Mental health and mental illness

Health- a state of complete physical, mental, and social wellness, not merely the absence of disease or
infirmity. (Defined by WHO)

Mental Health- is a state of emotional, psychological, and social wellness evidenced by satisfying
interpersonal relationships, effective behavior and coping, positive self- concept, and emotional
stability.

Factors influencing a person’s mental health

-individual or personal
-interpersonal or relationship
-social or cultural

Mental disorder- a clinically significant behavioral of psychological syndrome or pattern that occurs
in an individual and that is associated with present distress or disability or with a significantly
increased risk of suffering death, pain, disability, or an important loss of freedom. (American
Psychiatric Association, 2000)

General criteria to diagnose mental disorder:

-dissatisfaction of one’s characteristics, abilities, and accomplishments
-ineffective or unsatisfying relationship
-dissatisfaction with one’s place in the world
-Ineffective coping with life events
-lack of personal growth

Diagnostic and Statistical Manual of Mental Disoerders, 4th Edition, Text revision (DSM-IV-TR)
- is a taxonomy published by the APA.
- describes all mental disorders, outlining specific diagnostic criteria for each based on clinical
experience and research.
- 3 purposes:
1. to provide a standardized nomenclature and language for all mental health professionals.
2. to present defining characteristics or symptoms that differentiate specific diagnoses.
3. to assist in identifying the underlying causes of disorders.
- multiaxial classification system that involves assessment of several axes, or domains of
information, allows the practitioner to identify all factors that relate to a person’s condition.
• Axis I is for identifying all major psychiatric disorders except mental retardation and
personality disorders. Ex. Depression, schizophrenia, anxiety, and substance- related
disorders.
• Axis II is for reporting mental retardation and personality disorders as well as prominent
maladaptive personality features and defense mechanisms.
• Axis III is for reporting current medical conditions that are potentially relevant to
understanding or managing the person’s mental disorder as well as medical conditions that
might contribute to understanding the person.
• Axis IV is for reporting psychosocial and environmental problems that may affect the
diagnosis, treatment, and prognosis of mental disorder.
• Axis V presents Global Assessment of Functioning, which rates the person’s overall
psychological functioning on a scale of 0 to 100.

Standards of care- are authoritative statements by professional organizations that describe the
responsibilities for which the nurse is accountable.
STANDARD: I. Assessment –collects client health data.
II. Diagnosis- analyzes the data in determining diagnoses.
III. Outcome Identification- identifies expected outcomes individualized to the client.
 IV. Planning- develops a plan of care that prescribes interventions to attain expected
outcomes.
V. Implementation- implements the interventions identified in the plan of care.
Va. Counseling- uses counseling interventions to assist clients in improving or
regaining their previous coping abilities, fostering mental health, and
preventing mental illness and disability.
Vb. Milieu Therapy- nurse provides structures, and maintains a therapeutic
environment in collaboration with the client and other health care
providers.
Vc. Self-care Activities- nurse structures interventions around the client’s activities of
daily living to foster self- care and mental and physical being.
Vd. Psychobiologic Interventions- nurse uses knowledge of psychobiologic
interventions and applies clinical skills to restore the client’s health and
prevent further disability.
Ve. Health Teaching- assists the clients in achieving satisfying, productive, and healthy
patterns of living.
Vf. Case Management- to coordinate comprehensive health care services and ensure
continuity of care.
Vg. Health Promotion and Maintenance- employs strategies and interventions to
promote and maintain mental health and prevent mental illness.
VI. Evaluation- evaluate the client’s progress in attaining expected outcomes.

Self-Awareness- is the process by which the nurse gains recognition of his or her own feelings,
beliefs, and attitudes.

PSYCHOSOCIAL THEORIES
1. Psychoanalytic theories (Sigmund Freud- father of psychoanalysis) – supports the notion that
all human behavior is caused and can be explained.
-personality components: Id (innate desires, pleasure seeking behavior, aggression and
sexual impulses), Superego (moral and ethical concepts, values, and parental and social
expectations.), Ego (the balancing or mediating force between the id and superego.)
-3 levels of awareness: Conscious (perceptions, thoughts, and emotions that exist in the
person’s awareness), Preconscious (not currently in the person’s awareness, but he/she can recall
them with some effort.), Unconscious (realm of thought and feelings that motivate a person even
though he/she is totally unaware of them.
- Dream analysis- a primary method used in psychoanalysis, involves discussing a client’s
dream to discover their true meaning and significance.
- Free Associations- 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 in mind.
- Ego Defense Mechanisms- methods of attempting to protect the self and cope with basic drives
or emotionally painful thoughts, feelings or events.

Level I: The mechanisms on this level, when predominating, almost always are severely
pathological.

• Denial: Refusal to accept external reality because it is too threatening; arguing against an
anxiety-provoking stimulus by stating it doesn't exist; resolution of emotional conflict and
reduction of anxiety by refusing to perceive or consciously acknowledge the more unpleasant
aspects of external reality.
• Distortion: A gross reshaping of external reality to meet internal needs.
• Delusional Projection: Grossly frank delusions about external reality, usually of a persecutory
nature.

Level II: These mechanisms are often present in adults and more commonly present in adolescence.
 Fantasy: Tendency to retreat into fantasy in order to resolve inner and outer conflicts
Projection: Projection is a primitive form of paranoia. Projection also reduces anxiety by allowing
the expression of the undesirable impulses or desires without becoming consciously aware of them;
attributing one's own unacknowledged unacceptable/unwanted thoughts and emotions to another;
includes severe prejudice, severe jealousy, hyper vigilance to external danger, and "injustice
collecting". It is shifting one's unacceptable thoughts, feelings and impulses within oneself onto
someone else, such that those same thoughts, feelings, beliefs and motivations as perceived as being
possessed by the other.
Hypochondriasis: The transformation of negative feelings towards others into negative feelings
toward self, pain, illness and anxiety
Passive aggression: Aggression towards others expressed indirectly or passively
Acting out: Direct expression of an unconscious wish or impulse without conscious awareness of
the emotion that drives that expressive behavior.

Idealization: Subconsciously choosing to perceive another individual as having more positive

qualities than they may actually have.

Level III: These mechanisms are considered neurotic, but fairly common in adults.

• Displacement: Defense mechanism that shifts sexual or aggressive impulses to a more

acceptable or less threatening target; redirecting emotion to a safer outlet; separation of
emotion from its real object and redirection of the intense emotion toward someone or
something that is less offensive or threatening in order to avoid dealing directly with what is
frightening or threatening. For example, a mother may yell at her child because she is angry
with her husband.
• Dissociation: Temporary drastic modification of one's personal identity or character to avoid
emotional distress; separation or postponement of a feeling that normally would accompany a
situation or thought.
• Isolation: Separation of feelings from ideas and events, for example, describing a murder with
graphic details with no emotional response.
• Intellectualization: A form of isolation; concentrating on the intellectual components of a
situation so as to distance oneself from the associated anxiety-provoking emotions; separation
of emotion from ideas; thinking about wishes in formal, affectively bland terms and not acting
on them; avoiding unacceptable emotions by focusing on the intellectual aspects (e.g.
rationalizations).
• Reaction Formation: Converting unconscious wishes or impulses that are perceived to be
dangerous into their opposites; behavior that is completely the opposite of what one really
wants or feels; taking the opposite belief because the true belief causes anxiety. This defense
can work effectively for coping in the short term, but will eventually break down.
• Repression: Process of pulling thoughts into the unconscious and preventing painful or
dangerous thoughts from entering consciousness; seemingly unexplainable naivety, memory
lapse or lack of awareness of one's own situation and condition; the emotion is conscious, but
the idea behind it is absent.

Level IV: These are commonly found among emotionally healthy adults and are considered the most
mature, even though many have their origins in the immature level.

• Altruism: Constructive service to others that brings pleasure and personal satisfaction
• Anticipation: Realistic planning for future discomfort
• Humor: Overt expression of ideas and feelings (especially those that are unpleasant to focus
on or too terrible to talk about) that gives pleasure to others. Humor enables someone to call a
spade a spade, while "wit" is a form of displacement (see above under Category 3)
• Identification: The unconscious modeling of one's self upon another person's character and
behavior
 • Introjection: Identifying with some idea or object so deeply that it becomes a part of that
person
• Sublimation: Transformation of negative emotions or instincts into positive actions, behavior,
or emotion
• Suppression: The conscious process of pushing thoughts into the preconscious; the conscious
decision to delay paying attention to an emotion or need in order to cope with the present
reality; able to later access uncomfortable or distressing emotions and accept them.

-Transference –occurs when the client displaces onto the therapist attitudes and feelings that the
client originally experienced in other relationships.\

-Counter transference- occurs when the therapist displaces onto the client attitudes or feelings from
his/her past.

-Freud’s Stages of Psychosexual Development are, like other stage theories, completed in a
predetermined sequence and can result in either successful completion or a healthy personality or can
result in failure, leading to an unhealthy personality.

Oral Stage (Birth to 18 months). During the oral stage, the child if focused on oral pleasures
(sucking). Too much or too little gratification can result in an Oral Fixation or Oral Personality which
is evidenced by a preoccupation with oral activities. This type of personality may have a stronger
tendency to smoke, drink alcohol, over eat, or bite his or her nails. Personality wise, these individuals
may become overly dependent upon others, gullible, and perpetual followers. On the other hand,
they may also fight these urges and develop pessimism and aggression toward others.

Anal Stage (18 months to three years). The child’s focus of pleasure in this stage is on eliminating and
retaining feces. Through society’s pressure, mainly via parents, the child has to learn to control anal
stimulation. In terms of personality, after effects of an anal fixation during this stage can result in an
obsession with cleanliness, perfection, and control (anal retentive). On the opposite end of the
spectrum, they may become messy and disorganized (anal expulsive).

Phallic Stage (ages three to six). The pleasure zone switches to the genitals. Freud believed that
during this stage boy develop unconscious sexual desires for their mother. Because of this, he
becomes rivals with his father and sees him as competition for the mother’s affection. During this
time, boys also develop a fear that their father will punish them for these feelings, such as by
castrating them. This group of feelings is known as Oedipus Complex ( after the Greek Mythology
figure who accidentally killed his father and married his mother).Later it was added that girls go
through a similar situation, developing unconscious sexual attraction to their father. Although Freud
Strongly disagreed with this, it has been termed the Electra complex by more recent psychoanalysts.
According to Freud, out of fear of castration and due to the strong competition of his father, boys
eventually decide to identify with him rather than fight him. By identifying with his father, the boy
develops masculine characteristics and identifies himself as a male, and represses his sexual feelings
toward his mother. A fixation at this stage could result in sexual deviancies (both overindulging and
avoidance) and weak or confused sexual identity according to psychoanalysts.

Latency Stage (age six to puberty). It’s during this stage that sexual urges remain repressed and
children interact and play mostly with same sex peers.
Genital Stage (puberty on). The final stage of psychosexual development begins at the start of
puberty when sexual urges are once again awakened. Through the lessons learned during the
previous stages, adolescents direct their sexual urges onto opposite sex peers, with the primary focus
of pleasure is the genitals.

PSYCHOANALYSIS (therapy for the wealthy) – 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 anxiety.

2. Developmental theories

-Theory of Psychosocial Development has eight distinct stage, each with two possible outcomes.
According to the theory, successful completion of each stage results in a healthy personality and
successful interactions with others. Failure to successfully complete a stage can result in a reduced
ability to complete further stages and therefore a more unhealthy personality and sense of self.
These stages, however, can be resolved successfully at a later time.

Trust Versus Mistrust. From ages birth to one year, children begin to learn the ability to trust others
based upon the consistency of their caregiver(s). If trust develops successfully, the child gains
confidence and security in the world around him and is able to feel secure even when threatened.
Unsuccessful completion of this stage can result in an inability to trust, and therefore an sense of fear
about the inconsistent world. It may result in anxiety, heightened insecurities, and an over feeling of
mistrust in the world around them. Virtue: HOPE

Autonomy vs. Shame and Doubt. Between the ages of one and three, children begin to assert their
independence, by walking away from their mother, picking which toy to play with, and making
choices about what they like to wear, to eat, etc. If children in this stage are encouraged and
supported in their increased independence, they become more confident and secure in their own
ability to survive in the world. If children are criticized, overly controlled, or not given the
opportunity to assert themselves, they begin to feel inadequate in their ability to survive, and may
then become overly dependent upon others, lack self-esteem, and feel a sense of shame or doubt in
their own abilities. Virtue: WILL

Initiative vs. Guilt. Around age three and continuing to age six, children assert themselves more
frequently. They begin to plan activities, make up games, and initiate activities with others. If given
this opportunity, children develop a sense of initiative, and feel secure in their ability to lead others
and make decisions. Conversely, if this tendency is squelched, either through criticism or control,
children develop a sense of guilt. They may feel like a nuisance to others and will therefore remain
followers, lacking in self-initiative. Virtue: PURPOSE

Industry vs. Inferiority. From age six years to puberty, children begin to develop a sense of pride in
their accomplishments. They initiate projects, see them through to completion, and feel good about
what they have achieved. During this time, teachers play an increased role in the child’s
development. If children are encouraged and reinforced for their initiative, they begin to feel
industrious and feel confident in their ability to achieve goals. If this initiative is not encouraged, if it
is restricted by parents or teacher, then the child begins to feel inferior, doubting his own abilities and
therefore may not reach his potential. Virtue: COMPETENCE

Identity vs. Role Confusion. During adolescence, the transition from childhood to adulthood is most
important. Children are becoming more independent, and begin to look at the future in terms of
career, relationships, families, housing, etc. During this period, they explore possibilities and begin to
form their own identity based upon the outcome of their explorations. This sense of who they are can
be hindered, which results in a sense of confusion ("I don’t know what I want to be when I grow up")
about themselves and their role in the world. Virtue: FIDELITY

Intimacy vs. Isolation. Occurring in Young adulthood, we begin to share ourselves more intimately
with others. We explore relationships leading toward longer term commitments with someone other
than a family member. Successful completion can lead to comfortable relationships and a sense of
commitment, safety, and care within a relationship. Avoiding intimacy, fearing commitment and
relationships can lead to isolation, loneliness, and sometimes depression. Virtue: LOVE

Generativity vs. Stagnation. During middle adulthood, we establish our careers, settle down within
a relationship, begin our own families and develop a sense of being a part of the bigger picture. We
give back to society through raising our children, being productive at work, and becoming involved
in community activities and organizations. By failing to achieve these objectives, we become stagnant
and feel unproductive. Virtue: CARE

Ego Integrity vs. Despair. As we grow older and become senior citizens, we tend to slow down our
productivity, and explore life as a retired person. It is during this time that we contemplate our
accomplishments and are able to develop integrity if we see ourselves as leading a successful life. If
we see our lives as unproductive, feel guilt about our pasts, or feel that we did not accomplish our life
goals, we become dissatisfied with life and develop despair, often leading to depression and
hopelessness. Virtue: WISDOM

- Piaget’s Theory of Cognitive Development maintains that children go through specific stages as
their intellect and ability to see relationships matures. These stages are completed in a fixed order
with all children, even those in other countries. The age range, however can vary from child to child.

Sensorimotor Stage. This stage occurs between the ages of birth and two years of age, as infants
begin to understand the information entering their sense and their ability to interact with the world.
During this stage, the child learns to manipulate objects although they fail to understand the
permanency of these objects if they are not within their current sensory perception. In other words,
once an object is removed from the child’s view, he or she is unable to understand that the object still
exists.

The major achievement during this stage is that of Object Permanency, or the ability to understand that
these objects do in fact continue to exist. This includes his ability to understand that when mom
leaves the room, she will eventually return, resulting in an increased sense of safety and security.
Object Permanency occurs during the end of this stage and represents the child’s ability to maintain a
mental image of the object (or person) without the actual perception.
Preoperational Stage. The second stage begins after Object Permanency is achieved and occurs
between the ages of two to seven years of age. During this stage, the development of language occurs
at a rapid pace. Children learn how to interact with their environment in a more complex manner
through the use of words and images. This stage is marked by Egocentrism, or the child’s belief that
everyone sees the world the same way that she does. The fail to understand the differences in
perception and believe that inanimate objects have the same perceptions they do, such as seeing
things, feeling, hearing and their sense of touch.

A second important factor in this stage is that of Conservation, which is the ability to understand that
quantity does not change if the shape changes. In other words, if a short and wide glass of water is
poured into a tall and thin glass. Children in this stage will perceive the taller glass as having more
water due only because of it’s height. This is due to the children’s inability to understand reversibility
and to focus on only one aspect of a stimulus (called centration), such as height, as opposed to
understanding other aspects, such as glass width.

Concrete Operations Stage. Occurring between ages 7 and about 12, the third stage of cognitive
development is marked by a gradual decrease in centristic thought and the increased ability to focus
on more than one aspect of a stimulus. They can understand the concept of grouping, knowing that a
small dog and a large dog are still both dogs, or that pennies, quarters, and dollar bills are part of the
bigger concept of money.

They can only apply this new understanding to concrete objects ( those they have actually
experienced). In other words, imagined objects or those they have not seen, heard, or touched,
continue to remain somewhat mystical to these children, and abstract thinking has yet to develop.

Formal Operations Stage. In the final stage of cognitive development (from age 12 and beyond),
children begin to develop a more abstract view of the world. They are able to apply reversibility and
conservation to both real and imagined situations. They also develop an increased understanding of
the world and the idea of cause and effect. By the teenage years, they are able to develop their own
theories about the world. This stage is achieved by most children, although failure to do so has been
associated with lower intelligence.

3. interpersonal theories
- Harry Stack Sullivan: Interpersonal Relationships and Milieu Therapy
STAGE AGES FOCUS
Infancy Birth to Primary need for bodily contact and tenderness; prototaxic mode
onset of dominates(no relation between experiences); primary zones are oral
language and anal; if needs are met, infant has sense of wellbeing; unmet needs
lead to dread and anxiety.
Childhood Language Parents viewed as source of praise and acceptance; shift to parataxic
to 5 years mode (experiences are connected in sequence to each other); primary
zone is anal; gratification leads to positive self-esteem; moderate
anxiety leads to unceratiny and insecurity; severe anxiety results in
self-defeating patterns of behavior.
Juvenile 5-8 years Shift to the syntaxic mode begins (thinking about self and others based
on analysis of experiences in variety of situations); opportunities for
approval and acceptance of others; learn to negotiate own needs;
 severe anxiety may result in a need to control or in restrictive,
prejudicial attitudes.
Preadolescence 8-12 years Move to genuine intimacy with friend of the same sex; move away
from family as source of satisfaction in relationships; major shift to
syntaxic mode; capacity for attachment, love, and collaboration
emerges or fails to develop.
Adolescence Puberty to Lust is added to interpersonal equation; need for special sharing
adulthood relationship shifts to the opposite sex; new opportunities for social
experimentation lead to the consolidation of self- esteem or self-
ridicule; it the self-system is intact, areas of concern expand to include
values, ideals, career decisions, and concerns.

Milieu Therapy- involved client’s interactions with one another, that is, practicing interpersonal
relationship skills, giving one another feedback about behavior, and working cooperatively as a
group to solve day-to-day problems.

-Hildegard Peplau: Therapeutic Nurse-Patient Relationship

STAGE DEFINITION TASKS

Orientation Directed by the nurse and involves
engaging the client in treatment,
providing explanations and
information, and answering
questions.
Identification Begins when the client works
interdependently with the nurse,
expresses feelings and begins to
feel stronger.
Exploitation The client makes full use of the
services offered.
Resolution The client no longer needs
professional services and gives up
dependent behavior. The
relationship ends.
Clarification of patient’s problems and needs;
patient asks questions; explanation of hospital
routines and expectations; patient harnesses
energy toward meeting problems; patient’s full
participation is elicited.
Patient responds to persons he/she perceives as
helpful; patient feels stronger; expression of
feelings; interdependent work with the nurse;
clarification of roles of both patient and nurse.
Patient makes full use of available services; goals
such as going home and returning to work
emerge; patient’s behaviors fluctuate between
dependence and independence.
Patient gives up dependent behavior; services
are no longer needed by patient; patient assumes
power to meet own needs, set new goals, and so
forth.

ANXIETY LEVELS

MILD MODERATE SEVERE PANIC

-sharpened sense -selectively attentive -perceptual field -perceptual field
-increased motivation -perceptual field reduced to one detail or reduced to focus on self
-alert limited to the scattered details -cannot process
-enlarged perceptual immediate task -cannot complete tasks environmental stimuli
field -can be redirected -cannot solve problems -distorted perceptions
-can solve problems -cannot connect or learn effectively -loss of rational thought
-learning effective thoughts or events -behavior geared -personality
-restless independently toward anxiety relief disorganization
-gastrointestinal -muscle tension and is usually -doesn’t recognize
“butterflies” -diaphoresis ineffective danger
-sleepless -pounding pulse -feels awe, dread, -possibly suicidal
-irritable -headache horror -delusions or
-hypersensitive to noise -dry mouth -doesn’t respond to hallucination possible
 -higher voice pitch redirection -cant communicate
-increased rate of -severe headache verbally
speech -nausea, vomiting, -either cannot sit (may
-gastrointestinal upset diarrhea bolt and run) or is
-frequent urination -trembling totally mute or
-increased automatisms -rigid stance immobile.
(nervous mannerisms) -vertigo
-pale
-tachycardia
-chest pain
-crying
-ritualistic
(purposeless,
repetitive) behavior.

4. Humanistic Theories

Humanism- focuses on a person’s positive qualities, his/her capacity to change (human

potential), and the promotion of self esteem.

-Abraham Maslow: Hierarchy of needs

Self-actualization
Self-esteem needs (self-respect and esteem from others.
Love and belonging needs (intimacy, friendship, and acceptance).
Safety and security needs
Physiologic needs

-Carl Rogers: Client-centered therapy –focuses on the role of the client, rather than the therapist,
as the key to the healing process.
3 central concepts:
• Unconditional positive regard- a nonjudgmental caring for the client that is not dependent
on the client’s behavior
• 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 and communicates this understanding to the client.

5. Behavioral Theories

Behaviorism- is a school of psychology that focuses on observable behaviors and what one can do
externally to bring about behavior changes.

-Ivan Pavlov: Classical Conditioning- behavior can be changed through conditioning with
external or environmental conditions or stimuli.

-B.F. Skinner: Operant Conditioning –which says people learn their behavior from their history
or past experiences, particularly those experiences that were repeatedly reinforced.
Principles:
a) All behavior is learned.
b) Consequences result from behavior- broadly speaking, reward and punishment.
c) Behavior that is rewarded with reinforcers tends to recur.
d) Positive reinforcers that follow a behavior increase the likelihood that the behavior will
recur
e) Negative reinforcers that are removed after a behavior increase the likelihood that the
behavior will recur.
 f) Continuous reinforcement (a reward every time the behavior occurs) is the fastest way to
increase that behavior, but the behavior will not last long after the reward ceases.
g) Random intermittent reinforcement (an occasional reward for the desired behavior) is
slower to produce an increase in behavior, but the behavior continues after the reward
ceases.

Behavior modification- is a method of attempting to strengthen a desired behavior or response by

reinforcement, either positive or negative.

Positive reinforcement- giving the client attention and positive feedback.

Negative reinforcement- involves removing a stimulus immediately after a behavior occurs so that
the behavior is more likely to occur again.

Systematic desensitization- used to help clients overcome irrational fears and anxiety associated
with phobias. The client then is exposed to the least anxiety-provoking situation and uses the
relaxation techniques to manage the resulting anxiety.

6. Existential Theories –believe that behavioral deviations result when a person is out of touch
with himself or herself or the environment. The goal is to help the person discover an
authentic sense of self.

-Cognitive therapy- which focuses on immediate though processesing- how a person perceives or
interprets his/her experience and determines how he/she feels and behaves.

THERAPY THERAPIST THERAPEUTIC PROCESS

Rational Albert Ellis A cognitive therapy using confrontation of “irrational beliefs”
emotive that prevent the individual from accepting responsibility for self
therapy and behavior.
Logotherapy Viktor E. Frankl A therapy designed to help individuals assume personal
responsibility. The search for meaning (logos) in life is a central
theme.
Gestalt therapy Frederick S. A therapy focusing on the identification of feelings in the here
Peris and now, which leads to self-acceptance.
Reality therapy William Glasser Therapeutic focus is need for identity through responsible
behavior. Individuals are challenged to examine ways in which
their behavior thwarts their attempts to achieve life goals.

THERAPEUTIC RELATIONSHIPS

Components of a therapeutic relationship:

1) Trust – builds when the client is confident with the nurse and when the nurse’s presence
conveys integrity and reliability. (Congruence- occurs when words and actions match.)
2) Genuine Interest- clearly focused on the client.
3) Empathy- is the ability of the nurse to perceive the meanings and feeling of the client and
to communicate that understanding to the client. (sympathy- feelings of concern or
compassion one shows for another.)
4) Acceptance- avoiding judgments of the person, no matter what the behavior.
5) Positive Regard- nurse who appreciates the client as a unique worthwhile human being
can respect the client regardless of his/her behavior, background or lifestyle.

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.
• Values- are abstract standards that give a person a sense of right and wrong and
establish a code of conduct for living.
Values Clarification:
*Choosing- is when a 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 his/herself.
*Acting- is when the person puts the value into action.
• Beliefs- are ideas that one holds to be true.
• Attitudes- are general feeling or frame of reference around which a person
organizes knowledge about the world.
• Therapeutic use of self- when a nurse begins to use aspects of his/her personality,
experiences, values, feelings, intelligence, needs, coping skills, and perceptions to
establish relationship to the clients.
• Johari window- which creates a “word portrait” of a person in four areas and
indicates how well that person knows him/herself and communicates with others.
I. Open/public self- qualities one knows about oneself and others also know.
II. Blind/unaware self- qualities known only to others.
III. Hidden/private self- qualities known only to oneself.
IV. Unknown- and empty quadrant to symbolize qualities as yet discovered by
oneself or others.

Patterns of knowing
-Hildegard Peplau identified Preconceptions (ways one person expects another to behave or speak,
as a roadblock to the formation of an authentic relationship.

-Carper’s patterns of nursing knowledge:

Pattern Definition
Empirical knowing Obtained from the science of nursing.
Personal knowing Obtained from life experience.
Ethical knowing Obtained from moral knowledge of nursing
Aesthetic knowing Obtained from the art of nursing.

Types of relationships:
1) Social Relationship- is primarily initiated for the purpose of friendship, socialization,
companionship, or accomplishment of a task.
2) Intimate Relationship- involves two people who are emotionally committed to each other.
3) Therapeutic Relationship- focuses on the needs, experiences, feelings and ideas of the client
only.

Establishing the therapeutic relationship

(Peplau’s Model of 4 PHASES)
I. Preorientaion/ preinteraction Phase- begins when nurse is assigned to the patient. Major Task:
develop self-awareness.
II. Orientation Phase- begins when the nurse and client meet and ends when the client begins to
identify problems to examine. The nurse establishes roles, the purpose of meeting, and the
parameters of subsequent meetings; identifies the clients problems; and clarifies expectations.
Major Task: Build trust
-Nurse-Client Contract
-Confidentiality- means respecting the client’s right to keep private any information about
his/her mental and physical health and related care.
 -Duty to Warn
-Self-disclosure- means revealing personal information such as biographical information
and personal ideas, thoughts and feelings about oneself to clients.
III. Working Phase/ Exploitation Phase- more structured, longest and most productive phase. 2
subphase: 1) Problem identification- the client identifies the issues or concerns causing the
problems. 2) Exploitation- the nurse guides the client to examine feelings and responses and to
develop better coping skills and more positive self-image. Major Task: Implementation and
resolution of the patient’s problem.
IV. Termination Phase/Resolution Phase- is the final stage in the nurse-client relationship. It begins
when the problems are resolved and ends when the relationship is ended. Major Task-: Make
the client transfer what he/she has learned to others.

Avoiding behaviors that diminish the therapeutic relationship

• Inappropriate Boundaries
• Feelings of sympathy and encouraging client dependency
• Non-acceptance and avoidance
Roles of the nurse in a therapeutic relationship
• Teacher
• Caregiver
• Advocate
• Parent surrogate

Therapeutic Communication
The nurse must be aware of the therapeutic or nontherapeutic value of the communication
techniques used with the client—they are the “tools” of psychosocial intervention.
Interpersonal communication is a transaction between the sender and the receiver. Both persons
participate simultaneously.
In the transactional model, both participants perceive each other, listen to each other, and
simultaneously engage in the process of creating meaning in a relationship.

The Impact of Preexisting Conditions

Both sender and receiver bring certain preexisting conditions to the exchange that influence both the
intended message and the way in which it is interpreted.
– Values, attitudes, and beliefs.
Attitudes of prejudice are expressed through negative stereotyping.
– Culture or religion. Cultural mores, norms, ideas, and customs provide the basis for ways of
thinking.
– Social status. High-status persons often convey their high-power position with gestures of hands
on hips, power dressing, greater height, and more distance when communicating with individuals
considered to be of lower social status.
– Gender. Masculine and feminine gestures influence messages conveyed in communication with
others.
– Age or developmental level. The influence of developmental level on communication is especially
evident during adolescence, with words such as “cool,” “awesome,” and others.
– The environment in which the transaction takes place. Territoriality, density, and distance are
aspects of environment that communicate messages.
• Territoriality – the innate tendency to own space
• Density – the number of people within a given environmental space
• Distance – the means by which various cultures use space to communicate
 Four kinds of distance in interpersonal interactions:
– Intimate distance – the closest distance that individuals allow between themselves and others
– Personal distance – the distance for interactions that are personal in nature, such as close
conversation with friends
– Social distance – the distance for conversation with strangers or acquaintances
–Public distance – the distance for speaking in public or yelling to someone some distance away
Nonverbal Communication
Components of Nonverbal Communication
Physical appearance and dress
Body movement and posture
Touch
Facial expressions
Eye behavior
Vocal cues or paralanguage

RULES OF THUMB FOR THE PSYCHIATRIC NURSING STUDENT(8)

When asking questions there is a hierarchy.

Descriptions of the experience (situations)
Thoughts about the experience
Feelings the experience generated

HELP THE PATIENT EXPLORE THE SIGNIFICANCE OF THE SITUATION NOT SO MUCH THE
SITUATION ITSELF.

NEVER ASSUME ANYTHING

MAKE THE IMPLICIT EXPLICIT.

USE OPENENDED QUESTIONS

DIRECT QUESTIONS TOWARD STATEMENTS ABOUT PEOPLE IF THE PATIENT MENTIONS

PEOPLE AND THINGS.

NEVER TALK IN GENERALITIES. BE CONCRETE, SPECIFIC.

SPEAK ONLY FOR YOURSELF

Therapeutic Communication Techniques

Using silence – allows client to take control of the discussion, if he or she so desires
Accepting – conveys positive regard
Can you accept all communication?
Giving recognition – acknowledging, indicating awareness
Offering self – making oneself available
Giving broad openings – allows client to select the topic
Offering general leads – encourages client to continue
Placing the event in time or sequence – clarifies the relationship of events in time
Making observations – verbalizing what is observed or perceived
Encouraging description of perceptions – asking client to verbalize what is being perceived
Encouraging comparison – asking client to compare similarities and differences in ideas,
experiences, or interpersonal relationships
Restating – lets client know whether an expressed statement has or has not been understood
Reflecting – directs questions or feelings back to client so that they may be recognized and accepted
Focusing – taking notice of a single idea or even a single word
Exploring – delving further into a subject, idea, experience, or relationship
Seeking clarification and validation – striving to explain what is vague and searching for mutual
understanding
Presenting reality – clarifying misconceptions that client may be expressing
Voicing doubt – expressing uncertainty as to the reality of client’s perception
Verbalizing the implied – putting into words what client has only implied
Attempting to translate words into feelings – putting into words the feelings the client has
expressed only indirectly
Formulating a plan of action – striving to prevent anger or anxiety from escalating to an
unmanageable level the next time the stressor occurs

Nontherapeutic Communication Techniques

Giving reassurance – may discourage client from further expression of feelings if client believes the
feelings will only be belittled
Rejecting – refusing to consider client’s ideas or behavior
Giving approval or disapproval – implies that the nurse has the right to pass judgment on the
“goodness” or “badness” of client’s behavior
Defending – to defend what client has criticized implies that client has no right to express ideas,
opinions, or feelings
Requesting an explanation – asking “why” implies that client must defend his or her behavior or
feelings
Indicating the existence of an external source of power – encourages client to project blame for his
or her thoughts or behaviors on others
Belittling feelings expressed – causes client to feel insignificant or unimportant
Making stereotyped comments, clichés, and trite expressions – these are meaningless in a nurse-
client relationship
Using denial – blocks discussion with client and avoids helping client identify and explore areas of
difficulty
Interpreting – results in the therapist’s telling client the meaning of his or her experience
Introducing an unrelated topic – causes the nurse to take over the direction of the discussion

Active Listening
To listen actively is to be attentive to what client is saying, both verbally and nonverbally.
Several nonverbal behaviors have been designed as facilitative skills for attentive listening.
S – Sit squarely facing the client.
O – Observe an open posture.
L – Lean forward toward the client.
E – Establish eye contact.
R – Relax.
Process Recordings
Process recordings are written reports of verbal interactions with clients.
They are written by the nurse or student as a tool for improving communication techniques.
Feedback
Feedback is useful when it
– is descriptive rather than evaluative and focused on the behavior rather than on the client
– is specific rather than general
– is directed toward behavior that the client has the capacity to modify
– imparts information rather than offers advice
– is well timed

INTERVENING IN PSYCHOTIC COMMUNICATION

HALLUCINATIONS - false sensory perceptions or perceptual experiences that do not really exist.
Don’t deny
Look for feelings and empathize
Distract
 Connect to anxiety
Control
DELUSIONS- a fixed false belief not based on reality.
Empathize with feelings
Give concrete tasks
Refuse to discuss the delusion