PSYCH THEORIES

Bridget Heyne, RNC, FNP, MSN, Ed.D.

THEORY
Hypothesis, speculation, supposition Attempt to explain human behavior Explanation of behavior is based on the theorist assumptions, beliefs & world view

Psychoanalysis
Psychoanalysis focuses on discovering the causes of the clients unconscious and repressed thoughts, feelings, and conflicts believed to cause anxiety. People do not like conflict so develop certain structures in their mind or ways of responding to maintain equilibrium & keep conflicts from causing too much discomfort
Helping the client to gain insight into and resolve these conflicts and anxieties 3

Father of Psychoanalysis Sigmund Freud

FREUD-PSYCHOANALYTIC THEORY
Was a neurosurgeon who worked primarily with hysterical upper middle class women. Most mental disorders were due to unresolved issues originating in childhood (occurring during the first 5 years) NO human behavior is an accident but is motivated by an subconscious thought, feeling, need, wish or intent Freud believed that all psychologic and emotional events are understandable, that childhood experiences caused adult neuroses, and that therapy provided insight into the meaning of events. Use of defense mechanisms to deal with an incompatible/ unacceptable idea that causes internal conflict 5

FREUD
Felt that there were different levels of psychological awareness The mind as an iceberg Conscious part is the tip of the iceberg. What we are aware of- events and experiences we easily remember- phone #, dates of special holidays. Conscious mind is thought to be under the influence of the Ego Preconscious is just below the surface of awareness. Are not readily remembered but can be recalled relatively easily. Unconscious contains unacceptable urges, repressed memories. Greatly influences our feelings. Memories retrieved by hypnosis, in dreams or incomprehensible 6

Personality Makeup
Id, Super ego & Ego which are entities of the mind, used to explain observed behaviors resulting from conflicts r/t the needs of the individual, the restriction of society,& internal moral values Idunconscious, primitive, pleasure principle, cannot tolerate frustration, Impulsive, egocentric, cannot problem solve; We are all Id at birth. Superego (Perfection principle) concerned w/ moral & ethical behavior (all the should nots of life). Represents the ideal rather than the real. Legalistic, It seeks perfection rather than pleasure.. Ego (Rational self or reality driven)- strives for balance, is the mediator, mature adaptive behavior, reality tester, a problem solver, develops defenses mechanism to help the individual deal with stressful situations . Subject to anxiety if there is an imbalance between the Id & Super Ego. Ability to assess w/out anger or 7 aggression is an example of a healthy ego

DEFENSE MECHANISMS
Used to protect individuals (Protective mechanism) from internal conflicts (feelings, memories) and external stressors which causes the patient anxiety Used unconsciously . Begins in childhood but become maladaptive if used for too long (Gone with the wind) Distorts, hides, denies reality, disruptive relationships. Therefore, may project onto others how they feel about themselves
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Table Table 5.1 5.1 Defense Defense Mechanisms Mechanisms

Defense Mechanisms
Regression- returning to an earlier level of adaptation. Adolescence sucking thumb & not speaking. Not all defense mechanisms are bad. Some serve as health coping mechanisms used by mature adults Altruism: emotional conflict & stress are dealt with by meeting the needs of others. The person receives gratification by helping others or from the response of others to being helped. 6 months after loosing her husband, she spends 1 day a week doing grief counseling & is effective in helping others Sublimation: substituting socially acceptable activity for strong unacceptable impulses. Strong hostile feeling are channeled by playing a contact sport Humor: Deals with stressors by emphasizing the amusing or ironic 10 aspect of the conflict (stand up comics)

FREUD
He defined anxiety as a feeling of tension, distress & discomfort produced by a perceived or threatened loss of control. Felt that there was a repression or tucking away of things that were unsafe to remember. This defense bandage mechanism cannot be maintained for long & affects personality & behavior Psychopathology results when a person has difficulty transitioning from 1 stage to the next, when a person remains at a particular stage but should have transitioned upward or when there is regression to an earlier stage. 11

FREUD
Freud based his theory of childhood personality development on the belief that sexual energy was the driving force of human behavior. There are 5 stages of psychosexual development: Based on sexual growth/development: Oral stage (0-1 yr) smoking, biting, alcoholism. Sarcastic person Anal stage (1-3yr)- (anal retentiveness)Obsessive/compulsive, Hoarding, stinginess, rigid thoughts; (anal explusiveness)- messiness, destructiveness
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FREUD
Phallic stage (3-6 yrs)- repression of attraction to the opposite sex leading to same sex identification; lack of resolution results in difficulties w/ sexual identity & difficulty w/ authority figure Latency (6-12 yrs) conflict resolution w/ shift to other interest & friends. Difficulty identifying w/ others & developing social skills. Sense of inadequacy Puberty/ Genital (12 yrs & older)- reemerging sexuality. Development of satisfying sexual & emotional relationships w/ members of the opposite sex. Planning of life goal, emancipation from parents. Problems; Non-satisfying intimate relationships, lack of strong personal identity
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Harry Stack Sullivan

Social-Interpersonal Theory
Initially used the Freudian framework when working with patients Did not like dealing with the unseen & private mental process w/in the individual Sullivan interpersonal relationship theory is grounded in observable behavior that resulted from patient interactions Sullivan felt that the purpose of all behavior is to get needs met through interpersonal interactions (develop security) & to decrease or avoid anxiety (painful feeling or emotion arising from insecurity) that may result from negative responses to an interaction 15

SULLIVAN

SULLIVAN
Who I am & my sense of myself is built from childhood experiences. It results from reflected appraisals the person obtains and learns to accept from contact with significant others. The self develops in the process of seeking physical satisfaction of bodily needs and security. To feel secure, the self essentially requires feelings of approval and prestige as protection against anxiety
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SULLIVAN
Sullivan believed that the nurses role includes educating clients and assisting them in developing effective interpersonal relationships. Mutuality, respect for the client, unconditional acceptance, and empathy are cornerstones of Sullivans theory. The nurse must interact with the client A therapeutic environment (Milieu) is an accepting atmosphere and provides opportunities for clients to practice interpersonal skills 17

ERIK ERIKSON Stages of Development

ERIK ERIKSON
Follower of Freud but felt that it was negative & restrictive Eriksons developmental theory of personality attempted to account for biologic instincts as well as cultural and interpersonal tasks that must be accomplished to move forward developmentally. Each stage of growth involves maintaining a balance between disorder & stability to adjust & move forward to the next level/stage. Successful resolution affects success in next stage Failure to resolve stage may lead to psychological symptoms at later time His model spans the full life cycle & felt that personality 19 continues through old age (Unlike Freud)

ERIK ERIKSON
This theory can help identify age appropriate or arrested developmental interpersonal skills as clients with mental illness usually exhibit some degree of developmental delay or incomplete resolution of developmental task that parallel their chronological age Helps the nurse know what types of interventions are most likely to be effective based on the developmental level of the client through assessment of their developmental functioning
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Eriksons Stages
Trust vs. Mistrust(0-1 1/2yrs) The major task is to develop a basic trust in mothering figure & be able to generalize it to others. Suspicious, problem relating to others Autonomy vs.. shame & doubt (1 -3) - Gain self control & independence within the environment w/o loss of self esteem. Shame- something is wrong with me (I am wrong, ). Severe self doubt Initiative vs. guilt(3-6)- The goal is to develop a sense of purpose & the ability to initiate & direct ones own activity ( Exploration & daring). Guilt (I have done something wrong). 21 Sense of inadequacy &/ or guilt

Erickson's Stages
Industry vs Inferiority(6-12)- Development & mastery of social & cognitive skills. Task is to achieve a sense of self confidence (Social skills) by learning, competing & receiving recognition from significant others, peers & acquaintances. Difficulty learning & working, sense of inferiority Identity vs. role diffusion/confusion(12-20) secure sense of self & realization of competence vs feeling that will never be good enough. Confusion about who one is Intimacy (able to nurture self & others, to commit) vs. isolation(20-35). Goal is to form lasting relationships or a commitment to another person or cause. Emotional 22 isolation, egocentricity

Erickson's Stages
Generativity vs. stagnation(35-65) Creative, concern for others & future generations vs self indulgence, self absorption, inability to grow, despair over aging Ego integrity vs. despair(65+ to death) Review of ones life & derive meaning from events in ones life, sense of fulfillment, Positive sense of self worth vs loss of hope, helpless, denial & despair over the prospect of death

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Abraham Maslow
Maslows Hierarchy of Needs

MASLOW
Focused on human Needs Fulfillment Proposed an order of basic human needs. Physiological needs must be met before higher-level needs such as self-esteem and self actualization Sequencing nursing actions based on client priority needs Emphasized nursing prioritization of action in caring for the patient to take collect anything other the essential info when a client is struggling w/ drug w/drawl is inappropriate
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Maslows Basic Needs

MASLOW
Physiological Needs biological need for food, shelter etc Safety and security- is the one of the most basic needavoiding harm, physical safety & security, order, limits, Love and belonging- companionship, giving & receiving love, relationships Esteem and self-esteem- respect from others, success, achievement Self-actualization- takes years to achieve- fulfillment of unique potential, becoming everything that one is capable of becoming. An example of a highly evolved mature, balance individual

Burrhus Frederic Skinner Classical Conditioning

19041990

B. F. SKINNER
Classical Conditioning

Behaviorism focuses on behaviors and behavior changes, rather than explaining how the mind works
Behaviorist- Human behavior is learned Behavior has consequences (reward or punishment)

Rewarded behavior tends to recur

Positive reinforcement increases the frequency of behavior29 Operant conditioning

B. F. SKINNER
Removal of negative reinforces increases the frequency of behavior
Negative consequences decreases the likelihood of a behavior Continuous reinforcement is the fastest way to increase behavior; random intermittent reinforcement increases behavior more slowly but with longer-lasting effect Therefore learned behavior responses can be modified Treatment modalities based on behaviorism include behavior modification, token economy (get a token for a desired behavior), and systematic desensitization, Aversion therapy (punishment- ) Modeling behavior Milieu- safe supportive environment with emphasis on group & social 30 interaction. Rules through peer pressure

Jean Piagets Cognitive Theory

Jean Piagets Cognitive Theory

Cognitive therapy focuses on immediate thought processing. How a person perceives or interprets an experience determines how you feel & behave . Therefore must help correct distorted perceptions and dysfunctional beliefs. Cognitive behavioral theory focuses on the present rather than the past. Symptoms associated with neuroses and psychoses are identified as clusters of learned behaviors that persist because they are rewarding to the individual. Must learn to think more adaptively and realistically. Must substitute rational beliefs for irrational beliefs & eliminate 32 self defeating behavior

Biological Theory
Focuses on neurological, chemical, biological, c & genetic issues to understand how the brain & body interact to create emotion, memories & perceptual experiences Views abnormal behavior as a disease process or defect (usually in Limbic system of the brain) Targets site of the defect/ illness using surgery or drugs
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Nursing Theorists
Nursing theories assist nurses to: Organize assessment data, Identify problems, Plan interventions, Generate goals and nursing actions, And determine and evaluate outcomes.

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The Mother of Psychiatric Nursing

Hildergard Peplau

Hildergard Peplau
Emphasized the interpersonal nature of nursing and the need for nurses to use psychodynamic concepts and counseling techniques Nurse/client relationship The nurse-client relationship is structured to provide a model for adaptive interpersonal relationships that can be generalized to others Interpersonal experience is a learning experience for the nurses and can benefit both the nurse & client
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MADELEINE LEININGER
Cultural Care, Diversity and Universality Historically interventions centered on illness rather on prevention & health promotion Must have understanding of clients culture & associating stress that may lead to mental illness Important of respect in Hispanic culture. Asianavoids conflict, watch for non- verbal's Mental illness occurs within cultural framework
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DOROTHEA OREM
A Behavioral Nursing theory which focuses on self care deficit & includes both physical and psychosocial human needs Nursing care is needed when person can no longer provide self-care (inability to maintain life, health, and well-being) Needs (i.e. seriousness of mental illness) indicate appropriate nursing system Concrete because of an underlying disorder, the patient neglects self eg eating, rest, personal 38 hygiene, rest, safety

Culture
Still not well understood Describes a particular societys entire way of living, including beliefs, feelings & knowledge. These guides the members conduct & are passed down from one generation to the next Learned through socialization Shared by all group members Ever-changing and dynamic
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Culture & Mental Illness

Culture determines: What behavior is normal/what is abnormal (Behavior that is normal at a party is unacceptable at a business meeting). Often mental illness is seen as the degree to which a person fails to fulfill the expectation of the culture What beliefs are acceptable/what are not (What may be perfectly acceptable in one culture may be criminal in another). Concepts of mental health/mental illness. Stigma varies Acceptability of various treatment modalities, (exorcism, coining).
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Cultural Competence
Practice standards to ensure that clients of all cultures receive information about treatment in understandable ways considering education, acculturation, and language.
An essential step toward developing cultural competence is to examine ones own perceptions, prejudices, and stereotypes regarding the particular 41 cultural group of interest.

The Culturally Competent MENTAL HEALTH NURSE

Nurse must understand own culture Will be aware of similarities and differences between clients culture and nurses culture Will plan culturally sensitive care

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The Culturally Competent MENTAL HEALTH NURSE

Will have knowledge of central beliefs and behaviors of clients culture Will assess level of integration and identification with the dominant culture Cultural Assessment Adopt open and objective attitude toward others Recognize that variation within cultural groups exists Adapts care to the clients needs & preferences
(continues)
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Stages in Acquiring Cultural Competence

Unconscious Incompetence Not being aware of lacking information about other cultures Conscious incompetence Being aware of lacking information about other cultures but do not care Conscious Competence Actively learning about other cultures and verifying information Unconscious Competence Automatically providing culturally competent care

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Spirituality
Includes core beliefs about people, the divine, and relations between them. May derive comfort & inner strength from spiritual beliefs (decreases anxiety) Influenced by culture, life experiences Helps connect people to each other, the community, the world Along with religion and faith, may be experienced and expressed in a variety of ways Client may need support from priest, Rabbi especially in cases of spiritual distress.
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ETHICS
Is the rightness or wrongness of an action, the goodness or badness of ones motive, & the results (good or bad) of action taken Important in psychiatric nursing- dilemma of the right or obligation to the client vs obligation to the community Understanding basic principles can help in decisionmaking 46 What one should do

ETHICS
Ethical Dilemmas- Is a situation that requires an individual to make a choice between 2 equally unfavorable alternatives The dilemma generally creates overwhelming emotional responses Often the reasons supporting each sides of the argument is logical & appropriate Examples: right to refuse medication, the right to the least restrictive treatment alternative 47

News Flash
Not guilty by reason of insanity is a phrase that evokes passion in many people. Jeffery Dahmer, the cannibalist murderer, did not say that he did not do it. He said he was not guilty because he did not know what he was doing.

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Insanity Defense
Insanity: the person could not control his or her actions or understand the difference between right and wrong at the time of the crime (MNaghten rule) 13 states have provisions for a guilty but insane verdict that holds the person responsible for the crime while ensuring that he or she receives treatment. If the are unable to understand the charges against them then they cannot be tried for the crime until they do. Must be able to participate in their own defense.
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Legal Issues in MENTAL HEALTH NURSING

Law is involved in psychiatric nursing- individuals who do not understand the nature or implications of unlawful actions because of insanity cannot be held legally accountable for their actions Must balance rights of client and society: Tarasoff vs the Regents of the University of California. MH Professionals have a duty to warn of threat of harm to others
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Legal Issues in MENTAL HEALTH NURSING

Laws set out rules and procedures: Rogers vs. Okin (Boston), patients right to refuse medication. Had significant implications for nurses who are tempted to force patients to take their medication for their own good. Laws differ from state to state

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Legal Issues in the COMMUNITY

Informed consent-for medication & treatment Sexual involvement with clients Breaching confidentiality Self-destructive and violent behavior

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CLIENTS RIGHTS
Right to privacy- a consent form must be signed to release confidential information about a patient Right to keep personal items Right to enter into legal contracts Right of habeas corpus ( court proceeding to seek judicial discharge) Right to informed consent Right to refuse treatment
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TORT
A civil wrong or wrongful act against a person that violates his or her rights & results in injury, loss or damage Unintentional Torts Negligence: harm caused by failure to do what is reasonable and prudent (Suicidal patient near an open window) Malpractice: (Professional negligence) is negligence or incompetence on the part of a 54 professional that causes harm to the client

Intentional Torts
Assault: An act that results in a persons genuine fear & apprehension that the person will be touched w/out their consent Battery: harmful or unwanted actual contact False imprisonment: unjustifiable detention.
Holding a competent person against his or her will by verbal or physical means. Actual force is not a requirement. The individual needs only to be placed in fear of imprisonment by someone who has the ability to carry out the threat
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Intentional Torts
Slander: the sharing of information orally that could be detrimental to the clients reputation Libel: sharing of information in writing that could be detrimental to the clients reputation Deformation of character: when information is shared that could be detrimental to a clients reputation, the nurse may be at risk for defamation of character. Documented information should reflect objective findings, not the nurses perception of the client.
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Least Restrictive Environment

Treatment must be provided in the least restrictive environment appropriate to meet the clients needs Physical restraint or seclusion in a locked room can be used only when the person is imminently aggressive or threatening to harm himself

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Least Restrictive Environment

Restraint and seclusion, if used, must be in place for the shortest time necessary & after de-escalation has failed Many regulations govern the monitoring of clients in seclusion or restraint for their safety Maintain contact & assure the client that seclusion is a way to maintain safety
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Confidentiality HIPAA (1996)

Need the clients consent to disclose information to anyone except those necessary for the implementation of the clients treatment plan Both civil (fines) and criminal (prison sentences) penalties exist for violation of patient privacy

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Duty to Warn Third Parties

Duty to warn a third party is an exception to client confidentiality (Tarasoff ruling) Clinicians must warn identifiable third parties of threats made by a client Nurse must record this in their nurses notes & inform the physician, & other members of the health care team (treatment team) so the appropriate steps taken Is the client dangerous to others Is the danger the result of a serious mental illness Is the danger serious Are the means to carry out the threat available Is the danger targeted at a particular person/victim 60 Is the victim accessible

VOLUNTARY ADMISSION
Client makes direct application to the institution for service May sign out of facility at any time unless the HCP following mental status examination that the client may be harmful to..

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Involuntary Admission
If client is a A danger to self- emergency admission To others Mentally Ill Unable to provide for basis needs- gravely disabled

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EMERGENCY ADMISSION
A legal hold resulting temporary suspension of the civil rights of a person Detained for short time (valid for 72 hours)/5150 Will assess need for longer treatment Usually carried out by police in most jurisdictions Client must be deemed a danger to self (DTS), a danger to others ( DTO) or Gravely Disabled
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EMERGENCY ADMISSION
Gravely Disabled means that the individual is Not able to provide or make practical use of food, clothing & shelter May be released earlier if a licensed practitioner decides that they no longer meet the above criteria

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Civil Commitments
5250 allows for a hold extension of the 5150 up to 14 days This extension occurs only if the person remains a DTS, DTO or GD A hearing must occur w/in 3 business days with an unbiased hearing officer Even if psychotic or severely depressed but not a DTS, DTO or GD, then you cannot hold this person
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Civil Commitments
5260 Danger to self only ( Imminently suicidal). Can be kept for additional 14 days 5270 Gravely Disabled only. Can have up to 30 day hold

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Civil Commitments
Writ of Habeas Corpus ( a demand to appear before a judge) A hearing to determine if a patients legal rights are being suspended w/o cause Staff assist the patient to fill out forms & must come before a judge as soon as it is possible Judge decides if patient is to be released or under go further treatment
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Civil Commitments
Sterling Hearing Made regarding the legality of a legal hold Both the patient & the hospital facts are presented No decision is made on length of stay or any treatment issues Decision only involves whether patient will stay or be released immediately
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Civil Commitments
Reese Hearing When it is determined that a patient requires treatment eg medication but the patient refuses Must show that the patients impairment outweighs the potential risk of the medication. Medication will in all probability provide the help the patient needs That the patient is not able to evaluate the benefits of the treatment in question Patient must show logical reason for refusal of the medication Judge decides if the medication/treatment can be given 69 against the patients will

Civil Commitments
T- Con ( Temporary Conservatorship) Legal hold filled by the public Guardian Officer in Superior court With patient unable to make informed decisions about their care Valid for 30 days to allow time for treatment Another court date set prior to end of T-Con to determine if further treatment is necessary & T-Con should be extended
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Civil Commitments
Many clients view these restrictive interventions as forms of abuse, while mental health care providers see them as helping people who cant take care of themselves. It is assumed that a person without a mental disorder would not choose suicide. Thus, mental health caregivers seek to prevent suicide on the basis that this is what the client would choose if the 71 client were mentally capable of choosing.

Prevention of Liability
Nurses can minimize the risk of law suits through safe competent nursing care & descriptive accurate nursing care Nurses can minimize the risk of lawsuits through safe, competent nursing care and descriptive, accurate documentation

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THE END

Question #1 Please choose an answer

Determine the type of communication occurring in the following example: Nurse: Good morning, Mrs. Jones. How did you sleep last night? Patient: I had a lousy night. The person in the next room kept yelling in his sleep. Nurse: I know what you mean, sometimes my husband does that too. Im luckier than you were because I can shake him & get the shouting to stop. I guess you wont feel comfortable doing that to another person you dont really know. Patient: No, Besides that, who wants to walk around here at night? Still, I think I want to meet him. He looked pretty when I saw the nurse taking him around the unit after he was admitted 74

Question #1 cont
This interaction should be assessed as: a) Therapeutic b) Collegial c) Social d) Intrapersonal A- Does not promote client growth & is not client focused B- Is used for professional collaboration C- Is superficial, Of benefit to both individuals. No expectation of help exist 75 D- Takes place w/in an individual

Question #2 Please choose an answer

The nurse has begun to treat the client as a mutual friend, focusing on topics of social interest and seeking support from the client. The result that can be anticipated is most likely to be: a. blurred boundaries and role confusion. b. establishment and maintenance of trust. c. client experiencing freedom to grow. d. collaboration to determine client needs.
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Question #3 Please choose an answer

A psychiatric technician mentions that little of what takes place on the behavioral health unit seems to be theory based. The nurse can enlighten the technician by citing the fact that many of Sullivans theoretic constructs are used in A. the ongoing use of restraint and seclusion as behavior management tools. B. the structure of the therapeutic milieu of most behavioral health units. C. assessment tools based on age-appropriate versus arrested behaviors. D. the method nurses use to determine the best sequence for nursing actions.
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Question #3 answer
The structure of the therapeutic environment has as foci an accepting atmosphere and provision of opportunities for practicing interpersonal skills. Both constructs are directly attributable to Sullivans theory of interpersonal relationships. Option: A: Sullivans interpersonal theory did not specifically consider use of restraint or seclusion. Option C: Assessment based on developmental level is more the result of Eriksons theories. Option D: Sequencing nursing actions based on client priority needs is related to Maslows hierarchy of needs.
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