NCM 117 

Topic 4 • EGO - is the balancing or mediating force

between the id and the superego.
THERAPEUTIC MODELS AND ITS RELEVANCE
 Executive
TO NURSING
 REALITY PRINCIPLE
Psychoanalytic Theories: Sigmund Freud  Conscious
 Competencies
Sigmund Freud—the father of psychoanalysis.  Decision Maker; Problem- Solving;
• The Father of Psychoanalysis Critical and Creative Thinking
• “ Your behavior today is directly or
indirectly affected by your childhood FREUD’S COMPONENTS OF PERSONLITY
days experiences”.
• Psychoanalytic theory in the late 19th and
early 20th centuries in Vienna.
• Psychoanalytic theory supports the notion
that all human behavior is caused and can
be explained (deterministic theory).
• Their problems resulted from childhood
trauma or failure to complete tasks of
psychosexual development.
• The “hysterical” or neurotic behaviors
resulted from these unresolved conflicts.
• STRUCTURE- Personality Structure

Freud believed that repressed (driven from

conscious awareness) sexual impulses and desires
motivate much human behavior. He developed his Imbalances between Personality Elements
initial ideas and explanations of human behavior
from his experiences with a few clients, all of them ID SUPERGO =MAN
women who displayed unusual behaviors such as
disturbances of sight and speech, inability to eat, M-anic
and paralysis of limbs. These symptoms had no A- nti- Social
diagnosed physiologic basis, so Freud considered N-arcissistic
them to be “hysterical” or neurotic behaviors of
women. ID SUPEREGO = OA

Personality Components: Id, Ego, and O- bsessive Compulsive

Superego A- norexia Nervosa

• ID (4-5MONTHS) EGO = SCHIZOPHRENIA

• ID- is the part of one’s nature that reflects
basic or innate desires such as pleasure- EGO DEFENSE MECHANISM
seeking behavior, aggression, and sexual
impulses. The id seeks instant gratification, Function- To ward off anxiety
causes impulsive unthinking behavior, and  Without defense mechanism, anxiety might
has no regard for rules or social convention. overwhelm and paralyze us and interfere
 Impulsive / Instinctual drive with daily living.
 I want to…..PLEASURE PRINCIPLE 2 Features:
 I want to…..PHYSIOLOGIC NEEDS 1. They operate on an unconscious level
 I want to…..PRIMARY PROCESS ( Except suppression)
The ego represents mature and adaptive 2. They deny, falsify or distort reality to make it
behavior that allows a person to function less threatening.
successfully in the world. Freud believed that
anxiety resulted from the ego’s attempts to balance Pyschosexual Theory of FREUD
the impulsive instincts of the id with the stringent
rules of the superego. LIBIDO- Sexual energy responsible for survival of
human beings.
 SUPEREGO- part of a person’s nature that
reflects moral and ethical concepts, values, 1. ORAL STAGE
and parental and social expectations;
therefore, it is in direct opposition to the id. • 18 MONTHS
• Cry, suck, mouth
 Should not
• EGO at 6 months
 Small voice of GOD
 Child Cries- Fed- Successful
 Set norms, standards and values
 Child Cries- Ignored – Unimportant =
 MORAL PRINCICPLE
NARCISSISTIC
 Conscience
 FIXATION
  Occurs when a person is
stuck in a certain • Human personality functions at three levels
developmental stage of awareness: conscious, preconscious, and
 REGRESSION unconscious
 Returning to an earlier
developmental stage 1. Conscious- refers to the perceptions,
thoughts, and emotions that exist in the
 Infantile Behavior
person’s awareness, such as being aware
of happy feelings or thinking about a loved
2. ANAL STAGE one.
2. Preconscious - thoughts and emotions are
• 18 MONTHS- 3 YEARS OLD not currently in the person’s awareness, but
• SUPEREGO develops he or she can recall them with some effort—
• Toilet Training for example, an adult remembering what he
 Good Mother – Normal or she did, thought, or felt as a child.
 Bad Mother
 Clean, organized, obedient = 3. Unconscious - is the realm of thoughts and
OC-OC (anal retentive) feelings that motivates a person even
 Dirty, disorganized = though he or she is totally unaware of them.
ANTISOCIAL (anal
expulsive) EGO DEFENSE MECHANISM

3. PHALLIC STAGE

• PRESCHOOLER (3-6 YEARS OLD)

• Parent

 OEDIPUS COMPLEX
 Castration Fear
 ELECTRA COMPLEX
 Penis Envy
REPRESSION - UNCONSCIOUS forgetting of an DEFENSE MECHANISM COMMONLY USED IN
anxiety provoking concept. EACH RESPECTIVE DISORDERS
SUPRESSION - CONSCIOUS forgetting of an
 Paranoid-Projection
anxiety provoking situation.
 Phobia-Displacement
IDENTIFICATION - Attempts to resemble or pattern  Amnesia-Dissociation
the personality of a person being admired  Anorexia-Suppression
 Bipolar Disorder-Reaction Formation
INTROJECTION - Acceptance of another values  Bordeline-Splitting
and opinion as one’s own  Schizophrenia-Regression
4. LATENCY STAGE  Substance Abuse-Denial
 Depression-Introjection
• 6 TO 12 YEARS OLD  OC-Undoing
• School  Catatonic-Repression
• Reading, writing, arithmetic
IMPLICATIONS OF PSYCHOANALYTIC
• Ability to care about and relate to others
THEORY FOR NURSING PRACTICE
outside home.
 SUBLIMATION • Freud’s theory offers a comprehensive
 Placing sexual energies toward explanation of complex human processes.
more productive activities.
 SUBSTITUTION • Emphasizes the importance of childhood
 Replace a goal that can’t be experiences on personality development.
achieved for another that is more
realistic. • Nurses can be sources of support and
education for both parents and children to
5. GENITAL STAGE promote a healthy emotional environment.

• Freud’s theory of the unconscious mind is

• 12 YEARS OLD AND ABOVE
particularly valuable as a baseline for
• Developing satisfying sexual and emotional
considering the complexity of human
relationships with members of the opposite behavior.
sex.
• PLANNING LIFE’S GOALS • Considering conscious and unconscious
influences, a nurse can identify and begin to
think about the root causes of patient
BEHAVIOR MOTIVATED BY SUBCONSCIOUS suffering.
THOUGHTS AND FEELINGS
 • Freud emphasized the importance of • Can use these representational skills only to
individual talk sessions characterized by view the world from their own perspective.
attentive listening with a focus on underlying
themes as an important tool of healing in CONCRETE OPERATIONAL STAGE
psychiatric care.
•
Developmental Model: Erick Erikson

Erik Erikson and Psychosocial Stages of

Concrete operations—6 to 12 years:
Development
• Child begins to apply logic to thinking
• Understands spatiality and reversibility
• German-born psychoanalyst
• Increasingly social and able to apply rules;
• Focusing on social and psychological
however, thinking is still concrete.
development in the life stages.
• Cannot yet contemplate or solve abstract
• Childhood and Society,
problems.
• These tasks allow the person to achieve
life’s virtues: hope, purpose, fidelity, love,
caring, and wisdom
FORMAL OPERATIONAL STAGE

• Formal operations—12 to 15 years and

beyond:
• Learns to think and reason in abstract terms
• Develops logical thinking and reasoning
• Achieves cognitive maturity
• Can also reason theoretically.
•

Interpersonal Theory: Harry Stack Sullivan

Cognitive Theory- Jean Piaget Harry Stack Sullivan: Interpersonal

Relationships
Jean Piaget and Cognitive Stages of
Development • American psychiatrist
• Believed that one’s personality involves
• Explored how intelligence and cognitive more than individual characteristics,
functioning develop in children. particularly how one interacts with others.
• He thought that inadequate or non-
• Believed that human intelligence progresses satisfying relationships produce anxiety,
through a series of stages based on age, which he saw as the basis for all emotional
with the child at each successive stage problems
demonstrating a higher level of functioning • Five Life Stages
than at previous stages.
Sullivan’s Life Stages
• Believed that biologic changes and
maturation were responsible for cognitive
development.

SENSORIMOTOR

• Sensorimotor—birth to 2 years:
• 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. Nurse - Patient Relationship: Hildegard Peplau
• He or she begins to form mental images.
Hildegard Peplau: Therapeutic Nurse–Patient
PREOPERATIONAL STAGE
Relationships
• Preoperational—2 to 6 years:
• Hildegard Peplau (1909–1999;
• Develops the ability to express self with
• Nursing theorist and clinician who built on
language
Sullivan’s interpersonal theories
• Begins to classify objects.
• Understands the meaning of symbolic
gestures.
 • Developed the concept of the therapeutic 2. The identification phase begins when the
nurse–patient relationship, client works interdependently with the nurse,
• Four phases: orientation, identification, expresses feelings, and begins to feel stronger.
exploitation, and resolution
3. In the exploitation phase, the client makes
full use of the services offered.
Peplau’s Stages and Tasks of Relationships
4. In the resolution phase, the client no longer
Stages & Tasks needs professional services and gives up
dependent behavior. The relationship ends.
1. Orientation
ROLES OF THE NURSES IN THE THERAPEUTIC
• Patient’s problems and needs are clarified. RELATIONSHIP
• Patient asks questions.
 Stranger—offering the client the same
• Hospital routines and expectations are
acceptance and courtesy that the nurse
explained. would to any stranger
• Patient harnesses energy toward meeting  Resource person—providing specific
problems. answers to questions within a larger context
• Patient’s full participation is elicited.  Teacher—helping the client learn either
formally or informally
2. Identification  Leader—offering direction to the client or
group
• Patient responds to persons he or she  Surrogate—serving as a substitute for
perceives as helpful. another, such as a parent or sibling
• Patient feels stronger.  Counselor—promoting experiences leading
• Patient expresses feelings. to health for the client, such as expression
of feelings
• Interdependent work with the nurse occurs.
• Roles of both patient and nurse are clarified.
FOUR LEVELS OF ANXIETY
3. Exploitation
Mild anxiety
• Patient makes full use of available services.  Is a positive state of heightened awareness
• Goals such as going home and returning to and sharpened senses, allowing the person
work emerge. to learn new behaviors and solve problems.
• Patient’s behaviors fluctuate between  The person can take in all available stimuli
dependence and independence. (perceptual field).

4. Resolution Moderate anxiety

 Involves a decreased perceptual field (focus
on immediate task only);
• Patient gives up dependent behavior.
 The person can learn new behavior or solve
• Services are no longer needed by patient.
problems only with assistance.
• Patient assumes power to meet own needs,  Another person can redirect the person to
set new goals, and so forth. the task.

Severe anxiety
Implications of Interpersonal Theory to Nursing  Involves feelings of dread or terror.
 The person cannot be redirected to a task;
• Her theory is mainly concerned with the he or she focuses only on scattered details
processes by which the nurse helps patients and has
make positive changes in their healthcare  Physiologic symptoms of tachycardia,
status and well-being. diaphoresis, and chest pain.
 A person with severe anxiety may go to an
• Nurses are both participants and observers emergency department, believing he or she
in therapeutic conversations. is having a heart attack.
• She believed it was essential for nurses to Panic anxiety
observe the behavior not only of the patient  Can involve loss of rational thought,
but also of themselves. delusions, hallucinations, and complete
physical immobility and muteness.
 The person may bolt and run aimlessly,
During these phases, the client accomplishes often exposing him or herself to injury.
certain tasks and makes relationship changes that
help the healing process (Peplau, 1952): Cognitive Model: Jean Piaget, Aaron Beck, Albert
Ellis
1. The orientation phase is directed by the
nurse and involves engaging the client in treatment, Cognitive Development: The Stage Theory
providing explanations and information, and
answering questions. • JEAN PIAGET (1896-1980)
• Swiss pyschologist
• Believed child to be active explorer of his
environment ”Child Scientist”.
 • Developed the most influential theories of • The aim of rational-emotive therapy is to
cognitive development to date. remove core irrational beliefs by helping
• Proposed children put new information into people recognize thoughts that are not
schemas through assimilation or accurate, sensible, or useful.
accommodation. • Ellis described negative thinking as a simple
A-B-C process.

STAGE ONE: SENSORIMOTOR

• Birth – 2 years old

• Children up to eight months old do not have
a sense of object permanence – the • Perception influences all thoughts, which in
concept that an object continues to exist turn influence our behaviors.
even when it is out of sight.
• Children learn to primarily through senses • Recognized the role of past experiences on
and play. current beliefs, the focus of rational-emotive
• Develop representational thought-well therapy is on present attitudes, painful
formed mental representations. feelings, and dysfunctional behaviors.
 Mental images of toys or objects
 Usually develops between 18
months and 24 months of age. Cognitive-Behavioral Therapy: Aaron T. Beck
• Generally enter preoperational stage at 2
years. • Was originally trained in psychoanalysis.
• Noticed that people with depression thought
STAGE 2: PREOPERATIONAL differently than people who were not
depressed.
• 2-7 YEARS • Developed Cognitive-Behavioral Therapy
• Further development of mental (CBT) - which is based on both cognitive
representations psychology and behavioral theory.
• Communication progresses • Based to treat a variety of psychiatric
• Children are egocentric self-centered and disorders such as depression, anxiety,
incapable to taking another person’s point of phobias, and pain.
view
 A CHILD MAY COVER THEIR Implications of Cognitive Theories for Nursing
EYES AND BELIEVE THEY ARE
INVISIBLE • Recognizing the interplay between events,
negative thinking, and negative responses
STAGE 3: CONCRETE OPERATIONAL can be beneficial from both a patient-care
standpoint and a personal one.
• Usually occurs between age 7 and 11
• Children begin to develop the concepts of • Help nurses understand their own
conversation and reversibility. responses to a variety of difficult situations.
 CONVERSATION- Child recognizes
that despite a change in physical Example: the anxiety that some students feel
appearance, the amount of an object regarding the:
is constant.
• Psychiatric nursing clinical rotation.
• REVERSIBILITY- Ability of a child to
reverse a physical operation. • Students may overgeneralize (“All
psychiatric patients are dangerous.”) or
Example: A child can see that the amount of water personalize (“My patient doesn’t seem to be
remains constant if you pour it into a different size, better. I’m probably not doing him any
glass, and then pour it back in the original glass. good.”) the situation. The key to effectively
using this approach in clinical situations is to
Children at this stage can think logically, but they challenge the negative thoughts not based
are limited in abstract thinking. on facts then replace them with more
realistic appraisals.

STAGE 4: FORMAL OPERATIONAL

• Fourth and final stage

• Usually occurs around age 12 and beyond
• Children develop the ability to think Stress Model
abstractly about hypothetical concepts.
Selye’s Stress Adaptation Model: Hans Selye

• Hans Hugo Bruno Selye

Rational-Emotive Therapy: Albert Ellis • Most influential endocrinologists
• Effects of stress on the human body
• Albert Ellis (1913–2007) • Born in Vienna on 26th of January 1907.
• Developed rational-emotive therapy in 1955.
 • Selye conducted experiments on rats
injecting then with ovarian “extracts”. He
discovered that this stimulated the adrenal
glands causing atrophy of the thymus and
ulcers and eventually death. This led him to
the conclusion that physiological stress
could cause damage the body’s endocrine
system.
• Discovered that patients with an assortment
of ailments demonstrated lots of similar
symptoms, which he associated with their
effort to cope up with the stress of being ill.
• “General Adaptation Syndrome”
• Selye’s two major books The Stress of
Life (1956) and Stress Without
Distress (1974) were.

Lazaru’s Interactional Model

The Interactional Model of Stress (1982)

• Stress as seen as interaction between

environment and the individual’s perception
of it.
• It suggests that the appraisal of the event
and of your resources for dealing with it are
important in determining the level of stress
experienced.
• In this model, stress depends on the
individual’s appraisal of

A. How threatening an event could be

In this process, individual analyses the

severity of the event
Example: A life event, an exam i.e some may see
an exam as very threatening and some may see it
a challenge, a way to show what they know.

B. Whether or not he/ she is able to cope with it.

• Primary appraisal- is this a threat?

• Secondary appraisal- Have I some control

and can I cope?

• Decreasing the threat- increasing coping

strategy example. Stress management may
help here. Boosting social support can
increase self-efficacy, of course, you can do
it”. Also, increasing information may
decrease if a threat is perceived as a result
of appraisal and you can cope then the
event (threat) is not stressful.

• If you cannot cope and have no resource

then the threat is stressful.