, the parents were very worried about this as she could seriously injure herself. They had tried to change this behaviour a number of times, but she would not pay heed to their warnings. Infact they thought that her risky behaviours such as this had increased and now she would take every opportunity to jump of the table or even fling herself suddenly at the opposite person, uncaring of how badly she might get hurt or hurt the other person. If shouted at or stopped, she showed an unusually strong temper and become very obstinate. Thus discipline and obedience or boundary setting were major issues with her. She would still wet the bed in the night although not regularly and at times soil her panties. The mother mentioned that Rima was very fond of sand; therefore they had made a sand pit in the balcony for her to play in. But her play in sand was pretty unusual. Instead of making something out of sand, she spent hours just sifting through sand humming to herself a tune. As we talked, the mother recognized other behaviours which although she had noticed, never paid much attention to it. Rima’s inability to generalize learnt behaviours to other similar situations, her inability to focus on two or more things at a time, her insistence of ritualistic actions, her inability to substitute one toy for another similar toy. She also realized that all these behaviours together indicated Autism, a neurologically based life long and severe condition and not merely a late developmental issue or an emotional problem.
The therapist helped them understand how play therapy can benefit an autistic child and how an autistic child’s play differs from that of other children. She also went on to explain how play is a complex phenomenon that occurs naturally for most children and how they move through the various stages of play development and are able to add complexity, imagination, and creativity to their thought processes and actions. However, for many children with Autistic Spectrum Disorder (ASD) various stages of play never truly develop or develop in a fragmented fashion. These skills which a ‘normal’ person takes so much for granted is actually an uphill task for an ASD child. An ASD child suffers at all three levels of understanding and mastering the skills, cognitive social and behavioural.
Initially it was believed that play therapy is not effective treatment for ASD, recent research has convincingly proved that it is one of the most effective forms of treatment when used at times in a structured manner and especially if it is taught to parents and incorporated in the daily routine by the parents. Extensive opportunities in play therapy for social skills and emotional development help the child by increasing his awareness of other people’s mental states and their intentions. Play therapy then becomes a safe practice zone for the development of these skills.
These play therapy skills can also be taught to the parent / care taker who can incorporate it as a part of the daily routine. Treatment of ASD is highly specialized and a life time task, therefore often very expensive. Play way parenting equips parents to incorporate these play sessions in daily routine of the child and drastically reduces the cost. Parents are also encouraged to introduce it to the rest of the family so that it becomes another support for the ASD child to learn and master the skills. It also indirectly helps the other family members cope with their emotions with regards to the ASD child in a constructive manner.
Play therapy provides ample of opportunities to develop following skills in ASD children, necessary for their learning:
1. Imitation: imitation is a skill that is learnt very early in childhood. But the most crucial aspect of imitation is the ability to generalize these imitative behaviours to other situations. For example a child through imitation learns to smile and then uses cognitive and social skills to generalize smiling behaviour to situations requiring it. But ASD child find it difficult to generalize this to other situations. During play therapy, puppets, role enactment, make believe situations etc are used to increase the generalizations of these imitative responses.
2. Object exploration: children suffering from ASD find it difficult to initiate an exploratory play. This is because they get over whelmed with multiple stimuli and over a period of time, due to past experiences they learn to be socially reserved. In play therapy, the sensitive manner in which the therapist approaches the child establishes a safe and trusting environment for the child to attempt to explore. Then when the therapist incorporates some specific techniques such as restricting the space during play and giving them toy one by one the child finds it easier to learn them. A combination of skills and emotional support substantially increases these initiative responses in the child. It also helps to increase the child’s self confidence and self esteem.
3. Exploratory and Experimentation with play: Play therapy is often one of the first experiences of play without any target response goals for an ASD child. Being socially withdrawn they rarely take any initiatives to play on their own. Since play sessions are directed towards play only, it provides them with an opportunity to experiment and explore with play in a safe and trusting environment. Manipulation of toys in play session helps them to practice varying characteristics of toys, classification of toys such as sorting and matching, establish causal relationship between events and how to influence the world around them.
4. Communication skill: Communication skills such as expressing emotions, expressing specific needs, using gestures and joint attention are mastered during play sessions. Play therapists create surprise events during play sessions, using visual information to communicate verbally something that the child wants. This provides the child with ample opportunities to practice putting their emotions into gestures and words and thus reduces their frustration about not being able to get their needs met. It also reminds ASD children that communication and play involves another person and acts as a bridge toward more complicated or symbolic communication using words assessing not only their emotions and needs but also to match it with the other person. This is especially a difficult area for an ASD child as these skills are highly dependent also on social skills, both a problem area for the child. This skill can be taught using substitution of the play object (such as dolls), role enactment using various toys (puppets), recreating real life situations with numerous alternatives, helping the child to elaborate on intentions (involving verbal communication), helping the child to master ideas / themes, discussing with the child abstract themes and using obstacles to generate alternative solutions.
5. Signing or acting: Play sessions provide ample of opportunities to use a combination of gestures supported by verbal communication. This helps in the transition from no communication to gestures and then to verbal communication. This also helps to reduce the child’s frustration with people, usually strangers who are unable to understand their sign language. It thus increases their confidence socially and also boosts their self esteem. We often find a simultaneous reduction in anger in the child.
6. Peer Play: Peer play also relies on social cues which ASD child finds extremely difficult. Therefore we often find and autistic child unable to share, wait for turns, negotiate with another child, imitate other role models, ask for help, request for events / objects, initiate inviting another child for spontaneous play, all of which a necessity for any school going child. Through structured play sessions dealing with each of these skills and then slowly moving on to group play sessions or introducing it amongst the siblings the child gains enough confidence in these skills to be able to practice them at school or with other peers.
7. Increasing attention and concentration: also requires the child to comprehend the object and hold it in his thought symbolically. Play sessions intrinsically provide these opportunities to the child. It then becomes a practice field where the child learns to master these skills and then be able to use them outside.
8. Motor coordination also increases tremendously using play toys. The child learns to explore and experiment with different shapes, sizes textures and colours of toys in a non threatening, goal less, safe environment where the only goal is pleasure.
9. Parenting skills are also improved. Very often without realizing parents facilitate the learned helplessness in the child as he is unable to communicate. We often find the parent not being able to push the child to learn the above mentioned skills or become too harsh and frustrated. Neither of these behaviours are conducive for further development. During play sessions parents get an opportunity to examine their play deficits as well as express their own emotions and frustrations with the therapist. This kind of self exploration helps in dealing with parental anxiety of their child and his future in a manner which will help the child become independent.