MENTAL HEALTH: CHAPTER 3: PSYCHOSOCIAL THEORIES & THERAPY

Psychoanalytic Theories: Sigmund Freud: 5 Stages of Psychosexual Development: Genital:

- 11 to 13 years - Begins with puberty and the biologic capacity for orgasm; involves the capacity for true intimacy.

Jean Piaget and Cognitive Stages of Development: 4 Stages Of Cognitive Development: Formal Operations:

- 12 to 15 years and beyond - The child learns to think and reason in abstract terms, further develops logical thinking and reasoning, and achieves cognitive maturity.

Psychoanalytic Theories: Sigmund Freud: 5 Stages of Psychosexual Development: Anal:

- 18 to 36 months - Anus and surrounding area are major source of interest. - Voluntary sphincter control (toilet training) is acquired.

Jean Piaget and Cognitive Stages of Development: 4 Stages Of Cognitive Development: Preoperational:

- 2 to 6 years - The child develops the ability to express self with language, understands the meaning of symbolic gestures, and begins to classify objects.

Psychoanalytic Theories: Sigmund Freud: 5 Stages of Psychosexual Development: Phallic/oedipal:

- 3 to 5 years - Genital is the focus of interest, stimulation, and excitement. - Penis is organ of interest for both sexes. - Masturbation is common. - Penis envy (wish to possess penis) is seen in girls; oedipal complex (wish to marry opposite-sex parent and be rid of same-sex parent) is seen in boys and girls. - Resolution of oedipal complex.

Psychoanalytic Theories: Sigmund Freud: 5 Stages of Psychosexual Development: Latency:

- 5 to 11 or 13 years - Sexual drive channeled into socially appropriate activities such as school work and sports. - Formation of the superego. - Final stage of psychosexual development.

Interpersonal Theories: Harry Stack Sullivan: 5 Life Stages: Juvenile:

- 5 to 8 years - Shift to the syntaxic mode begins (thinking about self and others based on analysis of experiences in a variety of situations). - Opportunities for approval and acceptance of others. - Learn to negotiate own needs. - Severe anxiety may result in a need to control or in restrictive, prejudicial attitudes. - Move to genuine intimacy with friend of the same sex.

Jean Piaget and Cognitive Stages of Development: 4 Stages Of Cognitive Development: Concrete Operations:

- 6 to 12 years - The child begins to apply logic to thinking, understands spatiality and reversibility, and is increasingly social and able to apply rules; however, thinking is still concrete.

Interpersonal Theories: Harry Stack Sullivan: 5 Life Stages: Preadolescence:

- 8 to 12 years - Move to genuine intimacy with friend of the same sex. - Move away from family as source of satisfaction in relationships. - Major shift to syntaxic mode occurs. - Capacity for attachment, love, and collaboration emerges or fails to develop. - Lust is added to interpersonal equation.

Crisis:

- A crisis is a turning point in an individual's life that produces an overwhelming emotional response. - Individuals experience a crisis when they confront some life circumstance or stressor that they cannot effectively manage through use of their customary coping skills. - Note that not all events that result in crisis are "negative" in nature. - Events like marriage, retirement, and childbirth are often desirable for the individual but may still present overwhelming challenges. - Aguilera identified three factors that influence whether or not an individual experiences a crisis: the individual's perception of the event, the availability of emotional supports, and the availability of adequate coping mechanisms. - When the person in crisis seeks assistance, these three factors represent a guide for effective intervention. - The person can be assisted to view the event or issue from a different perspective, for example, as an opportunity for growth or change rather than as a threat. - Assisting the person in using existing supports, or helping the individual find new sources of support, can decrease the feelings of being alone or overwhelmed. - Finally, assisting the person in learning new methods of coping will help resolve the current crisis and give him or her new coping skills to use in the future. - Crisis is described as self-limiting; that is, the crisis does not last indefinitely but usually exists for 4 to 6 weeks. - At the end of that time, the crisis is resolved in one of three ways. - In the first two, the person either returns to his or her precrisis level of functioning or begins to function at a higher level; both are positive outcomes for the individual. - The third resolution is that the person's functioning stabilizes at a level lower than precrisis functioning, which is a negative outcome for the individual. - Positive outcomes are more likely when the problem (crisis response and precipitating event or issue) is clearly and thoroughly defined. Likewise, early intervention is associated with better outcomes. - Persons experiencing a crisis are usually distressed and likely to seek help for their distress. - They are ready to learn and even eager to try new coping skills as a way to relieve their distress. - This is an ideal time for intervention that is likely to be successful.

Stages Of Group Development:

- A group may be established to serve a particular purpose in a specified period such as a work group to complete an assigned project or a therapy group that meets with the same members to explore ways to deal with depression. - These groups develop in observable stages. In the pregroup stages, members are selected, the purpose or work of the group is identified, and group structure is addressed. - Group structure includes where and how often the group will meet, identification of a group leader, and the rules of the group—for example, whether individuals can join the group after it begins, how to handle absences, and expectations for group members. - The beginning stage of group development, or the initial stage, commences as soon as the group begins to meet. - Members introduce themselves, a leader can be selected (if not done previously), the group purpose is discussed, and rules and expectations for group participation are reviewed. - Group members begin to "check out" one another and the leader as they determine their levels of comfort in the group setting. - The working stage of group development begins as members begin to focus their attention on the purpose or task the group is trying to accomplish. - This may happen relatively quickly in a work group with a specific assigned project but may take two or three sessions in a therapy group because members must develop some level of trust before sharing personal feelings or difficult situations. - During this phase, several group characteristics may be seen. - Group cohesiveness is the degree to which members work together cooperatively to accomplish the purpose. - Cohesiveness is a desirable group characteristic and is associated with positive group outcomes. - It is evidenced when members value one another's contributions to the group; members think of themselves as "we" and share responsibility for the work of the group. - When a group is cohesive, members feel free to express all opinions, positive and negative, with little fear of rejection or retribution. - If a group is "overly cohesive," in that uniformity and agreement become the group's implicit goals, there may be a negative effect on the group outcome. - In a therapy group, members do not give one another needed feedback if the group is overly cohesive. - In a work group, critical thinking and creative problem-solving are unlikely, which may make the work of the group less meaningful. - Some groups exhibit competition, or rivalry, among group members. - This may positively affect the outcome of the group if the competition leads to compromise, improved group performance, and growth for individual members. - Many times, however, competition can be destructive for the group; when conflicts are not resolved, members become hostile, or the group's energy is diverted from accomplishing its purpose to bickering and power struggles. - The final stage, or termination, of the group occurs before the group disbands. - The work of the group is reviewed, with the focus on group accomplishments or growth of group members or both, depending on the purpose of the group. - Observing the stages of group development in groups that are ongoing is difficult with members joining and leaving the group at various times. - Rather, the group involvement of new members as they join the group evolves as they feel accepted by the group, take a more active role, and join in the work of the group. - An example of this type of group would be Alcoholics Anonymous, a self-help group with stated purposes. Members may attend Alcoholics Anonymous meetings as often or infrequently as they choose; group cohesiveness or competition can still be observed in ongoing groups.

Humanistic Theories: Abraham Maslow: Hierarchy of Needs:

- Abraham Maslow (1921-1970) was an American psychologist who studied the needs or motivations of the individual. - He differed from previous theorists in that he focused on the total person, not just on one facet of the person, and emphasized health instead of simply illness and problems. - Formulated the hierarchy of needs, in which he used a pyramid to arrange and illustrate the basic drives or needs that motivate people. - The most basic needs—the physiologic needs of food, water, sleep, shelter, sexual expression, and freedom from pain—must be met first. - The second level involves safety and security needs, which include protection, security, and freedom from harm or threatened deprivation. - The third level is love and belonging needs, which include enduring intimacy, friendship, and acceptance. - The fourth level involves esteem needs, which include the need for self-respect and esteem from others. - The highest level is self-actualization, the need for beauty, truth, and justice. - Maslow hypothesized that the basic needs at the bottom of the pyramid would dominate the person's behavior until those needs were met, at which time the next level of needs would become dominant. - For example, if needs for food and shelter are not met, they become the overriding concern in life; the hungry person risks danger and social ostracism to find food. - Maslow used the term self-actualization to describe a person who has achieved all the needs of the hierarchy and has developed his or her fullest potential in life. - Few people ever become fully self-actualized. - Maslow's theory explains individual differences in terms of a person's motivation, which is not necessarily stable throughout life. - Traumatic life circumstances or compromised health can cause a person to regress to a lower level of motivation. - For example, if a 35-year-old woman who is functioning at the "love and belonging" level discovers she has cancer, she may regress to the "safety" level to undergo treatment for the cancer and preserve her own health. - This theory helps nurses understand how clients' motivations and behaviors change during life crises

Ego Defense Mechanisms: Introjection:

- Accepting another person's attitudes, beliefs, and values as one's own - Person who dislikes guns becomes an avid hunter, just like a best friend

Ego Defense Mechanisms: Reaction Formation:

- Acting the opposite of what one thinks or feels - Woman who never wanted to have children becomes a supermom - Person who despises the boss tells everyone what a great boss she is

Crisis Intervention: Supportive Interventions:

- Aim at dealing with the person's needs for empathetic understanding, such as encouraging the person to identify and discuss feelings, serving as a sounding board for the person, and affirming the person's self-worth. - Techniques and strategies that include a balance of these different types of intervention are the most effective.

Psychoanalytic Theories: Sigmund Freud: Free Association:

- Another method used to gain access to subconscious thoughts and feelings is free association, in which the therapist tries to uncover the client's true thoughts and feelings by saying a word and asking the client to respond quickly with the first thing that comes to mind. - Freud believed that such quick responses would be likely to uncover subconscious or repressed thoughts or feelings.

Crisis Intervention: Directive Intervention:

- Are designed to assess the person's health status and promote problem-solving, such as offering the person new information, knowledge, or meaning; raising the person's self-awareness by providing feedback about behavior; and directing the person's behavior by offering suggestions or courses of action.

Crises occur in response to a variety of life situations and events and fall into three categories: Situational Crisis:

- Are unanticipated or sudden events that threaten the individual's integrity, such as the death of a loved one, loss of a job, and physical or emotional illness in the individual or family member.

Interpersonal Theories: Harry Stack Sullivan: 3 Developmental Cognitive Modes: The Parataxic Mode:

- Begins in early childhood as the child begins to connect experiences in sequence. - The child may not make logical sense of the experiences and may see them as coincidence or chance events. - The child seeks to relieve anxiety by repeating familiar experiences, though he or she may not understand what he or she is doing. - Sullivan explained paranoid ideas and slips of the tongue as a person operating in the parataxic mode.

Peplau's Stages and Tasks of Relationships: Identification Phase:

- Begins when the client works interdependently with the nurse, expresses feelings, and begins to feel stronger. - Patient expresses feelings. - Interdependent work with the nurse occurs. - Roles of both patient and nurse are clarified - Patient makes full use of available services.

Psychoanalytic Theories: Sigmund Freud: 5 Stages of Psychosexual Development: Oral:

- Birth to 18 months - Major site of tension and gratification is the mouth, lips, and tongue; includes biting and sucking activities. - Id is present at birth. - Ego develops gradually from rudimentary structure present at birth.

Jean Piaget and Cognitive Stages of Development: 4 Stages Of Cognitive Development: Sensorimotor:

- Birth to 2 years - The child develops a sense of self as separate from the environment and the concept of object permanence, that is, tangible objects do not cease to exist just because they are out of sight. He or she begins to form mental images.

Interpersonal Theories: Harry Stack Sullivan: 5 Life Stages: Infancy:

- Birth to onset of language - Primary need exists for bodily contact and tenderness. - Prototaxic mode dominates (no relation between experiences). - Primary zones are oral and anal. - If needs are met, infant has sense of well-being; unmet needs lead to dread and anxiety. - Parents are viewed as source of praise and acceptance. - Shift to parataxic mode; experiences are connected in sequence to each other.

Hildegard Peplau: 4 Levels Of Anxiety: 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 him or herself to injury. - Perceptual field reduced to focus on self - Cannot process environmental stimuli - Distorted perceptions - Loss of rational thought - Personality disorganization - Doesn't recognize danger - Possibly suicidal - Delusions or hallucination possible - Can't communicate verbally - Either cannot sit (may bolt and run) or is totally mute and immobile

Crisis Intervention: Caplan's Stages Of Crisis:

- Caplan (1964) identified the stages of crisis: (1) the person is exposed to a stressor, experiences anxiety, and tries to cope in a customary manner; (2) anxiety increases when customary coping skills are ineffective; (3) the person makes all possible efforts to deal with the stressor, including attempts at new methods of coping; (4) when coping attempts fail, the person experiences disequilibrium and significant distress.

Humanistic Theories: Carl Rogers: Client-Centered Therapy:

- Carl Rogers (1902-1987) was a humanistic American psychologist who focused on the therapeutic relationship and developed a new method of client-centered therapy. - Rogers was one of the first to use the term client rather than patient. Client-centered therapy focuses on the role of the client, rather than the therapist, as the key to the healing process. - Rogers believed that each person experiences the world differently and knows his or her own experience best - According to Rogers, clients do "the work of healing," and within a supportive and nurturing client-therapist relationship, clients can cure themselves. - Clients are in the best position to know their own experiences and make sense of them, to regain their self-esteem, and to progress toward self-actualization. - The therapist takes a person-centered approach, a supportive role, rather than a directive or expert role, because Rogers viewed the client as the expert on his or her life. - The therapist must promote the client's self-esteem as much as possible through three central concepts: •Unconditional positive regard—a nonjudgmental caring for the client that is not dependent on the client's behavior •Genuineness—realness or congruence between what the therapist feels and what he or she says to the client •Empathetic understanding—in which the therapist senses the feelings and personal meaning from the client and communicates this understanding to the client - Unconditional positive regard promotes the client's self-esteem and decreases his or her need for defensive behavior. - As the client's self-acceptance grows, the natural self-actualization process can continue. - Rogers also believed that the basic nature of humans is to become self-actualized, or to move toward self-improvement and constructive change. - We are all born with a positive self-regard and a natural inclination to become self-actualized. - If relationships with others are supportive and nurturing, the person retains feelings of self-worth and progresses toward self-actualization, which is healthy. - If the person encounters repeated conflicts with others or is in nonsupportive relationships, he or she loses self-esteem, becomes defensive, and is no longer inclined toward self-actualization; this is not healthy.

Interpersonal Theories: Harry Stack Sullivan: 3 Developmental Cognitive Modes: The Prototaxic Mode:

- Characteristic of infancy and childhood, involves brief, unconnected experiences that have no relationship to one another. - Adults with schizophrenia exhibit persistent prototaxic experiences

Behavioral Theories: B.F. Skinner: Systematic Desensitization:

- Conditioned responses, such as fears or phobias, can be treated with behavioral techniques. - Systematic desensitization can be used to help clients overcome irrational fears and anxiety associated with phobias. - The client is asked to make a list of situations involving the phobic object, from the least to the most anxiety-provoking. - The client learns and practices relaxation techniques to decrease and manage anxiety. - He or she is then exposed to the least anxiety-provoking situation and uses the relaxation techniques to manage the resulting anxiety. - The client is gradually exposed to more and more anxiety-provoking situations until he or she can manage the most anxiety-provoking situation. - Behavioral techniques can be used for a variety of problems. - In the treatment of anorexia nervosa, the goal is weight gain. - A behavioral contract between the client and the therapist or physician is initiated when treatment begins. - Initially, the client has little unsupervised time and is restricted to the hospital unit. - The contract may specify that if the client gains a certain amount of weight, such as 0.2 kg/day, in return, he or she will get increased unsupervised time or time off the unit as long as the weight gain progresses. - When working with children with attention-deficit/hyperactivity disorder, goals include task completion for homework, hygiene tasks, turn-taking when talking, and so forth. - The child is given a "star" or sticker when tasks are completed. Upon reaching a specified numbers of stars, the child receives a reward.

Ego Defense Mechanisms: Suppression:

- Conscious exclusion of unacceptable thoughts and feelings from conscious awareness - Student decides not to think about a parent's illness to study for a test - Woman tells a friend she cannot think about her son's death right now

Ego Defense Mechanisms: Dissociation:

- Dealing with emotional conflict by a temporary alteration in consciousness or identity - Amnesia that prevents recall of yesterday's auto accident - Adult remembers nothing of childhood sexual abuse

Developmental Theories: Erik Erikson and Psychosocial Stages of Development:

- Erik Erikson (1902-1994) was a German-born psychoanalyst, who extended Freud's work on personality development across the life span while focusing on social and psychological development in the life stages. - In 1950, Erikson published Childhood and Society, in which he described eight psychosocial stages of development. - In each stage, the person must complete a life task that is essential to his or her well-being and mental health. - These tasks allow the person to achieve life's virtues: hope, purpose, fidelity, love, caring, and wisdom - Erikson's eight psychosocial stages of development are still used in a variety of disciplines. - In his view, psychosocial growth occurs in sequential phases and each stage is dependent on completion of the previous stage and life task. - For example, in the infant stage (birth to 18 months), trust versus mistrust, the infant must learn to develop basic trust (the positive outcome) such as that he or she will be fed and taken care of. - The formation of trust is essential; mistrust, the negative outcome of this stage, will impair the person's development throughout his or her life.

Ego Defense Mechanisms: Repression:

- Excluding emotionally painful or anxiety-provoking thoughts and feelings from conscious awareness - Woman has no memory of the mugging she suffered yesterday - Woman has no memory before age 7, when she was removed from abusive parents

Ego Defense Mechanisms: Rationalization:

- Excusing own behavior to avoid guilt, responsibility, conflict, anxiety, or loss of self-respect - Student blames failure on teacher being mean - Man says he beats his wife because she does not listen to him

Ego Defense Mechanisms: Undoing:

- Exhibiting acceptable behavior to make up for or negate unacceptable behavior - Person who cheats on a spouse brings the spouse a bouquet of roses - Man who is ruthless in business donates large amounts of money to charity

Existential Theories:

- Existential theorists believe that behavioral deviations result when a person is out of touch with him or herself or the environment. - The person who is self-alienated is lonely and sad and feels helpless. - Lack of self-awareness, coupled with harsh self-criticism, prevents the person from participating in satisfying relationships. - The person is not free to choose from all possible alternatives because of self-imposed restrictions. - Existential theorists believe that the person is avoiding personal responsibility and is giving in to the wishes or demands of others. - All existential therapies have the goal of helping the person discover an authentic sense of self. - They emphasize personal responsibility for oneself, feelings, behaviors, and choices. - These therapies encourage the person to live fully in the present and to look forward to the future. - Carl Rogers is sometimes grouped with existential therapists.

Ego Defense Mechanisms: Conversion:

- Expression of an emotional conflict through the development of a physical symptom, usually sensorimotor in nature - Teenager forbidden to see X-rated movies is tempted to do so by friends and develops blindness, and the teenager is unconcerned about the loss of sight

Ego Defense Mechanisms: Denial:

- Failure to acknowledge an unbearable condition; failure to admit the reality of a situation or how one enables the problem to continue - Diabetic person eating chocolate candy - Spending money freely when broke - Waiting 3 days to seek help for severe abdominal pain

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.

Psychoanalytic Theories: Sigmund Freud: 5 Stages of Psychosexual Development:

- Freud based his theory of childhood development on the belief that sexual energy, termed libido, was the driving force of human behavior. - He proposed that children progress through five stages of psychosexual development: oral (birth to 18 months), anal (18-36 months), phallic/oedipal (3-5 years), latency (5-11 years or 13 years), and genital (11-13 years). - Psychopathology results when a person has difficulty making the transition from one stage to the next or when a person remains stalled at a particular stage or regresses to an earlier stage. - Freud's open discussion of sexual impulses, particularly in children, was considered shocking for his time

Psychoanalytic Theories: Sigmund Freud: Dream Analysis:

- Freud believed that a person's dreams reflect his or her subconscious and have significant meaning, though sometimes the meaning is hidden or symbolic. - Dream analysis, a primary technique used in psychoanalysis, involves discussing a client's dreams to discover their true meaning and significance. - For example, a client might report having recurrent frightening dreams about snakes chasing her. - Freud's interpretation might be that the woman fears intimacy with men; he would view the snake as a phallic symbol, representing the penis.

Psychoanalytic Theories: Sigmund Freud: Behavior Motivated by Subconscious Thoughts and Feelings:

- Freud believed that the human personality functions at three levels of awareness: conscious, preconscious, and unconscious - Conscious refers to the perceptions, thoughts, and emotions that exist in the person's awareness, such as being aware of happy feelings or thinking about a loved one. - Preconscious thoughts and emotions are not currently in the person's awareness, but he or she can recall them with some effort—for example, an adult remembering what he or she did, thought, or felt as a child. - The unconscious is the realm of thoughts and feelings that motivates a person even though he or she is totally unaware of them. - This realm includes most defense mechanisms and some instinctual drives or motivations. - According to Freud's theories, the person represses the memory of traumatic events that are too painful to remember into the unconscious. - Freud believed that much of what we do and say is motivated by our subconscious thoughts or feelings (those in the preconscious or unconscious level of awareness). - A Freudian slip is a term we commonly use to describe slips of the tongue—for example, saying "You look portly today" to an overweight friend instead of "You look pretty today." - Freud believed that these slips are not accidents or coincidences, but rather are indications of subconscious feelings or thoughts that accidentally emerge in casual day-to-day conversation.

Psychoanalytic Theories: Sigmund Freud: Ego Defense Mechanisms:

- Freud believed that the self, or ego, uses ego defense mechanisms, which are methods of attempting to protect the self and cope with basic drives or emotionally painful thoughts, feelings, or events. - For example, a person who has been diagnosed with cancer and told he has 6 months to live but refuses to talk about his illness is using the defense mechanism of denial, or refusal to accept the reality of the situation. - If a person dying of cancer exhibits continuously cheerful behavior, he could be using the defense mechanism of reaction formation to protect his emotions. - Most defense mechanisms operate at the unconscious level of awareness, so people are not aware of what they are doing and often need help to see the reality.

Group Leadership:

- Groups often have an identified or formal leader—someone designated to lead the group. - In therapy groups and education groups, a formal leader is usually identified based on his or her education, qualifications, and experience. - Some work groups have formal leaders appointed in advance, while other work groups select a leader at the initial meeting. - Support groups and self-help groups usually do not have identified formal leaders; all members are seen as equals. - An informal leader may emerge from a "leaderless" group or from a group that has an identified formal leader. - Informal leaders are generally members recognized by others as having the knowledge, experience, or characteristics that members admire and value. - Effective group leaders focus on group process as well as on group content. - Tasks of the group leader include giving feedback and suggestions; encouraging participation from all members (eliciting responses from quiet members and placing limits on members who may monopolize the group's time); clarifying thoughts, feelings, and ideas; summarizing progress and accomplishments; and facilitating progress through the stages of group development.

Interpersonal Theories: Harry Stack Sullivan: Interpersonal Relationships and Milieu Therapy:

- Harry Stack Sullivan (1892-1949) was an American psychiatrist who extended the theory of personality development to include the significance of interpersonal relationships. - Sullivan believed that one's personality involves more than individual characteristics, particularly how one interacts with others. - He thought that inadequate or nonsatisfying relationships produce anxiety, which he saw as the basis for all emotional problems. - The importance and significance of interpersonal relationships in one's life is probably Sullivan's greatest contribution to the field of mental health.

Hildegard Peplau: Therapeutic Nurse-Patient Relationships:

- Hildegard Peplau was a nursing theorist and clinician who built on Sullivan's interpersonal theories and also saw the role of the nurse as a participant observer. - Peplau developed the concept of the therapeutic nurse-patient relationship, which includes four phases: orientation, identification, exploitation, and resolution

Psychoanalytic Theories: Sigmund Freud: Personality Components:

- Id, Ego, and Superego. - 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, is the balancing or mediating force between the id and the superego. - 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 the id with the stringent rules of the superego.

Ego Defense Mechanisms: Fixation:

- Immobilization of a portion of the personality resulting from unsuccessful completion of tasks in a developmental stage - Never learning to delay gratification - Lack of a clear sense of identity as an adult

Hildegard Peplau: 4 Levels Of Anxiety: 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 - Selectively attentive - Perceptual field limited to the immediate task - Can be redirected - Cannot connect thoughts or events independently - Muscle tension - Diaphoresis - Pounding pulse - Headache - Dry mouth - Higher voice pitch - Increased rate of speech - Gastrointestinal upset - Frequent urination - Increased automatisms (nervous mannerisms)

Hildegard Peplau: 4 Levels Of Anxiety: Severe Anxiety:

- Involves feelings of dread or terror. - The person cannot be redirected to a task; he or she focuses only on scattered details and has physiologic symptoms of tachycardia, diaphoresis, and chest pain. - A person with severe anxiety may go to an emergency department, believing he or she is having a heart attack - Perceptual field reduced to one detail or scattered details - Cannot complete tasks - Cannot solve problems or learn effectively - Behavior geared toward anxiety relief and is usually ineffective - Feels awe, dread, or horror - Doesn't respond to redirection - Severe headache - Nausea, vomiting, diarrhea - Trembling - Rigid stance - Vertigo - Pale - Tachycardia - Chest pain - Crying - Ritualistic (purposeless, repetitive) behavior

Groups:

- Is a number of persons who gather in a face-to-face setting to accomplish tasks that require cooperation, collaboration, or working together. - Each person in a group is in a position to influence and to be influenced by other group members. - Group content refers to what is said in the context of the group, including educational material, feelings and emotions, or discussions of the project to be completed. - Group process refers to the behavior of the group and its individual members, including seating arrangements, tone of voice, who speaks to whom, who is quiet, and so forth. - Content and process occur continuously throughout the life of the group.

Hildegard Peplau: 4 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). - Sharpened senses - Increased motivation - Alert - Enlarged perceptual field - Can solve problems - Learning is effective - Restless - Gastrointestinal "butterflies" - Sleepless - Irritable - Hypersensitive to noise

Behaviorism:

- Is a school of psychology that focuses on observable behaviors and what one can do externally to bring about behavior changes. - It does not attempt to explain how the mind works.

Peplau's Stages and Tasks of Relationships: Orientation Phase:

- Is directed by the nurse and involves engaging the client in treatment, providing explanations and information, and answering questions. - Patient's problems and needs are clarified. - Patient asks questions. - Hospital routines and expectations are explained. - Patient harnesses energy toward meeting problems. - Patient's full participation is elicited. - Patient responds to persons he or she perceives as helpful. - Patient feels stronger.

Jean Piaget and Cognitive Stages of Development:

- Jean Piaget (1896-1980) explored how intelligence and cognitive functioning develop in children. - He believed that human intelligence progresses through a series of stages based on age, with the child at each successive stage demonstrating a higher level of functioning than at previous stages. - In his schema, Piaget strongly believed that biologic changes and maturation were responsible for cognitive development. - Piaget's four stages of cognitive development are as follows: Sensorimotor, preoperational, concrete operations, formal operations - Piaget's theory suggests that individuals reach cognitive maturity by middle to late adolescence. - Some critics of Piaget believe that cognitive development is less rigid and more individualized than his theory suggests. - Piaget's theory is useful when working with children. - The nurse may better understand what the child means if the nurse is aware of his or her level of cognitive development. - Also, teaching for children is often structured with their cognitive development in mind.

Behavioral Theories: Ivan Pavlov: Classical Conditioning:

- Laboratory experiments with dogs provided the basis for the development of Ivan Pavlov's theory of classical conditioning: Behavior can be changed through conditioning with external or environmental conditions or stimuli. - Pavlov's experiment with dogs involved his observation that dogs naturally began to salivate (response) when they saw or smelled food (stimulus). - Pavlov set out to change this salivating response or behavior through conditioning. - He would ring a bell (new stimulus), then produce the food, and the dogs would salivate (the desired response). - Pavlov repeated this ringing of the bell along with the presentation of food many times. - Eventually, he could ring the bell, and the dogs would salivate without seeing or smelling food. - The dogs had been "conditioned," or had learned a new response, to salivate when they heard the bell. - Their behavior had been modified through classical conditioning, or a conditioned response.

Existential Theories: Cognitive Therapy:

- Many existential therapists use cognitive therapy, which focuses on immediate thought processing—how a person perceives or interprets his or her experience and determines how he or she feels and behaves. - For example, if a person interprets a situation as dangerous, he or she experiences anxiety and tries to escape. - Basic emotions of sadness, elation, anxiety, and anger are reactions to perceptions of loss, gain, danger, and wrongdoing by others - Aaron Beck is credited with pioneering cognitive therapy in persons with depression.

Ego Defense Mechanisms: Identification:

- Modeling actions and opinions of influential others while searching for identity, or aspiring to reach a personal, social, or occupational goal - Nursing student becoming a critical care nurse because this is the specialty of an instructor she admires

Ego Defense Mechanisms: Regression:

- Moving back to a previous developmental stage to feel safe or have needs met - A 5-year-old asks for a bottle when new baby brother is being fed - Man pouts like a 4-year-old if he is not the center of his girlfriend's attention

Behavioral Theories: B.F. Skinner: Operant Conditioning:

- One of the most influential behaviorists was B.F. Skinner (1904-1990), an American psychologist. He developed the theory of operant conditioning, which says people learn their behaviors from their history or past experiences, particularly those experiences that were repeatedly reinforced. - Although some criticize his theories for not considering the role that thoughts, feelings, or needs play in motivating behavior, his work has provided several important principles still used today. - Skinner did not deny the existence of feelings and needs in motivation; however, he viewed behavior as only that which could be observed, studied, and learned or unlearned. - He maintained that if the behavior could be changed, then so could the accompanying thoughts or feelings. - Changing the behavior was what was important.

Interpersonal Theories: Harry Stack Sullivan: 5 Life Stages: Childhood:

- Onset of language to 5 years - Primary zone is anal. - Gratification leads to positive self-esteem. - Moderate anxiety leads to uncertainty and insecurity; severe anxiety results in self-defeating patterns of behavior. - Shift to the syntaxic mode begins (thinking about self and others based on analysis of experiences in a variety of situations).

Ego Defense Mechanisms: Compensation:

- Overachievement in one area to offset real or perceived deficiencies in another area - Napoleon complex: diminutive man becoming emperor - Nurse with low self-esteem working double shifts so that her supervisor will like her

Ego Defense Mechanisms: Resistance:

- Overt or covert antagonism toward remembering or processing anxiety-producing information - Nurse is too busy with tasks to spend time talking to a dying patient. - Person attends court-ordered treatment for alcoholism but refuses to participate

B. F. Skinner: Operant Conditioning:

- Positive reinforcement: increased frequency of behavior - Removal of negative reinforcers: increased frequency of behavior - Continuous reinforcement: fastest way to increase behavior; behavior does not last long after reward ceases - Random intermittent reinforcement increases behavior more slowly but has a longer lasting effect

Current Psychoanalytic Practice:

- Psychoanalysis focuses on discovering the causes of the client's unconscious and repressed thoughts, feelings, and conflicts believed to cause anxiety and on helping the client gain insight into and resolve these conflicts and anxieties. - The analytic therapist uses the techniques of free association, dream analysis, and interpretation of behavior. - Psychoanalysis is still practiced today but on a limited basis. - Analysis is lengthy, with weekly or more frequent sessions for several years. - It is costly and not covered by conventional health insurance programs; thus, it has become known as "therapy for the wealthy."

Interpersonal Theories: Harry Stack Sullivan: 5 Life Stages: Adolescence:

- Puberty to adulthood - Need for special sharing relationship shifts to the opposite sex. - New opportunities for social experimentation lead to the consolidation of self-esteem or self-ridicule. - If the self-system is intact, areas of concern expand to include values, ideals, career decisions, and social concerns.

TREATMENT MODALITIES: Benefits of Community Mental Health Treatment:

- Recent changes in health care and reimbursement have affected mental health treatment because they have all areas of medicine, nursing, and related health disciplines - Inpatient treatment is often the last, rather than the first, mode of treatment for mental illness. - Current treatment reflects the belief that it is more beneficial and certainly more cost-effective for clients to remain in the community and receive outpatient treatment whenever possible. - The client can often continue to work and can stay connected to family, friends, and other support systems while participating in therapy. - Outpatient therapy also takes into account that a person's personality or behavior patterns, such as coping skills, styles of communication, and level of self-esteem, gradually develop over the course of a lifetime and cannot be changed in a relatively short inpatient course of treatment. - Hospital admission is indicated when the person is severely depressed and suicidal, severely psychotic, experiencing alcohol or drug withdrawal, or exhibiting behaviors that require close supervision in a safe, supportive environment. .

Ego Defense Mechanisms: Substitution:

- Replacing the desired gratification with one that is more readily available - Woman who would like to have her own children opens a day care center

Group Roles:

- Roles are the parts that members play within the group. - Not all members are aware of their "role behavior," and changes in members' behavior may be a topic that the group will need to address. - Some roles facilitate the work of the group, while others can negatively affect the process or outcome of the group. - Growth-producing roles include the information seeker, opinion seeker, information giver, energizer, coordinator, harmonizer, encourager, and elaborator. - Growth-inhibiting roles include the monopolizer, aggressor, dominator, critic, recognition seeker, and passive follower.

Ego Defense Mechanisms: Intellectualization:

- Separation of the emotions of a painful event or situation from the facts involved; acknowledging the facts but not the emotions - Person shows no emotional expression when discussing serious car accident

Crises occur in response to a variety of life situations and events and fall into three categories: Maturational Crisis:

- Sometimes called developmental crises, are predictable events in the normal course of life, such as leaving home for the first time, getting married, having a baby, and beginning a career.

Crises occur in response to a variety of life situations and events and fall into three categories: Adventitious Crisis:

- Sometimes called social crises, include natural disasters like floods, earthquakes, or hurricanes; war; terrorist attacks; riots; and violent crimes such as rape or murder.

Hildegard Peplau: Roles of the Nurses in the Therapeutic Relationship

- Stranger: offering the client the same acceptance and courtesy that the nurse would to any stranger - Resource Person: providing specific answers to questions within a larger context - Teacher: helping the client learn either formally or informally - Leader: offering direction to the client or group - Surrogate: serving as a substitute for another, such as a parent or sibling - Counselor: promoting experiences leading to health for the client, such as expression of feelings - Peplau also believed that the nurse could take on many other roles, including consultant, tutor, safety agent, mediator, administrator, observer, and researcher. - These were not defined in detail but were "left to the intelligence and imagination of the readers

Ego Defense Mechanisms: Sublimation:

- Substituting a socially acceptable activity for an impulse that is unacceptable - Person who has quit smoking sucks on hard candy when the urge to smoke arises - Person goes for a 15-minute walk when tempted to eat junk food

Interpersonal Theories: Harry Stack Sullivan: Therapeutic Community or Milieu:

- Sullivan envisioned the goal of treatment as the establishment of satisfying interpersonal relationships. - The therapist provides a corrective interpersonal relationship for the client. - Sullivan coined the term participant observer for the therapist's role, meaning that the therapist both participates in and observes the progress of the relationship. - Sullivan is also credited with developing the first therapeutic community or milieu with young men with schizophrenia in 1929. - In the concept of therapeutic community or milieu, the interaction among clients is seen as beneficial, and treatment emphasizes the role of this client-to-client interaction. - Until this time, it was believed that the interaction between the client and the psychiatrist was the one essential component to the client's treatment. - Sullivan and later Jones observed that interactions among clients in a safe, therapeutic setting provided great benefits to clients. - The concept of milieu therapy, originally developed by Sullivan, involved clients' interactions with one another, including practicing interpersonal relationship skills, giving one another feedback about behavior, and working cooperatively as a group to solve day-to-day problems. - Milieu therapy was one of the primary modes of treatment in the acute hospital setting. In today's health care environment, however, inpatient hospital stays are often too short for clients to develop meaningful relationships with one another. - Therefore, the concept of milieu therapy receives little attention. Management of the milieu, or environment, is still a primary role for the nurse in terms of providing safety and protection for all clients and promoting social interaction.

Psychoanalytic Theories: Sigmund Freud:

- The Father of Psychoanalysis - Psychoanalytic theory supports the notion that all human behavior is caused and can be explained (deterministic theory). - Freud believed that repressed (driven from conscious awareness) sexual impulses and desires motivate much human behavior. - He developed his initial ideas and explanations of human behavior from his experiences with a few clients, all of them women who displayed unusual behaviors such as disturbances of sight and speech, inability to eat, and paralysis of limbs. - These symptoms had no diagnosed physiologic basis, so Freud considered them to be "hysterical" or neurotic behaviors of women. - After several years of working with these women, Freud concluded that many of their problems resulted from childhood trauma or failure to complete tasks of psychosexual development. - These women repressed their unmet needs and sexual feelings as well as traumatic events. - The "hysterical" or neurotic behaviors resulted from these unresolved conflicts.

Peplau's Stages and Tasks of Relationships: Exploitation Phase:

- The client makes full use of the services offered - Goals such as going home and returning to work emerge. - Patient's behaviors fluctuate between dependence and independence. - Patient gives up dependent behavior.

Peplau's Stages and Tasks of Relationships: Resolution Phase:

- The client no longer needs professional services and gives up dependent behavior. The relationship ends - Services are no longer needed by patient. - Patient assumes power to meet own needs, set new goals, and so forth.

Cultural Considerations:

- The major psychosocial theorists were white and born in Europe or the United States, as were many of the people whom they treated. - What they considered normal or typical may not apply equally well to people with different racial, ethnic, or cultural backgrounds. - For example, Erikson's developmental stages focus on autonomy and independence for toddlers, but this focus may not be appropriate for people from other cultures in which early individual independence is not a developmental milestone. - Therefore, it is important that the nurse avoids reaching faulty conclusions when working with clients and families from other cultures

Existential Therapies: Rational emotive therapy:

- Therapist: Albert Ellis - Therapeutic process: A cognitive therapy using confrontation of "irrational beliefs" that prevent the individual from accepting responsibility for self and behavior - Albert Ellis, founder of rational emotive therapy, identified 11 "irrational beliefs" that people use to make themselves unhappy. - An example of an irrational belief is, "If I love someone, he or she must love me back just as much." - Ellis claimed that continuing to believe this patently untrue statement will make the person utterly unhappy, but he or she will blame it on the person who does not return his or her love. - Ellis also believes that people have "automatic thoughts" that cause them unhappiness in certain situations. - He used the ABC technique to help people identify these automatic thoughts: A is the activating stimulus or event, C is the excessive inappropriate response, and B is the blank in the person's mind that he or she must fill in by identifying the automatic thought.

Existential Therapies: Gestalt Therapy:

- Therapist: Frederick S. Perls - Therapeutic process: A therapy focusing on the identification of feelings in the here and now, which leads to self-acceptance - Gestalt therapy, founded by Frederick "Fritz" Perls, emphasizes identifying the person's feelings and thoughts in the here and now. - Perls believed that self-awareness leads to self-acceptance and responsibility for one's own thoughts and feelings. - Therapists often use gestalt therapy to increase clients' self-awareness by having them write and read letters, keep journals, and perform other activities designed to put the past to rest and focus on the present.

Existential Therapies: Logotherapy:

- Therapist: Viktor E. Frankl - Therapeutic process: A therapy designed to help individuals assume personal responsibility (the search for meaning [logos] in life is a central theme) - Viktor Frankl based his beliefs in his observations of people in Nazi concentration camps during World War II. - His curiosity about why some survived and others did not led him to conclude that survivors were able to find meaning in their lives even under miserable conditions. - Hence, the search for meaning (logos) is the central theme in logotherapy. - Counselors and therapists who work with clients in spirituality and grief counseling often use the concepts that Frankl developed.

Existential Therapies: Reality Therapy:

- Therapist: William Glasser - Therapeutic process: Therapeutic focus is need for identity through responsible behavior; individuals are challenged to examine ways in which their behavior thwarts their attempts to achieve life goals - William Glasser devised an approach called reality therapy that focuses on the person's behavior and how that behavior keeps him or her from achieving life goals. - He developed this approach while working with persons with delinquent behavior, unsuccessful school performance, and emotional problems. - He believed that persons who were unsuccessful often blamed their problems on other people, the system, or the society. - He believed they needed to find their own identities through responsible behavior. - Reality therapy challenges clients to examine the ways in which their own behavior thwarts their attempts to achieve life goals.

Behavioral Theories: B.F. Skinner: Behavior Modification:

- These behavioral principles of rewarding or reinforcing behaviors are used to help people change their behaviors in a therapy known as behavior modification, which is a method of attempting to strengthen a desired behavior or response by reinforcement, either positive or negative. - For example, if the desired behavior is assertiveness, whenever the client uses assertiveness skills in a communication group, the group leader provides positive reinforcement by giving the client attention and positive feedback. - Negative reinforcement involves removing a stimulus immediately after a behavior occurs so that the behavior is more likely to occur again. - For example, if a client becomes anxious when waiting to talk in a group, he or she may volunteer to speak first to avoid the anxiety. - In a group home setting, operant principles may come into play in a token economy, a way to involve residents in performing activities of daily living. - A chart of desired behaviors, such as getting up on time, taking a shower, and getting dressed, is kept for each resident. - Each day the chart is marked when the desired behavior occurs. - At the end of the day or the week, the resident gets a reward or token for each time each of the desired behaviors occurred. - The resident can redeem the tokens for items such as snacks, TV time, or a relaxed curfew.

Psychoanalytic Theories: Sigmund Freud: Transference and Countertransference:

- Transference occurs when the client displaces onto the therapist attitudes and feelings that the client originally experienced in other relationships - Transference patterns are automatic and unconscious in the therapeutic relationship. - For example, an adolescent female client working with a nurse who is about the same age as the teen's parents might react to the nurse like she reacts to her parents. - She might experience intense feelings of rebellion or make sarcastic remarks; these reactions are actually based on her experiences with her parents, not with the nurse. - Countertransference occurs when the therapist displaces onto the client attitudes or feelings from his or her past. - For example, a female nurse who has teenage children and who is experiencing extreme frustration with an adolescent client may respond by adopting a parental or chastising tone. - The nurse is countertransfering her own attitudes and feelings toward her children onto the client. - Nurses can deal with countertransference by examining their own feelings and responses, using self-awareness, and talking with colleagues.

Ego Defense Mechanisms: Projection:

- Unconscious blaming of unacceptable inclinations or thoughts on an external object - Man who has thought about same-gender sexual relationship but never had one beats a man who is gay - Person with many prejudices loudly identifies others as bigots

Ego Defense Mechanisms: Displacement:

- Ventilation of intense feelings toward persons less threatening than the one who aroused those feelings - Person who is mad at the boss yells at his or her spouse - Child who is harassed by a bully at school mistreats a younger sibling

Developmental Theories: Erik Erikson and Psychosocial Stages of Development: Generativity vs. stagnation (middle adult):

- Virtue: Care - Being creative and productive; establishing the next generation

Developmental Theories: Erik Erikson and Psychosocial Stages of Development: Industry vs. inferiority (school age):

- Virtue: Competence - Emerging confidence in own abilities; taking pleasure in accomplishments

Developmental Theories: Erik Erikson and Psychosocial Stages of Development: Identity vs. role confusion (adolescence):

- Virtue: Fidelity - Formulating a sense of self and belonging

Developmental Theories: Erik Erikson and Psychosocial Stages of Development: Trust vs. mistrust (infant):

- Virtue: Hope - Viewing the world as safe and reliable; relationships as nurturing, stable, and dependable

Developmental Theories: Erik Erikson and Psychosocial Stages of Development: Intimacy vs. isolation (young adult):

- Virtue: Love - Forming adult, loving relationships, and meaningful attachments to others

Developmental Theories: Erik Erikson and Psychosocial Stages of Development: Initiative vs. guilt (preschool):

- Virtue: Purpose - Beginning development of a conscience; learning to manage conflict and anxiety

Developmental Theories: Erik Erikson and Psychosocial Stages of Development: Ego integrity vs. despair (maturity):

- Virtue: Wisdom - Accepting responsibility for oneself and life

Developmental Theories: Erik Erikson and Psychosocial Stages of Development: Autonomy vs. shame and doubt (toddler):

- Virtue: will - Achieving a sense of control and free will

Interpersonal Theories: Harry Stack Sullivan: 3 Developmental Cognitive Modes: The Syntaxic Mode:

- Which begins to appear in school-aged children and becomes more predominant in preadolescence, the person begins to perceive him or herself and the world within the context of the environment and can analyze experiences in a variety of settings. - Maturity may be defined as predominance of the syntaxic mode

Individual Psychotherapy:

- is a method of bringing about change in a person by exploring his or her feelings, attitudes, thinking, and behavior. - It involves a one-to-one relationship between the therapist and the client. - People generally seek this kind of therapy based on their desire to understand themselves and their behavior, to make personal changes, to improve interpersonal relationships, or to get relief from emotional pain or unhappiness. - The relationship between the client and the therapist proceeds through stages similar to those of the nurse-client relationship: introduction, working, and termination. - Cost-containment measures mandated by health maintenance organizations and other insurers may necessitate moving into the working phase rapidly so that the client can get the maximum benefit possible from therapy. - The therapist-client relationship is key to the success of this type of therapy. - Both the client and the therapist must be compatible for therapy to be effective. - Therapists vary in their formal credentials, experience, and model of practice. - Selecting a therapist is extremely important in terms of successful outcomes for the client. - The client must select a therapist whose theoretical beliefs and style of therapy are congruent with the client's needs and expectations of therapy. - The client may also have to try different therapists to find a good match. - A therapist's theoretical beliefs strongly influence his or her style of therapy - For example, a therapist grounded in interpersonal theory emphasizes relationships, while an existential therapist focuses on the client's self-responsibility. - The nurse or other health care provider who is familiar with the client may be in a position to recommend a therapist or a choice of therapists. - He or she may also help the client understand what different therapists have to offer. - The client should select a therapist carefully and ask about the therapist's treatment approach and area of specialization. - State laws regulate the practice and licensing of therapists; thus, from state to state, the qualifications to practice psychotherapy, the requirements for licensure, or even the need for a license can vary. - A few therapists have little or no formal education, credentials, or experience but still practice entirely within the legal limits of their states. - A client can verify a therapist's legal credentials with the state licensing board; state government listings are in the local phone book. - The Better Business Bureau can inform consumers if a particular therapist has been reported to them for investigation. - Calling the local mental health services agency or contacting the primary care provider is another way for a client to check a therapist's credentials and ethical practices.

Behavioral Theories: B.F. Skinner: The following principles of operant conditioning described by Skinner:

1. All behavior is learned. 2. Consequences result from behavior—broadly speaking, reward and punishment. 3. Behavior that is rewarded with reinforcers tends to recur. 4. Positive reinforcers that follow a behavior increase the likelihood that the behavior will recur. 5. Negative reinforcers that are removed after a behavior increase the likelihood that the behavior will recur. 6. Continuous reinforcement (a reward every time the behavior occurs) is the fastest way to increase that behavior, but the behavior will not last long after the reward ceases. 7. Random intermittent reinforcement (an occasional reward for the desired behavior) is slower to produce an increase in behavior, but the behavior continues after the reward ceases.

Which of the following includes the concept of automatic thoughts? A. Cognitive therapy B. Rational emotive therapy C. Logotherapy D. Gestalt therapy

B. Rational emotive therapy - Rationale: Rational emotive therapy focuses on 11 irrational beliefs and automatic thoughts. o Cognitive therapy focuses on immediate thought processing. Logotherapy involves therapy as a search for life with meaning. Gestalt therapy emphasizes self-awareness.

Is the following statement true or false? Abraham Maslow was the first theorist to focus on the client's role:

False - Rationale: Carl Rogers was the first to focus on the client's role in his client-centered therapy.

Is the following statement true or false? Freud identified three stages of psychosexual development.

False - Rationale: Freud identified five stages of psychosexual development: oral, anal, phallic/oedipal, latency, and genital.