Psychiatric Mental Health Nursing

PSYCHOSOCIAL THEORIES Developmental Theories

Psychoanalytic Theories  Erik Erikson and Psychosocial Stages of Development
 Sigmund Freud: The Father of Psychoanalysis  Extended Freud’s work on personality development
 Psychoanalytic theory supports the notion that all human across the life span while focusing on social and
behavior is caused and can be explained (deterministic psychological development in the life stages.
theory). Freud believed that repressed (driven from conscious  He described eight psychosocial stages of
awareness) sexual impulses and desires motivate much human development. In each stage, the person must
behavior. complete a life task that is essential to his or her well-
 Personality Components: Id, Ego, and Superego. being and mental health.
 The id is the part of one’s nature that reflects basic
or innate desires such as pleasure-seeking behavior,
aggression, and sexual impulses. The id seeks instant
gratification, causes impulsive unthinking behavior,
and has no regard for rules or social convention.
 The superego is the part of a person’s nature that
reflects moral and ethical concepts, values, and
parental and social expectations; therefore, it is in
direct opposition to the id.
 The ego represents mature and adaptive behavior
that allows a person to function successfully in the
world. Freud believed that anxiety resulted from the
ego’s attempts to balance the impulsive instincts of  Jean Piaget and Cognitive Stages of Development
the id with the stringent rules of the superego.  explored how intelligence and cognitive
 Behavior Motivated By Subconscious Thoughts And Feelings: functioning develop in children.
Three Levels of Awareness:  He believed that human intelligence progresses
 Conscious refers to the perceptions, thoughts, and through a series of stages based on age, with the
emotions that exist in the person’s awareness, such child at each successive stage demonstrating a higher
as being aware of happy feelings or thinking about a level of functioning than at previous stages.
loved one.  In his schema, Piaget strongly believed that biologic
 Preconscious thoughts and emotions are not changes and maturation were responsible for
currently in the person’s awareness, but he or she cognitive development.
can recall them with some effort. 1. Sensorimotor—birth to 2 years: The child develops a
 The unconscious is the realm of thoughts and sense of self as separate from the environment and the
feelings that motivates a person even though he or concept of object permanence; that is, tangible objects
she is totally unaware of them. According to do not cease to exist just because they are out of sight.
Freud’s theories, the person represses into the He or she begins to form mental images.
unconscious the memory of traumatic events that 2. Preoperational—2 to 6 years: The child develops the
are too painful to remember. ability to express self with language, understands the
 Freudian slip is a term we commonly use to describe slips of meaning of symbolic gestures, and begins to classify
the tongue. objects.
 Freud believed that a person’s dreams reflect his or her 3. Concrete operations—6 to 12 years: The child begins
subconscious and have significant meaning, although to apply logic to thinking, understands spatiality and
sometimes the meaning is hidden or symbolic. reversibility, and is increasingly social and able to apply
 Dream analysis, a primary technique used in psychoanalysis, rules; however, thinking is still concrete.
involves discussing a client’s dreams to discover their true 4. Formal operations—12 to 15 years and beyond: The
meaning and significance. child learns to think and reason in abstract terms,
 Another method used to gain access to subconscious thoughts further develops logical thinking and reasoning, and
and feelings is free association, in which the therapist tries to achieves cognitive maturity.
uncover the client’s true thoughts and feelings by saying a
word and asking the client to respond quickly with the first Interpersonal Theories
thing that comes to mind.  Harry Stack Sullivan: Interpersonal Relationships and
 Freud believed that the self, or ego, uses ego defense Milieu Therapy
mechanisms, which are methods of attempting to protect the  Sullivan believed that one’s personality involves
self and cope with basic drives or emotionally painful thoughts, more than individual characteristics, particularly how
feelings, or events. one interacts with others (interpersonal
 Transference occurs when the client displaces onto the relationship).
therapist attitudes and feelings that the client originally  three developmental cognitive modes of experience:
experienced in other relationships. Transference patterns are  The prototaxic mode, characteristic of infancy
automatic and unconscious in the therapeutic relationship and childhood, involves brief, unconnected
 Countertransference occurs when the therapist displaces onto experiences that have no relationship to one
the client attitudes or feelings from his or her past. another.
 Psychoanalysis focuses on discovering the causes of the  The parataxic mode begins in early childhood
client’s unconscious and repressed thoughts, feelings, and as the child begins to connect experiences in
conflicts believed to cause anxiety and on helping the client to sequence. The child may not make logical
gain insight into and resolve these conflicts and anxieties. The sense of the experiences and may see them as
analytic therapist uses the techniques of free association, dream coincidence or chance events. Sullivan
analysis, and interpretation of behavior. explained paranoid ideas and slips of the
 Five Stages of Psychosexual Development tongue as a person operating in the parataxic
mode.
 In the syntaxic mode, which begins to appear
in school aged children and becomes more
predominant in preadolescence, the person
begins to perceive himself or herself and the
world within the context of the environment
Psychiatric Mental Health Nursing
and can analyze experiences in a variety of  Severe anxiety involves feelings of dread or
settings. Maturity may be defined as terror. The person cannot be redirected to a
predominance of the syntaxic mode. task; he or she focuses only on scattered details
and has physiological symptoms of
tachycardia, diaphoresis, and chest pain.
 Panic anxiety can involve loss of rational
thought, delusions, hallucinations, and
complete physical immobility and muteness.
The person may bolt and run aimlessly, often
exposing himself or herself to injury.

Humanistic Theories
 Humanism focuses on a person’s positive qualities, his or her
capacity to change (human potential), and the promotion of
self-esteem. Humanists do consider the person’s past
experiences, but they direct more attention toward the present
and future.
 Abraham Maslow: Hierarchy of Needs
 He used a pyramid to arrange and illustrate the basic
drives or needs that motivate people.
 The most basic needs—the physiological needs of
food, water, sleep, shelter, sexual expression, and
freedom from pain—must be met first.
 The second level involves safety and security needs,
 Hildegard Peplau: Therapeutic Nurse–Patient which include protection, security, and freedom from
Relationships harm or threatened deprivation.
 a nursing theorist and clinician who built on  The third level is love and belonging needs, which
Sullivan’s interpersonal theories and also saw the role include enduring intimacy, friendship, and
of the nurse as a participant observer. acceptance.
 Peplau developed the concept of the therapeutic  The fourth level involves esteem needs, which
nurse–patient relationship. include the need for self-respect and esteem from
 During these phases, the client accomplishes certain others.
tasks and makes relationship changes that help the  The highest level is self-actualization, the need for
healing process: beauty, truth, and justice
 The orientation phase is directed by the nurse  Maslow used the term self-actualization to describe
and involves engaging the client in treatment, a person who has achieved all the needs of the
providing explanations and information, and hierarchy and has developed his or her fullest
answering questions. potential in life.
 The identification phase begins when the  Carl Rogers: Client-Centered Therapy
client works interdependently with the nurse,  focused on the therapeutic relationship and developed
expresses feelings, and begins to feel stronger. a new method of client-centered therapy.
 In the exploitation phase, the client makes full  Client-centered therapy focuses on the role of the
use of the services offered. client, rather than the therapist, as the key to the
 In the resolution phase, the client no longer healing process.
needs professional services and gives up  Rogers believed that each person experiences the
dependent behavior. The relationship ends. world differently and knows his or her own
 The primary roles she identified are as follows experience best
 Stranger—offering the client the same  The therapist must promote the client’s selfesteem as
acceptance and courtesy that the nurse would much as possible through three central concepts:
to any stranger,  Unconditional positive regard—a
 Resource person—providing specific answers nonjudgmental caring for the client that is not
to questions within a larger context, dependent on the client’s behavior
 Teacher—helping the client to learn formally  Genuineness—realness or congruence between
or informally, what the therapist feels and what he or she says
 Leader—offering direction to the client or to the client
group,  Empathetic understanding—in which the
 Surrogate—serving as a substitute for another therapist senses the feelings and personal
such as a parent or sibling, meaning from the client and communicates this
 Counselor—promoting experiences leading to understanding to the client.
health for the client such as expression of
feelings.
 Four Levels of Anxiety:
 Mild anxiety is a positive state of heightened
awareness and sharpened senses, allowing the
person to learn new behaviors and solve
problems. The person can take in all available
stimuli (perceptual field).
 Moderate anxiety involves a decreased
perceptual field (focus on immediate task
only); the person can learn new behavior or
solve problems only with assistance. Another
person can redirect the person to the task.
Psychiatric Mental Health Nursing
Behavioral Theories  William Glasser: Reality Therapy
 Behaviorism grew out of a reaction to introspection models that  focuses on the person’s behavior and how that
focused on the contents and operations of the mind. behavior keeps him or her from achieving life
 Behaviorism is a school of psychology that focuses on goals.
observable behaviors and what one can do externally to bring  He believed that persons who were unsuccessful
about behavior changes. It does not attempt to explain how the often blamed their problems on other people, the
mind works. system, or the society. He believed they needed to
 Behaviorists believe that behavior can be changed through a find their own identities through responsible
system of rewards and punishments. behavior.
 Ivan Pavlov: Classical Conditioning
 Behavior can be changed through conditioning with Crisis Intervention
external or environmental conditions or stimuli.  Crisis is a turning point in an individual’s life that produces
 Pavlov’s experiment with dogs involved his an overwhelming emotional response.
observation that dogs naturally began to salivate  Crises occur in response to a variety of life situations and
(response) when they saw or smelled food (stimulus). events and fall into three categories:
 B. F. Skinner: Operant Conditioning  Maturational crises, sometimes called
 people learn their behavior from their history or developmental crises, are predictable events in the
past experiences, particularly those experiences that normal course of life, such as leaving home for the
were repeatedly reinforced first time, getting married, having a baby, and
 Behavior modification, which is a method of beginning a career.
attempting to strengthen a desired behavior or  Situational crises are unanticipated or sudden
response by reinforcement, either positive or events that threaten the individual’s integrity,
negative. such as the death of a loved one, loss of a job, and
 Positive reinforcement by giving the client attention physical or emotional illness in the individual or
and positive feedback. family member.
 Negative reinforcement involves removing a  Adventitious crises, sometimes called social crises,
stimulus immediately after a behavior occurs so that include natural disasters like floods, earthquakes, or
the behavior is more likely to occur again hurricanes; war; terrorist attacks; riots; and violent
 Systematic desensitization can be used to help crimes such as rape or murder.
clients overcome irrational fears and anxiety  Directive interventions are designed to assess the person’s
associated with phobias health status and promote problem-solving, such as offering the
person new information, knowledge, or meaning; raising the
Existential Theories person’s self-awareness by providing feedback about behavior;
 Existential theorists believe that behavioral deviations result and directing the person’s behavior by offering suggestions or
when a person is out of touch with himself or herself or the courses of action.
environment.  Supportive interventions aim at dealing with the person’s
 The person who is self-alienated is lonely and sad and feels needs for empathetic understanding, such as encouraging the
helpless. Lack of self-awareness, coupled with harsh self- person to identify and discuss feelings, serving as a sounding
criticism, prevents the person from participating in satisfying board for the person, and affirming the person’s self-worth.
relationships.
 The person is not free to choose from all possible alternatives Individual Psychotherapy
because of self-imposed restrictions.  Individual psychotherapy is a method of bringing about change
 Existential theorists believe that the person is avoiding personal in a person by exploring his or her feelings, attitudes, thinking,
responsibility and is giving in to the wishes or demands of and behavior. It involves a one-to-one relationship between the
others therapist and the client.
 Aaron Beck: Cognitive Therapy  People generally seek this kind of therapy based on their desire
 focuses on immediate thought processing—how a to understand themselves and their behavior, to make personal
person perceives or interprets his or her experience changes, to improve interpersonal relationships, or to get relief
and determines how he or she feels and behaves from emotional pain or unhappiness.
 Albert Ellis: Rational Emotive Therapy
Groups
 identified 11 “irrational beliefs” that people use to  A group is a number of persons who gather in a face-to-face
make themselves unhappy setting to accomplish tasks that require cooperation,
 Ellis also believes that people have “automatic collaboration, or working together.
thoughts” that cause them unhappiness in certain  Group content refers to what is said in the context of the
situations. group, including educational material, feelings and emotions,
 He used the ABC technique to help people identify or discussions of the project to be completed.
these automatic thoughts: A is the activating stimulus  Group process refers to the behavior of the group and its
or event, C is the excessive inappropriate response, individual members, including seating arrangements, tone of
and B is the blank in the person’s mind that he or she voice, who speaks to whom, who is quiet, and so forth.
must fill in by identifying the automatic thought.  Stages of Group Development:
 Viktor Frankl: Logotherapy  The beginning stage of group development, or the
 the search for meaning (logos) is the central theme in initial stage, commences as soon as the group begins
logotherapy. to meet. Members introduce themselves, a leader can
 Counselors and therapists who work with clients in be selected (if not done previously), the group
spirituality and grief counseling often use the purpose is discussed, and rules and expectations for
concepts that Frankl developed. group participation are reviewed. Group members
 Frederick “Fritz” Perls: Gestalt Therapy begin to “check out” one another and the leader as
 emphasizes identifying the person’s feelings and they determine their levels of comfort in the group
thoughts in the here and now. setting.
 Perls believed that self-awareness leads to self-
acceptance and responsibility for one’s own
thoughts and feelings
Psychiatric Mental Health Nursing
 The working stage of group development begins as  Biologically based therapies use substances found
members begin to focus their attention on the purpose in nature, such as herbs, food, and vitamins. Dietary
or task the group is trying to accomplish. This may supplements, herbal products, medicinal teas,
happen relatively quickly in a work group with a aromatherapy, and a variety of diets are included.
specific assigned project, but may take two or three  Manipulative and body-based therapies are based
sessions in a therapy group because members must on manipulation or movement of one or more parts of
develop some level of trust before sharing personal the body, such as therapeutic massage and
feelings or difficult situations. During this phase, chiropractic or osteopathic manipulation.
several group characteristics may be seen. Group  Energy therapies include two types of therapy:
cohesiveness is the degree to which members work biofield therapies, intended to affect energy fields
together cooperatively to accomplish the purpose. that are believed to surround and penetrate the body,
Cohesiveness is a desirable group characteristic and such as therapeutic touch, qi gong, and Reiki, and
is associated with positive group outcomes. bioelectricbased therapies involving the
 The final stage, or termination, of the group occurs unconventional use of electromagnetic fields, such as
before the group disbands. The work of the group is pulsed fields, magnetic fields, and AC or DC fields.
reviewed, with the focus on group accomplishments
or growth of group members or both, depending on
the purpose of the group.
 Group therapy, clients participate in sessions with a
group of people. The members share a common
purpose and are expected to contribute to the group to
benefit others and receive benefit from others in
return
 Psychotherapy group is for members to learn about
their behavior and to make positive changes in their
behavior by interacting and communicating with
others as a member of a group.
 Open groups are ongoing and run
indefinitely, allowing members to join or
leave the group as they need to.
 Closed groups are structured to keep the
same members in the group for a specified
number of sessions.
 Family therapy is a form of group therapy in which
the client and his or her family members participate.
The goals include understanding how family
dynamics contribute to the client’s psychopathology,
mobilizing the family’s inherent strengths and
functional resources, restructuring maladaptive
family behavioral styles, and strengthening family
problem-solving behaviors
 Education group is to provide information to
members on a specific issue—for instance, stress
management, medication management, or
assertiveness training.
 Support groups are organized to help members who
share a common problem to cope with it.
 In self-help group, members share a common
experience, but the group is not a formal or structured
therapy group.

Complementary and Alternative Therapies

 Complementary medicine includes therapies used with
conventional medicine practices (the medical model).
 Alternative medicine includes therapies used in place of
conventional treatment. NCCIH conducts clinical research to
help determine the safety and efficacy of these practices
 Integrative medicine combines conventional medical therapy
and CAM therapies that have scientific evidence supporting
their safety and effectiveness.
 NCCIH studies a wide variety of complementary and
alternative therapies:
 Alternative medical systems include homeopathic
medicine and naturopathic medicine in Western
cultures, and traditional Chinese medicine, which
includes herbal and nutritional therapy, restorative
physical exercises (yoga and Tai chi), meditation,
acupuncture, and remedial massage.
 Mind–body interventions include meditation,
prayer, mental healing, and creative therapies that use
art, music, or dance.