psych theories

5/28/2018 Psych Theories

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Bridget Heyne, RNC, FNP,

MSN, Ed.D.

PSYCH THEORIES


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THEORY

Hypothesis, speculation, supposition

Attempt to explain human behavior

Explanation of behavior is based on the theoristassumptions, beliefs & world view

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Psychoanalysis

Psychoanalysisfocuses 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 muchdiscomfort

Helping the client to gain insight into and resolve these

conflicts and anxieties 3


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Father of PsychoanalysisSigmund Freud

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FREUD-PSYCHOANALYTICTHEORY

Was a neurosurgeon who worked primarily with hysterical uppermiddle class women.

Most mental disorders were due to unresolved issues originatingin childhood (occurring during the first 5 years)

NO human behavior is an accident but is motivated by ansubconscious thought, feeling, need, wish or intent

Freud believed

that all psychologic and emotional events are understandable,

that childhood experiences caused adult neuroses, and thattherapy provided insight into the meaning of events.

Use of defense mechanismsto deal with an incompatible/unacceptable idea that causes internal conflict

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FREUD

Felt that there were different levels of psychological awareness

The mind as an iceberg

Conscious part is the tipof 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

Preconsciousisjust belowthe surface of awareness. Are notreadily remembered but can be recalled relatively easily.

Unconsciouscontains unacceptable urges, repressed

memories. Greatly influences our feelings. Memories

retrieved by hypnosis, in dreams or incomprehensiblebehavior

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Personality Makeup

Id, Super ego & Ego which are entities of the mind, used toexplain observed behaviors resulting from conflicts r/t the needsof the individual, the restriction of society,& internal moral values

Idunconscious, primitive, pleasure principle, cannot tolerate

frustration, Impulsive, egocentric, cannot problem solve; We are allId at birth.

Superego (Perfection principle)concerned w/ moral & ethicalbehavior (all the should nots of life). Represents the ideal ratherthan the real. Legalistic, It seeks perfectionrather than pleasure..

Ego (Rational self or reality driven)- strives for balance, is themediator, mature adaptive behavior, reality tester, a problemsolver, develops defenses mechanism to help the individual dealwith stressful situations . Subject to anxiety if there is an imbalancebetween the Id & Super Ego. Ability to assess w/out anger or

aggression is an example of a healthy ego 7


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DEFENSE MECHANISMS

Used to protect individuals (Protective mechanism)from internal conflicts(feelings, memories) and

external stressorswhich causes the patient anxiety Used unconsciously .

Begins in childhood but become maladaptive ifused for too long(Gone with the wind)

Distorts, hides, denies reality, disruptiverelationships. Therefore, may project onto othershow they feel about themselves

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Table 5.1 Defense Mechanisms

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Table 5.1 Defense Mechanisms

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Defense Mechanisms

Regression- returning to an earlier level of adaptation. Adolescencesucking thumb & not speaking.

Not all defense mechanisms are bad. Some serve as health copingmechanisms used by mature adults

Altruism: emotional conflict & stress are dealt with by meeting theneeds of others. The person receives gratification by helping othersor from the response of others to being helped. 6 months afterloosing her husband, she spends 1 day a week doing grief counseling& is effective in helping others

Sublimation: substituting socially acceptable activity for strongunacceptable impulses. Strong hostile feeling are channeled byplaying a contact sport

Humor: Deals with stressors by emphasizing the amusing or ironic

aspectof the conflict (stand up comics) 10


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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


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FREUD

Freud based his theory of childhood personalitydevelopment on the belief that sexual energy was the drivingforce of human behavior. There are 5 stages of psychosexualdevelopment: Based on sexual growth/development:

Oral stage (0-1 yr)smoking, biting, alcoholism. Sarcasticperson

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


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SULLIVANSocial-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 behaviorthat 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

interaction15


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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


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SULLIVAN

Sullivan believed that the nurses role includeseducating clients and assisting them in developing

effective interpersonal relationships. Mutuality, respect for the client, unconditional

acceptance, and empathy are cornerstones ofSullivans theory.

The nurse must interact with the client A therapeutic environment (Milieu) is an accepting

atmosphere and provides opportunities for clientsto practice interpersonal skills

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ERIK ERIKSON

Stages of Development


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ERIK ERIKSON

Follower of Freud but felt that it was negative & restrictive

Eriksons developmental theory of personality attempted toaccount for biologic instincts as well as cultural andinterpersonal tasksthat must be accomplished to move forwarddevelopmentally.

Each stage of growth involves maintaining a balance betweendisorder & stability to adjust & move forward to the nextlevel/stage.

Successful resolution affects success in next stage

Failure to resolve stage may lead to psychological symptoms atlater time

His model spans the full life cycle & felt that personality

continues through old age (Unlike Freud) 19


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ERIK ERIKSON

This theory can help identify age appropriate or arresteddevelopmental interpersonal skillsas clients with mental

illness usually exhibit some degree of developmental delayor incomplete resolution of developmental task thatparallel their chronological age

Helps the nurse know what types of interventions are mostlikely to be effective based on the developmental level ofthe client through assessment of their developmentalfunctioning

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Eriksons Stages

Trust vs. Mistrust(0-1 1/2yrs)The major task is todevelop a basic trust in mothering figure & be able togeneralize 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 selfesteem. 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).

Sense of inadequacy &/ or guilt 21


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Erickson's Stages

Industry vs Inferiority(6-12)- Development & mastery ofsocial & cognitive skills.Task is to achieve a sense of selfconfidence (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 senseof self & realization of competencevs 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 acommitment to another person or cause. Emotional

isolation, egocentricity 22


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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 MaslowMaslows Hierarchy of Needs


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MASLOW

Focused on human Needs Fulfillment

Proposed an order of basic human needs.Physiological needs must be met before higher-level

needssuch as self-esteem and self actualization Sequencing nursing actions based on client priority

needs

Emphasized nursing prioritization of action in caring

for the patientto take collect anything other theessential info when a client is struggling w/ drugw/drawl is inappropriate

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MaslowsBasic Needs


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MASLOW

Physiological Needsbiological need for food, shelter etc

Safety and security-is the one of the most basic need-avoiding harm, physical safety & security, order, limits,

Love and belonging-companionship, giving & receivinglove, relationships

Esteem and self-esteem-respect from others, success,achievement

Self-actualization-takes years to achieve- fulfillment ofunique potential, becoming everything that one is capableof becoming. An example of a highly evolved mature,balance individual


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Burrhus Frederic SkinnerClassical Conditioning

19041990


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B. F. SKINNER

Classical Conditioning

Behaviorismfocuses 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 behavior-

Operant conditioning29


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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 slowlybut with longer-lasting effect

Therefore learned behavior responses can be modified

Treatment modalities based on behaviorism include behaviormodification, 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

interaction. Rules through peer pressure30


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Jean PiagetsCognitive Theory


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Jean PiagetsCognitive Theory

Cognitive therapy

focuses on immediate thought processing.

How a person perceives or interprets an experience

determines how you feel & behave . Therefore must helpcorrect distorted perceptions and dysfunctional beliefs.

Cognitive behavioral theoryfocuses on the present ratherthan the past. Symptoms associated with neuroses andpsychoses are identified as clusters of learned behaviors

that persist because they are rewarding to the individual.

Must learn to think more adaptively and realistically. Mustsubstitute rational beliefs for irrational beliefs & eliminate

self defeating behavior32


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Biological Theory

Focuses on neurological, chemical, biological, c &

genetic issues to understand how the brain & body

interact to create emotion, memories & perceptualexperiences

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

drugs33


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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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Hildergard PeplauThe Mother of Psychiatric Nursing


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Hildergard Peplau

Emphasized the interpersonal nature of nursing andthe need for nurses to use psychodynamic conceptsand counseling techniques

Nurse/client relationship

The nurse-client relationship is structured toprovide 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. Asian-avoids 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 selfcare deficit & includes both physical and psychosocialhuman needs

Nursing care is needed when person can no longerprovide self-care (inability to maintain life, health,and well-being)

Needs (i.e. seriousness of mental illness) indicateappropriate nursing system

Concretebecause of an underlying disorder, thepatient neglects self eg eating, rest, personal

hygiene, rest, safety38


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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 thatis normal at a party is unacceptable at a business meeting).

Often mental illness is seen as the degree to which aperson fails to fulfill the expectation of the culture

What beliefs are acceptable/what are not(What may beperfectly 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 culturalcompetence is to examine ones own perceptions,

prejudices, and stereotypes regarding the particular

cultural group of interest.41


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The Culturally CompetentMENTAL 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 CompetentMENTAL HEALTH NURSE

Will have knowledge of central beliefs and behaviors ofclients culture

Will assess level of integration and identification with thedominant 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)43


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Stages in Acquiring CulturalCompetence

Unconscious Incompetence

Not being awareof lacking information aboutother cultures

Conscious incompetence- Being aware of lacking information about

other cultures but do not care

Conscious Competence

Actively learningabout other cultures andverifying information

Unconscious Competence

Automaticallyproviding culturally competent care44


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Spirituality

Includes core beliefs about people, the divine, and relationsbetween them. May derive comfort & inner strength fromspiritual beliefs(decreases anxiety)

Influenced by culture, life experiences

Helps connect people to each other, the community, theworld

Along with religion and faith, may be experienced andexpressed in a variety of ways

Client may need support from priest, Rabbi especially incases 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 decision-

making

What one should do46


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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 alternative47


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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 actionsor understand the difference between right and wrongat the time of the crime(MNaghtenrule)

13 states have provisions for a guilty but insaneverdict that holds the person responsible for the crimewhile ensuring that he or she receives treatment.

If the are unable to understand the charges against

themthen they cannot be tried for the crime until theydo. Must be able to participate in their own defense.

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Legal Issues inMENTAL 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 others50


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Legal Issues inMENTAL HEALTH NURSING

Laws set out rules and procedures: Rogers vs. Okin

(Boston), patients right to refuse medication. Had

significant implications for nurses who are temptedto force patients to take their medication for

their own good.

Laws differ from state to state

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L l I i th


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Legal Issues in theCOMMUNITY

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 torelease confidential information about a patient

Right to keep personal items

Right to enter into legal contracts

Right of habeas corpus ( court proceeding to seekjudicial discharge)

Right to informed consent

Right to refuse treatment

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TORT

A civil wrongor wrongful actagainst 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

professional that causes harm to the client54


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Intentional Torts

Assault: An act that results in a persons

genuine fear & apprehension thatthe personwill 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 orallythat could be

detrimental to the clients reputation

Libel:sharing of information in writingthat 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. Documentedinformation should reflect objective findings, not the

nurses perception of the client.

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Least Restrictive


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Least RestrictiveEnvironment

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


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Least RestrictiveEnvironment

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


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ConfidentialityHIPAA (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


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Duty to Warn ThirdParties

Duty to warn a third party is an exception to clientconfidentiality (Tarasoff ruling)

Clinicians must warn identifiable third parties of threatsmade by a client

Nurse must record this in their nurses notes & inform thephysician, & 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

Is the victim accessible60

VOLUNTARY


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VOLUNTARYADMISSION

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


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EMERGENCYADMISSION

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), adanger to others ( DTO) or Gravely Disabled

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EMERGENCY


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EMERGENCYADMISSION

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

5250allows for a hold extension of the 5150 up to14 days

This extension occurs only if the person remains aDTS, 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 arepresented

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 treatmenteg medication but the patient refuses

Must show that the patients impairment outweighs thepotential risk of the medication.Medication will in allprobability 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

against the patients will69


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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 daysto allow time for treatment

Another court date set prior to end of T-Con todetermine if further treatment is necessary & T-Con

should be extended70


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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 ofthemselves.

It is assumed that a person without a mental

disorder would not choose suicide. Thus, mentalhealth caregivers seek to prevent suicide on the

basis that this is what the client would choose if the

client were mentally capable of choosing. 71

Prevention of


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Prevention ofLiability

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 anddescriptive, accurate documentation

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THE END

Question #1


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Question #1Please 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 admitted74

Question #1


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Question #1cont

This interaction should be assessed as:

a) Therapeutic

b) Collegial

c) Sociald) 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 expectationof help exist

D- Takes place w/in an individual75

Question #2


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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


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A psychiatric technician mentions that little of what takesplace on the behavioral health unit seems to be theorybased. The nurse can enlighten the technician by citing thefact that many of Sullivans theoretic constructs are used in

A. the ongoing use of restraint and seclusion as behaviormanagement tools.

B. the structure of the therapeutic milieu of mostbehavioral health units.

C. assessment tools based on age-appropriate versusarrested behaviors.

D. the method nurses use to determine the best sequencefor nursing actions.

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Question #3


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Question #3answer

The structure of the therapeutic environment has as foci anaccepting atmosphere and provision of opportunities forpracticing interpersonal skills. Both constructs are directlyattributable to Sullivans theory of interpersonal

relationships. Option:

A: Sullivans interpersonal theory did not specificallyconsider use of restraint or seclusion. Option

C:Assessment based on developmental level is more theresult of Eriksons theories. Option

D: Sequencing nursing actions based on client priorityneeds is related to Maslows hierarchy of needs.

psych theories

Documents

super ego ego

healthy ego

conscious mind

id super ego

childhood experiences

ego rational self

yearsno human behavior

emotional events