Maslow’s Hierarchy of Needs

Maslow developed a hierarchy of needs based on attainment of self-actualization, where one becomes highly evolved and attains his or
her full potential. The basic belief is that lower-level needs must be met first in order to advance to the next level of needs. Therefore,
physiologic and safety needs must be met before issues related to love and belonging can be addressed, through to self actualization.

General Adaptation Syndrome (Stress-Adaptation Syndrome)

Hans Selye (1976) divided his stress syndrome into three stages and, in doing so, pointed out the seriousness of prolonged stress on
the body and the need for identification and intervention.
1. Alarm stage – This is the immediate physiological (fight or flight) response to a threat or perceived threat.
2. Resistance – If the stress continues, the body adapts to the levels of stress and attempts to return to homeostasis.
3. Exhaustion – With prolonged exposure and adaptation, the body eventually becomes depleted. There are no more reserves to draw
upon, and serious illness may now develop (e.g., hypertension, mental disorders, cancer). Selye teaches us that without intervention,
even death is a possibility at this stage.

Fight-or-Flight Response
In the fight-or-flight response, if a person is presented with a stressful situation (danger), a physiological response (sympathetic
nervous system) activates the adrenal glands and cardiovascular system, allowing a person to rapidly adjust to the need to fight or flee
a situation.
■ Such physiological response is beneficial in the short term: for instance, in an emergency situation.
■ However, with ongoing, chronic psychological stressors, a person continues to experience the same physiological response as if
there were a real danger, which eventually physically and emotionally depletes the body.

Theories of Personality Development

Psychoanalytic Theory
Sigmund Freud, who introduced us to the Oedipus complex, hysteria, free association, and dream interpretation, is considered the
“Father of Psychiatry.” He was concerned with both the dynamics and structure of the psyche. He divided the personality into three
parts:
■ Id – The id developed out of Freud’s concept of the pleasure principle. The id comprises primitive, instinctual drives (hunger, sex,
aggression). The id says, “I want.”
■ Ego – It is the ego, or rational mind, that is called upon to control the instinctual impulses of the self-indulgent id. The ego says, “I
think/I evaluate.”
■ Superego –The superego is the conscience of the psyche and monitors the ego. The superego says “I should/I ought.” (Hunt 1994)

Topographic Model of the Mind

Freud’s topographic model deals with levels of awareness and is divided into three categories:
■ Unconscious mind – All mental content and memories outside of conscious awareness; becomes conscious through the
preconscious mind.
■ Preconscious mind – Not within the conscious mind but can more easily be brought to conscious awareness (repressive function of
instinctual desires or undesirable memories). Reaches consciousness through word linkage.
■ Conscious mind – All content and memories immediately available and within conscious awareness. Of lesser importance to
psychoanalysts.

Dream analysis, a primary method 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.
BAS
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.
Transference and Countertransference.
Freud developed the concept of transference and countertransference.
Transference occurs when the client displaces onto the therapist attitudes and feelings that the client originally experienced in other
relationships (Gabbard, 2000). 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 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.

ICS
Psychoanalysis focuses on discovering the causes of the client’s unconscious and repressed thoughts, feelings, and conflicts believed
to cause anxiety and helping the client to gain insight into and resolve these conflicts and anxieties.

STAGES OF PERSONALITY DEVELOPMENT

HARRY STACK SULLIVAN: INTERPERSONAL RELATIONSHIPS AND MILIEU THERAPY

Harry Stack Sullivan (1892–1949; Fig. 3-2) was an American psychiatrist who extended the theory of personality development to
include the significance of interpersonal relationships. Sullivan believed that one’s personality involved more than individual
characteristics, particularly how one interacted with others.

Sullivan also described three developmental cognitive modes of experience and believed that mental disorders were related to the
persistence of one of the early 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.
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, although 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. In the
syntaxic mode, which begins to appear in schoolage children and becomes more predominant in preadolescence, the person begins
to perceive himself 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 (Sullivan, 1953).

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.Credit also is given to Sullivan for developing the
first therapeutic community or milieu with young men with schizophrenia in 1929 (although that term was not used extensively until
Maxwell Jones published The Therapeutic Community in 1953).

The concept of milieu therapy, originally developed by Sullivan, involved clients’ interactions with one another; i.e., 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.
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 development as well as psychological development in the life stages.

JEAN PIAGET AND COGNITIVE STAGES OF DEVELOPMENT

Jean Piaget (1896–1980) explored how intelligence and cognitive functioning developed 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.

Piaget’s four stages of cognitive development are as follows:

1. Sensory motor stage (birth to two years). This stage is characterized by:
􀂃 The child has little capacity in representing objects that are not directly in front of him using images, language or symbols.
􀂃 For the child at this stage, objects and people do not exist when they are out of sight. It means children lack what Piaget called
object permanence.
2. Preoperational stage (2-7 years) It is characterized by:
􀂃 By the use of language children at this stage are able to represent objects, people, events and feelings that are not directly in front of
them.
􀂃 They pretend in plays like, for example, they push a chair across the floor symbolizing it for a car.
􀂃 The concept of a number appears as early as the third year of life. They can count a group of small number of objects in many ways,
starting with a different object each time.
Another immature feature of the preoperational children thinking is their inability to understand the principle of conservation. They
cannot understand that quantity does not change when arrangement and physical appearance of objects are changed.
3. concrete operational stage (7 to 12 years)
This stage of cognitive development is marked by mastery of the principle of conservation. They can think logically though their thought
process is limited to the concrete.
4. Formal operational thought starts to emerge during adolescence. At this stage adolescents:
􀂃 Use scientific reasoning;
􀂃 Test possible explanations in an attempt to prove or disprove hypothesis (example, adolescents sexual practice)
􀂃 Use abstract thinking.

KOHLBERG’S MORAL DEVELOPMENT/ THINKING/ JUDGEMENT

Level 1 - Pre-conventional morality
Authority is outside the individual and reasoning is based on the physical consequences of actions.

• Stage 1. Obedience and Punishment Orientation. The child/individual is good in order to avoid being punished. If a person is
punished they must have done wrong.

• Stage 2. Individualism and Exchange. At this stage children recognize that there is not just one right view that is handed down by
the authorities. Different individuals have different viewpoints.

Level 2 - Conventional morality

Authority is internalized but not questioned and reasoning is based on the norms of the group to which the person belongs.
• Stage 3. Good Interpersonal Relationships. The child/individual is good in order to be seen as being a good person by others.
Therefore, answers are related to the approval of others.

• Stage 4. Maintaining the Social Order. The child/individual becomes aware of the wider rules of society so judgments concern
obeying rules in order to uphold the law and to avoid guilt.

Level 3 - Post-conventional morality

Individual judgment is based on self-chosen principles, and moral reasoning is based on individual rights and justice.

• Stage 5. Social Contract and Individual Rights. The child/individual becomes aware that while rules/laws might exist for the good of
the greatest number, there are times when they will work against the interest of particular individuals. The issues are not always clear
cut. For example, in Heinz’s dilemma the protection of life is more important than breaking the law against stealing.

• Stage 6: Universal Principles. People at this stage have developed their own set of moral guidelines which may or may not fit the
law. The principles apply to everyone. E.g. human rights, justice and equality. The person will be prepared to act to defend these
principles even if it means going against the rest of society in the process and having to pay the consequences of disapproval and or
imprisonment. Kohlberg doubted few people reached this stage.

SIGMUND FREUD
Fixation- Immobilization of a portion of the personality resulting from unsuccessful completion of tasks in a developmental stage.
The Oedipal complex is a term used by Sigmund Freud in his theory of psychosexual stages of development to describe a boy's
feelings of desire for his mother and jealously and anger towards his father. Essentially, a boy feels like he is in competition with his
father for possession of his mother. He views his father as a rival for her attentions and affections.
Electra complex-girls feel desire for their fathers and jealousy of their mothers.

Psychosexual stages and how personality develops.

1. The oral stage
􀂃 Sexual pleasure focuses on the mouth.
􀂃 Sucking is an important activity at this stage not only to obtain food to satisfy hunger, but also a source of intense pleasure for the
child. This is why babies suck, lick, bite, and chew anything they can get.
Fixation at the oral stage can occur for the following reasons.
a. When babies repeatedly experience anxiety over whether food will be given or not given.
b. When they come to learn that they are totally dependent on others.
Consequences
􀂃 Passive, over dependent, unenterprising adult.
􀂃 A child who experienced strong oral fixation, due to the birth of a sibling may revert to thumb sucking and exaggerated dependency.
It is a form of regression.
2. The anal stage
􀂃 It occurs during the second year of life, when children begin to develop voluntary control over bowel movements.
􀂃 Holding in and expelling feces gives great sensual pleasure to the child.
􀂃 The demands of toilet training by parents are imposed at this stage.
􀂃 Toilet training, according to Freud, is a crucial event because it is the first big conflict between the child's id impulses and society's
rules.
Fixation at this stage can occur due to strict and punitive toilet training.
Consequences
􀂃 The child may resist completely the urge to defecate in a free and enjoyable manner.
􀂃 May result in extreme orderliness during adulthood.
􀂃 May result in excessive neatness during adulthood.
3. The phallic stage
􀂃 It covers the years from about three to five or six years.
􀂃 Pleasure focuses on masturbation (self-manipulation) of the genitals.
􀂃 It is the period when the Oedipal and Electra conflicts occurs.
The concept of Oedipal and Electra complex
At five or six, sexual behavior is directed to mother. The child sees his father as rival. This is the rise of Oedipal conflict. But the boy
fears to retaliate his father. Freud called this castration anxiety. Castration anxiety is the earliest form of subsequent anxieties. In girls it
is called Electra complex. The girl being jealous of her mother maintains relationship with her father. But ultimately both boys and girls
identify with parents of opposite sex with her mother. Resolution of the Oedipal conflict
􀂃 The boy or the girl recognizes that he or she can never biologically possess the characteristics of the opposite sex parent.
􀂃 By means of identification the boy or the girl tries to adopt the attitudes, behaviors, and moral values of the same-sex parent.
4. The Latency stage
􀂃 The resolution of the Oedipal complex brings about a latency period lasting from about age six to eleven.
􀂃 During this stage the sexual and aggressive drives, which produced crises at earlier periods, are temporarily dormant. There is no
sexual zone for this state.
􀂃 This doesn’t mean that the child’s life at this time is entirely conflict-free. For example, the birth of a sibling may rouse intense
jealousy.
5. The genital stage
The stability of the latency period, however, does not last long.
As Erickson says, ‘It is only a lull before the storm of puberty’.
At puberty sexual energy becomes high. Once again, Oedipal feelings threaten to break into consciousness, and now the young person
is big enough to carry them out in reality.
Successful resolution of the Oedipal complex may result in:
􀂃 The formation of deep and mature love relationships with the opposite sex.
􀂃 Enabling the personality to assumes a place in the world as a fully independent matured adult.

HILDEGARD PEPLAU: THERAPEUTIC NURSE–PATIENT RELATIONSHIP

Hildegard Peplau (1909–1999; Fig. 3-3) 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 (Table 3-5).
During these phases, the client accomplishes certain tasks and the relationship changes that help the healing process (Peplau, 1952).
1. The orientation phase is directed by the nurse and involves engaging the client in treatment, providing explanations and information,
and answering questions.
2. The identification phase begins when the client works interdependently with the nurse, expresses feelings, and begins to feel
stronger.
3. In the exploitation phase, the client makes full use of the services offered.
4. In the resolution phase, the client no longer needs professional services and gives up dependent behavior. The relationship ends.
Peplau’s concept of the nurse–client relationship, with tasks and behaviors characteristic of each stage, has been modified but remains
in use today

Roles of the Nurse in the Therapeutic Relationship.

Peplau also wrote about the roles of the nurse in the therapeutic relationship and how these roles helped to meet the client’s needs.
The primary roles she identified were as follows:
• 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 to learn 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

Four Levels of Anxiety.

Peplau defined anxiety as the initial response to a psychic threat. She described four levels of anxiety: mild, moderate, severe, and
panic (Table 3-6). These serve as the foundation for working with clients with anxiety in a variety of contexts
(see Chap. 13).
1. 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).
2. 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.
3. Severe anxiety involves feelings of dread or terror. The person cannot be redirected to atask; he or she focuses only on scattered
details and has physiologic symptoms of tachycardia, diaphoresis, and chest pain. People with severe anxiety often go to emergency
departments, believing they are having a heart attack.
4. Panic anxiety can involve loss of rational thought, delusions, hallucinations, and complete physical immobility and muteness. The
person may bolt and run aimlessly, often exposing himself or herself to injury.

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 clientcentered therapy. Rogers was one of the first to use the term “client” rather than “patient.” Client-centered therapy
focused on the role of the client, rather than the therapist, as the key to the healing process.

The therapist must promote the client’s selfesteem 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

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.

Behavior modification 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 providespositive 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 volunteerto speak first to avoid the anxiety.

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.

Systematic desensitization can be used to help clients overcome irrational fears and anxiety associated with a phobia.

Crisis Intervention
A crisis is a turning point in an individual’s life that produces an overwhelming emotional response.

Caplan (1964) identified the stages of crisis:

(1) the person is exposed to a stressor, experiences anxiety, and tries to cope in a customary fashion;
(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; and (4) when coping
attempts fail, the person experiences disequilibrium and significant distress.
Crises can occur in response to a variety of life
situations and events, and fall into three categories:
• Maturational crises, 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.
• Situational crises 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 of family member.
• Adventitious crises, sometimes called social crises, include natural disasters like floods, earthquakes, or hurricanes; war; terrorist
attacks; riots; and violent crimes such as rape or murder.
Types of Brain Imaging Techniques
Computed tomography (CT, also called computed axial tomography or CAT scan) is a procedure in which a precise x-ray beam takes
cross-sectional images (slices) layer by layer.

Magnetic resonance imaging (MRI), a type of body scan, an energy field is created with a huge magnet and radio waves. The energy
field is converted to a visual image or scan. MRI produces more tissue detail and contrast than CT and can show blood flow patterns
and tissue changes such as edema.

Positron emission tomography (PET) and single photon emission computed tomography (SPECT), are used to examine the
function of the brain. Radioactive substances are injected into the blood; the flow of those substances in the brain is monitored as the
client performs cognitive activities as instructed by the operator.

PET uses two photons simultaneously; SPECT uses a single photon

Psychoimmunology- examines the effect of psychosocial stressors on the body’s immune system.
-A compromised immune system could contribute to the development of a variety of illnesses particularly in
populations already genetically at risk.