Psychiatric Nursing
Practice
Penny Applegarth, RN, MSN,
FNP
Psychoanalytic
Theories & Therapies
Sigmund Freuds Psychoanalytic
Theory
Conscious part of the brain:
involves perceptions, memories,
thoughts, fantasies & feelings
Sigmund Freuds
Psychoanalytic Theory
Preconscious: awareness that is
below the level of conscious
retrieval, but can be accessed
with conscious effort
Sublimation:
Modification of an instinctual but
socially unacceptable impulse into a
constructive acceptable behavior
Defensive Mechanisms
Splitting:
Failure to integrate positive & negative
aspects of self or others, resulting in
polarized images of self & others as all
good or all bad
Suppression:
Conscious inhibition of an impulse,
idea, or affect. The person is usually
fully aware of the behavior
Freuds Five
Psychosexual Stages
of Development
Developmental stages from
infancy to adulthood
Main focus is on the first five years
of lifes experiences &
development
Freud believed that all mental
illness was a result of early intra-
psychic conflict
Important Terms
Transference: the clients feelings are
projected onto the nurse or therapist
that were originally held toward a
significant other in their life
Countertransference: the health care
workers unconscious personal
feelings are projected onto the client
Feelings Displaced in
Transference
Desire for affection
Desire for gratification of
dependency needs
Love
Hostility
Jealousy
Competitiveness
Resistance
Psychoanalysis:
Process in which the ego opposes
the conscious recall of unpleasant
experiences
Therapy:
Client puts road blocks to dealing
with identified issues
Erik Eriksons Ego
Theory
Describes eight stages of development
from infancy to late adulthood
Stressed development influenced by
the mother-child-father triangle (like
Freud), but also felt cultural & social
influences were very important
Didnt feel the personality was fixed
by age 5
Eriksons Model in
Nursing
Used to identify developmental
level for age
Can help with the development of
the care plan, to keep goals
realistic
Harry Stack Sullivans
Interpersonal Theory
Defined personality as behavior that
can be observed within
interpersonal relationships
Premise: the purpose of all behavior
is to:
Meet needs through interpersonal
interactions
To decrease or avoid anxiety
Psychotherapeutic
Environment
Group psychotherapy, family
therapy, & educational / skills
training programs can be
incorporated into the clients
treatment
This is used in residential & day
hospital settings today
Psych Nursing
Sullivans theory is the foundation
for Hildegard Peplaus nursing
theory of interpersonal relationships
Participant observer: the
professional helpers cannot be
isolated from the therapeutic
situation if they are to be effective
Hildegard Peplaus Theory of
Interpersonal Relationships in
Nursing
In 1952, established a systemic
theoretical framework for
psychiatric nursing
Identified psychiatric nursing as
an essential element of general
nursing & as a specialty
Nurse Patient
Relationship
First nursing theorist to describe the
nurse- patient relationship as the
foundation of nursing practice
An evolving process through three
distinct interlocking & overlapping
phases
1. Orientation phase
2. Working phase
3. Termination phase
Boundaries
Rigid or flexible
Transparent or opaque
Close or Distant
Culturally Determined
The nurse is planning care for a client
i-clicker?:
with anxiety who will be admitted to the unit
shortly. Which nursing action is most
important?
a. Consider interventions that will
increase the clients sense of value
b. Choose a roommate that could
develop a friendship with the new
client
c. Identify a room where the client will
have comfortable surroundings
d. Plan methods of decreasing stimuli
that could cause heightened anxiety
Behavioral Theories /
Therapies
Conditioning: pairs behavior with a
condition that reinforces or diminishes
the behaviors occurrence
Ivan Pavlovs Classical Conditioning
Theory
John B. Watson: behaviorism-
personality traits & responses were
socially learned through classical
conditioning
B. F. Skinners Operant
Conditioning Theory
Operant conditioning:
voluntary behaviors learned
through consequences
Reinforcement: the behavior
responses elicited occur more
frequently when reinforced
Reinforcement
Positive reinforcement:
consequence is a pleasant or
pleasurable experience
Negative reinforcement:
removal of an objectionable or
aversive stimulus
Behavioral Therapy
Based on the assumption that changes
in maladaptive behavior occur without
insight into the underlying causes
Successful in treatment for phobias,
alcoholism, schizophrenia
Modeling: therapist provides a role
model, demonstrates more effective
behaviors to help client cope
Cognitive Theories &
Therapies
Rational- Emotive Behavior Therapy
(REBT)
http://www.youtube.com/watch?v
=73hzaaSlNr0&feature= fvwrel
Cognitive- Behavioral Therapy
(CBT)
http://www.youtube.com/watch?v
=GqW8p9WPweQ&feature=related
Cognitive Therapy
Identifying maladaptive
underlying assumptions
Testing the validity of the
assumptions
Humanistic Theories
Abraham Maslows Humanistic
Psychology Theory
Hierarchy of Needs
Emphasis on human potential & the
clients strengths as key to success
for the nurse- client relationship
Establishes priorities for nursing
interventions
Hierarch of Needs
Maslow:
Self Actualization Needs
Esteem & Recognition
Love and Belonging
Safety Needs
Physiological Needs
Which behavior, seen in a 30 y.o. client
i-clicker?:
would alert the nurse that the client is not in
the appropriate developmental stage according
to Erickson?
Wholistic approach
Other Therapies
Milieu therapy focuses on the
total environment as an element
of treatment
Incorporates the people, setting,
structure, & emotional climate as
elements of treatment
Therapeutic
Community
May use a variety of different
therapeutic modalities from
behavioral, structured,
spontaneous, humanistic oriented
Psychiatric Nursing
Roles
Instrumental in providing the
structure, framework, &
implementation of interventions
to reach goals of the milieu model
Examples: provide safety for
suicidal clients, do crisis
intervention strategies, run
groups, one to one counseling
Therapeutic
Relationships
Between nurse & client established
to enhance client growth
Focuses on client issues, problems, &
concerns
Communication techniques used to
Genuineness
Congruence between verbal
content & affect/ behaviors
Empathy
Understanding ideas expressed &
feelings present in the other
Factors Enhancing
Growth in Others
Positive Regard
Implies respect: attitudes & actions
(attending, suspending value
judgments)
Helping
Clients Develop
Resources
Awareness, encouragement shown
toward positive behaviors
Positive Regard
Behaviors
Mutually establishing times to
begin & end time for talking or
activities
Being on time to all scheduled
meetings
Listening (actively) to client
Neutral comments; nonjudgmental
responses
Factors Hampering
Relationships
Lack of nurse availability or
lack of contact
Lack of nurse self-awareness
Orientation
Establish boundaries of relationship
Role/responsibilities of nurse/client
Establish Confidentiality agreement
Formal/informal contract
Time, place, date, duration of meetings
Mutual goals
Assessment & Care plan
Termination terms
Working Phase: Tasks
Maintain relationship
Gather further data
Promote client problem-solving skills,
self-esteem & communication
Facilitate behavioral change
Overcome resistance behaviors
Evaluate problems & goals, redefine prn
Practice & express alternative adaptive
behaviors (role play)
Termination: When
Symptoms improved
Social functioning improved
Goals achieved
Impasse in therapy
Change of staff
Termination: What
Finalize termination