Nursing Reviews

Prepared by: Ms.Sreeedevi. C, MSN, Manipal College of Nursing, Manipal University

Introduction

No one likes to talk about dying and death, for yourself or your loved ones. Yet, birth and death are two aspects of life, which will happen to everyone. Dying and death are painful and personal experiences for those that are dying and their loved ones caring for them. Death affects each person involved in multiple ways, including physically, psychologically, emotionally, spiritually, and financially. Whether the death is sudden and unexpected, or ongoing and expected, there is information and help available to address the impact of dying and death.
Definition of death
Death is defined in three ways: As cessation of heart- lung function, or of whole brain function, or of higher brain function.
The heart- lung definition (cessation of heart beat and respirations) is widely used to define clinical death
The President’s Commission for the study of Ethical problems in Medicine and Biomedical and Behavioral research (1983) defined death as either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brain stem.
Responses to dying and death
Although each person reacts to the knowledge of impending death or to loss in his or her own way, there are similarities in the psychosocial responses to the situation.
Kubler-Ross’ (1969) theory of the stages of grief when an individual is dying has gained wide acceptance in nursing and other disciplines, probably because she was a pioneer in developing sensitive, compassionate care for the dying.
The stages of dying, much like the stages of grief, may overlap, and the duration of any stage may range from as little as a few hours to as long as months. The process vary from person to person. Some people may be in one stage for such a short time that it seems as if they skipped that stage. Some times the person returns to a previous stage. According to Kubler- Ross, the five stages of dying are:
 Denial
 Anger
 Bargaining
 Depression
 Acceptance

1. Denial
On being told that one is dying, there is an initial reaction of shock. The patient may appear dazed at first and may then refuse to believe the diagnosis or deny that anything is wrong. Some patients never pass beyond this stage and may go from doctor to doctor until they find one who supports their position.
2. Anger
Patients become frustrated, irritable and angry that they are sick. A common response is,” Why me? ” They may become angry at God, their fate, a friend, or a family member. The anger may be displaced onto the hospital staff or the doctors who are blamed for the illness.
3. Bargaining
The patient may attempt to negotiate with physicians, friends or even God, that in return for a cure, the person will fulfill one or many promises, such as giving to charity or reaffirm an earlier faith in God.
4. Depression
The patient shows clinical signs of depression- withdrawal, psychomotor retardation, sleep disturbances, hopelessness and possibly suicidal ideation. The depression may be a reaction to the effects of the illness on his or her life or it may be in anticipation of the approaching death.
5. Acceptance
The patient realizes that death is inevitable and accepts the universality of the experience. Under ideal circumstances, the patient is courageous and is able to talk about his or her death as he or she faces the unknown. People with strong religious beliefs and those who are convinced of a life after death can find comfort in these beliefs (Zisook & Downs, 1989).
Physical signs of dying.
Dying is a different experience for everyone involved. A member of your loved one’s health care team can give you a more accurate idea of what to expect. Nevertheless, these signs and symptoms are typical:
 Confusion – about time, place, and identity of loved ones; visions of people and places that are not present
 A decreased need for food and drink, as well as loss of appetite – this may be caused by the body’s need to conserve energy and its decreasing ability to use foods properly
 Drowsiness – an increased need for sleep and unresponsiveness
 Withdrawal and decreased socialization – can be caused by mentally preparing for dying, decreased oxygen to the brain and decreased blood flow
 Loss of bowel or bladder control – caused by relaxing muscles in the pelvic area
 Skin becomes cool to the touch – especially in the hands and feet, skin may become bluish in color caused by decreased circulation to the extremities
 Rattling or gurgling sounds while breathing or breathing that is irregular and shallow, decreased number of breaths per minute, or breathing that switches between rapid and slow
 Involuntary movements (called myoclonus), changes in heart rate, and loss of reflexes in the legs and arms also mean that the end of life is near
Changes in body after death:
 Rigor Mortis: body becomes stiff within 4 hours after death as a result of decreased ATP production. ATP keeps muscles soft and supple.
 Algor Mortis: Temperature decreases by a few degrees each hour. The skin loses its elasticity and will tear easily.
 Livor Mortis: Dependant parts of body become discolored. The patient will likely be lying on their back, their backside being the ‘dependant’ body part. The discoloration is a result of blood pooling, as the hemoglobin breaks down.
Hospice and palliative care
Hospice is a specialized program that addresses the needs of the catastrophically ill and their loved ones. A team approach is provided in hospice that may involve physicians, nurses, social workers, clergy, home health aids, volunteers, therapists and family caregivers. Hospice workers can help a dying person manage pain, provide medical services and offer family support through every stage of the process, from diagnosis to bereavement.
Hospice services are available in the comfort of your own home, in a hospice facility, or often in settings such as nursing homes and hospitals. Many people who use hospice tell of a wonderfully positive experience with a compassionate staff who focus on caring for the whole person and their families.
Individuals enrolled in hospice have to have a doctor give them a diagnosis of six months or less to live. Many persons in the last stages of dementia-related illnesses, cardiovascular disease, and respiratory and pulmonary illnesses are now enrolled in hospice. Often, health insurance covers hospice services.Components of hospice care programme include the following:
 Client and family as the unit of care
 Co ordinated home care with access to available inpatient and nursing home beds
 Control of symptoms(physical, sociological, psychological and spiritual)
 Physician directed services
 Provision of an interdisciplinary care team of physicians, nurses, spiritual advisers, social workers and counselors.
 Medical and nursing services available at all times
 Bereavement follow up after a client’s death
 Use of trained volunteers for frequent visitation and respite support
 Acceptance into the programme on the basis of health care needs rather than the ability to pay
Palliative Care
As defined by the world Health Organization, palliative care is the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms and of psychologic, social and spiritual problems is paramount. The goal of palliative care is the achievement of the best possible quality of life for patients and their families. In other words palliative care is a special care, which affirms life and regards dying as a normal process, neither hastens nor postpones death, provides relief from pain and other distressing symptoms, integrates the psychological and spiritual aspects of patient care and offers a support system to help patients live as actively as possible until death and helps the family cope during the patient’s illness and in their own bereavement. Palliative care is based on five major principles (Foley and Carver, 2001)
• It respects the goals, likes and choices of the dying person.
• It looks after the medical emotional, social and spiritual needs of the dying person.
• It supports the needs of the family members.
• It helps gain access to needed health care providers and appropriate care settings.
• It builds ways to provide excellent care at the end of life.
The relief of suffering is one of the central goals of palliative care in terminal illnesses. Suffering is frequently associated with the experience of aversive physical symptoms (eg, pain); however, many patients suffer even in the absence of such symptoms. Secondly, suffering due to advanced disease does not appear to be limited to the affected patient. Family members also suffer, which may, in turn, exacerbate the patient’s suffering. According to psychosocial perspective, suffering is best viewed as a subjective phenomenon that can be influenced by biological, psychological, and social processes. The potential sources of suffering in terminal illnesses can extend beyond physical symptoms to include psychological and psychiatric complications (eg, anxiety, depression, and cognitive disorders) and existential distress emanating from past, present, and future concerns. Relief of these sources of suf fering can be achieved through a multidisciplinary approach to patient care in which experts in mental health and pastoral care contribute to the treatment effort. Addressing the psychosocial aspects as well as the medical aspects of palliative care can further reduce the suffering experienced by patients with terminal illnesses.
MANAGING DEATH ANXIETY
Human beings have a basic self-preservation drive. Combining this drive with the realization that death is inevitable creates in them a paralyzing terror of death. In other words all human drama is, to a great extent, a story of how human beings cope with the terror of death, and how they overcome death anxiety through a great variety of conscious efforts and unconscious defense mechanisms. Taking into consideration all these factors, it becomes necessary to help people manage death anxiety in such a way that facilitates growth. Following are some of the most commonly used techniques to deal with death anxiety.
Role of Religiosity/ Spirituality
Religion is a prime source of strength and sustenance to many people when they are dealing with death. Different religious theories explain the inevitability and even necessity of death from different perspectives. According to the Gita, soul is not destructible but immortal. It says that death of the body is certain and irrelevant but eternal Self or the universal Self is immortal, therefore there should be no grief over what is inevitable, even necessary. It further explains that the Self instead of dying, merely goes on to take a new body and start the process all over again, therefore it is pointless to worry about the discarding of the present body (Srimadbhagvadgita, ch. 2, verse 11, 22, 23; Kamath, 1993). In The Bible also death has been viewed in a positive manner. It says “Blessed are the dead who die in the Lord from now on…….that they may rest from their labors, and their works follow them (Revelations, ch. 14, verse 13)”. This verse captures well the Christian views about death that there is no life after death; one has to rejoice death as it is means of entering into God’s kingdom depending the deeds on earth.
Spirituality and religiosity have been reported to play significant role in managing death anxiety and enhancing sense of well being, as mentioned by various researchers. Alvarado et al (1995) report that persons with lower death anxiety had greater strength of conviction and greater belief in afterlife. Nelson et al (2002) also have found strong negative association between the Spiritual Well-Being scale and the HDRS.
Existential Psychotherapy
Death anxiety is inversely proportional to life satisfaction (Yalom, 1980). When an individual is living authentically, anxiety and fear of death decrease (Richard, 2000). The central objective of existential psychotherapy is to enable the person to live authentically: actively observed and involved with other people and things, while appreciating and accepting his nature as being the world (Encyclopedia of Psychotherapy, 2002).
Human beings are in a presumably unique position as compared to other species, given that they are forward-looking and can anticipate some aspects of the future. Ultimately, the future brings death for all. Recognition of death plays a significant role in psychotherapy, for it can be the factor that helps us transform a stale mode of living into a more authentic one (Yalom, 1980). Confronting this realization produces anxiety. Frankl (1969) also contends that people can face pain, guilt, despair and death in their confrontation, challenge their despair and thus triumph. It also postulates that a distinctly human characteristic is the struggle for a sense of significance and purpose in life. Existential therapy provides the conceptual framework for helping the client challenge the meaning in his or her life.
The existentialism does not view death negatively but holds that awareness of death as a basic human condition gives significance to living and that human suffering can be turned into human achievement by the stand an individual takes in the face of it. A distinguishing human character is the ability to grasp the reality of the future and inevitability of death. It is necessary to think about death if we are to think significantly about life. If we defend ourselves against the reality of our eventual death, life becomes insipid and meaningless. But if we realize that we are mortal, we know that we do not have an eternity to complete our projects and that each present moment is crucial. In this way our awareness of death is the source of zest for life and creativity.
Heintz and Baruss(2001) reported that death anxiety is negatively correlated with existential well-being. Kissane et al (1997) evaluated the effectiveness of Cognitive-existential group therapy for patients with primary breast cancer–techniques and found it to be useful helping the patients coping with death anxiety, the collaborative doctor-patient relationship, relationships with partner, friends and family, life style effects and future goals.
Management of dying patient
Cassen (1991) suggests seven essential features in the management of the dying patient:
1. Concern: Empathy, compassion, and involvement are essential.
2. Competence: Skill and knowledge can be as reassuring as warmth and concern. Patients benefit immeasurably from the reassurance that their providers will not allow them to live or die in pain.
3. Communication: Allow patients to speak their minds and get to know them.
4. Children: If children want to visit the dying, it is generally advisable; they bring consolation to dying patients.
5. Cohesion: Family cohesion reassures both the patient and family. The clinician who gets to know the family maximizes patient support and is prepared to help the family through bereavement.
6. Cheerfulness: A gentle, appropriate sense of humor can be palliative; a somber or anxious demeanor should be avoided.
7. Consistency: Continuing, persistent attention is highly valued by patients who often fear that they are a burden and will be abandoned; consistent physician involvement mitigates these fears.
Symptom Management
The management of individual symptoms in terminally ill follows a general stepwise approach (Dial, 1999):
• Assessment of the severity of the symptoms.
• Evaluation for the underlying cause.
• Addressing the social, emotional and spiritual aspects of the symptom.
• Discussing the treatment options with the patient and family.
• Using therapies designed as around the clock interventions for chronic symptoms.
• Reevaluating the control of the symptom periodically.
The major focus of most dying patients is the avoidance of pain. Controlling pain in terminally ill patients requires attention to the following:
• Potential etiology of pain
• Use of medications
• Use of nonpharmacologic methods
Nonpharmacologic interventions are important adjuvants, as well as primary mechanisms, for controlling pain. Several behavioural therapies, hypnotherapy, biofeedback techniques and relaxation can be used. Other physical symptoms like dyspnea, constipation, nausea and vomiting and urinary retention also require to be treated appropriately. Similarly, the psychiatric symptoms and existential distress should also be dealt carefully using both pharmacological and nonpharmacological techniques.
Guidelines for Terminal Care Providers
Physicians have most often been criticized for limiting themselves to brisk and perfunctory interactions that do not respond to their patient’s cognitive and emotional needs (Encyclopedia of psychology, 2000). Therefore there is a need that all the professionals including physicians, psychologists, social workers and nursing staff, who decide to involve themselves in the treatment of a dying person, must commit themselves (Schwartz and Karasu, 1997) to:
• Deal with mental anguish and fear of death,
• Try to respond appropriately to patient’s needs by listening carefully to the complaints and
• Be fully prepared to accept their own counter transferences, as doubts, guilt and damage to their narcissism are encountered.
Management of the dying patient often elicits anxiety in physicians. Kvale et al (1999) identified the association of physicians’ personal fear of death, tolerance of uncertainty and attachment style with physicians’ attitudes toward dying patients and reported that physician tolerance of uncertainty plays a significant role in physicians’ attitudes toward the dying patient and that decreasing physicians’ stress from uncertainty by educating them in the management of the dying patient may improve their attitude toward death and may better prepare them to provide end-of-life care. Viswanathan (1996) also explored gender and specialty differences in death anxiety, locus of control, and purpose in life of physicians, and if these variables might influence the clinical behavior of physicians regarding death notification. Results showed that female physicians scored higher in death anxiety and that purpose in life was inversely correlated with death anxiety and external locus of control.
Guidelines to Improve the Quality of Care
In recent years, there have been several researches in the direction of discovering effective approaches to improve the quality of communication and therefore the quality of care in death related situations (Encyclopedia of psychology, 2000). These guidelines can be summarized as follows:
Additionally, studies suggest that whatever strengthens a person’s sense of purpose, in life and connection with enduring values, also improve one’s ability to withhold the stress of terminal illness, grief and offering services to those affected (Schnider and Kastenbaum, 1993; Vishvanathan,1996).
• Education and role playing can improve perspective taking and empathetic skills, respect each other’s point of view as well as appreciate the situation of patient and their families.
• Developing a sense of control and efficacy.
• Encouraging peer groups for families coping with bereavement.
• Developing increased resourcefulness in dealing with death related situations.
• Recognizing that a moderate level of death anxiety is not only acceptable, but useful and has been found that empathy, openness and willingness to help vulnerable and suffering people often are associated with a discernible level of death anxiety.
• Improving our understanding of pain and suffering will also improve communication and effective interactions.
SOME ISSUES RELATED TO MANAGEMENT
Ethical and Legal Issues
The contemporary practice of palliative care raises important ethical issues that deserve thoughtful consideration. Patients have a right to refuse Life-sustaining treatment, even if they die as a consequence (Stanley, 1992). This right is a component of the ethical and legal doctrines of informed consent and informed refusal. Here the patient must have the ability to comprehend the available choices and their risks and benefits, to think rationally and to express a treatment preference. The law makes no distinction between withholding and withdrawing treatment once the patient has refused it (Meisel, 1991). Patient who lacks a decision making capacity requires a surrogate decision maker. Advanced directives and appointment of a health-care agent are also used (Bernat, 2001).
Right to refuse life-sustaining treatment derives from the concept of respect for self-determination and autonomy and the right to be left alone. Physicians are allowed to help patients only to the extent that patients permit them to, physician can make strong recommendations but patients will choose to accept it. The doctrine of informed consent and refusal has three elements all of which must be met for validity: adequate information must be conveyed to the patient, the patient must be able to decide, and the patient must have freedom from coercion.
Before accepting refusal of life sustaining treatment, physician must ensure its validity that this is not due to reversible depression, irrational thinking or impulsive reaction to particular situation. During discontinuation of life-sustaining treatment, proper palliative care has to be given.
“Double Effect”
This concept provides that known but unintended consequences of opioids, such as respiratory suppression and sedation, are acceptable, even if they hasten death, because the primary effect of the treatment is the relief of suffering.
Hospice Versus Hospital and Home Care
The hospice care is much less stressful for the patient than a traditional hospital (Adkins, 1984; Kane et al., 1985).
Patients in specialized palliative care found to differ from more dying in hospital, in terms of less isolation, anxiety and positive feelings (Linda et al., 1994).
While home care can be emotionally the most satisfying for the patient, studies do show that even with help from home based hospice program, home care can place tremendous stress on other members of the family (Aneshensal et al., 1993).
The Dying patient and the Physician
The process of death can release overwhelming emotions not only in patient but also in physicians. Perhaps, as a result of their education and conditioning, physician, are afraid to feel helpless and project hopelessness to their patients. To stand by and watch a person slip away, requires confronting the feelings that arises when we are with the dying. Thus, some physicians show their discomfort and uneasiness either by continuing useless therapies or by detaching themselves from the care.
Role of Psychologists
There are many ways in which psychologists might contribute to the care of the dying, but the present situation is unsatisfactory. American Psychological Association (2000) reported that psychologists are virtually absent in end of life care arenas.
Lastly, the current state of affairs can be summarized in Emanuel’s words ‘there is gap between accepted policies and actual practices, things are far from ideal, too many patients are unprepared for death, too many patients still have symptoms left untreated, too many patients are not involved in decision making, too many patients die in hospital with inadequate care, too many families are crushed by the burden of caring for a terminally ill relative. To overcome these problems we need to end the taboo against talking about death’ (Emanuel, 1997).
LIFE AFTER DEATH
Near death experience (NDE) and cases of reincarnation type are the two phenomena that have been claimed as evidence of after life.
Near Death Experience
NDE is an altered state of consciousness usually occurring after traumatic injury and almost invariably involve risk of life. This is an episode split-off from the patient’s usual life and marked by unusual dream like events. Some people belief that they were actually “in death”. They report that after “dying” they left their body and floated away, become enveloped in a dark tunnel, and then enter a soothing light, later when they come back to life they are able to recall the events that occurred when they were dead. During the episode their entire past flash before them.
Hallucinations caused by hyperactivation of amygdala-hippocampus-temporal lobe a response of oxygen starved brain, have been proposed as a physiological explanation.
Greyson (1997) argued that correlating NDEs with physical structures or chemicals in the brain, would not necessarily tells us, what causes NDEs.
After effects of NDEs include: increase in spirituality, concern for others, appreciations of life and decrease in fear of death, materialism, and competitiveness.
Reincarnation
Since 1960s, Stevension and Pasricha have systematically investigated hundreds of cases of children, who claim to remember their previous life. These children show atypical behavioural and emotional patterns consistent with their claims. Various explanations like fantasy, fraud, cryptamnesia, paramnesia, socio-cultural expectations have been proposed, but their data is in favour of reincarnation hypothesis. Before accepting or rejecting this more investigations have to be done to rule out normal mode of transfer of information and skills.
CRYONICS
Cryonics is the preservation of the dead body to be revived, till the time, medical technology advances to do so. The main arguments against cryonics are:
• Reflects denial of the inevitable.
• There is no way to preserve bodies so that their organ will resume functioning when they are thawed (Darwin and Wowk, 1992).
• Immortality does not yet fall within the province of technology (Shermer, 1992).
Currently, these efforts are simply wastage of resources.
Cultural Aspects of Death, Dying and Bereavement
Death, dying and bereavement find a way of impacting our daily living. We see images of real or fictional death when watching television or movies. Death can impact us on a personal and a cultural level. This section includes information on the cultural aspects and attitudes of death, dying and bereavement, exploring death in art, music, the media, religion/spirituality, humor and history.
Culture and Death (12) Causes and Risks (9) Death Language (3) Fascination with Death (15)
Celebrating All Saints’ Day - Remembering the Dead
A look at two different holidays in November to remember the dead - All Saint’s Day and Day of the Dead.
Celebration of All Soul’s Day To Remember the Dead
A look at two different observances to remember the dead celebrated in the beginning of November - All Soul’s Day and Day of the Dead.
Good Death
Definition of a Good Death
A Good Death is A Peaceful Death
For residents in a rural community in Ghana, the epitome of a Good Death is a peaceful one that occurs at home, surrounded by children and grandchildren. This article explores other requirements for a good, peaceful death
Twelve Principles of a Good Death
Twelve principles of a Good Death were identified in The Future of Health and Care of Older People by the Debate of the Age Health and Care Study Group. These principles of a good death are included in the article.
Pardons Granted for Shell-Shocked WWI Soldiers
Nearly 90 years after their deaths, 306 soldiers who were shot for military offences during World War I have been granted posthumous pardons from the British Ministry of Defense.
A Pioneer of Hospice: Dr. Elisabeth Kubler Ross
This article was written about one of the pioneers of hospice and the death with dignity movement in the United States article, Dr. Elisabeth Kubler Ross. This article also includes a special collection of her inspiring quotes the cover many topics of death and dying.
Culture and Response to Grief and Mourning
From the National Cancer Institute’s PDQ® series comes an overview online article exploring the cultural responses to grief and mourning. The article includes some questions to consider that will help show respect for a person’s or family’s cultural heritage in regards to death.
Cultural Responses to Grief and Mourning - Professional Version
This article is part of an extensive presentation given at an AMSA conference of medical students as part of their Interest Group on Death & Dying. The Cross-Cultural Responses to Grief and Mourning was based on the reprintable professional version of the from the National Cancer Institute’s PDQ® resources.
Cultural Awareness of Sickness and Death Issues
This article is part of an extensive presentation given at an AMSA conference of medical students as part of their Interest Group on Death & Dying. A list of the eight helpful questions is provided. These questions can be asked to determine a person’s “Explanatory Model” of sickness or awareness of death.
Talking About Death Across Cultures
This informative article on talking about death across cultures comes from Kokua Mau a partnership in Hawaii of over 250 individuals and organizations devoted to providing continuous care for their residents. This article looks at issues of cultural sensitivity, offers helpful tips and gives a universal protocol for care of the dying.
(PDF File) End-of-Life Care Tips for the Latino Culture
From the University of Washington Medical Center a pdf file with helpful tips on end-of-life care when dealing with people and patients from the Latino Culture. These handouts were designed to increase awareness about concepts and preferences of people from diverse cultures.
(PDF File) End-of-Life Care Tips for the Russian Culture
From the University of Washington Medical Center a pdf file with helpful tips on end-of-life care when dealing with people and patients with a Russian Background. These handouts were designed to increase awareness about concepts and preferences of people from diverse cultures.
(PDF File) End-of-Life Care Tips for the Vietnamese Culture
From the University of Washington Medical Center a pdf file with helpful tips on end-of-life care when dealing with people and patients from the Vietnamese Culture. These handouts were designed to increase awareness about concepts and preferences of people from diverse cultures.
Religion, Spirituality, and End of Life Care
One of the modules of EndLink, a Resource for End of Life Care Education developed at the Northwestern University with funding from the National Cancer Institute. Module 14 covers the topics of Religion, Spirituality, and End of Life Care.
Handbook on Cultural, Spiritual and Religious Beliefs
An online resource prepared for the South Devon Healthcare NHS Trust as a resource for their general practitioners. This resource looks at cultural, spiritual and religious beliefs for various different cultures and the major world religions. It also includes a section on Care of the Dying.
Twelve Reasons to Ask About Religious Beliefs and Practices
One of the resources in the EndLink module on Religion, Spirituality, and End of Life Care. This sections looks at reasons one should be asking about religious beliefs and practices in patients.
Readings, Prayers and Spiritual Resources
From Hospice Net a collection of readings, prayers and spiritual resources from different religious traditions for those keeping vigil and giving care. The selection reflects on God’s presence in death and dying. These readings were selected to affirm the common struggle with death and a need for God’s comfort and assurance
CONCLUSION
Death is still an unknown phenomenon. At the same time we all know that it is the only certainty in life. All living organisms die; there is no exception. However, human beings alone are burdened with the cognitive capacity to be aware of their own inevitable mortality and to fear what may come afterwards. In this enlightened age, man still reacts to death with fear. Much of our response to death is avoidance. Talking about death on a personal level creates discomfort. Fear and anxiety are among the most frequently used to characterize orientations toward death throughout the life span. This is because human beings have a basic self-preservation drive. Combining this drive with the realization that death is inevitable creates in them a paralyzing terror of death. But if people realize that they are mortal, they know that they do not have an eternity to complete their projects and that each present moment is crucial. In this way the awareness of death can be the source of zest for life and creativity.
REFERENCES:
1. Robbins J, Moscrop J. caring for the dying & family. 3rd ed. London: Chapman&Hall;1995
2. Craven R F, Hirnle C J. Fundamentals of Nursing. 5th ed. Philadelphia: Lippincott Williams & Wilkins Publishers;2006
3. Feinberg A. W. The care of dying patients. Annals of internal medicine. 2007 Jan 17; 126 (2): 164-65. Available from http://www.pubmedcentral.nih.gov/article
4. Meyers T. a turn towards dying: presence, signature, and the social course of chronic illness in urban America. Med Anthropol(PMID 17654261). 2007 July-Sept;26(3):205-27. Available from http://www.pubmedcentral.nih.gov/article

Thought stopping technique
Assertive thinking is sometimes inhibited by repetitive negative thoughts of which the mind refuses to let go. Individuals with low self worth may be obsessed with thoughts such as “I am too ugly”, “I know he had never want to go out with me”, “I know I never be able to do this job well”etc. This type of thoughts rosters the beliefs that one’s individual rights do not deserve the same consideration as those of others and reflects nonassertive communication and behavioral response patterns. Thought stopping techniques was developed by psychiatrist Joseph Wolpe and are intended to eliminate intrusive, unwanted thoughts.
Method
Thought stopping is a covert techniques used to treat recurring negative or self –defeating thoughts. Thoughts of death, losing control, low self- worth, overeating and unrequited love are among problems that have been treated with these techniques. Thoughts stopping typically progresses from overt to covert control. The purpose is to block the undesired thought and redirect the client’s attention.
In a practice setting with closed eyes, an individual concentrates on unwanted recurring thoughts. Once the thought is clearly established in the mind he or she should aloud: STOP. This action will interrupt the thought and it is actually removed from the awareness. The individual then immediately shift the thoughts to one that is considered pleasant and desirable.
It is possible that the unwanted thought may recur soon, but with practice the length of time between recurrences will increase until the unwanted thought is no longer intrusive. Obviously one cannot go about his or her daily life shouting, STOP in public places. After a number of practice sessions, the technique is equally effective if the word stop is used silently in the mind.
Thought stopping is an excellent way to eliminate negative self-talk. This simple technique involves using a verbal or physical trigger to halt undesirable thinking. The most popular trigger is the word “STOP,” said out loud or to yourself. You might even try screaming “STOP” inside your head. You can also clap your hands, snap your fingers, squeeze your eyes tightly shut, think of a large red stop sign, or pop your wrist with a rubber band. Whichever you choose, your trigger allows you to break free from unproductive and debilitating thinking. Remember, that one should be consistent in your use of thought stopping. Use it every time you have irrational thoughts. As you continue to use this technique, you’ll gain control of your thinking and notice the frequency of your negative self-talk decreasing.

What is thought stopping?
Thought stopping is the:
• Process by which you are able to cease dwelling on a thought bothersome to you.
• Procedure used to stop thoughts that are cues to acting impulsively or compulsively.
• Process by which you are able to break the power of the cues that lead you into addictive or binge-like behavior.
• Substitution of a healthy thought for an unhealthy thought.
• Act of deliberately turning to cues that break unhealthy patterns or habits.
• Ability to discontinue obsessing on an idea, image, thought, fear or stimuli that is a cue for unhealthy behavior.
• Practice of using mental energy in a positive way.
• Technique used to reduce the negative impact of stress, unhealthy emotional cues, and fears.
• Stress-reduction technique that eliminates the overwhelming impact of stress and/or crisis events.

How does thought stopping work?
In thought stopping you could use one of the following or a combination of them:
• Replace one thought for another, i.e., the thought of eating is replaced by the thought of exercising.
• Hear “stop'’ literally or figuratively whenever a negative or unhealthy thought arises, e.g., the desire for a cigarette appears and “stop'’ is immediately heard.
• Are able to break an obsessive, unhealthy thought pattern by substituting a healthy thought pattern.
• Are able to replace a negative or unhealthy image with a positive visual image.
• Find you divert or detour your mind from unhealthy or negative thoughts.
• Clear your mind of all unnecessary and unhealthy thoughts that create stress or cues for acting out in unhealthy ways.
What are some thought stopping techniques?

Thought Replacement: when an unwanted thought enters, immediately replace the thought with a healthy, rational one.
Yelling ‘STOP'’: on thinking the unwanted thought, immediately yell STOP. The yell can be out loud or only in the mind. Continue to yell STOP until the unwanted thought ceases.
Substituting a Healthy Thought Pattern: if you have a tendency to think irrationally due to irrational beliefs, you can develop a rational pattern of thinking by challenging every thought that comes to mind, asking: Is this a rational thought? If not, what is irrational about it? What would be a rational replacement for this thought?

Replacement Visual Image: if you have a tendency to visualize negative images, replace these negative images by positive, healthy images.
Aversive Replacements: if you have a tendency to think of an unhealthy behavior in an acceptable manner, immediately replace these acceptable images with more honest images, i.e., thoughts of alcohol, drugs, junk foods can be replaced by the words “poison,'’ “unhealthy,'’ “disgusting,'’ “barf'’ or “killers.'’ Thoughts of cigarettes can be replaced by “cancer sticks'’ or “coffin nails.'’
Irrational thinking which blocks you from letting thought stopping work for you
• It’s OK if I just think about it and do nothing about it.
• What’s the harm of thinking about it?
• People will never know if I just think about it for a little while.
• I’ve denied myself so much, why can’t I just think about it once in a while?
• You can’t condemn me for thinking.
• I never thought about it before I acted so why should I avoid thinking about it now?
• It is too much of a battle to fight these thoughts. It’s easier to give in and then start over again in the morning.
• What difference does it make if I think about it?
• It seems so silly to control my mind from having thoughts about it.
• This feels like brainwashing and I think brainwashing is bad.
• I don’t have time to do this.
• I don’t need this in order to be successful in achieving recovery.
• This is another far-out psychological gimmick-too stupid to try.

Directions for thought stopping

First: Use relaxation training and breathing exercises to get yourself relaxed. It is important that you be at ease to stop a recurring thought.

Second: Record the word stop in alternating 1, 2, and 3 minute intervals on a 30 minute tape. Using the stop tape in a relaxed state, think your unwanted thought and every time you hear stop, discontinue the thought. Go back to the thought again and cease the thought only when you hear stop. Do this for 30 minutes every night for two weeks or until you can consistently discontinue the thought when you hear stop.

Third: After you are trained to arrest your thought using the stop tape, you are ready to try arresting your thought by yelling stop out loud. Think of your unwanted thought for 30 minutes and yell stop to discontinue the thought. Once you arrest the thought, go back to thinking about it for awhile, then yell stop again. Do this for 30 minutes each night for two weeks or until you are able to consistently discontinue the thought by yelling stop.

Fourth: After you have trained yourself to stop thoughts by yelling stop, you are ready to train your thoughts to end by whispering stop. For thirty minutes, repeat the process of dwelling on your unwanted thought, but this time whisper stop to halt them. Do this 30 minutes nightly for two weeks or until you are able to consistently discontinue the thought by whispering stop.

Fifth: After you have trained yourself to discontinue unwanted thoughts by whispering stop, you are ready to train your thoughts to discontinue by thinking the word stop. Repeat the process of dwelling on your thought for 30 minutes, but this time simply think stop to discontinue unwanted thoughts. Do this for 30 minutes nightly for two weeks or until you are able to consistently discontinue unwanted thoughts by thinking the word stop.
Sixth: The technique of either taping, yelling, whispering, or thinking stop can be effective in discontinuing unwanted thoughts. Ideally you could get to the point where simply thinking stop would work; however, use whichever mode works best for you and keep practicing. Remember to start the process in a relaxed state.

Bibliography  Stuart GW. Laraia MT. Principles and practice of psychiatric nursing. 1st edn. Noida. Mosby publishers.2001
 Townsend MC. Psychiatric mental health nursing. 3rd edn. Philadelphia. FH Davis publishers.

Introduction
Family has long been recognised as a fundamental unit of social organisation in the lives of humans. The significance of family factors in the maintenance as well as the treatment of mental disorders has been established by many studies. Family therapy is any intervention that focuses on altering the interactions among family members and attempts to improve the functioning of the family as a unit of individual members of the family. The term ¡¥family therapy’, coined by the American psychiatrist Nathan Ackerman in the 1950s, covers a variety of approaches and is practised by a variety of professionals. Family psychopathology reflects recurring, problematic interactional patterns among family members. Several or all of the family members take part in this treatment. Usually both parents are involved, often together with a child whose problems have made the family to seek help.

History
The origins of family therapy are vague. The beginning of family interventions can be traced to the Child-guidance and marriage counseling movements in early 1900s. Sigmund Freud (1909/1977) was the first among to include a parent in the psychotherapy of a child. Freud explained about marital and family relationships and their possible roles in both individual normal development and psychopathology. Freud’s description of unconscious processes like introjection, projection, and identification explained how individual experiences could be transmitted across the generations in a family. Freud’s successors, Anna Freud, Melanie Klein, and Donald Winnicott, elaborated and modified his formulations.

The Aims of Family Therapy
The aim of the treatment is to alleviate the problems hat led to the disorder in the identified patient and improve family functioning. Family therapy is advised not only to resolve problems and difficulties but also to teach the family to solve further impasses by itself, to communicate more clearly with one another, to develop strategies for avoidance of conflicts, to accept another¡¦s handicaps and differences without blaming and scapegoating, and to foster functional processes for appropriate balancing of competing values such as family cohesiveness and individuation, balanced separateness and togetherness, stability and flexibility (Bodin, 1984).

Models of Intervention
Many models of family therapy exist, none of which superior to others. Whatever the methods, family therapist have the following goals for the family: (a). improved communication, (b) improved autonomy for each member, ©. improved agreement about roles, (d). reduced conflict, and (e).reduced distress in the member who is the patient

1. Psychodynamic methods
These methods use concepts taken from the psychoanalytical treatment of individual patients. it is assumed that current problems in the family originates in the separate past experiences of its individual members, particularly those of t he parents. Present problems arise in part from unconscious conflict within individual members. Family members need to gain insight in these conflicts in order to change their behaviour. The therapist¡¦s goal is to help members to gain these insights into their own unconsciousness, and into the ways in which one person¡¦s problems may interlock with those of other. The therapist does this by examining the relationship between himself and the different family members to throw light on the conscious aspects of the problems. The therapist may give interpretations but is not directive.

2. Bowen Model
Murray Bowen called his model family systems. Here the person¡¦s differentiation form his family of origin., their ability to be their true selves in the face of familial and other pressures that threaten the loss of love or social position. Problem families are assessed on two levels: the degree of their enmeshment versus the degree of their ability to differentiate and the analysis of emotional triangles in the problem for which they seek help. An emotional triangle is defined as a three-party system arranged so that the closeness of two members expressed as their love or repetitive conflict tends to exclude the third. Emotional cross currents can happen when the excluded person tries to join one of the other. The therapist¡¦s role is, first , to stabilise or shift the ¡§hot¡¨ triangle and second to work with the most psychologically available family members, individually if necessary , to achieve enough personal differentiation so hat the hot triangle does not recur. Therapist has to keep his neutrality. Bowen also originated the ¡¥genogram¡¦.

3. Structural family model
The term family structure refers to a set of unspoken rules that recognise the ways in which family members relate to one another. Some rules determine the hierarchy in the family. Some rules determine cooperation in the family. Rules also determine the boundaries: sometimes these are broken, for example when an unhappy wife involves her son involves her son in the problems with her husband. In structural family therapy, hypotheses are presented to the family in a paradoxical way: for example, ¡¥you seem to be very dependent on your wife: what does she do to make you feel less competent?¡¦ Some interventions may increase family tension in the short term until a new set of rules is established.

4. General Systems model
It is based on the General systems theory originally developed by Von Bertalanffy (1962). It is the study of the relationships between and among interacting components of a system that exists over time. The family is construed similarly as a system. Families have external boundaries and internal rules. Every member presumed to play a role (spokesperson, persecutor, victim, rescuer, symptom bearer, nurturer), which is relatively stable, but which member each role may change. Some families scapegoat one member by blaming him or her for the families problems. The general systems model overlaps with some of the other models, particularly Bowen and Structural models.

5. Eclectic Methods
Comprehensive review of outcome research suggests that many models equally effective in most situations. But levels of effectives vary with variety of clinical problems. But often a combined approach is used in practice.

Indications for family therapy
Family therapy is a mode of psychological treatment, and does not constitute a unitary approach. The problem in relating can involve a couple, a parent¡Vchild dyad, siblings, or any member of the family.
Six categories can be listed as indication of family therapy:

1. The clinical problem manifests in explicitly family terms, i.e. family dysfunction. For example, a marital conflict dominates; with repercussions for the rest of the family; or tension between parents and an adolescent child dislocates family life with everyone get involved in the prevailing conflict. Here family therapy is the treatment of choice.

2. The family has experienced a major stressful or disruptive life event, which has led or is leading to dysfunction. These events are either predictable or accidental and include, for instance, accidental or suicidal death, severe financial embarrassment, diagnosis of a serious physical illness, the unexpected departure of a child from the home, and so forth. As such, any family equilibrium that previously prevailed has been disturbed; the ensuing disequilibrium becomes associated with family dysfunction and/or the development of symptoms in one or more members.

3. Continuing demanding circumstances in a family are of such a magnitude as to lead to poor or inappropriate adjustment. The family’s resources may be stretched to the hilt; external sources of support may be scanty or unavailable. Typical situations are chronic physical illness, persistent or recurrent psychiatric illness, and the presence in the family of a frail elderly member.

4. An identified patient may have become symptomatic in the context of a poorly functioning family. Symptoms are an expression of that dysfunction. Depression in a mother, an eating problem in a daughter, alcohol misuse in a father, on family assessment, are adjudged to reflect underlying family difficulties.

5. A family member is diagnosed as having a specific conventional condition such as schizophrenia, agoraphobia, obsessive¡V compulsive disorder, or depression-the complicating factors are the adverse reverberations in the family stemming from that diagnosis. For example, the son with schizophrenia taxes his parents in ways that exceed their ¡¥problem-solving’ capacity; an agoraphobic woman insists on the constant company of her husband in activities of daily living; a recurrently depressed mother comes to rely on the support of her eldest daughter. In these circumstances, family members begin to respond maladaptively towards the diagnosed relative, which paves the way for deterioration of his condition, manifest as chronicity or a relapsing course.

6. Thoroughly disorganized families, faced by many problems, are viewed as the principal target of help. E.g. one member abuses drugs, another is prone to violence, and a third manifests antisocial behaviour.

Contraindications for family therapy
These are more straightforward than indications.
1. The family is unavailable because of geographical dispersal or death.
2. There is no shared motivation for change. One or more family members may wish to participate, but their chances of benefiting from a family approach are likely to be less than if committing themselves to individual therapy. (Need to distinguish here between poor motivation and ambivalence; in the latter, the assessor teases out factors that underlie the ambivalence and may encourage the family’s engagement.)
3. The level of family disturbance is so severe or long-standing, or both, that a family approach seems prognostically futile. For example, a family that has fought bitterly for years is unlikely to engage in the constructive purpose of exploring their patterns of functioning.
4. Family equilibrium is so precarious that the inevitable turbulence arising from family therapy is likely to lead to decompensation of one or more members; for example, a sexually abused adult may do better in individual therapy than by confronting the abusing relative.
5. The patient is too incapacitated to withstand the demands of family therapy. The person in the midst of a psychotic episode or someone buffeted by severe melancholia is too affected by the illness to engage in family work.

Structure & Composition of Therapy
o Family therapy may be conducted with:
o one patient or client present (e.g., Bowen family systems therapy),
o may be limited to the nuclear family (e.g., behavioral, psychoanalytic), or
o may even be transgenerational (e.g., structural, symbolic-experimental):
o combined therapies (e.g., individual and family) are more common.
o Most family therapy is conducted by a single therapist, though co-therapy (especially of one male and one female therapist) is somewhat common in training centres, and is even preferred in some family therapy approaches (e.g., contextual, symbolic-experiential).
o The length of family therapy ranges from ideal courses of fewer than ten visits (e.g., Mental Research Institute brief therapy) to up to dozens of visits (e.g., Bowen family systems) or even hundreds (e.g., psychoanalytic) over several years.
o Most family and couple therapy lasting 10 to 20 sessions over a period of less than 6 months.
o Family therapy is typically conducted in private offices and clinics but not uncommonly takes place on hospital wards and even in family homes.

The Process of Family therapy
Steps in the process of family therapy include: assessment and goal-setting, formulation of hypothesis, working phase, evaluation, termination. These steps may overlap as hypotheses can be formulated during the process of assessment. Similarly, evaluation and assessment can be done anytime during working phase.

1. Assessment and Goal-Setting
Family assessment, an extension of conventional individual psychiatric assessment, adds a broader context to the final formulation. It has four phases.
* History from the patient
* A provisional formulation concerning the relevance of the family
* An interview with one or more family members, and
* A revised formulation.

A. History from the patient
The most effective way to obtain a family history is by constructing a family tree. Apart from showing the family structure, it allows further information to be added summarising important events and a wide range of family features. Personal details can be recorded for each family member such as age, date of birth and death, occupation, education and illness, as well as critical family events (for example, migration, crucial relationship changes, notable losses, and achievements), and the quality of relationships.

Following questions gives more information:
o Who knows about the problem?
o How does each of them see it?
o Has anyone else in the family had similar problems?
o Who have you found most helpful, and least helpful thus far?
o What do they think needs to be done?

The presenting problem and changes in the family
Questions aimed at understanding the current context include:
o What has been happening recently in the family?
o Have there been any changes (e.g. births, deaths, illness, losses).
o Has your relationship with other family members changed?
o Have relationships within the family altered?’

B. The wider family context
* Questions about the family’s response to major events can be posed: for example, ¡¥How did the family react when your grandmother died? Who took it the hardest?
* Relationships should be explored at all levels, covering those between the patient and other family members and between those other members themselves.
* Conflicted ties are particularly illuminating. Understanding the roles’ taken by members is also useful: ¡¥Who tends to take care of others? Who needs most care? Who tends to be the most sensitive to what is going on in the family?’

C. The family in problem maintenance
Interactions revolving around the patient’s illness may act to maintain it.
* First, the illness becomes a way of ¡¥solving’ a family problem.
o E.g. Anorexia nervosa in a teenager due to attend a distant university may lead to her abandoning this plan since she feels unable to care for herself. Were she to leave, parental conflict would become more exposed and her mother, with whom the patient is in coalition against her father, would find herself unsupported. The illness therefore keeps the patient at home and enmeshed in the parental relationship, and also provides a focus for shared concerns and an ostensible sense of unity.
* Maintenance of the illness does not solve a family problem, but may have done so in the past.
o In the previous example, the father’s mother died 9 months later. His wife subsequently expressed feelings of closeness, feelings not experienced by him for years; their relationship gradually improved. Both parents, however, continued to treat their daughter as incapable of achieving autonomy, reinforcing her own uncertainty about coping independently if she were to recover.

D. The family interview
* A non-judgemental stance is important.
* Introductions are made in the initial phase.
* Names and preferred modes of address are clarified.
* The therapist then explains the meeting’s purpose, details of which may crucially influence future family participation.
* The therapist invites everyone to share their views about the nature and effects of problems they have encountered.
* The therapist may have an idea about how the identified patient’s problems relate to family function, and can test it out by asking probing questions and observing interactions.
* This idea is characteristically kept private since it is unhelpful for a hypothesis to be put forward prematurely.
* Triadic relationships can be scrutinized both through questioning (what does A do when B says this to C?) and observation (what does A do when B and C reveal tensions?).
* A third person may be asked to comment on what two others convey to each other when a particular event occurs.
* The discussion then extends to all spheres of family life: beliefs, traditions, rules, and values.
* Concerns are attended to and the members strengths and efforts acknowledged.
* The interview concludes with a summary of what has emerged.
* Arrangements are made for a follow-up session.

E. Revised hypotheses formulation
* Since more information becomes available at each level, the initial formulation can be revised as necessary.
* The five observational levels of structure, transitions, relationships, patterns of interaction, and global family functioning are re-examined in terms of the family as reactive, resourceful, or problem-maintaining.
* Appropriate interventions can be planned, at least for a follow-up session. We can now turn to the course of typical family therapy.

Working Phase
Based on the theoretical orientation of the therapist, intensity of the problem and information gathered in the assessment phase, therapy progresses. There can be altercations among the members, but the therapist should intervene only when required. Observation of the interaction of family members help the therapist to verify the information already gathered. Depending on the assessment made in the initial session, therapist can decide on the number of sessions.

Termination
A regular review of goals help the therapist in planning the final phase. If objectives are clear and the process is moving towards the termination is easy. Follow up may be required on regular basis.
Role of the family therapist
Beels and Ferber, among the first observers to consider various roles for family therapists, divided them into ‘conductors’ and reactors’.
* The therapist as a conductor is represented in the work of practitioners like Satir, Bowen, and Minuchin. Satir emphasises on communication, the family therapist is a teacher who shares expertise in optimal communication by setting goals and the direction of treatment. The therapist is an explicit authority, who intervenes actively in implementing change.
* The therapist as reactor plays a different role by resonating with, and responding to, what the family manifests. Therapists in the psychoanalytical tradition belong to this group. Typically, the therapist shares observations about patterns of interaction and relating that emerge during the sessions.
Problems encountered in therapy
* Family treatment does not always succeed. Indeed, deterioration may occur, albeit in a small percentage of cases.
* What common difficulties are encountered?
o Missed appointments may punctuate the course of therapy, often linked to turbulent experiences between sessions or apprehension about what a forthcoming session may reveal.
o Like any psychotherapy, drop-out is possible. On occasion, this is appropriate in that the indication for family therapy was misconstrued. In other circumstances, drop-out is equivalent to failure and may derive from such factors as therapist ineptitude, unearthing of family conflict which they cannot tolerate, and inappropriate selection of family therapy based on faulty assessment.
o The family’s dysfunction may be so intractable that it proves impervious to change, the family may lack the psychological sophistication required, members may retreat in the face of change because of insecurity..
o Dependency becomes a problem as the family discards any vestige of autonomy and encounters a greater security when relying on the authority of the therapist
o Finally, part of the family may harbour a secret that threatens the principle of open communication between members

Marital (Couple) Therapy

The term marital therapy implies treatment for husband and wife. Couples or marital therapy is a form of psychotherapy designed to psychologically modify the interaction between two persons who are in conflict with each other on a variety of parameters-social, emotional, sexual, or economic. The problem is conceived as resulting from the way partners interact, and treatment is directed to that direction. The stages through which marriage passes: first living together, then bringing up children, and finally readjusting when children leave home. At any of these stages marital conflicts may emerge. The goals include alleviation of emotional distress and disability and to promote the level of well-being of both partners together and of each as an individuals.

Types of therapies
1. Individual therapy
Here the partners may consult different therapists, who do not necessarily communicate each other. The goal of the therapy is to strengthen each partner¡¦s adaptive capacities. At times only one of the partners may be in treatment.
2. Individual Couple Therapy
In individual couple therapy, each partner is in therapy, which is either concurrent with same therapist or collaborative, with each partner seeing a different therapist.
3. Conjoint Therapy
The most common method in couple therapy, either one or two therapist treat the partners in joint sessions.
4. Group Psychotherapy
Group usually consists of three to four couples and one or two therapists. The couple identify which each other and recognise that others have similar problems, each gain support and empathy from fellow group members of the same or opposite sex.
Indications
o Problems in communication between partners are a prime indication for couples therapy.
o Conflicts in one or several areas, such as partner¡¦s sexual life
o Difficulty in establishing satisfactory social, economical, parental or emotional roles implies that the couple needs help.
Contraindications
o Patients with severe psychosis, particularly with paranoid element
o Marriages in which one or both partners really want to divorce
Effectiveness of Family Therapy and Couple Therapy
¡V Schizophrenia
o Research has demonstrated unequivocally the effectiveness of a range of psychoeducational and behavioral treatment methods that teach family members about schizophrenia, and emphasize the reduction of expressed emotion and the enhancement of skills for coping with stress. These psychosocial methods are used in conjunction with medication.
¡V Mood Disorders
o Psychoeducational methods have recently shown promise in the family treatment of bipolar I disorder as well as schizophrenia.
* Substance Abuse
o family therapy for opiate addicts showed that a decrease in drug use and related behavior problems, and increased social functioning.
* Anxiety Disorders
o The inclusion of the spouse of the patient with agoraphobia in therapy sessions, appears to lead consistently to lower dropout rates and more reliable practicing of exposure. In addition, spouse involvement in cases that are accompanied by marital distress may help to reduce marital tension, which in turn may make symptomatic spouses less anxious overall.
* Marital Discord
o Since as many as 40 to 50 percent of the reasons for adults seeking mental health services may involve marital dissatisfaction, marital conflict constitutes a significant condition.
* Sexual Dysfunction
o Conjoint couples sex therapy is well established as the treatment of choice for common sexual dysfunction as premature ejaculation, vaginismus, primary female orgasmic disorder, and secondary erectile dysfunction. On the other hand, ejaculatory inhibition, primary erectile disorder, secondary orgasmic dysfunction, and problems of inhibited sexual desire are not so effectively dealt with by conjoint therapy.
Childhood Conduct Disorders
o Behavioral Parent Training -places central emphasis on learning¡Vtheory-based contingency management procedures, in which parents are taught essential parenting skills for providing appropriate consequences for desirable and undesirable child behaviors
o Delinquency and Substance Abuse
Other Indications
o Dealing with the process of marital separation and divorce, addressing the complexities of remarriage and stepfamily life, crises of mid-life adaptation, extramarital affairs, cross-cultural transitions, and chronic non-psychiatric conflict

Conclusion
Family therapy and couple therapy has developed substantially since the 1950s. the effectiveness of these method of treatment has been proven through many studies. Current practitioners do not strictly adhere to any theoretical approaches, rather an eclectic approach is mostly used.

References
Books
1. Ackerman, N.W. The psychodynamic of family life. Basic Books, New York, 1958.
2. Bowen, M. Family therapy in clinical practice. Aronson, New York.1971, 1981.
3. McGoldrick, M. and Gerson, R.. Genograms in family assessment. Norton, New York, 1985.
4. Bloch, S., Hafner, J., Harari, E., and Szmukler, G. The family in clinical psychiatry. Oxford University Press, 1994.
5. Satir, V. Conjoint family therapy. Science and Behaviour Books, Palo Alto, CA,1967.
6. Beels, C. and Ferber, A. Family therapy: a view. Family Process, 8, 280¡V332. 1969.
7. Wolberg, L.R.. The techniques of psychotherapy ,4th Edn. Harcourt Brace Jovanovich, New York, 1988.
8. Videbeck, SL. Psychiatric Mental heath Nursing 2nd edition. LWW Philadelphia 2004.
9. Gelder M., Gath D., Mayou R., Owen P. Oxford Textbook of Psychiatry. Third Edition. Oxford University Press. New delhi 2000.
10. Gurman LS. LEBOW, JL. Family and couple therapy. In.Saddock BJ &. Sadock VA Eds. Comprehensive textbook of psychiatry. 7th ed Vol.2. baltimore: Lippincott Williams & Wilkins. 200:2356.
11. Videbeck, SL. Psychiatric Mental heath Nursing 2nd edition. LWW Philadelphia 2004.
Journals
12. Gurman, A. and Kniskern, D. (1978). Deterioration in marital and family therapy: empirical, clinical, and conceptual issues. Family Process, 17, 3¡V20.
13. Jenkins, H. (1989). Precipitating crises in families: patterns which connect. Journal of Family Therapy, 11, 99¡V109.