1. Theories and Therapies
Chapter 2
Theories and Therapies
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Objectives
Evaluate the premises behind the various therapeutic models discussed in this chapter.
Describe the evolution of therapies for psychiatric disorders.
Identify ways each theorist contributes to the nurse’s ability to assess a patient’s behaviors.
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Objectives (Cont.)
Provide responses to the following based on clinical experience:
An example of how a patient’s irrational beliefs influenced behavior.
An example of countertransference in your relationship with a patient.
An example of the use of behavior modification with a patient.
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Objectives (Cont.)
Identify Peplau’s framework for the nurse–patient relationship.
Choose the therapeutic model that would be most useful for a particular patient or patient problem.
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Objectives (Cont.)
Identify Peplau’s framework for the nurse–patient relationship.
Choose the therapeutic model that would be most useful for a particular patient or patient problem.
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Introduction
Psychological theories help us to explain behavior
Psychological therapies are treatments based on these theories
An overview of theories and therapies and their relevance to nursing and psychiatric mental health nursing are described in this chapter
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7. Psychoanalytic Theories
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8. Psychoanalytic Theory
Levels of awareness
Conscious
Preconscious
Unconscious
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9. Psychoanalytic Theory (Cont.)
Personality structure Id
Pleasure principle
Reflex action
Primary process
Ego
Problem solver
Reality tester
Superego
Moral component
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10. Psychoanalytic Theory (Cont.)
Defense mechanisms and anxiety
Operate on unconscious level
Deny, falsify, or distort reality to make it less threatening
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11. Psychoanalytic Theory (Cont.)
Oral (0 to 1 year)
Anal (1 to 3 years)
Phallic (oedipal) (3 to 6 years)
Latency (6 to 12 years)
Genital (12 years and beyond)
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12. Classical Psychoanalysis
Seldom used today
Intrapsychic conflict no longer considered to be the cause of all mental illness
Valid tools and concepts
Transference
Countertransference
Transference refers to unconscious feelings that the patient has toward a health care worker that were originally felt in childhood for a significant other.
Countertransference refers to unconscious feelings that the health care worker has toward the patient.
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13. Audience Response Questions
According to Freud, which aspect of the personality motivates an individual to seek perfection? Id
Ego
Superego
Not sure
ANS: C
The superego represents the ideal rather than the real; it seeks perfection, as opposed to seeking pleasure or engaging reason.
REF: 21
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14. Psychodynamic Therapy
Newer psychoanalytic model
Focuses more on here and now
Uses many tools of psychoanalysis
Best candidates are the “worried well”
Have a clear area of difficulty
Are intelligent and well motivated for change
Rapid back and forth between therapist and patient
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Case Study
Ms. V is admitted to your unit after being picked up by police for intoxication and anxiety. After she is stabilized, she spends the rest of the night on suicide watch. In the morning, she is admitted for a stay of 3 to 5 days for evaluation.
The police are not pressing charges for disturbing the peace because she has promised to get help.
Source:
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Interpersonal Theory
Purpose of all behavior is to get needs met through interpersonal interactions and to reduce or avoid anxiety
Anxiety: painful feeling or emotion that arises from social insecurity or prevents biological needs from being satisfied
Security operations: measures the individual employs to reduce anxiety and enhance security
Self-system: all of the security operations an individual uses to defend against anxiety and ensure self-esteem
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17. Interpersonal Therapy
Interpersonal therapy is most effective in treating:
Grief and loss
Interpersonal disputes
Role transition
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Case Study
Ms. V reveals that she began drinking heavily over the last couple of weeks when her boyfriend tried to break up with her. During her stay she receives medication for depression and begins having sessions of interpersonal therapy.
The nurse should realize the importance of maintaining self-awareness and seeking supervisory guidance as the therapeutic relationship progresses.
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19. Sullivan’s Theory and Nursing
Foundation for Hildegard Peplau’s theory
Participant observer
Mutuality
Respect for the patient
Unconditional acceptance
Empathy
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20. Hildegard Peplau’s Theory of Interpersonal Relationships in Nursing
Peplau influenced by Sullivan’s work
The art of nursing
Provide care, compassion, and advocacy
Enhance comfort and well-being
The science of nursing
Application of knowledge to
Understand a broad range of human problems and psychosocial phenomena
Intervene in relieving patients’suffering and promote growth
Based on Sullivan’s interpersonal theory, Peplau is considered the “mother” of psychiatric mental health nursing.
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21. Peplau and the Therapeutic Relationship
Levels of anxiety
Interventions to lower anxiety
Aim to improve patient’s ability to think and function
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22. Behavioral Theories and Therapies
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Behavior Theories
Pavlov’s classical conditioning theory
Watson’s behaviorism theory
Skinner’s operant conditioning theory
Implications for nursing
Modifying or replacing behaviors
Behavior management
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Behavioral Therapy
Modeling
Operant conditioning
Systematic desensitization
Aversion therapy
Biofeedback
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25. Cognitive Theories and Therapies
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26. Cognitive Theory and Therapies
Dynamic interplay between individuals and the environment
Thoughts come before feelings and actions
Thoughts about the world and our place in it are based on our own unique perspectives, which may or may not be based on reality.
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Cognitive Theories
Rational-emotive behavior therapy (Ellis)
Aims to eradicate irrational beliefs
Recognize thoughts that are not accurate
Cognitive-behavioral therapy (Beck)
Test distorted beliefs and change way of thinking; reduce symptoms
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Humanistic Theories
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29. Theory of Human Motivation
Asserts that psychology must go beyond experiences of hate, pain, misery, guilt, and conflict to include love, compassion, happiness, exhilaration, and well-being
Human beings are active participants in life, striving for self-actualization
When lower needs are met, higher needs are able to emerge
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30. Maslow’s Hierarchy of Needs
Human beings are active participants in life, striving for self-actualization
When lower needs are met, higher needs are able to emerge
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31. Maslow’s Hierarchy of Needs (Cont.)
Physiological needs
Safety
Belonging and love needs
Esteem needs
Self-actualization
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32. Theory of Human Motivation
Emphasis on human potential and the patient’s strengths
Prioritizing nursing actions in the nurse–patient relationship
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33. Audience Response Question
As you begin working with her, you notice Ms. V has an uncanny resemblance to your younger sister. As a child, this sister lied and criticized you constantly, then screamed and cried to others if you challenged her. You realize that you are responding negatively to this patient. What’s going on here?
Mutuality
Self-system
Self-actualization
Countertransference
ANS: D
Countertransference—unconscious feelings the health care worker has toward the patient.
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Discussion
Now that you have identified the personal struggles you have in working with this patient, what should you do?
The nurse should realize the importance of maintaining self-awareness and seeking supervisory guidance as the therapeutic relationship progresses.
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35. Biological Theories and Therapies
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The Biological Model
Focus on
Neurological
Chemical
Biological
Genetic
How the body and brain interact to create
Emotions
Memories
Perceptual experiences
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37. The Biological Model (Cont.)
Consider other influences that play a role in the development and treatment of mental disorders
Social, environmental, cultural, economic
Focus on
Qualities of a therapeutic relationship
Understanding patient’s perspective
Communicating to facilitate recovery
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38. More Biological Therapies
Psychopharmacology therapy
Use of medication to treat psychiatric illness
Brain stimulation therapies
Electroconvulsive therapy (ECT)
Transcranial magnetic stimulation—repetitive (rTMS)
Vagus nerve stimulation (VNS)
Deep brain stimulation (DBS)
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39. Developmental Theories
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40. Developmental Theories
Cognitive development (Piaget)
Sensorimotor stage
Preoperational stage
Concrete operational stage
Formal operational stage
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41. Developmental Theories (Cont.)
Theory of psychosocial development (Erikson)
Eight stages of development
Personality continues to develop through old age
Stage
Age
Trust vs. mistrust
0-1.5
Identity vs. role confusion
12-20
Autonomy vs. shame-doubt
1.5-3
Intimacy vs. isolation
20-35
Initiative vs. guilt
3-6
Generativity vs. self-absorption
35-65
Industry vs. inferiority
6-12
Integrity vs. despair
65+
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42. Developmental Theories (Cont.)
Theory of object relations
Past relationships influence sense of self and present relationships
“Object” = a significant person
Disruption of early separation
Progression from black-and-white thinking to complex decision making
Preconventional level
Conventional level
Post-conventional level
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43. Developmental Theories (Cont.)
Ethics of care theory
Gilligan and Kohlberg
Morality of care versus “justice view” of morality
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44. Development Theories in Nursing
Developmental model is important part of nursing assessment
Helps determine what types of interventions are most likely to be effective
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45. Audience Response Questions
Which theorist most influenced the professional practice of psychiatric nursing?
Harry Stack Sullivan
Hildegard Peplau
Erik Erikson
Ivan Pavlov
ANS: B
Peplau not only established the foundation for the professional practice of psychiatric nursing, she also continued to enrich psychiatric nursing theory and work for the advancement of nursing practice throughout her career. Invite students to identify major contributions of the other theorists listed.
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46. Audience Response Questions
Schemata, automatic thoughts, and cognitive distortions are terms that relate to
rational-emotive behavioral therapy.
cognitive-behavioral therapy.
operant conditioning theory.
biofeedback.
ANS: B
Rapid, unthinking responses based on schemas are known as automatic thoughts. Often automatic thoughts, or cognitive distortions, are irrational and lead to false assumptions and misinterpretations. Making changes to these cognitive errors is part of cognitive-behavioral therapy.
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