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Psychoanalytic Theories
Pioneered by Sigmund Freud (1856 1939) in Vienna
Father of Psychoanalysis - Your behavior today is directly or indirectly affected by your childhood days or experiences.
- STRUCTURE Personality
Structure
All human behavior is caused and can be explained Personality components conceptualized as id, ego, and superego Behavior motivated by subconscious thoughts and feelings; treatment involving analysis of dreams and free association Ego defense mechanisms Psychosexual stages of development Transference and countertransference
the causes of the clients 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. Psychoanalysis is lengthy, expensive, and practiced on a limited basis today; however, Freuds defense mechanisms remain current.
ID (4-5MONTHS)
Impulsive / I want to I want to I want to
Personality Structure
Instinctual drive PLEASURE PRINCIPLE PHYSIOLOGIC NEEDS PRIMARY PROCESS
EGO
Executive REALITY PRINCIPLE Conscious Competencies Decision Maker; Problem-Solving; Critical and Creative thinking
SUPEREGO
Should not Small voice of GOD Set norms, standards and values MORAL PRINCIPLE Conscience
SE
SE
ID
EGO
Schizophrenia
During the phallic stage, what significant development will Susan expect of her child? A.sexual gratification in urination and defecation B.sexual disinterest in the opposite sex C.sexual and body awareness D.sexual identification and maturity
Answer: C Rationale: the child during the phallic stage begins to explore the body and be aware of basic sexual differences of a girl and a boy, a reason for penis envy and castration fear to set in. A is what toddlers experience during the anal stage. D is achieved during adolescence. B. maybe a sexual dysfunction.
LATENCY STAGE 6 to 12 years old School Reading, writing, arithmetic Ability to care about and relate to others outside home
GENITAL STAGE 12 years old and above Developing satisfying sexual and emotional relationships with members of the opposite sex Planning lifes goals
A 36-year-old client with paranoid schizophrenia believes the room is bugged by the Armed Forces of the Philippines and a roommate is a foreign spy. The client has never had a romantic relationship, has no contact with family, and has not been employed for the past 14 years. Based on Eriksons theories, the nurse should recognize that this client is in which stage of psychosocial development? A. autonomy vs. shame and doubt B. generativity vs. stagnation C. integrity vs. despair D. trust vs. mistrust
Answer: D Rationale: This clients paranoid ideation indicates difficulty in trusting others. The stage of autonomy vs. shame and doubt deals with separation, cooperation, and self-control. Generativity vs. stagnation is the normal stage for this clients chronological age. Integrity vs. despair is the stage for accepting the positive and negative aspects of ones life, which would be difficult or impossible for this client.
Erik Erickson
Psychosocial Theory of Development
0-18 mos.
-attachment to mother which lays foundations for later trust in others -conflict: general difficulties relating to others. suspicion, fear of the future
18 m0s 3 yrs
Autonomy vs.
Shame/Doubt
Gaining some basic control of self and environment Conflict: independence-fear conflict, severe feelings of self-doubt
3 yrs 6 yrs
-becoming purposeful and directive -conflict: aggression-fear conflict; sense of inadequacy and guilt
6 yrs 12 yrs Industry vs. Inferiority Developing social, physical and school skills, competence Conflict: sense of inferiority; difficulty learning and working
12 yrs 20 yrs Identity vs. Role Diffusion Making transition from childhood to adulthood; developing a sense of identity Conflict: confusion of who one is, identity submerged in relationships or group memberships
21 yrs 35 yrs Intimacy vs. Isolation -establishing intimate bonds of love and friendship -conflict: emotional isolation
Generativity vs.
-fulfilling lifes goals that involve family, career and society, developing concerns that embrace future generations -conflict: self-absorption. Inability to grow as a person
55 yrs above Integrity vs. Despair Looking back into ones life and accepting its meaning Conflict: dissatisfaction with life, denial of or despair over prospect of death
SENSORIMOTOR STAGE-development
0 to 18 months
PRE-OPERATIONAL STAGE-development
proceeds from sensorimotor representation to prelogical thought and solutions to problems can use these representational skills only to view the world from their own perspective. Understand the meaning of symbolic gestures
2 to 7 years
CONCRETE OPERATIONAL-development
proceeds from prelogical thought to logical solutions to concrete problems understand concrete problems cannot yet contemplate or solve abstract problems
7 to 12 years
FORMAL OPERATIONAL-development
proceeds from logical solutions to concrete problems to logical solutions to all classes of problems cannot yet contemplate or solve abstract problems can also reason theoretically
12 and above
(18921949)
Established five life stages of personality development that included the significance of interpersonal
relationships
Described three developmental cognitive modes: prototaxic, parataxic, syntaxic Believed that unsatisfying relationships were the basis for all emotional problems Described the concept of therapeutic milieu or community
Leading nursing theorist and clinician: developed the nurse patient relationship with phases and tasks Identified roles of the nurse: stranger, resource person, teacher, leader, surrogate, counselor Described four levels of anxiety (mild, moderate, severe, panic) still widely used today
needs, safety and security needs, love and belonging needs, esteem needs, selfactualization
IvanBehavioral Theories Pavlov (18491936) B. F. Skinner (19041990) Behaviorism focuses on behaviors and behavior changes rather than on explaining how the mind works All behavior is learned Behavior has consequences (reward or punishment) Rewarded behavior tends to recur
Positive reinforcement increases the frequency of behavior Removal of negative reinforcers increases the frequency of behavior Continuous reinforcement is the fastest way to increase behavior; random intermittent reinforcement increases behavior more slowly but with longer-lasting effect Treatment modalities based on behaviorism include behavior
Existential Theories Cognitive therapy focuses on immediate thought processing and is used by most existential therapists
Albert Ellis Rational emotive therapy: people make
themselves unhappy through irrational beliefs and automatic thinkingthe basis for the technique of changing or stopping thoughts
therapy is the search for that meaning
Frederick Fritz Perls Gestalt therapy emphasizes selfWilliam Glasser Reality therapy focuses on the
awareness and identifying thoughts and feelings in the here and now
persons behavior and how that behavior keeps the person from achieving life goals Existential theorists believe that deviations occur when the person is out of touch with self or environment; thus, the goal of therapy is to return the person to an authentic sense of self.
Treatment Modalities
The client can often continue to work and can stay connected with family, friends, and other support systems while participating in therapy Personality or behavior patterns gradually develop over the course of a lifetime and cannot be changed in a relatively short inpatient course of treatment
Severely depressed and suicidal Severely psychotic Experiencing alcohol or drug withdrawal Exhibiting behaviors that require close supervision in a safe, supportive environment
Individual Psychotherapy
A method of bringing about change in a person by exploring his or her feelings, attitudes, thinking, and behavior It involves a one-to-one relationship between the therapist and the client The therapists theoretical beliefs strongly influence his or her style of therapy
SEVEN SUBTYPES
1.CLASSICAL PSYCHOANALYSIS Based on Freuds theory To uncover unconscious feelings and thoughts that interfere with the clients living a fuller life Free association- client is encouraged to say anything that comes to mind, without censoring thoughts or feelings Dream analysis Working through (transference)-process of repeated interpretation to the person of his or her unconscious processes has the effect of bringing about change
2. PSYCHOANALYTICAL PSYCHOTHERAPY
Uses DREAM ANALYSIS, TRANSFERENCE and FREE ASSOCIATION AND COUNTERTRANSFERENCE Therapist is much more involved and interacts with the client more freely Done through intimate professional relationship between the nurse/therapist and the client over a period of time (introductory, working and termination phase)
3. SHORT TERM DYNAMIC PSYCHOTHERAPY Indication-persons with specific symptom or interpersonal problem that he/she wants to work on Therapist directs the content Use of transference and dream analysis, NO FREE ASSOCIATION Weekly sessions (total number-12 to 30) Successful for highly motivated individuals who have insight and with positive relationship with the therapist
4. TRANSACTIONAL ANALYSIS Eric Berne Each person has three ego states and change from one to another frequently Parent-concepts of standards of behavior and how things should be done e.g. Go and take out the garbage. Adult-rational thinking and data analyzing part of the personality e.g. Would you please take out the garbage Child- feelings associated with persons, things or incidents represent the need-gratifying aspects of the personality. E.g. Is that why you married me?To be your garbage man? For group, family and individual Client to identify ego states for each given situation Rewarding of positive or negative behaviors with strokes Client work through these behaviors
A nurse teaches a client to control his panic by countering his negative thoughts of Im a failure, I cant pass any examinations, with I have passed most examinations and Ill try my best to pass the next test. This is an example of: A. psychoeducation B. distraction C. positive self-talk D. panic control treatment
Answer: C Rationale: Positive self-talk is an intervention the client can learn to counter fearful or negative thoughts that occur when faced with increased anxiety and panic. These are preplanned, rehearsed statements that give the client an area to focus on when symptoms of panic begin.
5. COGNITIVE PSYCHOTHERAPY Restructuring or changing ways in which people think about themselves 3 steps: 1.Thought stopping 2. Positive self-talk 3. Decatastrophizing Therapists help patients identify these thoughts
6. BEHAVIORAL THERAPY Changes in maladapted behavior can occur without insight into the underlying cause Based on learning theory (B.F.Skinner, Pavlov) Modeling Operant conditioning Self-control therapy- combination of cognitive & behavioral approaches talking to self Systematic desensitization Aversion therapy Token economy
7. GESTALT THERAPY Emphasis on the here and now Only present behavior can be changed, not history Uncover repressed feelings and needs Techniques: have a person behave the opposite of the way he/she feels, presuming that a person can then come in contact with a submerged part of the self; in dreams, person is ask to play the roles of persons in the dream to get in touch with different repressed feelings
During the meetings of a therapy group one member tends to monopolize the group discussion and no one is confronted this behavior. This nurse would best handle this situation by: A. saying to the client, You use too much time in our sessions. B. Ignoring the behavior because the client may become upset if confronted C. Encouraging the members of the group to do more talking by calling on various silent member D. Saying the group. Im wondering why the group is so willing to let this client do so much of the talking.
Group Therapy
Group therapy involves a therapist or leader and a group of clients sharing a common purpose; members contribute to the group and expect to benefit from it. Types of groups include: Psychotherapy groups, family therapy, family education, support groups, self-help groups, education groups
Group leadership
Therapy groups and education groups: formal leader Support groups and self-help groups: no formal leader Effective group leaders focus on group process as well as group content
Group roles
Growth-producing roles: information-seeker, opinionseeker, information-giver, energizer, coordinator, harmonizer, encourager, and elaborator Growth-inhibiting roles: monopolizer, aggressor, dominator, critic, recognition-seeker, and passive follower
The therapeutic results of group therapy (Yalom, 1995) include the following:
Gaining new information or learning Gaining inspiration or hope Interacting with others Feeling acceptance and belonging Universality -Becoming aware that one is not alone and that others share the same problems Gaining insight into ones problems and behaviors and how they affect others Altruism - Giving of oneself for the benefit of others
Psychosocial interventions are nursing activities that enhance the clients social and psychological functioning and promote social skills, interpersonal relationships, and communication. These interventions are used in mental health and other practice areas.
Psychosocial Interventions
The nurse recognizes that the focus of milieu therapy Is to: A.role-play life events to meet individual needs B.use natural remedies rather than drugs to control behavior C.manipulate the environment to bring about positive changes in behavior D.allow the clients freedom to determine whether or not they will be involved in activities
Milieu Therapy
Milieu Therapy
The nurse plans to use family therapy as a means of assisting a family to cope with their childs terminal illness. The nurses basis for this choice is that:
A. it is more time-efficient to deal with the whole family together B. the entire family is involved, since what happens to one member impacts all C. the nurse can control manipulation and alliances better by using this mode of intervention D. it will prevent the parents from deceiving each other about the true nature of their childs condition
Answer: B Rationale: Family therapy views the whole (Gestalt) within the context in which the emotional problems are occurring. Time efficiency is not an adequate rationale for choosing this therapeutic approach. Option C may or may not be true; an astute nurse can control manipulation and alliance within any group. Promotion of truthfulness is a secondary gain achieved through this mode of therapy
Purpose
Improve relationships among family members Promote family function Resolve family problems
ATTITUDE THERAPY
1. Paranoid Passive Friendliness 2. Withdrawn Active Friendliness 3. Depressed / Anorexia Kind Firmness 4. Manipulative Matter of Fact 5. Assaultive No Demand 6. Anti-social Firm, consistent
PSYCHOSOMATIC THERAPY
One of the chief benefits of ECT is that it: A. shortens the hospitalization and followup periods B. often serves as an adjunct to psychotherapy and other treatment C. decreases the need for medication and psychotherapy D. enable the client to terminate psychiatric treatment
Electroconvulsive Therapy
Effective in most affective disorders The induction of a grandmal seizure in the brain. Abnormal firing of neurons in the brain causes an increase in neurotransmitters Number of Treatments: 6-12 ,3 times a week, about .5-2seconds Unilateral or bitemporal
Indications: Patients who require rapid response Patients who cannot tolerate pharmacotherapy or cannot be exposed to pharmacotherapy Patients who are depressed but have not responded to multiple and adequate trials of medication
Preparations for ECT: Pretreatment evaluation and clearance Consent NPO from midnight until after the treatment Atropine Sulfate- to decrease secretions, succinylcholine (Anectine)- to promote muscle relaxation, Methohexital Sodium(Brevital)- anesthethic Empty bladder Remove jewelry, hairpins, dentures and other accessories Check vital signs Attempt to decrease patients anxiety
CRISIS
situation that occurs when an individuals habitual coping ability becomes ineffective to merit demands of a situation
Crisis Intervention
Exposure to stressor Increased anxiety when customary coping is ineffective Increased efforts to cope Disequilibrium and significant distress
Types of crises:
Maturational Situational Adventitious
Identify the degree of disruption the client is experiencing Assess the clients perception of the event Formulate nursing diagnoses Involve the patient and family if applicable with planning Implement interventions- new and old coping mechanisms Evaluate-reassessment, reinforcement
Anger
Anger is a strong, uncomfortable, emotional response to a provocation, either real or perceived. It results when one is frustrated, hurt, or afraid and energizes the body for defense (fight or flight).
Denying or suppressing angry feelings can lead to physical or emotional problems Anger that is expressed inappropriately can lead to hostility and aggression Appropriate expression of anger involves assertive communication skills that lead to problem solving or conflict resolution
Venting angry feelings by engaging in safe but aggressive activities (punching bag, yelling) is called catharsis. However, research has shown that catharsis may increase rather than alleviate angry feelings Clients with depression may have anger attacks when they feel emotionally trapped
Which nursing intervention is most important when restraining a violent client? A. reviewing facility policy regarding how long the client can be restrained B. preparing an as needed dose of the clients psychotropic medication C. checking that the restraints have been applied correctly D. asking if the client needs to use the bathroom or is thirsty
Hostile and aggressive behavior may occur suddenly without warning, but often stages or phases can be identified: Triggering Escalation Crisis Recovery Postcrisis
Hostility is an emotion expressed by: Verbal abuse Lack of cooperation Violation of rules or norms Threatening behavior (verbal aggression)
Related Disorders
Most psychiatric clients are not aggressive, but some exhibit angry, hostile, or aggressive behavior caused by: Paranoid delusions Auditory (command) hallucinations Dementia, delirium Head injury Intoxication with alcohol or drugs Antisocial and borderline personality
Rare psychiatric diagnosis involving discrete episodes of aggressive impulses resulting in serious injury or property damage Episodes are out of proportion to any provocation, and the person is remorseful and embarrassed afterward.
Acting Out
An immature defense mechanism in which the person deals with emotional conflict or stress by actions rather than reflection or feelings; the person is trying to feel less powerless or helpless by acting out.
Neurobiologic theories: decreased serotonin, increased dopamine and norepinephrine; damage to frontal or temporal lobes Psychosocial theories: failure to develop impulse control and ability to delay gratification
Treatments and Medications Treatment often focuses on treating the underlying or comorbid psychiatric diagnosis such as schizophrenia or bipolar disorder.
Lithium for bipolar disorder, conduct disorder, or mental retardation Carbamazepine (Tegretol) or valproate (Depakote) for dementia, psychosis, or personality disorders Atypical antipsychotics such as clozapine (Clozaril), risperidone (Risperdal), and olanzapine (Zyprexa) for dementia, brain injury, mental retardation, and personality disorders Benzodiazepines for older adults with dementia Haloperidol (Haldol) and lorazepam (Ativan) for clients with psychoses
Aggressive Clients
Assessment
Early assessment and intervention needed when clients are angry or hostile to avoid physically aggressive episodes Nurse must assess both individual clients and the therapeutic milieu or environment Assessment and intervention are based on five phases of aggression
Data Analysis
Common nursing diagnoses: Risk for Other-Directed Violence Ineffective Coping
Intervention
Interventions are most effective and least restrictive when implemented early in the cycle of aggression.
Managing the milieu includes:
Having planned activities; informal discussions Scheduled one-to-one interactions; letting clients know what to expect Helping clients with conflicts to solve their problems, including expression of angry feelings
Escalation phase:
Take control Provide directions in firm, calm voice Direct client to room or quiet area for time out Offer medication again Let client know aggression is unacceptable and nurse or staff will help maintain/regain control if needed If ineffective to that point, obtain assistance from other staff (show of force) to get client to take time out or take medication
Crisis phase: Staff must take control of situation as determined by facility or agency policy (trained in techniques for behavioral management) Use restraint or seclusion only if necessary Recovery phase as client regains control:
Talk about the situation or trigger Help client relax or sleep Explore alternatives to aggressive behavior Provide documentation of any injuries Staff debriefing
Postcrisis phase: Client is removed from any restraint or seclusion and rejoins the milieu Calm discussion of behavior; no lecturing or chastising; return to activities, groups, and so forth Focus is on appropriate expression of feelings, resolution of problems or conflicts in nonaggressive manner
Regular follow-up appointments, compliance with prescribed medication, and participation in community support programs help the client to achieve stability Anger management groups are available to help clients express their feelings and learn problem-solving and conflict-resolution techniques
Community-Based Care
How nurse handles own angry feelings Comfort with expression of anger from others Ability to be calm, nonjudgmental Nurse must have assertive communication skills, conflict resolution skills, ability to see that clients behavior/anger is not personal or a sign of nurses failure, and ability to deal with own fear when clients are aggressive or threatening
Self-Awareness Issues
Abuse is the wrongful use and maltreatment of another person can be child, spouse, partner, or elder parent
Victims of abuse and trauma can have both physical and psychological injuries, including: Agitation anxiety, silence Suppressed anger or resentment Shame and guilt Feelings of being degraded or dehumanized; low self-esteem Relationship problems; mistrust of authority figures
Social isolation Alcohol and other drug abuse Power and control by abusive person Intergenerational transmission process
Involves the mistreatment of one person by another in the context of an intimate relationship 90% to 95% of domestic violence victims are women Pregnancy escalates domestic violence Abuse can occur in same-sex relationships
Psychodynamics Often done by the husband to his wife Abusive husband believes that he owns his wife (as one of his possessions) and starts to be violent and abusive when the wife shows signs of being independent (like having her own job)
When preparing to present a community program about women who are victims of physical abuse, which of the following would the nurse stress about the incidence of battering? a. Death from battering is rare. b. Battering is a major cause of injury to women. c. Lower socioeconomic groups are primarily affected. d. Battering rarely involves pregnant women.
Assessment
It is necessary to identify victims of abuse in all settings, since they often do not seek treatment directly SAFE questions can be used to assess:
Stress/Safety- What stress do you experience in your
relationship? Do you feel safe in your relationship?
relationship where you have felt afraid
Afraid/Abused- Have there been situations in your Friends/Family- Are your friends aware that you have Emergency plan Do you have a safe place to go and
the resources you & your children need in an emergency? been hurt? Do your family/siblings know about this abuse?
Effect of Violence on the Children The violence the children experience has a great impact on their health and development. They tend to be more aggressive and
A 3-year-old client is bought to the emergency room with a fractured wrist and suspicious bruising on his arms. The step-father claims the boy fell out of bed. What is the most important criterion for the nurse to consider when deciding to report suspected child abuse? a. Inappropriate parental concern or the degree of injury. b. Absence of parents for questioning about the injury. c. Inappropriate between the history and injury. d. Incompatibility between the history and injury.
Child Abuse
Julia, 6 years old the youngest of 4 daughter of Mr. & Mrs. Gomez was brought to the emergency room with bruises all over the body and lacerations on her face. During the initial interview with the parents, they gave a typical description of an abused child when they say that Julia: A. has always been different from her sisters B. does not show respect for others C. tends to lie frequently D. always displays temper tantrums
Assessment
Delays in seeking treatment; old injuries that were not treated Unusual injuries such as scalding and cigarette burns Multiple, unexplained bruises Inconsistent history, or illogical explanation for the injuries Urinary tract infections; red, swollen, or bruised genitalia; tears of vagina or
Sexual Abuse Involves sexual acts committed by an adult towards an individual below 18 years of age
This may involve incest, rape, sodomy, exposure, rubbing or fondling of the victims genitals
This also includes sexual exploitation of involving minors in acts of pornography or in doing obscene acts
Neglect Intentional or ignorant withholding of physical, emotional, or educational needs for the improvement of the childs well-being May be in the form of: refusal or delay in seeking medical treatment abandonment inadequate supervision recklessness with the childs safety spouse abuse in the childs presence, failure to enroll the child in school
Psychological Abuse Abuse which adversely affects the childs emotional make-up These may include: verbal abuse blaming screaming name-calling constant family arguments resulting to fighting and yelling withholding of affection and experiences that promote love, security, and self-worth
Psychological Oblivion- Appearing numb of oblivious to the surroundings Shame/Silence -Often suffering in silence and continue to experience guilt and shame Hapless -Children come to believe that they are to be blamed for everything Agitation Mistrust -They develop difficulty in trusting and relating with others Emotions are intense -Emotionally, they are labile, intense, often unpredictable and may fear intimacy
A. B.
C.
D.
A nursing intervention which would help abusive parents is: Allow them to relate the history of child abuse in their family Instruct them on how they can encourage their children to obey them Teach them to handle angry behavior before it gets out of control Explain to them that as the child grows older, their needs differ.
Safe place - Getting the child to a safe place once abuse is identified Individual therapy for the child, play therapy Family therapy Treatment for parents for any substance abuse or psychiatric issues Social Services -Intensive involvement of social service agencies Note: Report
AUTHORITY. all cases of child abuse to the
A nurse is performing an admission assessment on a child and notes the presence of old and new bruises on the childs back and legs. The nurse. suspects physical abuse and would: a. File charges against the mother and the father of the child b. Report the case to legal authorities c. Ask the mother to identify the individual who is physically abusing the child d. Tell the child that she will need to go to a foster home until the situation is straightened out.
Elder Abuse
Physical, sexual, or psychological abuse or neglect Self-neglect Financial exploitation Denial of adequate medical treatment
Assessment
Possible indicators of physical abuse: Malnourished, dehydrated Rashes, sores, lice Smell of urine, feces, dirt Failure to keep needed medical appointments Untreated medical condition
Possible indicators of emotional or psychological abuse: Reluctance to talk openly Helplessness Withdrawal or depression Anger or agitation
Possible indicators of selfneglect: Inability to manage own finances Inability to perform activities of daily living Inadequate clothing Signs of malnutrition or dehydration
Possible indicators of abuse by caregiver: Caregiver speaks for the elderly person Caregiver shows indifference or anger Caregiver blames elderly person for physical problems Caregiver shows defensiveness Caregiver and client give conflicting accounts
Possible indicators of financial exploitation: Recent changes in will that client could not make Different signatures on checks Unusual activity in bank accounts Missing valuables Inability to manage money
Treatment and intervention may involve: Providing adequate support and respite for the caregivers Changing caregiving arrangements Moving the elderly person to a safe environment
Rape
Rape is a crime of violence and
aggression expressed through sexual means. The act is against the victims will or against someone who cannot give consent.
a.
b.
c. d.
A female victim of a sexual assault is being seen in the crisis center for a third visit. She states that although the rape occurred nearly 2 months ago, she still feels as though the rape just happened yesterday. The nurse would respond by stating: What can you do to alleviate some of your fears about being assaulted again. Tell me more about those aspects of the rape that cause you to feel like the rape just occurred. In time, our goal will be to help you move on from these strong feelings about your rape. In reality, the rape did not just occur. It has been over 2 months now.
The victim can be any age Half of rapes are committed by someone known to the victim Rape is underreported to the police Same-sex rape can occur between partners but is most common in institutions
Male rapists have been categorized as: Sadists- Sexual sadists aroused by pain of victim Anger -Those who rape as a displaced expression of anger and rage Predators- Exploitative predators Inadequate men
Physical and psychological trauma to rape victims is severe: Medical problems: victims are significantly less healthy; pregnancy, STDs, HIV are concerns Psychological Trauma -Victims may feel frightened, helpless, guilty, humiliated, and embarrassed; may avoid previously pleasurable activities Relational Problems -Relationship problems may occur, mistrust
Giving the victim control over choices whenever possible Prophylactic treatment for STDs Referral to therapy services; counseling; and groups for longer-term help
Psychiatric Disorders Related to Abuse and Violence Two psychiatric disorders are associated with histories of violence and abuse: 1. Posttraumatic stress disorder (PTSD) 2. Dissociative disorders
PTSD
Disturbing behavior resulting after a traumatic event at least 3 months after the trauma occurred Up to 60% of persons at risk (combat veterans, victims of violence and natural disasters) develop PTSD.
Dissociative Disorders
mechanism that helps a person protect the emotional self from recognizing the full impact of some horrific or traumatic event by allowing the mind to forget or remove itself from the painful situation or memory. Dissociation can occur both during and after the event and becomes easier with repeated use.
Which of the following statements made by a client whose husband has just died would be the most important in determining whether her response is normal or delayed or extended? My husband died 1 week ago. I feel sad and want to cry all the time. We were married for 40 years. We grew apart during the later years.
A. B. C. D.
emotions and affect that are a normal response to loss. Grieving, also known as bereavement, is the process of experiencing grief. Anticipatory grief is facing an imminent loss. Mourning is the outward sign of grief.
Experiences of grief and loss are essential and normal in the course of life; letting go, relinquishing, and moving on happen as we grow and develop.
Losses may be planned, expected, or sudden. Loss of a loved one is probably the most devastating type of loss, but there are many other types of losses: (Maslows) Physiologic (loss of limb, ability to breathe) Safety (domestic violence, posttraumatic stress disorder, breach of confidentiality)
Types of Losses
Security/sense of belonging (relationship loss [death, divorce]) Self-esteem (ability to work, children leaving home) Self-actualization (loss of personal goals, such as not going to college, never becoming an artist or dancer)
Nurses must recognize the signs of grieving to understand and support the client through the grieving process. The therapeutic relationship and therapeutic communication skills are paramount when assisting grieving clients.
52 year old Renee Sandoval comes to the mental health clinic and related that since the death of her husband she feels really miserable. She says in a loud voice, How could he leave me? I cant deal with this! Which of the following stages of the grief reaction is she most likely displaying at this time? B. anger D. resolution
A. Denial C. Bargaining
Denial (shock and disbelief) Anger (toward God, relatives, health care providers) Bargaining (trying to get more time, prolonging the inevitable loss) Depression (awareness of the loss becomes acute) Acceptance (person comes to terms with impending death or loss)
John Harveys phases of grieving: Shock, outcry, and denial Intrusion of thoughts, distractions, and obsessive reviewing of loss Confiding in others to emote and cognitively restructure
Rodebaughs stages of grieving: Reeling Feelings Dealing Healing There are many similarities among theorists about grief. Not all clients follow predictable steps or make steady progress.
A.
B.
C. D.
What is the most therapeutic initial nursing intervention in helping a client deal with feelings after the loss of a spouse? Help the client see the positive aspects of the relationship with a spouse. Describe the stages of the grieving process Support the clients expression of feelings Explain that in time the hurt feelings will lessen
Dimensions of Grieving
Questioning and trying to make sense of the loss Attempting to keep the lost one present
Emotional responses to grief Spiritual responses to grief Behavioral responses to grief Physiologic responses to grief
The nurse must encourage clients to discover and use effective and meaningful grieving behaviors: Praying Attending memorials and public services Performing rituals Staying with the body
Nurses Role
Assessment (P-S-C)
Does the client have adequate support? Does the client have adequate coping behaviors?
Intervention (P-S-C)
Regarding perception of the loss
Explore perception and meaning of the loss
Essential communication and interpersonal skills to assist grieving: (BUTTONS) Beliefs- Respect the clients personal beliefs Uniqueness -Respect the clients unique process of grieving Touch -Appropriate use of touch indicates caring Trust -Be honest, dependable, consistent, and worthy of the clients trust Offer Smile -Offer a welcoming smile and eye contact Name- Refer to a loved one or object of loss by name (if acceptable in the clients culture) Simple - Use simple, nonjudgmental
Self-Awareness Issues
Examining ones own experiences with grief and loss Taking a self-awareness inventory and reflecting on the results may be helpful.