Lesson 2 Outline

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PSYCHIATRIC MODELS

LEARNING OUTCOMES
After working on this module, you should:
1. Identify the factors that protects or puts a person’s mental health at-risk through
the individual, interpersonal, and Cultural factors;
2. Distinguish the basic beliefs and approaches of the following psychosocial theories:
psychoanalytic, developmental, interpersonal, humanistic, behavioral, existential; and
3. Determine the various ego defense mechanisms applied in specific circumstances.

I. Risk and Protective Factors


A. Individual Factors
1. Age, Growth, and Development
- Age and Coping with Illness:
- Age at onset of schizophrenia predicts prognosis.
- Younger onset associated with poorer outcomes
(more negative signs, less effective coping).

- Younger clients may lack experiences of successful independent living and self-sufficiency, impacting
personal identity.
- Age and Expression of Illness:
- Young children with attention-deficit/hyperactivity disorder may struggle to describe
feelings.
- Nurses need to understand a child's language level to manage the disorder effectively.
- Erik Erikson's Psychosocial Development:
- Developmental tasks at each life stage.
- Successful completion of each stage crucial for well-being and mental health.
- Failure to complete tasks in one stage hinders future task completion.
- Example: Infancy stage (birth to 18 months) - "trust versus mistrust," essential for
developing trust in relationships.
- Impact of Age on Psychosocial Development:
- Erikson's stages highlight the importance of age in forming essential life skills.
- Successful completion contributes to positive mental health.
- Failure in early stages may affect later relationships and well-being.

A. Individual Factors
2. Genetics and Biologic Factors
- Heredity and biologic factors are beyond voluntary control.
- Genetic links identified in disorders like Alzheimer's.
- While specific genetic links are not identified for some mental disorders, research indicates a
familial tendency.
- Genetic makeup plays a significant role in a person's response to illness and potentially treatment.
- Nursing Assessment Importance:
- Family history and background are crucial components of nursing assessment.
- Understanding genetic influences helps inform the approach to care and treatment.

A. Individual Factors
3. Physical Health and Health Practices
- Better physical health enhances coping with stress or illness.
- Poor nutritional status, lack of sleep, or chronic physical illness may hinder coping abilities.
- Unlike genetic factors, lifestyle choices can influence these factors.
- Nurses should assess physical health even when clients seek help for mental health issues.
- Personal Health Practices:
- Exercise as a self-help intervention can mitigate negative effects of depression and anxiety.
- Group exercise fosters increased social support, improved well-being, and happiness.
- Continued participation in exercise indicates positive health indicators, while cessation may
suggest declining mental health.
A. Individual Factors
4. Response to Drugs
- Biologic differences affect client response to psychotropic drugs.
- Ethnic groups vary in drug metabolism and efficacy.
- Some groups metabolize drugs more slowly, requiring lower doses to achieve the desired effect.
- Nurses must monitor side effects and serum drug levels, especially in clients from diverse ethnic
backgrounds.

A. Individual Factors
5. Self-Efficacy
- Self-efficacy Defined:
- Belief that personal abilities and efforts influence life events.
- Those with high self-efficacy take action, set goals, are self-motivated, and cope effectively
with stress.
- Low self-efficacy is linked to low aspirations, self-doubt, anxiety, and depression.
- Factors Influencing Self-efficacy:
- Experience of success or mastery in overcoming obstacles.
- Social modeling (observing successful people inspires belief in one's potential).
- Social persuasion (encouraging self-belief).
- Stress reduction, building physical strength, and positive interpretation of physical
sensations. (e.g., viewing fatigue as a sign that one has accomplished something rather than as a lack
of stamina)
- Impact of Self-efficacy on Clients:
- Higher self-efficacy leads to confidence and positive expectations.
- Clients returning to the community with increased self-efficacy show improved
interpersonal relationships, coping skills, functional living, and community integration.
- Therapeutic Interventions for Self-efficacy:
- Focused on assessing physical health.
- Facilitating experiences of success.
- Providing social models for inspiration.
- Engaging in social persuasion.
- Emphasizing stress reduction, physical strength building, and positive interpretation of
physical sensations.

A. Individual Factors
6. Hardiness
- Hardiness Defined:
- Ability to resist illness during stressful situations.
- Three components:
1. Commitment: Active involvement in life activities.
2. Control: Ability to make appropriate decisions in life activities.
3. Challenge: Ability to perceive change as beneficial rather than just stressful.
- Moderating Effect on Stress:
- Hardiness moderates or buffers the impact of stress.
- High hardiness linked to lower occurrence of illness in individuals experiencing high stress.
- Personal Hardiness Characteristics:
- Described as a pattern of attitudes and actions.
- Helps turn stressful circumstances into opportunities for growth.
- Individuals with high hardiness perceive stressors accurately and problem-solve effectively.
Resilience Factor:
- Important resilience factor for families dealing with mental illness.
- Assists individuals in coping with psychological stress and adversity.
Potential Limitations of Hardiness:
- Some view the concept as vague and indistinct.
- Not universally beneficial; may be more relevant for those who value individualism.
- May not be as useful for people and cultures that prioritize relationships over individual
achievement.

A. Individual Factors
7. Resilience and Resourcefulness
- Resilience Defined:
- Healthy responses to stressful circumstances or risky situations.
- Explains varying reactions to stress; why some experience severe anxiety while others do
not.
- Associations with Mental Health:
- High resilience linked to promoting and protecting mental health, often described as
flourishing.
- Family Resilience:
- Successful coping of family members under stress.
- Factors in resilient families include positive outlook, spirituality, family accord, flexibility,
communication, and support networks.
- Resilient families engage in shared activities, recreational pursuits, and rituals.
- Resourcefulness Defined:
- Involves using problem-solving abilities and believing in one's ability to cope with adverse
or novel situations.
- Developed through successful coping with life experiences.
- Examples of Resourcefulness:
- Performing health-seeking behaviors.
- Learning self-care practices.
- Monitoring thoughts and feelings about stressful situations.
- Taking proactive action to deal with stressful circumstances.

A. Individual Factors
8. Spirituality
- Spirituality Defined:
- Involves the essence of a person's being and beliefs about the meaning of life and purpose
for living.
- Encompasses belief in God or a higher power, religious practices, cultural beliefs, and a
relationship with the environment.
- Role in Coping:
- While some with mental disorders may have disturbing religious delusions, for many,
religion and spirituality provide comfort and help during stress or trauma.
- Spirituality serves as a primary coping device for adults with mental illness, offering
meaning and coherence in their lives and establishing a social network.
- Impact of Religious Activities:
- Church attendance, praying, and associated social support are linked with better health and
a sense of well-being.
- These activities help people cope with poor health, and hope and faith are critical factors in
psychiatric and physical rehabilitation.
- Support for Families:
- Religion and spirituality provide support and solace to caregivers of relatives with mental
illness

B. Interpersonal Factors
1. Sense of Belonging
- Definition of Sense of Belonging:
- Feeling connected or involved in a social system or environment.
- Described by Abraham Maslow as a basic human psychosocial need.

- Components of Sense of Belonging:


- Value: Feeling needed and accepted.
- Fit: Feeling that one meshes or fits in with the system or environment.

- Examples of Support Systems:


- Family, friends, coworkers, clubs, social groups, and health care providers.

- Impact on Functioning:
- Closely related to social and psychological functioning.
- Promotes health, while a lack impairs health.
- Associated with decreased anxiety.

- Benefits of Sense of Belonging:


- Decreased alienation and isolation.
- Sense of purpose.
- Belief in being needed by others.
- Social productivity.

- Nursing Focus:
- Interventions to increase a client’s sense of belonging.

B. Interpersonal Factors
2. Social Networks and Social Support
- Social Networks and Health:
- Groups of people one knows, providing emotional support.
- Studies show a social network helps reduce stress, diminish illness, and positively influence coping.

- Social Support Defined:


- Emotional sustenance from friends, family, and health care providers during challenges.
- Different from social contact, which may lack emotional support.

- Healthier Outcomes with Support:


- Emotionally and functionally supported individuals are found to be healthier.

- Impact on Older Adults:


- Meaningful social relationships with family or friends improve health and well-being outcomes.

- Components of Satisfactory Support:


- Person’s ability and willingness to request support.
- Support system's ability and willingness to respond.

- Key Components for Effective Support System:


- Client’s perception of support system.
- Responsiveness of the support system.

- Client's Perception:
- Support system bolstering confidence and self-esteem.
- Providing stress-related interpersonal help, like assisting in problem-solving.

- Consistency with Client's Desires:


- Actions of the support system align with client’s desires and expectations.

- Direct Help and Material Aid:


- Support system capable of providing direct help or material aid (e.g., transportation or follow-up
appointments).

- Capacity to Seek Help:


- Some individuals have the capacity to seek help when needed.
- Nurse's Role:
- Assisting the client in finding supportive individuals.
- Teaching the client to request support when needed.

B. Interpersonal Factors
3. Family Support
- Family as Social Support:
- Key factor in the recovery of clients with psychiatric illnesses.
- Despite potential challenges, family is often crucial for recovery.

- Irreplaceability of Family:
- Health care professionals cannot entirely replace the role of family members.

- Nurse's Role:
- Encourage family support during hospitalization.
- Identify family strengths, such as love and caring, as a valuable resource for the client.

C. Cultural Factors
1. Beliefs about Causes of Illness
- Culture's Influence on Health Beliefs:
- Culture has the most significant impact on a person's health beliefs and practices.
- Influences the concept of disease and illness.

- Types of Beliefs in Non-Western Cultures:


- Natural and unnatural or personal beliefs about the causes of illness.
- Unnatural or personal beliefs attribute illness to the intervention of an outside agent, spirit, or
supernatural force.
- Natural view believes natural conditions or forces (cold, heat, wind, dampness) cause illness.

- Impact on Behavior and Health Practices:


- Individuals with natural beliefs may not see the relationship between their behavior or health
practices and illness.
- Prefer traditional cultural remedies over medication or changes in health practices.

- Stigma Related to Cultural or Personal Beliefs:


- Stigma may exist when cultural or personal beliefs about mental illness or seeking help cause guilt
or shame.
- Shame may be experienced for having mental health issues or seeking outside help.

- Stigmatization of Suicidal Ideation:


- Suicidal ideation can be stigmatized, associated with weakness or failure of personal or religious
beliefs.

C. Cultural Factors
2. Communication
- Challenges in Verbal Communication:
- Difficulty arises when the client and nurse speak different languages.

- Importance of Nonverbal Communication:


- Nonverbal communication varies in meaning across cultures.

- Cultural Variances in Touch:


- Some cultures welcome touch as supportive, while others find it offensive.
- Varied perceptions of handshake firmness: aggressive or a sign of strength and good character.

- Diverse Views on Eye Contact:


- Direct eye contact may be positive in some cultures, while considered rude in others.
- Intense eye contact may be perceived as glaring, leading to differing interpretations.

- Significance of Understanding Cultural Differences:


- Inferences about a person's behavior often based on the frequency or duration of eye contact.

- Reference to Detailed Discussion:


- Chapter 6 provides an in-depth discussion of communication techniques.

C. Cultural Factors
3. Physical Distance or Space
- Cultural Perspectives on Physical Distance:
- Diverse cultures hold varying views on comfortable communication distances.
- Preferences range from 2 to 3 ft, closer proximity, or distances greater than 2 or 3 ft.

- Nurse's Role in Cultural Awareness:


- Nurses should be aware of these cultural differences in physical space.
- Ensure adequate room for clients to feel comfortable based on their cultural preferences.

C. Cultural Factors
4. Social Organization
- Definition of Social Organization:
- Encompasses family structure, religious values, ethnicity, and culture.
- Influences an individual's role and, consequently, health and illness behavior.

- Decision-Making Preferences:
- Individuals may seek advice from friends or family or make decisions independently.
- Strong emphasis on family role in health care decisions for many individuals.
- Delays in decision-making until consultation with appropriate family members are common.

- Cultural Perspective on Autonomy:


- Autonomy in health care decisions may be unfamiliar and undesirable in certain cultures.
- Collective focus rather than individual autonomy is prevalent.

C. Cultural Factors
5. Time Orientation
- Definition of Time Orientation:
- Refers to whether one views time as precise or approximate.

- Cultural Differences in Time Perception:


- Cultures may vary in their focus on the urgency of time.
- Some cultures value punctuality and precise schedules, while others may have a more relaxed view.

- Challenges in Health Care:


- Health care providers may face challenges when clients from different cultures do not adhere to
specific schedules or treatment regimens.

- Avoiding Mislabeling:
- Nurses should avoid labeling clients as noncompliant without considering cultural differences.
- Sensitivity to the client's time orientation is crucial, especially with follow-up appointments.

- Communication about Timing:


- When precise timing is crucial, nurses should explain the importance of adherence, particularly
with medications.

C. Cultural Factors
6. Environmental Control
- Definition of Environmental Control:
- Refers to a client's ability to control the surroundings or direct factors in the environment.

- Influence on Health Behavior:


- People who believe they can control their health are more likely to seek care, change behaviors,
and follow treatment recommendations.

- Impact on Seeking Health Care:


- Those attributing illness to nature or natural causes may be less inclined to seek traditional health
care, as they may doubt its effectiveness.

C. Cultural Factors
7. Biologic Variations
- Biologic Variations:
- Exist among individuals from different cultural backgrounds.

- Understanding Biologic Variations:


- Research is ongoing to comprehend these variations.

- Examples of Ethnicity-Related Biologic Variations:


- Differences related to ethnicity/cultural origins influence responses to psychotropic drugs.

- Biologic Variations Based on Physical Makeup:


- Arise from one's race.

- Examples of Cultural Variations:


- Sickle cell anemia is prevalent in African Americans.
- Tay–Sachs disease is most common in the Jewish community.

C. Cultural Factors
8. Socioeconomic Status and Social Class
Socioeconomic Status (SES)
- Refers to income, education, and occupation.

- Influence on Health:
- Strongly influences health, affecting factors like insurance, access to healthcare, and treatment
affordability.

- Risks Associated with Poverty:


- People in poverty face health threats, such as inadequate housing, violence, and substandard
schools.

- Social Class in the United States:


- Has less influence due to loose barriers and common mobility.
- Higher income can provide access to better schools, housing, healthcare, and lifestyle.

- Social Class in Other Countries:


- In some countries, social class is fixed and strongly influences social relationships.
- Examples like the caste system in India can impact how people relate to healthcare based on their
social class.

- Nurse's Role:
- Must assess if social class influences how clients relate to healthcare providers and the system.

C. Cultural Factors
9. Cultural Patterns and Differences
- Understanding Cultural Patterns:
- Provides a starting point for the nurse to relate to individuals with different ethnic backgrounds.
- Enables the nurse to know what to ask and how to assess preferences and health practices.

- Individual Variations:
- Variations among people from any culture are wide; not everyone fits the general pattern.
- Individual assessment of each person and family is necessary for culturally competent care.

- Learning Requirements for Nurses:


- Nurses need to learn about greetings, acceptable communication patterns, tone of voice, and
beliefs regarding mental illness, healing, spirituality, and medical treatment.
- Aims to provide the best care possible tailored to the client's needs.

Nurse's Role

- Assessing Cultural Values:


- Nurse should gather information about a client’s cultural values, beliefs, and health practices.
- Asking questions like “How would you like to be cared for?” or “What do you expect (or want) me
to do for you?” is crucial.

- Observing Cultural Cues:


- At the initial meeting, nurse should observe client's preferences for greetings, eye contact, and
physical distance.
- Adapt approach based on the client’s behavior, being sensitive to individual differences.

- Assessing Health Practices and Beliefs:


- Inquire about dietary preferences, restrictions, and religious beliefs.
- Understand the client’s health and illness beliefs by asking questions like “How do you think this
health problem came about?” and “What remedies have you tried at home?”

- Avoiding Assumptions:
- Never assume a patient's preferences based on stereotypes or the dominant culture.
- Always ask the client and/or family about their cultural beliefs and practices, demonstrating respect
and avoiding errors.

- Open and Objective Approach:


- Approach the client openly without skepticism or judgment.
- Demonstrate genuine interest in understanding the client's personal and cultural information.

- Applying Questions Universally:


- Ask these questions to clients from all cultural backgrounds, including those from the nurse's own
cultural group.
- Acknowledge the wide variations within cultural groups, avoiding assumptions about individual
beliefs or practices.

A. Psychosocial Theories
1. Psychoanalytic
Sigmund Freud: The Father of Psychoanalysis

- Deterministic Nature of Psychoanalytic Theory:


- All human behavior is seen as caused and explainable within psychoanalytic theory.

- Freud's Clinical Basis:


- Initial ideas derived from experiences with female clients.
- Clients exhibited unusual behaviors: disturbances of sight, speech, inability to eat, and limb
paralysis.
- Symptoms lacked diagnosed physiological basis, labeled as "hysterical" or neurotic behaviors.
- Repressed Sexual Impulses:
- Freud believed repressed sexual impulses and desires to be a major motivator of human behavior.

- Link to Childhood Trauma:


- Freud concluded that many problems stemmed from childhood trauma or incomplete psychosexual
development tasks.

- Repression of Needs and Feelings:


- Women repressed unmet needs, sexual feelings, and traumatic events.

- Resulting Behaviors:
- "Hysterical" or neurotic behaviors seen as manifestations of unresolved conflicts.

Personality Components

- Id:
- Reflects basic and innate desires.
- Includes pleasure-seeking behavior, aggression, and sexual impulses.
- Seeks instant gratification.
- Causes impulsive and unthinking behavior.
- Disregards rules and social conventions.

- Superego:
- Reflects moral and ethical concepts.
- Represents values and parental/social expectations.
- Opposes the id.

- Ego:
- Balancing force between id and superego.
- Represents mature and adaptive behavior.
- Enables successful functioning in the world.

- Freud's Concept:
- Anxiety results from the ego balancing id's impulsive instincts and superego's stringent rules.

Freud's Three Levels of Awareness:


Conscious: Perceptions, thoughts, and emotions in the person's immediate awareness
(e.g., happy feelings or thoughts about a loved one).
Preconscious: Thoughts and emotions not currently in awareness but recallable with effort
(e.g., remembering childhood experiences).
Unconscious: Realm of thoughts and feelings motivating a person, often unaware, including defense
mechanisms and instinctual drives.

Role of the Unconscious:


- Freud posited that the unconscious motivates behavior, housing repressed memories of traumatic
events.
- Much of human behavior and speech is believed to be driven by subconscious thoughts or feelings
from the preconscious or unconscious levels.

Freudian Slip:
- A term used to describe slips of the tongue, such as saying something unintentionally.
- Freud viewed these slips not as accidents but as indications of subconscious feelings or thoughts
surfacing in casual day-to-day conversation.

Freud's Dream Analysis:


- Dreams are seen as reflections of the subconscious with hidden or symbolic meanings.
- Dream analysis, a core psychoanalytic technique, involves exploring a client's dreams to unveil their
true significance.
Example: Recurrent dreams of snakes might be interpreted as a fear of intimacy, with the snake
symbolizing the penis in Freud's view.

Free Association:
- A method to access subconscious thoughts and feelings by prompting quick responses to words.
- Freud believed this technique could reveal repressed thoughts or feelings.

Ego Defense Mechanisms:


- The ego employs defense mechanisms to cope with basic drives or emotionally challenging
thoughts, feelings, or events.
- Defense mechanisms, largely unconscious, aim to protect the self. Example: Denial in response to a
terminal illness diagnosis.

- Awareness of Defense Mechanisms:


- Most defense mechanisms operate at the unconscious level, requiring external help for individuals
to recognize their behaviors and face reality.

Freud’s Developmental Stages


1. Oral Stage (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.

2. Anal Stage (18–36 months):


Anus and surrounding area are major source of interest.
Voluntary sphincter control (toilet training) is acquired.

3. Phallic/Oedipal Stage (3–5 years):


Genitals are 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.

4. Latency Stage (5–11 or 13 years):


Resolution of oedipal complex.
Sexual drive channeled into socially appropriate activities such as school work and sports.
Formation of the superego.
Final stage of psychosexual development.

5. Genital Stage (11–13 years):


Begins with puberty and the biologic capacity for orgasm; involves the capacity for true intimacy.

Transference:
- Definition: Client displaces onto the therapist attitudes and feelings originally experienced in other
relationships.
- Nature: Automatic and unconscious in the therapeutic relationship.
- Example: Adolescent female client reacts to a nurse of similar age as her parents, displaying intense
feelings of rebellion or making sarcastic remarks based on her experiences with her parents, not the
nurse.

Countertransference:
- Definition: Therapist displaces onto the client attitudes or feelings from his or her past.
- Nature: Involves the therapist's emotional reactions to the client.
- Example: A female nurse with teenage children and extreme frustration may adopt a parental or
chastising tone with an adolescent client, projecting her own attitudes and feelings toward her
children onto the client.

Dealing with Countertransference:

Self-Examination: Therapists can examine their own feelings and responses to identify
countertransference.

Self-Awareness: Developing awareness of personal biases and emotional reactions is crucial in


managing countertransference.

Communication: Talking with colleagues and seeking supervision to discuss and process
countertransference reactions.

Professional Growth: Continuous learning and personal development to minimize the impact of
countertransference on therapeutic relationships.

Current Psychoanalytic Practice


Objective:
- Focus on discovering causes of unconscious and repressed thoughts, feelings, and conflicts.
- Aim to address these issues believed to cause anxiety.

Therapeutic Goal:
- Help the client gain insight into and resolve conflicts and anxieties.

Techniques:
- Utilize free association as a method for clients to express thoughts and feelings without censorship.
- Apply dream analysis to uncover hidden meanings and conflicts.
- Interpret behavior to reveal unconscious motivations.

Practice Characteristics:
- Psychoanalysis is still practiced but on a limited basis.
- Analysis is lengthy, involving weekly or more frequent sessions for several years.

Financial Considerations:
- Considered costly and not covered by conventional health insurance programs.
- Earned the reputation of "therapy for the wealthy" due to financial barriers.

A. Psychosocial Theories
2. Developmental
Erik Erikson and Psychosocial Stages of Development
(1902–1994)

German-born psychoanalyst.
Extended Freud's work on personality development.
Focused on social and psychological development across the lifespan.

1. Trust vs. Mistrust (Infancy):


- Stage: Birth to 18 months.
- Development: Infants learn to perceive the world as safe and relationships as nurturing and
dependable.

2. Autonomy vs. Shame and Doubt (Toddler):


- Stage: 18 months to 3 years.
- Development: Toddlers strive for a sense of control and free will.

3. Initiative vs. Guilt (Preschool):


- Stage: 3 to 5 years.
- Development: Preschoolers start forming a conscience, learning conflict management, and dealing
with anxiety.

4. Industry vs. Inferiority (School Age):


- Stage: 6 to 11 years.
- Development: Children gain confidence in their abilities and find pleasure in accomplishments.

5. Identity vs. Role Confusion (Adolescence):


- Stage: 12 to 18 years.
- Development: Adolescents form a sense of self and establish a feeling of belonging.

6. Intimacy vs. Isolation (Young Adult):


- Stage: 18 to 40 years.
- Development: Young adults build adult, loving relationships and meaningful attachments to others.

7. Generativity vs. Stagnation (Middle Adult):


- Stage: 40 to 65 years.
- Development: Middle-aged adults focus on creativity, productivity, and establishing the next
generation.

8. Ego Integrity vs. Despair (Maturity):


- Stage: 65 years to death.
- Development: Older adults accept responsibility for themselves and life, reflecting on life's
meaning and accomplishments.

Jean Piaget and Cognitive Stages of Development


(1896–1980):

Focus: Explored intelligence and cognitive functioning in children.


Belief: Intelligence progresses through stages based on age, with each stage demonstrating higher
functioning.
Influence: Biologic changes and maturation are central to cognitive development.

Four Stages of Cognitive Development:


1. Sensorimotor (Birth to 2 years):
- Development of self-awareness separate from the environment.
- Formation of the concept of object permanence.
- Beginning to form mental images.

2. Preoperational (2 to 6 years):
- Development of language expression.
- Understanding symbolic gestures.
- Commencement of object classification.

3. Concrete Operations (6 to 12 years):


- Application of logic to thinking.
- Understanding spatiality and reversibility.
- Increasing social awareness and ability to apply rules, though thinking remains concrete.

4. Formal Operations (12 to 15 years and beyond):


- Ability to think and reason in abstract terms.
- Further development of logical thinking and reasoning.
- Achievement of cognitive maturity.

Cognitive Maturity: Piaget suggests individuals reach cognitive maturity by middle to late
adolescence.

-Critiques of Piaget's Theory:


- Some critics argue cognitive development is less rigid and more individualized.

- Practical Applications:
- In Child Interaction:
- Understanding a child's cognitive development aids in interpreting their expressions.
- Educational Context:
- Structuring teaching methods based on cognitive development enhances learning for children.

A. Psychosocial Theories
3. Interpersonal
Harry Stack Sullivan: Interpersonal Relationships and Milieu Therapy
(1892–1949):

American psychiatrist.
Extended personality development theory to emphasize the significance of interpersonal
relationships.

Key Beliefs:
Personality involves interactions with others, not just individual characteristics.
Inadequate or unsatisfying relationships lead to anxiety, the basis for emotional problems.

Major Contribution:
Emphasized the importance of interpersonal relationships in mental health.
Five Life Stages

1. Infancy:
Focus: Early interpersonal relationships.

2. Childhood:
Focus: Development of relationships during childhood.

3. Juvenile:
Focus: Interpersonal dynamics in juvenile years.

4. Preadolescence:
Focus: Relationships during preadolescence.

5. Adolescence:
Focus: Interpersonal interactions in adolescence.

Developmental Cognitive Modes:


Prototaxic Mode (Infancy and Childhood):

Characteristics: Brief, unconnected experiences with no relationship.


Example: Adults with schizophrenia exhibit persistent prototaxic experiences.
Parataxic Mode (Early Childhood):

Characteristics: Connecting experiences in sequence, possibly without logical sense.


Behavior: Repeating familiar experiences to relieve anxiety.
Explanation: Sullivan linked paranoid ideas and slips of the tongue to the parataxic mode.
Syntaxic Mode (School-Aged Children and Preadolescence):

Characteristics: Perceiving oneself and the world within the environmental context.
Ability: Analyzing experiences in various settings.
Maturity: Predominance of the syntaxic mode is associated with maturity.
Overall Perspective:

Mental disorders are related to the persistence of one of the early cognitive modes.
Maturity is defined by the predominance of the syntaxic mode.

3. Interpersonal
Hildegard Peplau: Therapeutic Nurse–Patient Relationships
(1909–1999)
- Developed the concept of the therapeutic nurse–patient relationship based on Sullivan’s
interpersonal theories.
- Emphasized the role of the nurse as a participant observer.
- Identified four phases of the therapeutic nurse–patient relationship: orientation, identification,
exploitation, and resolution.
1. Orientation Phase
- Nurse-directed phase involving clarification of patient's problems and needs.
- Explanation of hospital routines and expectations.
- Patient's full participation is encouraged.
2. Identification Phase
- Begins when the patient perceives helpful individuals and expresses feelings.
- Interdependent work with the nurse occurs.
- Roles of both patient and nurse are clarified.
3. Exploitation Phase
- Patient makes full use of available services.
- Goals such as returning home and work emerge.
- Patient fluctuates between dependence and independence.
4. Resolution Phase
- Patient no longer needs professional services and gives up dependent behavior.
- Assumes power to meet own needs and set new goals.

Roles of Nurses in the Therapeutic Relationship


- Identified primary roles:
- Stranger
- Resource person
- Teacher
- Leader
- Surrogate
- Counselor
- Also suggested other roles such as consultant, tutor, safety agent, mediator, administrator,
observer, and researcher.

- Four Levels of Anxiety


1. Mild Anxiety
- Heightened awareness and sharpened senses.
- Positive state allowing learning and problem-solving.
2. Moderate Anxiety
- Decreased perceptual field, requiring assistance for problem-solving.
- Can be redirected by another person.
3. Severe Anxiety
- Feelings of dread or terror.
- Cannot be redirected, focuses only on scattered details.
- Physiological symptoms such as tachycardia and chest pain.
4. Panic Anxiety
- Loss of rational thought, delusions, hallucinations.
- Complete physical immobility and muteness.
- May exhibit aimless behavior, risking injury.

A. Psychosocial Theories
4. Humanistic
Abraham Maslow: Hierarchy of Needs
(1921–1970)
- American psychologist
- Focused on individual needs and motivations
- Emphasized holistic approach and health

- Hierarchy of Needs:
- Maslow (1954) formulated hierarchy as a pyramid
- Illustrates basic drives or needs motivating human behavior
- Arranged in levels:
- Physiological Needs: Food, water, sleep, shelter, sexual expression, freedom from pain
- Safety and Security Needs: Protection, security, freedom from harm or deprivation
- Love and Belonging Needs: Enduring intimacy, friendship, acceptance
- Esteem Needs: Self-respect, esteem from others
- Self-Actualization: Pursuit of beauty, truth, justice

- Behavioral Dominance:
- Basic needs dominate behavior until fulfilled
- Successive levels become dominant upon fulfillment
- Example: Unmet needs for food and shelter overshadow other concerns, leading to risk-taking
behaviors

- Self-Actualization:
- Achievement of all needs in hierarchy
- Realization of fullest potential in life
- Attainment is rare

- Motivation and Behavior:


- Motivation not necessarily stable throughout life
- Traumatic life circumstances or compromised health can cause regression
- Example: A cancer diagnosis may lead to regression to safety needs for treatment and health
preservation

- Implications for Nursing:


- Understanding how clients' motivations and behaviors evolve during crises
- Facilitating nuanced care approaches to address changing needs

Carl Rogers: Client-Centered Therapy


(1902–1987)
- American humanistic psychologist
- Pioneered client-centered therapy, emphasizing the therapeutic relationship
- Introduces term "client" instead of "patient"

Key Tenets of Client-Centered Therapy


- Client's Role: Central to healing process
- Client as Expert: Each person experiences the world uniquely, knows own experience best
- Client's Autonomy: Clients "do the work of healing" within a supportive relationship
- Therapist's Role: Supportive, non-directive approach

Central Concepts for Therapist's Approach:


- Unconditional Positive Regard: Nonjudgmental caring for the client irrespective of behavior
- Genuineness: Realness or congruence in therapist's feelings and communication
- Empathetic Understanding: Sensing client's feelings and communicating understanding

Impact of Unconditional Positive Regard


- Promotes client's self-esteem, decreases defensive behavior
- Facilitates natural self-actualization process
- Views self-actualization as innate human tendency toward self-improvement and constructive
change

Behavioral Theories
- Foundation of Behaviorism:
- Reaction to introspection models
- Focuses on observable behaviors rather than internal mental processes
Principles:
- *Reward and Punishment:* Behavior can be changed through rewards and punishments
- *Examples:*
- Regular paycheck as positive reinforcement for work
- Speeding ticket as negative reinforcement for speeding behavior
- Removal of negative reinforcer may lead to resumption of behavior

This outline encapsulates Carl Rogers' client-centered therapy approach and introduces key concepts
in behavioral theories, emphasizing observable behaviors and mechanisms of behavior change.

A. Psychosocial Theories
5. Behavioral
Ivan Pavlov: Classical Conditioning
(1849–1936)
- Pavlov's theory of classical conditioning asserts behavior change through conditioning with external
stimuli.
- Experimental Basis:
- Conducted laboratory experiments with dogs.
- Observed dogs' natural salivation response to food stimuli.
- Pavlov's Experiment:
- Introduced new stimulus: ringing a bell.
- Paired bell with presentation of food.
- Dogs salivated in response to food.
- Repeated Conditioning:
- Repeated bell ringing with food presentation numerous times.
- Dogs learned to associate bell with food and salivated upon hearing the bell alone.
- Outcome:
- Dogs "conditioned" to salivate at the sound of the bell.
- Behavior modified through classical conditioning.

B. F. Skinner: Operant Conditioning


(1904–1990)
- Influential behaviorist American psychologist
- Developed theory of operant conditioning, emphasizing learned behaviors from past experiences

Skinner's Perspective on Behavior:


- Behavior as observable, learned or unlearned
- Focus on observable behaviors rather than internal thoughts or feelings
- Emphasized changing behavior as paramount

Principles of Operant Conditioning:


1. All behavior is learned.
2. Consequences follow behavior—rewards and punishments.
3. Behavior rewarded with reinforcers tends to recur.
4. Positive reinforcers increase likelihood of behavior recurrence.
5. Negative reinforcers, when removed after behavior, increase likelihood of recurrence.
6. Continuous reinforcement (reward every time behavior occurs) increases behavior quickly but
may not last.
7. Intermittent reinforcement (occasional reward) slower to increase behavior but maintains it
longer.

Application in Behavior Modification:


- Utilized in behavior modification therapy
- Reinforcement, either positive or negative, strengthens desired behaviors
- Example: Assertiveness training with positive reinforcement for assertive behavior

Examples of Negative Reinforcement:


- Removal of anxiety-provoking stimulus after behavior
- Example: Volunteering to speak first in a group to avoid anxiety

Application in Token Economy:


- Used in group home settings for residents' daily activities
- Desired behaviors tracked on chart, rewarded with tokens for various privileges or items

Treatment of Conditioned Responses:


- Behavioral techniques used for fears or phobias
- Systematic desensitization involves gradual exposure to anxiety-inducing situations, paired with
relaxation techniques

Application in Anorexia Nervosa Treatment:


- Behavioral contracts for weight gain
- Weight gain rewarded with increased privileges or autonomy

Application in Attention-Deficit/Hyperactivity Disorder (ADHD) Treatment:


- Rewards for task completion, hygiene tasks, turn-taking, etc.
- Example: Stickers or stars given for completed tasks, leading to rewards upon reaching specified
goals.

A. Psychosocial Theories
6. Existential
Jean-Paul Sartre
(1905-1980)
1. Existentialism and Humanism:
- Sartre's essay "Existentialism is a Humanism" (1945) emphasizes that without a divine designer
(God), there is no intrinsic essence of human life.
- Consequently, humans must invent their own purpose and define their own "essence."

2. Existential Phenomenology:
- Sartre's early works build upon classic phenomenology but diverge from Husserl's approach.
- He focuses on understanding human existence rather than the external world.
- Key themes include freedom, consciousness, and the tension between facts and freedom in an
indifferent world.
3. Being and Nothingness:
- Sartre's philosophical masterpiece, "Being and Nothingness," outlines his ontology.
- He defines two types of reality:
- Being of the object of consciousness ("in-itself"): Independent and non-relational existence.
- Being of consciousness itself ("for-itself"): Defined in relation to something else.
- Negative power of consciousness: Allows us to experience "nothingness."
- Self-identity as a task: The unity of the self is not given but created through projects.
- Authenticity vs. bad faith: Choosing in a way that reveals both factual and transcendent existence.

4. Universal Dimension in Singularity:


- Sartre believes that authentic projects express a universal dimension within each individual's
unique life.
- Our proper exercise of freedom creates values shared by all humans in similar situations.

Viktor Frankl
(1905-1997)
1. Logotherapy:
- Developed by Viktor Frankl, logotherapy is a form of existential psychotherapy.
- The term "logos" refers to meaning or purpose, emphasizing its central focus.
- Frankl believed that humans are motivated by a "will to meaning", which drives them to seek and
create meaning in life.
- Logotherapy has been recognized as a scientifically based school of psychotherapy by professional
associations¹.

2. Fundamental Properties:
- Healthy Core: Every person possesses an inner core of health and resilience.
- Enlightenment: Logotherapy aims to enlighten individuals about their internal resources and
provide tools for self-discovery.
- Purpose and Fulfillment: While life offers meaning, it does not guarantee happiness or fulfillment.

3. Finding Meaning:
- Logotherapy asserts that finding meaning in life is a primary motivational force.
- Even in the face of suffering, individuals can discover meaning through their attitudes, choices, and
actions.
- Three ways to find meaning:
- Creative value: Creating or accomplishing tasks.
- Experiential value: Appreciating and receiving from the world.
- Attitudinal value: Choosing one's response to life's challenges.

4. Holocaust Experience:
- Frankl's personal experience in Nazi concentration camps deeply influenced his theory.
- He observed that those who found meaning and purpose were more resilient in adversity.

5. "Man's Search for Meaning":


- Frankl's influential book explores how individuals can maintain hope and meaning even in extreme
suffering.
- The search for meaning becomes a powerful tool for survival and psychological well-being.

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.

Methods employed by the ego to protect the self and cope with basic drives or emotionally painful
thoughts, feelings, or events.
- Most operate at the unconscious level of awareness.
- Often require external help to recognize reality.

Examples of Defense Mechanisms:

1. Compensation:
- Overachievement in one area to offset deficiencies in another.
- Example: Nurse with low self-esteem works double shifts to gain supervisor's approval.
Management: Encourage self-awareness and self-acceptance. Help the individual identify their
strengths and weaknesses realistically. Offer opportunities for skill development and provide positive
feedback on achievements in various areas to build self-esteem. Therapy focused on enhancing self-
esteem can also be beneficial.

2. Conversion:
- Expression of emotional conflict through development of physical symptoms.
- Example: Teenager forbidden to watch X-rated movies develops blindness unconcernedly.
Management: Provide psychological support and therapy to help the individual understand and
express their emotions in a healthy way. Teach coping skills to manage emotional conflicts effectively.
Address underlying issues contributing to the conversion symptoms through therapy, such as
cognitive-behavioral therapy or psychodynamic therapy.

3. Denial:
- Failure to acknowledge unbearable condition or reality.
- Examples: Diabetic person indulging in chocolate; spending money freely when broke.
Management: Create a supportive environment where the individual feels safe to acknowledge and
discuss their concerns. Provide education about the importance of facing reality and seeking
appropriate help. Encourage open communication and offer reassurance. Therapy aimed at increasing
insight and coping skills can be beneficial.

4. Displacement:
- Ventilation of intense feelings towards less threatening targets.
- Examples: Person mad at boss yells at spouse; bullied child mistreats younger sibling.
Management: Help the individual identify and understand their feelings and triggers for displacement.
Teach healthy ways to express emotions and manage anger or frustration, such as assertiveness
training or relaxation techniques. Address underlying issues contributing to the displacement through
therapy, such as anger management or interpersonal therapy.

5. Dissociation:
- Temporary alteration in consciousness or identity to deal with emotional conflict.
- Examples: Amnesia following auto accident; adult forgetting childhood sexual abuse.
Management: Provide a safe and supportive environment for the individual to explore and process
their experiences. Offer therapy focused on grounding techniques, mindfulness, and coping strategies
for managing dissociative episodes. Address underlying trauma or stressors contributing to
dissociation through trauma-focused therapy or dialectical behavior therapy.

6. Fixation:
- Immobilization of personality due to unsuccessful task completion in developmental stage.
- Examples: Never learning to delay gratification; lack of clear identity as adult.
Management: Encourage exploration and development in areas where the individual feels stuck.
Provide opportunities for personal growth and achievement. Offer therapy focused on addressing
unresolved developmental tasks and promoting adaptive coping strategies. Support the individual in
developing a sense of identity and autonomy.

7. Identification:
- Modeling actions and opinions of influential others while searching for identity or goal.
- Example: Nursing student choosing critical care specialty admired by instructor.
Management: Encourage self-reflection and exploration of personal values and beliefs. Help the
individual differentiate between their own identity and the influence of others. Offer therapy focused
on building self-awareness, assertiveness, and self-esteem. Support the individual in developing
autonomy and making independent choices.

8. Intellectualization:
- Separating emotions of painful event from facts involved.
- Example: Showing no emotional expression when discussing serious car accident.
Management: Encourage emotional expression and exploration of underlying feelings. Help the
individual connect their thoughts with their emotions and experiences. Offer therapy focused on
increasing emotional awareness and processing difficult emotions. Support the individual in
developing healthy coping strategies for managing emotional challenges.

9. Introjection:
- Accepting another's attitudes, beliefs, and values as one's own.
- Example: Person disliking guns becoming avid hunter like best friend.
Management: Facilitate exploration of personal values and beliefs independent of others. Encourage
critical thinking and reflection on the origin of adopted attitudes and beliefs. Offer therapy focused on
building self-confidence and assertiveness. Support the individual in developing a sense of self and
making authentic choices.

10. Projection:
- Unconscious blaming of unacceptable thoughts on external objects.
- Examples: Man projecting thoughts about same-gender relationship onto gay man; person loudly
identifying others as bigots.
Management: Provide education about projection and help the individual recognize when they are
projecting onto others. Encourage self-reflection and exploration of underlying feelings and
motivations. Offer therapy focused on increasing self-awareness and addressing underlying
insecurities or conflicts. Support the individual in developing healthy coping strategies for managing
emotions.

11. Rationalization:
- Excusing own behavior to avoid guilt or responsibility.
- Examples: Student blaming failure on mean teacher; man justifying beating wife for not listening.
Management: Encourage accountability and responsibility for one's actions. Provide education about
rationalization and its potential consequences. Help the individual explore alternative perspectives
and challenge rationalizations. Offer therapy focused on increasing self-awareness and addressing
underlying fears or insecurities. Support the individual in developing healthy coping strategies for
managing guilt and anxiety.

12. Reaction Formation:


- Acting opposite to true feelings.
- Examples: Woman becoming supermom despite not wanting children; person praising despised
boss.
Management: Provide support and validation for the individual's true feelings and desires. Encourage
exploration of underlying conflicts and fears that may be driving the reaction formation. Offer therapy
focused on increasing emotional awareness and authenticity. Support the individual in developing
healthy ways of expressing and coping with their true feelings.

13. Regression:
- Returning to previous developmental stage to feel safe or have needs met.
- Examples: 5-year-old asking for bottle like baby brother; man pouting like 4-year-old for attention.
Management: Provide support and reassurance during times of stress or transition. Help the
individual identify triggers for regression and develop alternative coping strategies. Offer therapy
focused on building resilience and adaptive coping skills. Support the individual in processing
underlying feelings and addressing unresolved issues contributing to regression.

14. Repression:
- Excluding emotionally painful thoughts or feelings from conscious awareness.
- Examples: Woman forgetting mugging incident; woman having no memory before age 7 due to
abusive childhood.
Management: Create a safe and supportive therapeutic environment where the individual feels
comfortable exploring difficult thoughts and emotions. Help the individual develop insight into their
repressed thoughts and feelings. Offer therapy focused on increasing emotional awareness and
processing unresolved trauma or conflicts. Support the individual in developing healthy coping
strategies for managing distress.

15. Resistance:
- Overt or covert antagonism toward remembering or processing anxiety-producing information.
- Examples: Nurse avoiding time with dying patient; person attending treatment but refusing to
participate.
Management: Establish trust and rapport with the individual to facilitate open communication.
Validate the individual's concerns and fears about facing anxiety-provoking information. Offer therapy
focused on exploring the underlying reasons for resistance and addressing any underlying conflicts or
anxieties. Support the individual in developing coping strategies for managing anxiety and increasing
willingness to engage in therapy.

16. Sublimation:
- Substituting socially acceptable activity for unacceptable impulse.
- Examples: Former smoker sucking on hard candy; person going for walk when tempted to eat junk
food.
Management: Encourage the individual to channel their impulses into socially acceptable activities.
Provide opportunities for creative expression and skill development in areas of interest. Offer therapy
focused on identifying and cultivating healthy outlets for emotional expression and gratification.
Support the individual in finding meaningful ways to channel their energy and impulses.

17. Substitution:
- Replacing desired gratification with more readily available option.
- Example: Woman opening day care center instead of having own children.
Management: Help the individual explore and address the underlying desires or needs driving the
substitution. Provide support and guidance in pursuing alternative avenues for gratification or
fulfillment. Offer therapy focused on increasing self-awareness and developing coping strategies for
managing unmet needs or desires. Support the individual in making positive changes to improve their
well-being.

18. Suppression:
- Conscious exclusion of unacceptable thoughts or feelings from conscious awareness.
- Examples: Student avoiding thoughts of parent's illness to study; woman telling friend she can't
think about son's death.
Management: Provide education about the potential consequences of suppressing thoughts and
feelings. Encourage the individual to explore and express their emotions in a safe and supportive
environment. Offer therapy focused on increasing emotional awareness and processing unresolved
issues. Support the individual in developing healthy coping strategies for managing distress and
regulating emotions.

19. Undoing:
- Exhibiting acceptable behavior to negate unacceptable behavior.
- Examples: Cheating spouse bringing bouquet to spouse; ruthless businessperson donating to
charity.
Management: Encourage accountability and responsibility for one's actions. Help the individual
explore and address the underlying motivations for undoing behaviors. Offer therapy focused on
increasing self-awareness and developing healthier ways of coping with guilt or anxiety. Support the
individual in building self-esteem and making positive changes in their behavior patterns.

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