NCM 105 PPT Chapters 3-8

PSYCHIATRIC-MENTAL
HEALTH NURSING
CHEENA P. BERBER, MAN RN LPT
Instructor
Chapter 3
Psychosocial Theories
and Therapy
PSYCHOSOCIAL THEORIES
Types of psychosocial theories:
• Psychoanalytic
• Developmental
• Interpersonal
• Humanistic
• Behavioral
Psychoanalytic Theories
Sigmund Freud
The father of psychoanalysis
Psychoanalytic theory supports the notion
that all human behavior is caused and can
be explained
EVERY BEHAVIOR HAS MEANING!
Sexual impulses and desires motivate much human
behavior.
Personality is formed during the first six
years of life
Personality Components: Id, Ego, and Superego
ID is the part of one’s nature that reflects basic
or innate desires such as pleasure-
seeking behavior, aggression, and sexual
impulses.
The id seeks instant gratification, causes
impulsive unthinking behavior, and has
no regard for rules or social convention.
SUPEREGO is the part of a person’s nature

that reflects moral and ethical concepts,
values, and parental and social expectations
DON’Ts of the society

The ego, is the balancing or mediating force

between the id and the superego.
The ego represents mature and adaptive

behavior that allows a person to function
successfully in the world.
Level of Consciousness: Conscious; Preconscious and Unconscious
Conscious--perceptions, thoughts, and emotions that exist in

the person’s awareness
Preconscious---thoughts and emotions are not currently in
the person’s awareness, but he or she can recall them with
some effort
*A Freudian slip is a term we commonly use to describe slips of the tongue
Unconscious is the realm of thoughts and feelings that
motivate a person even though he or she is totally unaware of
them.
Freud’s Dream Analysis and Free Association
Dream analysis
a primary technique used in psychoanalysis, involves
discussing a client’s dreams to discover their true meaning and
significance.
Free association
Therapist tries to uncover the client’s true thoughts and
feelings by saying a word and asking the client to respond quickly
with the first thing that comes to mind
Ego Defense Mechanisms
Methods of attempting to
protect the self and cope with basic
drives or emotionally painful thoughts,
feelings, or events.
Denial- unconscious refusal to admit an

unacceptable idea or behavior
Repression-unconscious and involuntary forgetting of
painful ideas, events, and conflicts
Suppresion-conscious exclusion from awareness
anxiety-producing feelings, ideas or situations
Rationalization-conscious or unconscious attempts to make

or prove that one’s feelings are justifiable
Intellectualization-consciously or unconsciously
using only logical explanations without feelings or
an affective component
Dissociation-the unconscious separation of painful
feelings and emotions from an unacceptable idea,
situation, or object
Identification-conscious or unconscious attempt to

model oneself after a respected person
Introjection-unconsciously incorporating values
and attitudes of others as if they were your own
Compensation-consciously covering up for
weakness by overemphasizing or making up a
desirable trait
Sublimation-consciously or unconsciously channeling

instinctual drives into acceptable activities
Reaction formation-a conscious behavior that is
exact opposite of an unconscious feeling
Undoing-consciously doing something to counteract or make up
for transgression or wrongdoing
Displacement-unconsciously discharging pent-up

feelings to a less threatening object
Projection-unconsciously or consciously blaming
someone else for one’s difficulties or placing one’s
unethical desire on someone else
Regression-unconscious return to an earlier and more
comfortable developmental level
Substitution-the replacement of a highly

valued, unacceptable or unavailable object
by a less valuables, acceptable, or available object
Conversion-expression of an emotional
conflict through the development of
physicalsymptom, usually sensorimotor in nature
Fixation-Immobilization of portion of personality

resulting from unsuccessful completion of
task in a developmental stage
Resistance-Overt or covert antagonism toward
remembering or processing anxiety-producing
information
Five Stages of Psychosexual Development
Belief that sexual energy, termed libido, was the driving

force of human behavior
Psychopathology results when a person has

difficulty making the transition from one stage
to the next or when a person remains stalled at a
particular stage or regresses to an earlier
stage.
Five Stages of Psychosexual Development
Transference and Countertransference
Transference occurs when the client displaces onto the

therapist attitudes and feelings that the
client originally experienced in other relationships
Countertransference occurs when the therapist

displaces onto the client attitudes or feelings
from his or her past
Current Psychoanalytic Practice
Psychoanalysis focuses on discovering the

causes of the client’s unconscious and repressed
thoughts, feelings, and conflicts believed to
cause anxiety and on helping the client to gain
insight into and resolve these conflicts and
anxieties.
Developmental Theories
Psychosocial Stages of Development
Erik Erikson (1902–1994) was a

German-born psychoanalyst
who extended Freud’s work on
personality development
across the life span while
focusing on social and
psychological development in
the life stages.
In each stage, the person must complete a life

task that is essential to his or her
well-being and mental health.
The conflicts faced by an individual at

every stage of psychosocial
development are called CRISIS.
Cognitive Stages of Development
Jean Piaget (1896–1980) explored how
intelligence and cognitive functioning
develop in children.
He believed that human intelligence
progresses through a series of
stages based on age, with the child at each
successive stage demonstrating a higher
level of functioning than at
previous stages.
Sensorimotor
The child learns about himself and his
environment through motor and reflex actions.
Teaching for a child in this stage should be

geared to the sensorimotor system
Preoperational
The child begins to use symbols to represent objects
The child is now better able to think about things and events
that are not immediately present
Oriented to the present, the child has difficulty
conceptualizing time
Preoperational
His thinking is influenced by fantasy-the way he’d like

things to be and he assumes that others see
situations from his viewpoint
Concrete
During this stage accommodation increases
The child develops to think abstractly and to make
rational judgments about concrete or observable
events
Concrete
Implications:
Giving the child the opportunity to ask
questions and to explain things back
to you allows him to mentally manipulate
information
Formal Operations
This stage brings cognition to its final form.
At this point, he is capable of hypothetical
and deductive reasoning
Interpersonal Theories
Interpersonal Relationships and Milieu Therapy
Harry Stack Sullivan (1892–1949) was an

American psychiatrist
One’s personality involves more than
individual characteristics, particularly
how one interacts with others.
He thought that inadequate or
non-satisfying relationships produce
anxiety, which he saw as the basis for all
emotional problems
Prototaxic mode involves brief, unconnected experiences
that have no relationship to one another
Parataxic mode begins to connect experiences in sequence.
*Paranoid ideas and slips of the tongue
Syntaxic mode, the person begins to perceive himself or herself and
the world within the context of the environment and can analyze
experiences in a variety of settings.
*Maturity
Milieu Therapy
ENVIRONMENT!
Participant observer therapist both participates in and
observes the progress of the relationship.
MILIEU THERAPY
involved clients’ interactions with one another, including
practicing interpersonal relationship skills, giving one another
feedback about behavior, and working cooperatively as a
group to solve day-to-day problems.
Milieu Therapy
Milieu therapy was one of the primary

modes of treatment in the acute
hospital setting.
Therapeutic Nurse-Patient Relationship
Hildegard Peplau
developed the concept of the therapeutic nurse–
patient relationship
“The purpose of nursing is to educate and to be a
maturing force to a patient, for
him to get a new view of himself.”
1. The orientation phase is directed by the nurse

and involves engaging the client in treatment,
providing explanations and information, and
answering questions.
2. The identification phase begins when the client
works interdependently with the nurse, expresses
feelings, and begins to feel stronger.
3. In the exploitation phase, the client makes

full use of the services offered.
4. In the resolution phase, the client no longer needs
professional services and gives up
dependent behavior. The relationship ends.
PROFESSIONAL RELATIONSHIP
Orientation Phase
• Get acquainted phase of the nurse-patient relationship.
• Problem defining phase
• Preconceptions are worked through
• Parameters are established and met
• Early levels of trust are developed
• Roles begin to be understood
• Nurse responds, explains roles to the client, helps to identify
problems and to use available resources and services.
Factors influencing orientation phase

Identification Phase
• The client begins to identify problems to be worked on
within relationship
• Patient begins to have a feeling of belongingness and
capability of dealing with the problem which decreases the
feeling of happiness and hopelessness.
• The goal of the nurse: help the patient to recognize his/her
own interdependent/participation role and promote
responsibility for self
Exploitation Phase
• Client’s trust of nurse reached full potential
• Client making full use of nursing services
• Solving immediate problems
• Use of professional assistance for problem solving
alternatives
• Advantages of service are used is based on the
interest of the patients
Resolution Phase
• Termination of professional relationship
• The patients need have already been met by collaborative effect
of patient and nurse
• Client met needs
• Sense of security is formed
• Patient is less reliant on nurse
• Increased self-reliance to deal with own problems.
• Patient drifts away and breaks bond with nurse and healthier emotional
balance is demonstrated and both becomes mature
Roles of the Nurse in the Therapeutic Relationship
The primary roles she identified are as follows:
• Stranger––offering the client the same acceptance and
courtesy that the nurse would to any stranger;
• Resource person––providing specific answers to
Questions within a larger context; feelings
Roles of the Nurse in the Therapeutic Relationship
The primary roles she identified are as follows:
• Teacher––helping the client to learn formally or
informally;
• Leader––offering direction to the client or group;
• Surrogate––serving as a substitute for another such as a
parent or sibling;
• Counselor––promoting experiences leading to health
for the client such as expression of feelings
Levels of Anxiety
Anxiety as the initial response to a psychic threat.
She described four levels of anxiety:

mild, moderate, severe, and panic
These serve as the foundation for working with

clients with anxiety in a variety of contexts.
1. Mild anxiety is a positive state of heightened awareness and

sharpened senses, allowing the person to learn new
behaviors and solve problems. The person can take in all available
stimuli (perceptual field).
2. Moderate anxiety involves a decreased perceptual field (focus on
immediate task only); the person can learn new behavior or solve
problems only with assistance. Another
person can redirect the person to the task.
3. Severe anxiety involves feelings of dread or terror. The
person cannot be redirected to a task; he or she focuses only
on scattered details and has physiological symptoms of tachy-
cardia, diaphoresis, and chest pain. A person with severe anxiety may go
to an emergency department, believing he or she is
having a heart attack.
4. Panic anxiety can involve loss of rational thought, delusions,
hallucinations, and complete physical immobility and muteness. The
person may bolt and run aimlessly, often exposing himself or herself to
injury.
Humanistic Theories
Humanism
Focuses on a person’s positive qualities, his or her

capacity to change (human potential), and the
promotion of self-esteem.
Humanists do consider the person’s past experiences, but

they direct more attention toward the present
and future.
Humanistic Theories
Abraham Maslow: Hierarchy of Needs
Abraham Maslow (1921–1970) was

an American psychologist who
studied the needs or
motivations of the individual.
Humanistic Theories
Traumatic life circumstances or compromised health

can cause a person to regress to a
lower level of motivation.
This theory helps nurses understand how

clients’ motivations and behaviors change
during life crises
Humanistic Theories
Humanistic Theories
Carl Rogers: Client-Centered Therapy
Carl Rogers (1902–1987) was a

humanistic American psychologist who
focused on the therapeutic
relationship and developed a new
method of client-centered therapy
Rogers was one of the first to use

the term client rather than patient
Humanistic Theories
Client-centered therapy focuses on the role of the

client, rather than the therapist, as the key to the
healing process.
Clients do “the work of healing,” and within a

supportive and nurturing client–therapist
relationship, clients can cure themselves.
Humanistic Theories
The therapist must promote the client’s self-esteem as

much as possible through three central concepts:
• Unconditional positive regard—a nonjudgmental caring
• Genuineness—realness or congruence between what
the therapist feels and what he or she says to the client
• Empathetic understanding—in which the therapist
senses the feelings and personal meaning from the client
Behavioral Theories
Behaviorism
School of psychology that focuses on observable

behaviors and what one can do externally to bring about
behavior changes.
It does not attempt to explain how the mind

works.
Behavioral Theories
Ivan Pavlov: Classical Conditioning
Behavior can be changed through conditioning with

external or environmental conditions or
stimuli.
Their behavior had been modified through
classical conditioning, or a conditioned response.
Behavioral Theories
B. F. Skinner: Operant Conditioning
He developed the theory of operant

conditioning, which says people learn
their behavior from their history or past
experiences, particularly those
experiences that were repeatedly
reinforced.
Behavioral Theories
These behavioral principles of rewarding or

reinforcing behaviors are used to help
people change their behaviors in a therapy known
as behavior modification, which is a
method of attempting to strengthen a
desired behavior or response by
reinforcement, either positive or negative.
Behavioral Theories
Conditioned responses, such as fears or phobias, can be

treated with behavioral techniques.
Systematic desensitization
can be used to help clients overcome irrational
fears and anxiety associated with phobias.
CRISIS INTERVENTION
CRISIS
A crisis is a turning point in an individual’s life that
produces an overwhelming emotional
response.
Individuals experience a crisis when they
confront some life circumstance or stressor
that they cannot effectively manage through
use of their customary coping skills.
CRISIS INTERVENTION
CRISIS
Maturational crises, sometimes called developmental
crises, are predictable events in the normal course of
life, such as leaving home for the first time, getting
married, having a baby, and beginning a career.
CRISIS INTERVENTION
CRISIS
• Situational crises are unanticipated or sudden events
that threaten the individual’s integrity, such as the death
of a loved one, loss of a job, and physical or emotional
illness in the individual or family member.
CRISIS INTERVENTION
CRISIS
• Adventitious crises, sometimes called
social crises, include natural disasters like
floods, earthquakes, or hurricanes; war;
terrorist attacks; riots; and violent crimes
such as rape or murder.
CRISIS INTERVENTION
CRISIS
Note that not all events that result in crisis are
“negative” in nature.
Crisis is described as self-limiting;

usually exists for 4 to 6 weeks.
CRISIS INTERVENTION
CRISIS
Crisis intervention includes a variety of techniques:
Directive interventions directing the person’s behavior

by offering suggestions or courses of action
Supportive interventions aim at dealing with the
person’s needs for empathetic understanding, such as
encouraging the person to identify and discuss feelings, serving
as a sounding board for the person, and
affirming the person’s self-worth.
TREATMENT MODALITIES
Individual Psychotherapy
Individual psychotherapy is 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 therapist–client relationship is key to the success of
this type of therapy. The client and the therapist must be
compatible for therapy to be effective.
Group Therapy
In group therapy, clients participate in sessions with a group of
people. The members share a common
purpose and are expected to contribute to the group
to benefit others and receive benefit from others in
return.
Group rules are established, which all members must observe.
Psychotherapy Group
The goal of a psychotherapy group is for members to learn
about their behavior and to make positive
changes in their behavior by interacting and
communicating with others as a member of a group
Open group and closed group

Family therapy
Family therapy is a form of group therapy in
which the client and his or her family members
participate.
Family Education
The course discusses the clinical treatment of
these illnesses and teaches the knowledge and
skills that family members need to cope more
effectively. The specific features of this education
program include emphasis on emotional
understanding and healing in the personal realm and on
power and action in the social realm.
Education Group
The goal of an education group is to provide
information to members on a specific issue—for
instance, stress management, medication
management, or assertiveness training. The group
leader has expertise in the subject area and may be a
nurse, therapist, or other health professional.
Education groups usually are scheduled for a specific
number of sessions and retain the same members
for the duration of the group.
Support Group
Support groups are organized to help
members who share a common problem to
cope with it.
The group leader explores members’ thoughts and
feelings and creates an atmosphere of acceptance so
that members feel comfortable expressing
themselves.
Self-Help Group
In a self-help group, members share a
common experience, but the group is not a
formal or structured therapy group. Although
professionals organize some self-help groups, many
are run by members and do
not have a formally identified leader
Psychiatric Rehabilitation
Psychiatric rehabilitation involves providing services
to people with severe and persistent mental illness
to help them to live in the
community.
These programs are often called
community support services or community
support programs.
Psychiatric Rehabilitation
CHAPTER 5
THERAPEUTIC
RELATIONSHIPS
Therapeutic Relationship
The ability to establish therapeutic relationships with

clients is one of the most important skills a nurse can develop.
The nurse-client relationship is the foundation on

which psychiatric nursing is established.
Therapeutic Nurse-Client Relationship
It is a helping and caring relationship in which both

participants must recognize each other as unique and
important human beings.
It is also a relationship in which mutual

learning occurs.
Therapeutic Nurse-Client Relationship
Components involved in establishing

appropriate therapeutic nurse–client
relationships:
trust, genuine interest, acceptance,
positive regard, self-awareness, and
therapeutic use of self.
COMPONENTS OF A THERAPEUTIC RELATIONSHIP: TRUST
Trust
The nurse–client relationship requires trust.
Trust builds when the client is confident in the nurse and

when the nurse’s presence conveys integrity and reliability.
Trust develops when the client believes that the nurse will be
consistent in his or her words and actions and can be relied
on to do what he or she says.
Congruence occurs when words and actions match.


When working with a client with psychiatric problems, some

of the symptoms of the disorder, such as
paranoia, low self-esteem, and anxiety, may make
trust difficult to establish.
Examining one’s own behavior and doing one’s best

to make messages clear, simple, and congruent help
to facilitate trust between the nurse and the client.
COMPONENTS OF A THERAPEUTIC RELATIONSHIP: Genuine Interest
Genuine Interest
When the nurse is comfortable with himself or
herself, aware of his or her strengths and limitations, and
clearly focused, the client perceives a genuine person
showing genuine interest.
COMPONENTS OF A THERAPEUTIC RELATIONSHIP: Empathy
Empathy is the ability of the nurse to perceive the

meanings and feelings of the client and to
communicate that understanding to the
client.
COMPONENTS OF A THERAPEUTIC RELATIONSHIP: Empathy

COMPONENTS OF A THERAPEUTIC RELATIONSHIP: Acceptance
Acceptance
The nurse who does not become upset or respond
negatively to a client’s outbursts, anger, or acting out
conveys acceptance to the client.
Avoiding judgments of the person, no matter what the
behavior, is acceptance.
This does not mean acceptance of inappropriate behavior but
acceptance of the person as worthy.
COMPONENTS OF A THERAPEUTIC RELATIONSHIP: Positive Regard
Positive Regard
The nurse who appreciates the client as a unique
worthwhile human being can respect the client
regardless of his or her behavior, background, or
lifestyle.
This unconditional nonjudgmental attitude is
known as positive regard and implies respect.
COMPONENTS OF A THERAPEUTIC RELATIONSHIP: Positive Regard
Calling the client by name, spending time with the

client, and listening and responding openly are
measures by which the nurse conveys
respect and positive regard to the client.
COMPONENTS OF A THERAPEUTIC RELATIONSHIP:

Self-Awareness
Self-Awareness and Therapeutic Use of Self
Self-awareness is the process of developing an

understanding of one’s own values, beliefs, thoughts,
feelings, attitudes, motivations, prejudices, strengths, and
limitations and how these qualities affect others.
Self-Awareness
Values are abstract standards that give a person

a sense of right and wrong and
establish a code of conduct for living.
Sample values include hard work, honesty,

sincerity, cleanliness, and orderliness.
Self-Awareness
The values clarification process has three steps:

choosing, prizing, and acting.
Choosing is when the person considers a range of
possibilities and freely chooses the value that feels right.
Prizing is when the person considers the value, cherishes it, and
publicly attaches it to himself or herself.
Acting is when the person puts the value into action
Self-Awareness
Beliefs are ideas that one holds to be true.

Self-Awareness
Attitudes are general feelings or a frame of reference around

which a person organizes knowledge about
the world.
Attitudes, such as hopeful, optimistic, pessimistic,
positive, and negative, color how we look at the
world and people.
A positive mental attitude occurs when a person
chooses to put a positive spin on an experience,
a comment, or a judgment.
Self-Awareness
A person who does not assess personal attitudes and beliefs

may hold:
Prejudice or bias
Stereotypical images
Ethnocentrism
Therapeutic Use of Self
Nurse can use aspects of his or her personality, experiences, values,

feelings, intelligence, needs, coping skills, and
perceptions to establish relationships with clients. This is
called therapeutic use of self.
Nurses use themselves as a therapeutic tool to establish

therapeutic relationships with clients and to help clients
grow, change, and heal.
The nurse’s personal actions arise from conscious and

unconscious responses that are formed by life
experiences and educational, spiritual, and cultural
values.
Johari window creates a “word portrait” of a person

in four areas and indicates how well
that person knows himself or herself and
communicates with others.
The four areas evaluated are as follows:

Quadrant 1: Open/public self—qualities one knows about oneself and
others also know.
Quadrant 2: Blind/unaware self—qualities known only to others.
Quadrant 3: Hidden/private self—qualities known only to oneself.
Quadrant 4: Unknown—an empty quadrant to symbolize qualities as
yet undiscovered by oneself or others.
COMPONENTS OF A THERAPEUTIC RELATIONSHIP: Patterns of
Knowing
Patterns of Knowing
Hildegard Peplau:
Preconceptions
Ways one person expects another to behave or speak
Roadblock to the formation of an authentic
relationship.
COMPONENTS OF A THERAPEUTIC RELATIONSHIP: Patterns of
Knowing
Carper:
four patterns of knowing:
empirical knowing
personal knowing
ethical knowing
aesthetic knowing
Patterns of Knowing
Munhall:
Unknowing
For the nurse to admit she or he does not know the
client or the client’s subjective world opens the way for a truly
authentic encounter.
The nurse in a state of unknowing is open to seeing and hearing

the client’s views without imposing any of his or her values or
viewpoints.
TYPES OF RELATIONSHIPS: Social Relationship
Social Relationship
Primarily initiated for the purpose of friendship, socialization,

companionship, or accomplishment of a task.
Communication usually focuses on sharing ideas, feelings,

and experiences and meets the basic need for people to
interact.
TYPES OF RELATIONSHIPS: Intimate Relationship
Intimate Relationship
Involves two people who are emotionally committed to

each other.
An intimate relationship has no place in the nurse–client

interaction.
TYPES OF RELATIONSHIPS: Therapeutic Relationship
In the therapeutic relationship the parameter:
the focus is the client’s needs, not the nurse’s.
ESTABLISHING A THERAPEUTIC RELATIONSHIP
Phases: Used to understand and document progress

with interpersonal interactions
• orientation
• working (problem identification and exploitation)
• resolution or termination
In real life, these phases are not that clear-cut; they

overlap and interlock.
ESTABLISHING A THERAPEUTIC RELATIONSHIP

ESTABLISHING A THERAPEUTIC RELATIONSHIP: Orientation Phase

Orientation Phase
• Get acquainted phase of the nurse-patient relationship.
• Problem defining phase
• Preconceptions are worked through
• Parameters are established and met
• Early levels of trust are developed
• Roles begin to be understood
• Nurse responds, explains roles to the client, helps to identify
problems and to use available resources and services.
Nurse–Client Contracts
The contract should state the following:
• Time, place, and length of sessions
• When sessions will terminate
• Who will be involved in the treatment plan (family members or health
team members)
Client responsibilities (arrive on time and end on time)
• Nurse’s responsibilities (arrive on time, end on time, maintain
confidentiality at all times, evaluate progress with client, and document
sessions).
Confidentiality
Respecting the client’s right to keep private any information about
his or her mental and physical health and related
care.
Self-Disclosure
Revealing personal information such as biographical
information and personal ideas, thoughts, and feelings
about oneself to clients.
ESTABLISHING A THERAPEUTIC RELATIONSHIP:
Working Phase
Identification Phase
• The client begins to identify problems to be worked on
within relationship
• Patient begins to have a feeling of belongingness and
capability of dealing with the problem which decreases the
feeling of happiness and hopelessness.
• The goal of the nurse: help the patient to recognize his/her
own interdependent/participation role and promote
responsibility for self
Working Phase
Exploitation Phase
• Client’s trust of nurse reached full potential
• Client making full use of nursing services
• Solving immediate problems
• Use of professional assistance for problem solving
alternatives
• Advantages of service are used is based on the
interest of the patients
Working Phase
Exploitation Phase
Transference
Patient to nurse
Countertransference
Nurse to patient
Resolution Phase
Resolution Phase
• Termination of professional relationship
• The patients need have already been met by collaborative effect
of patient and nurse
• Client met needs
• Sense of security is formed
• Patient is less reliant on nurse
• Increased self-reliance to deal with own problems.
• Patient drifts away and breaks bond with nurse and healthier emotional
balance is demonstrated and both becomes mature
AVOIDING BEHAVIORS THAT DIMINISH THE THERAPEUTIC RELATIONSHIP
The nurse has power over the client by virtue of his or

her professional role.
That power can be abused if excessive familiarity or an
intimate relationship occurs or if
confidentiality is breached.
Inappropriate Boundaries
The nurse must maintain professional boundaries to ensure the best
therapeutic outcomes.
-Touch
-Attraction
-Accepting gifts or giving a client one’s home
address or phone number would be considered
a breach of ethical conduct
Nonacceptance and Avoidance
The nurse–client relationship can be jeopardized if the nurse finds

the client’s behavior unacceptable or distasteful and
allows those feelings to show by avoiding the client or
making verbal responses or facial expressions of annoyance or
turning away from the client.
ROLES OF THE NURSE IN A THERAPEUTIC
RELATIONSHIP
Teacher
Caregiver
Advocate
Parent Surrogate
ROLES OF THE NURSE IN A THERAPEUTIC
RELATIONSHIP
Advocate
Nurse informs the client and then supports him or her in

whatever decision he or she makes
Advocacy is the process of acting on the client’s behalf when he or

she cannot do so.
Points to Consider When Building Therapeutic Relationships
• Attend workshops about values clarification, beliefs, and

attitudes to help you assess and learn about
yourself.
• Keep a journal of thoughts, feelings, and lessons
learned to provide self-insight.
• Listen to feedback from colleagues about your
relationships with clients.
Points to Consider When Building Therapeutic Relationships
• Participate in group discussions on self-growth at the

local library or health center to aid self-understanding.
• Develop a continually changing care plan for self-growth.
• Read books on topics that support the strengths you
have identified and help to develop your areas of weakness.
Chapter 6
Therapeutic Communication
COMMUNICATION is the process that people use

to exchange information.
Messages are simultaneously sent and received on

two levels:
-verbal-- through the use of words
-nonverbal-- by behaviors that accompany the words
Verbal communication
Content is the literal words that a person speaks.
Context is the environment in which communication occurs
Nonverbal communication is the behavior that accompanies verbal content
such as body language, eye contact, facial expression, tone of voice, speed and
hesitations in speech, grunts and groans, and
distance from the listeners.
Process denotes all nonverbal messages that the speaker
uses to give meaning and context to the message.
Congruent message
Conveyed when content and process agree
Incongruent message
But when the content and process disagree—when what
the speaker says and what he or she does do not agree
WHAT IS THERAPEUTIC COMMUNICATION?
Therapeutic communication is an interpersonal

interaction between the nurse and the client during which
the nurse focuses on the client’s specific needs to promote
an effective exchange of information.
THERAPEUTIC COMMUNICATION
Privacy and Respecting Boundaries

Privacy is desirable but not always possible in therapeutic
communication.
Proxemics is the study of distance zones between people
during communication
People feel more comfortable with smaller distances when
communicating with someone they know rather than with
strangers
Four distance zones:

• Intimate zone (0 to 18 inches between people): personal contact or people
whispering.
• Personal zone (18 to 36 inches): between family and friends who are talking.
• Social zone (4 to 12 feet): communication in social, work, and
business settings.
• Public zone (12 to 25 feet): between a speaker and an audience,
small groups, and other informal functions
The therapeutic communication interaction is most

comfortable when the nurse and client are
3 to 6 feet apart.
If a client invades the nurse’s intimate space (0 to

18 inches), the nurse should set limits gradually,
depending on how often the client has invaded the
nurse’s space and the safety of the situation.
Touch
As intimacy increases, the need for distance decreases.
Five types of touch:

• Functional-professional touch
• Social-polite touch
• Friendship-warmth touch
• Love-intimacy touch
• Sexual-arousal touch
Active Listening and Observation

Active listening means refraining from other internal mental
activities and concentrating exclusively on what the client says.
Active observation means watching the speaker’s nonverbal

actions as he or she communicates.
Active listening and observation help the nurse to:

• Recognize the issue that is most important to the client at
this time.
• Know what further questions to ask the client.
• Use additional therapeutic communication techniques to
guide the client to describe his or her perceptions fully.
• Understand the client’s perceptions of the issue instead of
jumping to conclusions.
• Interpret and respond to the message objectively.
VERBAL COMMUNICATION SKILLS
Concrete Messages
When speaking to the client the nurse should use words
that are as clear as possible so that the client can understand
the message
Abstract messages
unclear patterns of words that often contain figures of speech that are
difficult to interpret.
A hot potato
At the drop of a hat
Ball is in your court
Barking up the wrong tree
Best of both worlds
Caught between two stools
Cry over spilt milk
Every cloud has a silver lining
Hear it on the grapevine
It takes two to tango
Once in a blue moon
THERAPEUTIC COMMUNICATION TECHNIQUES
Using Therapeutic Communication

Techniques
The choice of technique depends on the
intent of the interaction and the client’s
ability to communicate verbally.
Nontherapeutic Communication
Nontherapeutic Communication
These responses cut off communication and make it
more difficult for the interaction to
continue.
Interpreting Signals or Cues
Cues (overt and covert) are verbal

or nonverbal messages that signal key words or
issues for the client.
Interpreting Signals or Cues
Overt cues are clear, direct statements of

Intent
“I want to die.”
Covert cues are vague or indirect messages
that need interpretation and exploration
“Nothing can help me.”
NONVERBAL COMMUNICATION SKILLS
Nonverbal communication is the behavior a person exhibits

while delivering verbal content.
It includes facial expression, eye contact, space,

time, boundaries, and body movements.
Ways in which nonverbal messages accompany verbal

messages:
• Accent: using flashing eyes or hand movements
• Complement: giving quizzical looks, nodding
• Contradict: rolling eyes to demonstrate that the
meaning is the opposite of what one is saying
• Regulate: taking a deep breath to demonstrate readiness to speak,

using “and uh” to signal the wish to continue speaking
• Repeat: using nonverbal behaviors to augment the verbal
message, such as shrugging after saying “Who knows?”
• Substitute: using culturally determined body movements
that stand in for words, such as pumping the arm up and
down with a closed fist to indicate success
Facial Expression
The human face produces the most visible, complex, and
sometimes confusing nonverbal messages.
Facial expressions can be categorized into:
• An expressive face
• An impassive face
• A confusing face
Body Language
gestures, postures, movements, and body positions
Closed body positions, such as crossed legs or

arms folded across the chest, indicate that the
interaction might threaten the listener who is
defensive or not accepting.
Vocal Cues
Vocal cues are nonverbal sound signals transmitted along
with the content: voice volume, tone, pitch, intensity,
emphasis, speed, and pauses augment the sender’s message.
Emphasis refers to accents on words or phrases that highlight the

subject or give insight into the topic.
Speed is the number of words spoken per minute.
Pauses also contribute to the message, often adding emphasis or
feeling.
Eye
“mirror of the soul”
reflect our emotions
Eye contact, looking into the other person’s eyes during

communication, is used to assess the other person and
the environment and to indicate whose turn it is to speak
Silence
Silence or long pauses in communication may indicate
many different things. The client may seem to be:
“lost in his or her own thoughts”
not paying attention to the nurse
It is important to allow the client sufficient time to

respond, even if it seems like a long time.
UNDERSTANDING THE MEANING OF

COMMUNICATION
UNDERSTANDING CONTEXT
UNDERSTANDING SPIRITUALITY
UNDERSTANDING SPIRITUALITY
Spirituality is a client’s belief about life, health, illness,
death, and one’s relationship to the universe.
Don’t impose his or her own belief on the client
Client is not ignored or ridiculed because his or her beliefs and values
differ from those of the staff.
CULTURAL CONSIDERATIONS
Culture is all the socially learned behaviors, values,

beliefs, and customs transmitted down to each
generation.
Each culture has its own rules governing verbal and

nonverbal communication.
THE THERAPEUTIC COMMUNICATION SESSION
Goals
The nurse uses all the therapeutic communication techniques
and skills previously described to help achieve the
following goals:
• Establish rapport
• Actively listen to the client
• Gain an in-depth understanding of the client’s perception
• Explore the client’s thoughts and feelings.

• Facilitate the client’s expression of thoughts and feelings.
• Guide the client to develop new skills in problem solving.
• Promote the client’s evaluation of solutions.
Nondirective Role
Directive Role
ASSERTIVE COMMUNICATION
Assertive communication is the ability to express

positive and negative ideas and feelings in an open,
honest, and direct way
It recognizes the rights of both parties, and is useful in a variety

of situations, such as resolving conflicts,
solving problems, and expressing feelings or thoughts
that are difficult for some people to express
ASSERTIVE COMMUNICATION
• Aggressive
• Passive-aggressive
• Passive
• Assertive
Chapter 7
Client’s Response to Illness
Building nurse client relationship
Nursing describe the person or individual as a

biopsychosocial being who possesses unique
characteristics and responds to others and
the world in various and diverse ways.
Culture is all the socially learned behaviors,

values, beliefs, customs, and ways of thinking of a
population that guide its members’ views of
themselves and the world.
INDIVIDUAL FACTORS
 Age, Growth, and Development

 Genetics and Biologic Factors
 Physical Health and Health Practices
 Response to Drugs
 Self-Efficacy
 Hardiness
 Resilience and Resourcefulness
 Spirituality
INTERPERSONAL FACTORS
 Sense of Belonging
 Social Networks and Social Support
 Family Support
CULTURAL FACTORS
 Beliefs About Causes of Illness

 Socioeconomic Status and Social Class
INDIVIDUAL FACTORS
Age, Growth, and Development
Younger clients may have difficulty expressing their

thoughts and feelings, so they often have poorer
outcomes when experiencing stress or
illness at an early age.
INDIVIDUAL FACTORS
Genetics and Biologic Factors
Heredity and biologic factors are not under

voluntary control.
INDIVIDUAL FACTORS
Physical Health and Health Practices
The healthier a person is, the better he or she can cope

with stress or illness.
Poor nutritional status, lack of sleep, or a chronic physical
illness may impair a person’s ability to
cope.
INDIVIDUAL FACTORS
Response to Drugs
Ethnic groups differ in the metabolism and

efficacy of psychoactive compounds.
INDIVIDUAL FACTORS
Self-Efficacy
Belief that personal abilities and efforts affect the events
in our lives.
A person who believes that his or her behavior

makes a difference is more likely to take action.
INDIVIDUAL FACTORS
Hardiness
Ability to resist illness when under stress.
Three components:
1. Commitment: active involvement in life activities
2. Control: ability to make appropriate decisions in life
activities
3. Challenge: ability to perceive change as beneficial
rather than just stressful.
INDIVIDUAL FACTORS
Resilience defined as having healthy responses to

stressful circumstances or risky situations.
Resourcefulness involves using problem-solving

abilities and believing that one can cope with
adverse or novel situations.
INDIVIDUAL FACTORS
Spirituality involves the essence of a person’s being and his

or her beliefs about the meaning of life and the purpose for
living.
It may include belief in God or a higher power, the practice

of religion, cultural beliefs and practices,
and a relationship with the environment.
Sense of Belonging
A sense of belonging is the feeling of connectedness with or
involvement in a social system or environment of which a
person feels an integral part.
Feeling of both value and fit

Social networks are groups of people whom one

knows and with whom one feels connected.
Social support is emotional sustenance that comes from

friends, family members, and even health-
care providers who help a person when a problem arises.
Family Support
The nurse must encourage family members to

continue to support the client even while he or she is
in the hospital and should identify family strengths,
such as love and caring, as a
resource for the client
CULTURAL FACTORS
Culturally competent nursing care means

being sensitive to issues related to culture,
race, gender, sexual orientation, social class,
economic situation, and other factors.
CULTURAL FACTORS
Unnatural or personal beliefs attribute

the cause of illness to the active, purposeful
intervention of an outside agent, spirit, or
supernatural force or deity.
Natural view is rooted in a belief that
natural conditions or forces, such as cold, heat, wind,
or dampness, are responsible for the
illness
CULTURAL FACTORS
Socioeconomic status refers to one’s income,

education, and occupation.
CULTURAL FACTORS
Cultural Patterns and Differences
Being aware of the usual differences can

help the nurse know what to ask or how to
assess preferences and health practices
CULTURAL FACTORS
Points to Consider When Working
with Individual Responses to Illness
• Approach the client with a genuine caring attitude.

• Ask the client at the beginning of the interview how he or
she prefers to be addressed and ways the nurse can promote
spiritual, religious, and health practices.
Points to Consider When Working
with Individual Responses to Illness
• Recognize any negative feelings or stereotypes and discuss

them with a colleague to dispel myths and misconceptions.
• Remember that a wide variety of factors influence
the client’s complex response to illness.
Chapter 8
ASSESSMENT
BUILDING THE NURSE-CLIENT RELATIONSHIP:ASSESSMENT
Psychosocial Assessment
a mental status examination
Purpose: to construct a picture of the client’s current
emotional state, mental capacity, and behavioral function
 Serves as the basis for developing a plan of care to
meet the client’s needs
 Clinical baseline used to evaluate the effectiveness of
treatment and interventions or a measure of the
client’s progress
FACTORS INFLUENCING ASSESSMENT

1. Client participation/feedback
2. Client’s health status
3. Client’s previous experiences/misconceptions about
health care
4. Client’s ability to understand
5. Nurse’s attitude and approach

1. Client Participation/Feedback
A thorough and complete psychosocial assessment

requires active client participation.
If the client is unable or unwilling to participate, some

areas of the assessment will be incomplete or vague.

2. Client’s Health Status
If the client health status is not stable, the nurse may have
difficulty eliciting the client’s full participation in the
assessment.

3. Client’s Previous Experiences/ Misconceptions About Health Care
The client’s perception of his or her circumstances can elicit emotions

that interfere with obtaining an accurate psychosocial assessment.
Address the client’s feelings and perceptions to establish a trusting

working relationship before proceeding

4. Client’s Ability to Understand
The nurse also must determine the client’s ability to hear,

read, and understand the language being used in the
assessment.
result of poor communication


5. Nurse’s Attitude and Approach
 rushed or pressured
client may provide only superficial information
 nonaccepting, defensive, or judgmental

client may refrain from providing sensitive information
HOW TO CONDUCT THE INTERVIEW

1. Environment
2. Input from family and friends
3. How to phrase questions

1. Environment
Comfortable, private, and safe for both the client and the
nurse.
Comfortable: fairly quiet with few distractions: full attention

Privacy: ensures the client that no one will overhear what is
being discussed.
Safety: isolated location for the interview

Input From Family and Friends
Nurse should obtain their perceptions of the client’s

behavior and emotional state
This is accomplished depends on the situation.


 Open-ended questions
 Direct questions
Clear, simple, and focused on one specific behavior or symptom
“How are your eating and sleeping habits and have you been
taking any over-the-counter medications that affect your eating
and sleeping?”


Nonjudgmental tone and language
Using nonjudgmental language and a matter-of-fact tone

tends the client to become defensive or to not tell the truth
“How often do you physically punish your child?”

 “What types of discipline do you use?”
CONTENT OF THE ASSESSMENT

assess the client in a thorough and systematic
way that lends itself to analysis and serves as a
basis for the client’s care

Components:
1. History
2. General appearance and motor behavior
3. Mood and affect
4. Thought process and content
5. Sensorium and intellectual processes
6. Judgment and insight
7. Self-concept
8. Roles and relationships
9. Physiologic and self-care concerns


1. History
AGE
DEVELOPMENTAL STAGE
CULTURAL CONSIDERATIONS
SPIRITUAL BELIEFS
PREVIOUS HISTORY

Non-stop?
2. General Assessment and Motor Behavior
Automatisms: repeated purposeless
Hygiene and Preserverate?
grooming
behaviors often indicative of anxiety
Minimal response?
Appropriate dress
Psychomotor retardation: overall slowed
Relevant?
movements
Posture
Fast or slow?
Waxy flexibility: maintenance of posture or
Eye contact Audible or loud?
position
Unusualover time even
movement or when it is awkward
mannerism
Rhyming manner?
or uncomfortable
Speech NEOLOGISMS
3. Assessment data about the client’s speech patterns
are
categorized in which of the following areas?
a. History
b. General appearance and motor behavior
c. Sensorium and intellectual processes
d. Self-concept

3. Mood and Affect
Mood
Refers to the client’s pervasive and enduring
emotional state
Affect
Outward expression of the client’s emotional state

3. Mood and Affect
Blunted affect: showing little or a slow-to-respond facial expression

Broad affect: displaying a full range of emotional expressions
Flat affect: showing no facial expression
Inappropriate affect: displaying a facial expression that is incongruent
with mood or situation; often silly or giddy regardless of circumstances
Restricted affect: displaying one type of expression, usually serious or
somber.

3. Mood and Affect
Remember!
When the client exhibits unpredictable and rapid mood
swings from depressed and crying to euphoria with no
apparent stimuli, the mood is called labile (rapidly changing).
Mood intensity?
Rate from 1 to 10

4. Thought process and content
Thought process refers to how the client thinks.

The nurse can infer a client’s thought process from speech and
speech patterns.
-HOW the client thinks
Thought content is what the client actually says.
-WHAT the client thinks
CONTENT OF THE ASSESSMENT: 4. Thought process and content
Circumstantial thinking: a client eventually answers a

question but only after giving excessive unnecessary
detail
Delusion: a fixed false belief not based in reality
Flight of ideas: excessive amount and rate of speech
composed of fragmented or unrelated ideas
Ideas of reference: client’s inaccurate interpretation that

general events are personally directed to him or her, such as
hearing a speech on the news and believing the message had
personal meaning
Loose associations: disorganized thinking that jumps from
one idea to another with little or no evident relation between
the thoughts
Tangential thinking: wandering off the topic and never
providing the information requested
Thought blocking: stopping abruptly in the middle of a

sentence or train of thought; sometimes unable to continue
the idea
Thought broadcasting: a delusional belief that others
can hear or know what the client is thinking
Thought insertion: a delusional belief that others are
putting ideas or thoughts into the client’s head—that is,
the ideas are not those of the client
Thought withdrawal: a delusional belief that others are

taking the client’s thoughts away and the client is
powerless to stop it
Word salad: flow of unconnected words that convey no

meaning to the listener.
ASSESSMENT OF SUICIDE OR HARM TOWARD OTHERS

The nurse must determine whether the depressed or hopeless client has
suicidal ideation or a lethal plan.
Ideation: “Are you thinking about killing yourself?”

Plan: “Do you have a plan to kill yourself?”
Method: “How do you plan to kill yourself?”
Access: “How would you carry out this plan? Do you have access to the means
to carry out the plan?”
ASSESSMENT OF SUICIDE OR HARM TOWARD OTHERS
Access: “How would you carry out this plan? Do you have access to the
means to carry out the plan?”
Where: “Where would you kill yourself?”
When: “When do you plan to kill yourself?”
Timing: “What day or time of day do you plan to kill yourself?”
 DUTY TO WARN

5. Sensorium and Intellectual Processes
a. Orientation
Person, place and time
Disoriented loses track of time, then place, and person.
b. Memory
c. Ability to concentrate
d. Abstract thinking and intellectual abilities

c. Ability to concentrate
 Spell the word world backward.

 “serial sevens.”
 Repeat the days of the week backward.
 Perform a three-part task
d. Abstract thinking and intellectual abilities

A stitch in time saves nine.
People who live in glass houses shouldn’t throw stones.
“What is similar about an apple and an orange?”
“What do the newspaper and the television have in common?”

6. Judgment and insight
Judgment
Ability to interpret one’s environment and situation
correctly and to adapt one’s behavior and decisions
accordingly
Insight
ability to understand the true nature of one’s situation
and accept some personal responsibility for that situation

7. Self-concept
The way one views oneself in terms of personal worth and
dignity
Body-image
Emotions
Coping strategies

8. Roles and Relationships
The nurse assesses the roles the client occupies, client

satisfaction with those roles, and whether the client believes he
or she is fulfilling the roles adequately.
Relationships vary in terms of significance, level of intimacy or

closeness, and intensity.

9. Physiologic and Self-Care Considerations
Emotional problems often affect some areas of physiologic
function
DATA ANALYSIS
Data analysis involves thinking about the overall assessment
rather than focusing on isolated bits of information.
 Patterns and themes
 congruence of information
Data analysis leads to the formulation of nursing diagnoses as a

basis for the client’s plan of care.
PSYCHOLOGICAL TESTS
Two basic types of tests are intelligence tests and personality
tests.
Intelligence tests are designed to evaluate the client’s cognitive
abilities and intellectual functioning.
Personality tests reflect the client’s personality in areas such as

self-concept, impulse control, reality testing, and major
defenses
PSYCHOLOGICAL TESTS
Personality tests
Objective
Constructed of true-and-false or multiple-choice questions
Projective tests
Unstructured and are usually conducted by the interview
method
PSYCHOLOGICAL TESTS
Projective tests
Draw-a-person Test
Rorschach test
10 stimulus cards of inkblots; client describes perceptions of
inkblots
Thematic Apperception Test (TAT)
20 stimulus cards with pictures; client tells a story about the
picture
Sentence completion test
MENTAL STATUS EXAM

These exams usually include items such as orientation to
person, time, place, date, season, and day of the week;
ability to interpret proverbs;
ability to perform math calculations;
memorization and short-term recall;
naming common objects in the environment;
ability to follow multistep commands;
ability to write or copy a simple drawing

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PSYCHIATRIC-MENTAL

SUPEREGO is the part of a person’s nature

DON’Ts of the society

The ego, is the balancing or mediating force

The ego represents mature and adaptive

Conscious--perceptions, thoughts, and emotions that exist in

Denial- unconscious refusal to admit an

Rationalization-conscious or unconscious attempts to make

Identification-conscious or unconscious attempt to

Sublimation-consciously or unconsciously channeling

Displacement-unconsciously discharging pent-up

Substitution-the replacement of a highly

Fixation-Immobilization of portion of personality

Belief that sexual energy, termed libido, was the driving

Psychopathology results when a person has

Transference occurs when the client displaces onto the

Countertransference occurs when the therapist

Psychoanalysis focuses on discovering the

Erik Erikson (1902–1994) was a

In each stage, the person must complete a life

The conflicts faced by an individual at

Teaching for a child in this stage should be

His thinking is influenced by fantasy-the way he’d like

Harry Stack Sullivan (1892–1949) was an

Milieu therapy was one of the primary

1. The orientation phase is directed by the nurse

3. In the exploitation phase, the client makes

Factors influencing orientation phase

She described four levels of anxiety:

These serve as the foundation for working with

1. Mild anxiety is a positive state of heightened awareness and

Focuses on a person’s positive qualities, his or her

Humanists do consider the person’s past experiences, but

Abraham Maslow (1921–1970) was

Traumatic life circumstances or compromised health

This theory helps nurses understand how

Carl Rogers (1902–1987) was a

Rogers was one of the first to use

Client-centered therapy focuses on the role of the

Clients do “the work of healing,” and within a

The therapist must promote the client’s self-esteem as

School of psychology that focuses on observable

It does not attempt to explain how the mind

Behavior can be changed through conditioning with

He developed the theory of operant

These behavioral principles of rewarding or

Conditioned responses, such as fears or phobias, can be

Crisis is described as self-limiting;

Directive interventions directing the person’s behavior

Individual psychotherapy is a method of bringing about change

Open group and closed group

The ability to establish therapeutic relationships with

The nurse-client relationship is the foundation on

Therapeutic Nurse-Client Relationship

It is a helping and caring relationship in which both

It is also a relationship in which mutual

Therapeutic Nurse-Client Relationship

Components involved in establishing

COMPONENTS OF A THERAPEUTIC RELATIONSHIP: TRUST

Trust builds when the client is confident in the nurse and

COMPONENTS OF A THERAPEUTIC RELATIONSHIP: TRUST

Congruence occurs when words and actions match.

COMPONENTS OF A THERAPEUTIC RELATIONSHIP: TRUST