Mental Health: ▪ Medications: Alcohol, Sedatives, Opioids, Caffeine

WHO definition: state of complete physical, mental, and social 3. Individual psychological factors:
wellness, not merely absence of disease or infirmity ▪ poor self-esteem OR negative thinking
▪ Events in Childhood
State of emotional, psychological, and social wellness evidenced ▪ Adverse life experiences during childhood
by:
▪ satisfying interpersonal relationships Major Criteria for the Diagnosis of Mental Illness (Psychosis)
▪ effective behavior and coping 1. Abnormal behavior
▪ a positive self-concept 2. Abnormal experience
▪ emotional stability 3. Loss of reality contact
4. Lack of insight
Factors Influencing a Person’s Mental Health
1. Individual factors: Prevention of Mental Illness:
ability to find meaning in life 1. Avoid marriages in first cousin
autonomy and independence 2. Give appropriate and adequate pre and postnatal care.
biologic makeup 3. Prevent separation of parents.
capacity for growth 4. Avoid over exertion, criticizing and punishment
coping or stress management abilities 5. A person may be strong in one subject and work in the other ways
emotional resilience or hardiness of life. (Encourage him/her in supportive/ positive manner)
reality orientation 6. Early diagnoses of any abnormal behavior reduce the chances of
self-esteem severe mental illness.
sense of belonging 7. Educate community for substance additional drug abuse.
vitality 8. Communicate problems; find solutions with discussion, self-
2. Interpersonal factors: expression and understanding.
effective communication intimacy 9. Improve skills of coping with stress and crisis by self-analysis of
ability to help others strength and weakness.
balance of separateness and connectedness 10. Find new ways of satisfactory needs and reacting on unpleasant
3. Social/cultural factors: experiences.
sense of community 11. Have adequate sleep, Balance diet and reasonable physical
access to adequate resources exercises.
intolerance of violence 12. Establish successful relationship and emotional relationship
stability with others.
support of diversity among people
mastery of the environment
positive, yet realistic, view of one’s world Difference: NEURSOSIS and PSYCHOSIS
NEUROSIS PSYCHOSIS
Mental Illness: condition in which mal an abnormal condition of the
adaptive behaviors serves as a mind, and is a generic
▪ Historically viewed as possession by demons, punishment for
protection against a source of psychiatric term for a mental
religious or social transgressions, weakness of will or spirit, and unconscious anxiety. state often described as
violation of social norms involving a "loss of contact
▪ Today seen as a medical problem, although some stigma from with reality".
previous beliefs remains Reality Oriented Out of contact with reality
denies reality
Mental disorder is “a clinically significant behavioral or Demonstrates acceptable Demonstrates bizarre
psychological syndrome or pattern that occurs in an individual and behavior socially inappropriate, behavior
that is associated with distress or disability or with a significantly Interacts with the real Creates a new world or
increased risk of suffering death, pain, disability, or an important environment environment withdraws from
loss of freedom” reality in an effort to seek
security in the newly created
world
Factors Affecting a Person’s Mental Health
Doesn’t exhibit maladaptive Exhibits maladaptive
1. Stressful Life Events/social factors:
behavior (e.g. hallucinations behaviors
▪ Family conflicts ▪ unemployment or delusions)

▪ death of a loved one ▪ money problem Difference: Mental Health and Mental Illness
▪ infertility ▪ violence
MENTAL HEALTH MENTAL ILLNESS
▪ Poverty 1. Accepts self and others 1. Feelings of inadequacy-
▪ Lack of support from relationships Poor self-
▪ Difficulties in childhood: sexual or physical violence concept
▪ emotional neglect 2. Ability to cope or tolerate 2. Inability to cope-
▪ early death of a parent stress. Can return to normal Maladaptive behavior
▪ Unhealthy behaviors: as drug and alcohol abuse functioning if temporarily
2. Biological Factors: disturbed
▪ Chemical imbalance in brain: Dopamine, serotonin, 3. Ability to form close and 3. Inability to establish a
norepinephrine levels lasting Relationships meaningful relationship
▪ Genetics: Family 4. Uses sound judgment to 4. Displays poor judgment
make decisions
▪ Brain injury: Pre-natal damage; Birth trauma, head injury
5. Accepts responsibility for 5. Irresponsibility or inability
▪ Chronic illness: viral infections, cerebrovascular disease,
actions to accept responsibility for
metabolic or endocrine conditions, autoimmune disorders, HIV or
actions
certain cancers
6. Optimistic 6. Pessimistic
 7. Recognizes limitations 7. Does not recognize Factitious Disorders
(abilities and deficiencies) limitations - With Combined Psychological and Physical Signs and Symptoms
8. Can function effectively 8. Exhibits dependency needs - With Predominantly Physical Signs and Symptoms
and independently because of - With Predominantly Psychological Signs and Symptoms
feelings of inadequacy
9. Able to perceive imagined 9. Inability to perceive reality Impulse-Control Disorders (Not Classified Elsewhere)
circumstances
- Impulse-Control Disorder Not Otherwise Specified (NOS)
from reality
- Intermittent Explosive Disorder
10. Able to develop potential 10. Does not recognize
and talents potential and talents - Kleptomania
to fullest extent due to a poor self-concept - Pathological Gambling
11. Able to solve problems 11. Avoids problems rather - Pyromania
than handling - Trichotillomania
them or attempting to solve Mental Disorders Due to a General Medical Condition
them - Catatonic Disorder Due to a General Medical Condition
12. Can delay immediate 12. Desires or demands - Personality Change Due to a General Medical Condition
gratification immediate gratification Mood Disorders
13. reflects a person’s 13. inability to cope with - Bipolar I Disorder
approach to life by stress, resulting in - Bipolar II Disorder
communicating disruption, disorganization, - Bipolar Disorder Not Otherwise Specified (NOS)
emotions, giving and inappropriate reactions,
- Cyclothymic Disorder
receiving. unacceptable behavior
- Depressive Disorder Not Otherwise Specified (NOS)
- Depression (General Overview)
- Dysthymic Disorder
Diagnostic and Statistical Manual of Mental Disorder (4th
Edition) - Major Depressive Disorder
▪ The DSM-IV-TR is a taxonomy published by APA and is used by - Mood Disorder Due to a General Medical Condition
all mental health professionals. - Mood Disorder Not Otherwise Specified (NOS)
▪ It describes all mental disorders according to specific diagnostic - Substance-Induced Mood Disorder
criteria. Schizophrenia and other Psychotic Disorders
▪ The DSM-IV-TR is based on a multiaxial classification system: - Paranoid Type
- Axis I: ▪ all major psychiatric disorders except - Disorganized Type
mental retardation and personality disorders. - Catatonic Type
- Undifferentiated Type
Major Categories of DSM: Clinical Disorders - Residual Type
Adjustment Disorders - Brief Psychotic Disorder
- With Anxiety - Delusional Disorder
- Psychotic Disorder Due to a General Medical Condition
- With Depressed Mood
- Psychotic Disorder Not Otherwise Specified
- With Disturbance of Conduct
- Schizoeffective Disorder
- With Mixed Anxiety and Depressed Mood
- Schizophreniform Disorder
- With Mixed Disturbance of Emotions and Conduct Unspecified
- Substance-Induced Psychotic Disorder
- Acute Stress Disorder
Sexual and Gender Identity Disorders
- Agoraphobia
Paraphilias:
- Agoraphobia Without History of Panic Disorder
- Exhibitionism
- Anxiety Disorder Due to a General Medical Condition
- Fetishism
- Anxiety Disorder Not Otherwise Specified (Anxiety Disorder
NOS) - Frotteurism
- Generalized Anxiety Disorder (GAD) - Pedophilia
- Obsessive-Compulsive Disorder (OCD) - Sexual Masochism
- Panic Attack - Sexual Sadism
- Panic Disorder With Agoraphobia - Transvestic Fetishism
- Panic Disorder Without Agoraphobia - Voyeurism
- Posttraumatic Stress Disorder - Paraphilia Not otherwise Specified
- Social Phobia Sexual Dysfunction:
- Specific Phobia - Hypoactive Sexual Desire Disorder
- Substance-Induced Anxiety Disorder - Female Orgasmic Disorder (Inhibited Female Orgasm)
Cognitive Disorders - Female Sexual Arousal Disorder
- Amnestic - Male Erectile Disorder
- Delirium - Male Orgasmic Disorder (Inhibited Male Orgasm)
- Dementia - Premature Ejaculation
an unwillingness to get involved in sexual activity, with avoidance
Dissociative Disorders - Sexual Aversion Disorder of any touching or communication that might lead to sexual
involvement.
- Depersonalization Disorder - Sexual Dysfunction Due to a General Medical Condition
- Dissociative Amnesia - Substance-Induced Sexual Dysfunction
- Dissociative Fugue - Sexual Dysfunction Not Otherwise Specified (NOS)
- Dissociative Identity Disorder Sexual Pain Disorders:
- Dissociative Disorder Not Otherwise Specified (NOS) - Dyspareunia persistent or recurrent genital pain that occurs just before,
during or after sex.

Eating Disorders - Vaginismus the body's automatic reaction to the fear of some or all types of vaginal penetration.
- Anorexia Nervosa Sleep Disorders
- Bulimia Nervosa - Breathing-Related Sleep Disorder
- Eating Disorder Not Otherwise Specified (NOS) - Circadian Rhythm Sleep Disorder
 cause trouble falling asleep or staying asleep.
- Dyssomnias Not Otherwise Specified. (NOS) ▪ This number is expected to continue to decrease as more U.S.
- Insomnia Related to Another Mental Disorder residents trace their ancestry to Africa, Asia, or the Arab or Hispanic
- Nightmare Disorder (Dream Anxiety Disorder) worlds in the future.
- Primary Sleep Disorders: ▪ Nurses must be prepared to care for this culturally diverse
- Primary Insomnia population, and that includes being aware of cultural differences that
- Primary Hypersomnia influence mental health and the treatment of mental illness.
- Narcolepsy day.
a sleep disorder that makes people very drowsy during the ▪ Diversity is not limited to culture; the structure of families in the
- Sleep Disorder Due to a General Medical Condition United States has changed as well.
- Sleep Disorder Related to Another Mental Disorder ▪ With a divorce rate of 50% in the United States, single parents head
- Sleep Terror Disorder many families, and many blended families are created when
- Sleepwalking Disorder divorced persons remarry.
- Substance-Induced Sleep Disorder ▪ Twenty-five percent of households consist of a single person
Somatoform Disorders (Wright, 1995), and many people live together without being
- Somatization Disorder significant focus on physical married. Gay men and lesbians form partnerships and sometimes
symptoms, such as pain,
weakness or shortness of
adopt children.
- Undifferentiated Somatoform Disorder breath, to a level that results in
▪ The face of the family in the United States is varied, providing a
- Conversion Disorder major distress and/or problems
functioning. challenge to nurses to provide sensitive, competent care.
- Pain Disorder condition in which a person
experiences physical and Psychiatric Nursing Practice
- Hypochondriasis sensory problems, such as
paralysis, numbness, ▪ In 1873, Linda Richards graduated from the New England Hospital
- Body Dysmorphic Disorder blindness, deafness or
seizures, with no underlying for Women and Children in Boston.
- Somatoform Disorder not Otherwise Specified (NOS) neurologic pathology.
▪ She went on to improve nursing care in psychiatric hospitals and
Substance-Related Disorders a person spends a lot of time worrying
about flaws in their appearance. organized educational programs in state mental hospitals in Illinois.
- Substance-Induced Anxiety Disorder
▪ Richards is called the first American psychiatric nurse; she
- Substance-Induced Mood Disorder
believed that “the mentally sick should be at least as well cared for
- Substance-Induced Psychotic Disorder
as the physically sick” (Doona, 1984).
- Substance-Induced Sleep Disorder
▪ The first training of nurses to work with persons with mental illness
was in 1882 at McLean Hospital in Waverly, Mass.
- Axis II: ▪ mental retardation, personality disorders, maladaptive
▪ The care was primarily custodial and focused on nutrition, hygiene,
personality features, and defense mechanisms.
and activity.
CLUSTER A:
▪ Nurses adapted medical-surgical principles to the care of clients
Paranoid Personality Disorder with psychiatric disorders and treated them with tolerance and
✓ Schizoid Personality Disorder kindness.
✓ Schizotypal Personality Disorder Role of Psychiatric Nurse
CLUSTER B: ▪ Expanded as somatic therapies for the treatment of mental
Antisocial Personality Disorder disorders were developed. Treatments such as insulin shock therapy
✓ Borderline Personality Disorder (1935),
✓ Histrionic Personality Disorder ▪ Psychosurgery (1936),
▪ Electroconvulsive therapy (1937) required nurses to use their
✓ Narcissistic Personality Disorder
medical-surgical skills
CLUSTER C:
further.
Avoidant Personality Disorder
✓ Dependent Personality Disorder Historical Perspective
✓ Obsessive-Compulsive Personality Disorder ▪ Ancient times: sickness represented displeasure of the gods,
Personality Disorder Not Otherwise Specified punishment for wrongdoing; treatments included starving, urging,
✓ Mental Retardation bloodletting
- Axis III: ▪ current medical conditions ▪ Period of Enlightenment (1790s) saw the creation of asylums or
- Axis IV: ▪ psychosocial and environmental safe havens to offer protection
problems, including problems with primary support group, social ▪ Sigmund Freud and others studied mental disorders scientifically
environment, education, occupation, housing, economics, access to by the 1900s
health care, legal system. ▪ Psychotropic drugs first available in 1950
➢ codes the major psychosocial stressors the individual has ▪ Deinstitutionalization began with the Community Mental Health
faced recently. Centers Act of 1963
➢ e.g. recent divorce, death of spouse, job loss etc In early Christian times (1–1000 AD)
- Axis V: ▪ presents a Global Assessment of Functioning (GAF), ▪ Primitive beliefs and superstitions were strong.
which rates the person’s overall psychological functioning on a scale ▪ All diseases were again blamed on demons, and the mentally ill
of 0 to 100 were viewed as possessed.
▪ Priests performed exorcisms to rid evil spirits.
Community-Based Care ▪ When that failed, they used more severe measures such as
▪ After deinstitutionalization, the 2,000 community mental health incarceration in dungeons, flogging, starving, and other brutal
centers (CMHCs) that were supposed to be built by 1980 had not treatments.
materialized. During the Renaissance (1300–1600)
▪ By 1990, only 1,300 programs provided various types of ▪ People with mental illness were distinguished from criminals in
psychosocial rehabilitation services. Persons with severe and England.
persistent mental illness were either ignored or underserved by the ▪ Those considered harmless were allowed to wander the
CMHCs countryside or live in rural communities, but the more “dangerous
Cultural Considerations: lunatics” were thrown in prison, chained, and starved (Rosenblatt,
▪ The United States Census Bureau (2000) estimates that 62% of the 1984).
population has European origins. ▪ In 1547, the Hospital of St. Mary of Bethlehem was officially
declared a hospital for the insane, the first of its kind.
▪ By 1775, visitors at the institution were charged a fee for the • Deficits in the functioning of significant biologic, emotional, and
privilege of viewing and ridiculing the inmates, who were seen as cognitive symptoms
animals, less than human (McMillan, 1997). • Emotional stress or crisis components of illness, pain, and
Period of Enlightenment and Creation of Mental Institutions disability
▪ In the 1790s, a period of enlightenment concerning persons with • Self-concept changes, developmental issues, and life process
mental illness began. Phillippe Pinel in France and William Tukes changes
in England formulated the concept of asylum as a safe refuge or • Problems related to emotions such as anxiety, anger, sadness,
haven offering protection at institutions where people had been loneliness, and grief
whipped, beaten, and starved just because they were mentally ill • Physical symptoms that occur along with altered psychological
(Gollaher, 1995). functioning
▪ With this movement began the moral treatment of the mentally ill. • Alterations in thinking, perceiving, symbolizing, communicating,
▪ In the United States, Dorothea Dix (1802–1887) began a crusade and decision-making
to reform the treatment of mental illness after a visit to Tukes’ • Difficulties relating to others
institution in England. • Behaviors and mental states that indicate the client is a danger to
▪ Dix believed that society was obligated to those who were mentally self or others or has a severe disability
ill and promoted adequate shelter, nutritious food, and warm • Interpersonal, systemic, sociocultural, spiritual, or environmental
clothing (Gollaher, 1995). circumstances or events that affect the mental or emotional well-
Sigmund Freud and Treatment of Mental Disorders being of the individual, family, or community
▪ The period of scientific study and treatment of mental disorders • Symptom management, side effects/toxicities associated with
began with Sigmund Freud (1856–1939) and others such as Emil psychopharmacologic intervention, and other aspects of the
Kraepelin (1856–1926) treatment regimen
▪ Eugene Bleuler (1857–1939). With these men, the study of
psychiatry and the diagnosis and treatment of mental illnesses Areas of Practice
started in earnest. BASIC-LEVEL FUNCTIONS
Development of Psychopharmacology ▪ Counseling
▪ A great leap in the treatment of mental illness began in about 1950 o Interventions and communication techniques
with the development of psychotropic drugs (drugs used to treat o Problem solving
mental illness). o Crisis intervention
▪ Chlorpromazine (Thorazine), an antipsychotic drug, and lithium, o Stress management
an antimanic agent, were the first drugs to be developed. o Behavior modification
▪ Over the following 10 years, monoamine oxidase inhibitor ▪ Milieu therapy
antidepressants; haloperidol (Haldol), an antipsychotic; tricyclic o Maintain therapeutic environment
antidepressants; and antianxiety agents called benzodiazepines were
o Teach skills
introduced.
o Encourage communication between clients and others
Mental Illness in the 21st Century
o Promote growth through role-modeling
▪ 56 million Americans have a mental illness (DHHS, 2002)
▪ Self-care activities
▪ Hospital stays shorter, but more numerous: revolving door
o Encourage independence
▪ Increased aggression among mentally ill clients
o Increase self-esteem
▪ An increased number of people with mental illness are incarcerated
o Improve function and health
▪ Homeless population of persons with mental illness, including
▪ Psychobiologic interventions
substance abuse, is growing
o Administer medications
▪ Most health care dollars still spent on inpatient psychiatric care;
o Teaching
community services not adequately funded
o Observations
▪ Healthy People 2010 mental health objectives strive to improve
▪ Health teaching
care of mentally ill persons
▪ Case management
▪ Community-based care includes community support services,
▪ Health promotion and maintenance
housing, case management, residential services outside the hospital.
ADVANCED-LEVEL FUNCTIONS
▪ Cost containment efforts include utilization review, HMOs,
managed care, case management • Psychotherapy
▪ Cultural considerations: diversity increasing in U.S. in terms of • Prescriptive authority for drugs (in many states)
ethnicity and changing family structures • Consultation
Psychiatric Nursing Practice • Evaluation
▪ Psychiatric nursing practice emerged in 1873 when Linda Richards
said, “The mentally sick should be at least as well cared for as the Neurobiological Theories and Psychopharmacology
physically sick” Neurobiological Theories
▪ 1882 was first formal training of nurses in mental health ▪ Great strides are being made in understanding the brain and mental
▪ First psychiatric textbook in 1920 illness, but much is still unknown; nurses need to keep abreast of
▪ This is a relatively new field in comparison with other areas developments to provide effective teaching
▪ Standards of Psychiatric-Mental Health Clinical Nursing Practice
developed Central Nervous System
in 1973, revised in 1982, 1994, 2000 ▪ Brain
▪ Psychiatric Mental Health Nursing Phenomena of Concern: 12 ▪ Cerebrum
areas of concern that mental health nurses focus on when caring for Divided into two hemispheres with four lobes:
clients Frontal lobe: thought, body movement, memories emotions, moral
Psychiatric Mental Health Nursing Phenomena of Concern behavior
Actual or potential mental health problems pertaining to: Parietal lobe: taste, touch, spatial orientation
• The maintenance of optimal health and well-being and the Temporal lobe: smell, hearing, memory, emotional expression
prevention of psychobiologic illness Occipital lobe: language, visual interpretation
• Self-care limitations or impaired functioning related to mental and ▪ Cerebellum
emotional distress
▪ Receives and integrates information from all body areas to ▪ Tapering rather than abrupt cessation to avoid rebound or
coordinate movement and posture. withdrawal
▪ Research has shown that inhibited transmission of dopamine, a ▪ Follow-up care
neurotransmitter, in this area is associated with the lack of smooth, ▪ Simplify the regimen for increased compliance
coordinated movements in diseases such as Parkinson’s and
dementia. Antipsychotic Drugs
▪ Brain stem (Conventional; Atypical; New Generation)
Midbrain: Uses:
Pons Locus coeruleus ▪ Schizophrenia, acute mania, psychotic depression, drug-induced
Medulla oblongata Cranial nerve nuclei 3-12 psychosis, other psychotic symptoms
▪ Limbic system Action:
Above brain stem and includes: ▪ Treat psychotic symptoms, such as delusions and hallucinations,
Thalamus by blocking dopamine receptors
Hypothalamus
Amygdala Conventional Antipsychotic Drugs
▪Spinal Cord phenothiazines: (Thorazine, Prolixin, Mellaril, Stelazine); Navane,
▪ Nerves that control voluntary acts Haldol, Loxitane, Moban
Side effects Patient teaching
Neurotransmitters: Extrapyramidal side • Adhering to medication regimen
▪ Chemical substances manufactured in the neuron to aid in effects (EPSs) • Managing side effects
transmission of information Pseudo parkinsonism – Thirst
▪ Either inhibitory or excitatory Dystonia – Constipation
▪ Dopamine: (control of complex movements, motivation, cognition, Akathisia – Sedation
regulation of emotional responses) Anticholinergic side
▪ Norepinephrine: attention, learning, memory, sleep, wakefulness, effects
mood regulation) Tardive dyskinesia
▪ Epinephrine: flight-or-fight response (TD)
▪ Serotonin: (food intake, sleep, wakefulness, temperature Neuroleptic malignant
syndrome (NMS)
regulation, pain control, sexual behaviors, regulation of emotions)
▪ Histamine: (alertness, control of gastric secretions, cardiac
Atypical Antipsychotic Drugs
stimulation, peripheral allergic responses)
Clozaril, Risperdal, Zyprexa, Seroquel, Geodon
▪ Acetylcholine: sleep and wakefulness cycle, signals muscles to
become alert Side effects Patient teaching
▪ Glutamate: an excitatory amino acid Fewer EPSs • Adhering to medication regimen
Weight gain • Reducing sugar and caloric intake
▪ GABA: modulates other neurotransmitters
Agranulocytosis • Clozaril
(Clozaril) – Weekly WBC monitoring
Brain Imaging Techniques: – Discontinue medication and seek
o Computed tomography (CT) care at first sign of infection
o Magnetic resonance imaging (MRI)
o Positron emission tomography (PET) New-Generation Antipsychotic Drugs
o Single photon emission computed tomography (SPECT) aripiprazole (Abilify)
Side effects Patient teaching
Headache • Adhering to medication regimen
Anxiety
Nausea

Antidepressant Drugs
SSRIs; TCAs; MAOIs
Uses:
▪ Major depression, panic disorder and other anxiety disorders,
Causes of Mental Illness: bipolar depression, psychotic depression
▪ Genetics and heredity: Action:
- play a role but alone do not account for development of mental ▪ Interact with the monoamine neurotransmitter systems in the brain,
illness particularly the neurotransmitters norepinephrine and serotonin
▪ Psychoimmunology: SSRI Antidepressant Drugs
- a compromised immune system could contribute, especially in at- fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft),
risk populations citalopram (Celexa), escitalopram (Lexapro)
▪ Infections, particularly viruses, may play a role Side effects Patient teaching
Anxiety • Take in the morning
PSYCHOPHARMACOLOGY: Agitation • Take with food
medication management are important in the treatment of many Akathisia • Propanolol given for akathisia
mental illnesses Nausea
Insomnia
Principles that guide the use of medications include: Sexual dysfunction
▪ Effect on target symptom
▪ Adequate dosage for sufficient time TCA Antidepressant Drugs
▪ Lowest dose needed for maintenance imipramine (Tofranil), desipramine (Norpramin), amitriptyline
▪ Lower doses for the elderly (Elavil), doxepin (Sinequan), clomipramine (Anafranil)
Side effects Patient teaching
 Anticholinergic (blurred • Take in the evening Uses:
vision, urinary retention, • Using caution when driving ▪ Aversion therapy for treatment of alcoholism
dry Action:
mouth, constipation) ▪ Causes an adverse reaction when alcohol is ingested
Orthostatic hypotension Side effects Patient teaching
Sedation Fatigue • Avoiding alcohol
Weight gain Drowsiness (including products
Tachycardia Halitosis such as shaving cream,
Sexual dysfunction Tremor aftershave, cologne,
Impotence many OTC
MAOI Antidepressant Drugs medications)
phenelzine (Nardil), tranylcypromine (Parnate), isocarboxazid • Family should never
(Marplan) administer without the
person's knowledge
Side effects Patient teaching
Sedation • Following tyramine-free diet
(avoid Cultural Considerations
Insomnia
Weight gain aged cheeses, aged meats, beer ▪ Ethnic backgrounds influence responses to some psychotropic
and medications:
Dry mouth
Orthostatic hypotension wine, sauerkraut, soy) ▪ African Americans respond more rapidly to antipsychotic and
Sexual dysfunction • Avoiding sympathomimetic tricyclic antidepressant medications than do whites and have a
drugs greater risk of side effects
Hypertensive crisis with
excessive • Using caution when driving ▪ Asians metabolize antipsychotic and tricyclic antidepressants more
tyramine or slowly, requiring lower doses to produce the same effects
sympathomimetic drugs ▪ Hispanics require lower doses of antidepressants than whites to
achieve desired effects
Mood Stabilizing Drugs ▪ Asians and African Americans require lower doses of lithium than
lithium; anticonvulsant medications (carbamazepine (Tegretol), whites to produce desired effects
valproic acid (Depakote), lamotrigine (Lamictal), gabapentin Self-Awareness Issues
(Neurontin) ▪ Viewing chronic mental illness as having remissions and
Uses: exacerbations, just as chronic physical illnesses do
▪ Bipolar disorder ▪ Remaining open to new ideas that may lead to future breakthroughs
Action: ▪ Understanding that medication noncompliance is often part of the
▪ Act on the neurotransmitters of the brain illness, not willful misbehavior
Side effects Patient teaching TREATMENT MODALITIES
Nausea • Taking with food Community (outpatient) mental health treatment
Diarrhea • Having monthly blood levels ▪ The client can often continue to work and can stay connected with
Anorexia drawn family, friends, and other support systems while participating in
Fine hand tremor 12 hours after last dose therapy
Polydipsia (maintain therapeutic levels ▪ Personality or behavior patterns gradually develop over the course
Polyuria between 0.5–1.5 of a lifetime and cannot be changed in a relatively short inpatient
Fatigue mEq/L) course of treatment
Weight gain
Acne Hospital (inpatient) treatment
▪ Severely depressed and suicidal
Antianxiety Drugs ▪ Severely psychotic
benzodiazepines; buspirone (BuSpar) ▪ Experiencing alcohol or drug withdrawal
Uses: ▪ Exhibiting behaviors that require close supervision in a safe,
▪ Anxiety disorders, insomnia, OCD, depression, PTSD, alcohol supportive environment
withdrawal
Action: Individual psychotherapy
▪ Moderate the actions of GABA ▪ A method of bringing about change in a person by exploring his or
Side effects Patient teaching her feelings, attitudes, thinking, and behavior
Tolerance and dependence • Using caution during driving ▪ It involves a one-to-one relationship between the therapist and the
Drowsiness due to slower client
Sedation reflexes and response time ▪ Progression through stages
Poor concentration • Never discontinuing abruptly ▪ Relationship as key to success
Impaired memory as withdrawal can be fatal ▪ The therapist’s theoretical beliefs strongly influence his or her style
Clouded sensorium • Avoiding alcohol of therapy

Stimulant Drugs Group therapy

methylphenidate (Ritalin), pemoline (Cylert), dextroamphetamine - involves a therapist or leader and a group of clients sharing a
Side effects Patient teaching common purpose
Anorexia • Avoiding caffeine, sugar, and - members contribute to the group and expect to benefit from it.
Weight loss chocolate Types of Groups:
Nausea • Taking after meals Psychotherapy Groups Education Groups
Nausea • Long-term use can cause Family therapy Support Groups
dependency Family Education Self-help Groups

Disulfiram Stages of Group Development

Antabuse ▪ Pre-group stage ▪ Working stage
▪ Initial stage ▪ Termination stage and might more appropriately be called conceptual models or
frameworks.
Group Leadership ▪ Psychoanalytic
▪ Therapy groups and education groups: formal leader ▪ Developmental
▪ Support groups and self-help groups: no formal leader ▪ Interpersonal
▪ Humanistic
Group Roles: ▪ Behavioral
▪ Growth-producing roles: ▪ Existential
Information-seeker, opinion-seeker, information giver,
energizer, coordinator, harmonizer, encourager, and elaborator Psychoanalytic Theories
▪ Growth-inhibiting roles: Sigmund Freud (1856-1939) in Vienna
monopolize, aggressor, dominator, critic, recognition-seeker, ▪ Developed psychoanalytic theory in the late 19th
and passive follower and early 20th centuries in Vienna, where he spent
most of his life.
▪ All human behavior is caused, explainable
▪ Repressed sexual impulses, desires as motivation for behavior
The therapeutic results of group therapy (Yalom, 1995) include the ▪ Personality components
following: ✓Id
▪ Gaining new information or learning ✓Ego
▪ Gaining inspiration or hope
✓Superego
▪ Interacting with others
▪ Psychoanalytic theory supports the notion that all human behavior
▪ Feeling acceptance and belonging
is caused and can be explained (deterministic theory).
▪ Becoming aware that one is not alone and that others share the
▪ Freud believed that repressed (driven from conscious awareness)
same problems
sexual impulses and desires motivated much human behavior.
▪ Gaining insight into one’s problems and behaviors and how they
▪ He developed his initial ideas and explanations of human behavior
affect others
from his experiences with a few clients, all of them women who
▪ Giving of oneself for the benefit of others (altruism)
displayed unusual behaviors such as disturbances of sight and
speech, inability to eat, and paralysis of limbs.
Psychiatric Rehabilitation
▪ All human behavior is caused and can be explained
▪ Involves providing services to clients with persistent and severe
▪ Personality components conceptualized as id, ego, and superego
mental illness in the community
▪ Behavior motivated by subconscious thoughts and feelings;
▪ May involve medication management, transportation, shopping,
treatment involving analysis of dreams and free association
food preparation, hygiene, finances, social support, vocational
▪ Ego defense mechanisms
referral
▪ Psychosexual stages of development
▪ Transference and countertransference
Psychosocial Interventions
▪ Psychosocial interventions are nursing activities that enhance the
Personality Components
client’s social and psychological functioning and promote social
Id
skills, interpersonal relationships, and communication.
▪ one’s nature that reflects basic or innate desires such as pleasure-
▪ These interventions are used in mental health and other practice
seeking behavior, aggression, and sexual impulses.
areas.
▪ seeks instant gratification; causes impulsive, unthinking behavior;
and has no regard for rules or social convention.
Self-Awareness Issues
Ego
▪ No one theory or treatment approach is effective for all clients.
▪ Is the balancing or mediating force between the id and the
▪ Using a variety of psychosocial approaches increases nurse
superego.
effectiveness.
▪ The ego represents mature and adaptive behavior that allows a
▪ The client’s feelings and perceptions are most influential in
person to function successfully in the world.
determining his or her response.
▪ Freud believed that anxiety resulted from the ego’s attempts to
Complementary and Alternative Therapies
balance the impulsive instincts of the id with the stringent rules of
▪ Alternative medical systems (homeopathy, traditional Chinese
the superego.
medicine)
Superego
▪ Mind-body interventions (meditation, art, music therapy)
▪ Is the part of a person’s nature that reflects moral and ethical
▪ Biologically based therapies (herbs, foods, vitamins)
concepts, values, and parental and social expectations; therefore, it
▪ Manipulative and body-based therapies (therapeutic massage,
is in direct opposition to the id.
chiropractic manipulation)
▪ Energy therapies (therapeutic touch, qi gong, pulsed fields,
Behavior Motivated by Subconscious Thoughts and Feelings
magnetic fields)
▪ Freud believed that the human personality functions at three levels
of awareness: conscious, preconscious, and unconscious (Gabbard,
PSYCHOSOCIAL THEORIES and THERAPY
2000).
Psychosocial Theories:
▪ Conscious refers to the perceptions, thoughts, and emotions that
▪ Many theories attempt to explain human behavior, health, and exist in the person’s awareness such as being aware of happy
mental illness. feelings or thinking about a loved one.
▪ Each theory suggests how normal development occurs based on ▪ Preconscious thoughts and emotions are not currently in the
the theorist’s beliefs, assumptions, and view of the world. person’s awareness, but he or she can recall them with some effort.
▪ These theories suggest strategies that the clinician can use to work —for example, an adult remembering what he or she did, thought,
with clients. or felt as a child.
▪ Many of the theories discussed were not based on empirical or ▪ The unconscious is the realm of thoughts and feelings that motivate
research evidence; rather, they evolved from individual experiences a person, even though he or she is totally unaware of them.
▪ This realm includes most defense mechanisms and some
instinctual drives or motivations.
▪ According to Freud’s theories, the person represses into the
unconscious the memory of traumatic events that are too painful to
remember.
Freud’s Dream Analysis
▪ Freud believed that a person’s dreams reflected his or her
subconscious and had significant meaning, although sometimes the
meaning was hidden or symbolic (Gabbard, 2000).
Dream analysis
▪ A primary method used in psychoanalysis, involves discussing a
client’s dreams to discover their true meaning and significance.
example: a client might report having recurrent, frightening dreams
about snakes chasing her.
▪ Another method used to gain access to subconscious thoughts and
feelings is 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
▪ Freud believed the self or ego used ego defense mechanisms,
- methods of attempting to protect the self and cope with
basic drives or emotionally painful thoughts, feelings, or
events.
DEFENSE MECHANISM OR MENTAL MECHANISMS
Defense Mechanism
- to reduce anxiety or resolved conflict by modifying or
changing our behavior
- attempting to protect the self and cope with basic drives or
emotionally painful thoughts, feelings, or events
Purposes of defense mechanisms are:
1. To resolve a mental conflict
2. To reduce anxiety or fear
3. To protect one's self esteem
4. To protect one's sense of security
Ego Defense Mechanism
Compensation Overachievement in one area to offset real or
perceived deficiencies in another area
• Napoleon complex: diminutive man becoming
emperor
• Nurse with low self-esteem works double shifts so
her supervisor will like her
Conversion Expression of an emotional conflict through the
development of a physical symptom, usually
sensorimotor in nature
• A teenager forbidden to see X-rated movies is
tempted to do so by friends and develops blindness,
and the teenager is unconcerned about the loss of
sight.
Denial Failure to acknowledge an unbearable condition;
failure to admit the reality of a situation, or how one
enables the problem to continue
• Diabetic eating chocolate candy
• Spending money freely when broke
• Waiting 3 days to seek help for severe abdominal
pain
Displacement Ventilation of intense feelings toward persons less
threatening than the one who aroused those feelings
• A person who is mad at the boss yells at his or her
spouse.
• A child who is harassed by a bully at school
mistreats a younger sibling.
Dissociation Dealing with emotional conflict by a temporary
alteration in consciousness or identity
• Amnesia that prevents recall of yesterday’s auto
accident
• An adult remembers nothing of childhood sexual
abuse.
Fixation Immobilization of a portion of the personality
resulting from unsuccessful completion of tasks in a
developmental stage.
• Never learning to delay gratification
• Lack of a clear sense of identity as an adult
Identification Modeling actions and opinions of influential others
while searching for identity, or aspiring to reach a
personal, social, or occupational goal
• Nursing student becoming a critical care nurse
because this is the specialty of an instructor she
admires.
Intellectualization Separation of the emotions of a painful event or
situation from the facts involved; acknowledging
the facts but not the emotions
• Person shows no emotional expression when
discussing serious car accident.
Introjection Accepting another person’s attitudes, beliefs, and
values as one’s own
• A person who dislikes guns becomes an avid
hunter, just like a best friend.
Projection Unconscious blaming of unacceptable inclinations
or thoughts on an external object
• Man who has thought about same-gender sexual
relationship but never had one, beats a man who is
gay.
• A person with many prejudices loudly identifies
others as bigots.
Rationalization Excusing own behavior to avoid guilt,
responsibility, conflict, anxiety, or loss of self-
respect
• Student blames failure on teacher being mean.
• Man says he beats his wife because she doesn’t
listen to him.
Reaction Acting the opposite of what one thinks or feels
Formation • Woman who never wanted to have children
becomes a super-mom.
• Person who despises the boss tells everyone what
a great boss she is.
Regression Moving back to a previous developmental stage in
order to feel safe or have needs met
• Five-year-old asks for a bottle when new baby
brother is being fed.
• Man pouts like a four-year-old if he is not the
center of his girlfriend’s attention.
Repression Excluding emotionally painful or anxiety-
provoking thoughts and feelings from conscious
awareness
• Woman has no memory of the mugging she
suffered yesterday.
• Woman has no memory before age 7 when she was
removed from abusive parents.
Resistance Overt or covert antagonism toward remembering or
processing anxiety-producing information
• Nurse is too busy with tasks to spend time talking
to a dying patient.
• Person attends court-ordered treatment for
alcoholism but refuses to participate
Sublimation Substituting a socially acceptable activity for an
impulse that is unacceptable
• Person who has quit smoking sucks on hard candy
when the urge to smoke arises.
• Person goes for a 15-minute walk when tempted to
eat junk food.
Substitution Replacing the desired gratification with one that is
more readily available
• Woman who would like to have her own children
opens a day care center.
Suppression Conscious exclusion of unacceptable thoughts and
feelings from conscious awareness
• A student decides not to think about a parent’s
illness in order to study for a test.
• A woman tells a friend she cannot think about her
son’s death right now.
Undoing Exhibiting acceptable behavior to make up for or
negate unacceptable behavior
• A person who cheats on a spouse brings the spouse
a bouquet of roses.
• A man who is ruthless in business donates large
amounts of money to charity.
Psychosexual Stages of Development
PHASE FOCUS
 Oral (0-18 m) - Major site of tension and gratification is Stage: Trust vs. - Viewing the world as safe and
the mouth, lips, and tongue; includes mistrust (Infant) reliable;
biting and sucking activities. - Relationships as nurturing,
- Id present at birth
Virtue: Hope stable, and dependable
- Ego develops gradually from rudimentary
structure present at birth. Stage: Autonomy - Achieving a sense of control
Anal (18-36 m) - Anus and surrounding area are major vs. Shame and and free will
source of interest. Doubt (Toddler) - Self control/Independence
- Acquisition of voluntary sphincter control Virtue: Will
(toilet training) Stage: Initiative vs. - Beginning development of a
Phallic/Oedipal - Penis is organ of interest for both sexes.
Guilt (Preschool) conscience;
(3-5 y/o) - Masturbation is common.
- Penis envy (wish to possess penis) seen in Virtue: Purpose - Learning to manage conflict
girls; and anxiety
- oedipal complex (wish to marry opposite- Stage: Industry vs. - Emerging confidence in own
sex parent and be rid of same-sex parent) Inferiority (School abilities;
seen in boys and girls Age) - Taking pleasure in
Latency - Resolution of oedipal complex Virtue: accomplishments
(5-11 or 13 y/o) - Sexual drive channeled into socially Competence
appropriate activities such as school work
and sports Stage: Identity vs. - Formulating a sense of self and
- Formation of the superego Role Confusion belonging
Genital - Final stage of psychosexual development (Adolescence) - Self confidence
(11-13 y/o) - Begins with puberty and the biologic Virtue: Fidelity
capacity for orgasm; involves the capacity Stage: Intimacy vs. - Forming adult, loving
for true intimacy Isolation (Young relationships and meaningful
Adult) attachments to others
Transference and Countertransference Virtue: Love
▪ Transference occurs when the client displaces onto the therapist Stage: Generativity - Being creative and productive;
attitudes and feelings that the client originally experienced in other vs. Stagnation - Establishing the next
relationships (Gabbard, 2000). (Middle Adult) generation
▪ Transference patterns are automatic and unconscious in the Virtue: Care
therapeutic relationship. Stage: Integrity vs. - Accepting responsibility for
example: an adolescent female client working with a nurse who is Despair (Maturity) one’s self and life
about the same age as the teen’s parents might react to the nurse Virtue: Wisdom
like she reacts to her parents.
▪ Countertransference occurs when the therapist displaces onto the
client attitudes or feelings from his or her past. ▪ Jean Piaget (1896–1980)
example: a female nurse who has teenage children and who is ✓Described cognitive and intellectual development in children in
experiencing extreme frustration with an adolescent client may four stages: sensorimotor, preoperational, concrete operations,
respond by adopting a parental or chastising tone. formal operations
- explored how intelligence and cognitive functioning
CURRENT PSYCHOANALYTIC PRACTICE developed in children
▪ Free association, dream analysis, behavior interpretation used to - believed that human intelligence progresses through a
gain insight into and resolve these conflicts, anxieties series of stages based on age with the child at each
▪ Lengthy, expensive, practiced on limited basis today successive stage demonstrating a higher level of
▪ Freud’s defense mechanisms still current functioning than at previous stages
Psychoanalysis - biologic changes and maturation were responsible for
- Focuses on discovering the causes of the client’s cognitive development.
unconscious and repressed thoughts, feelings, and conflicts Cognitive Functioning Development in Children
believed to cause anxiety and helping the client to gain 1. Sensorimotor (birth – 2 years)
insight into and resolve these conflicts and anxieties. - child develops a sense of self as separate from the
environment and the concept of object permanence;
Developmental Theorists: - that is, tangible objects don’t cease to exist just because
▪ Erik Erikson (1902–1994) they are out of sight.
2. Preoperational (2-6 years)
✓Described eight stages of psychosocial development
- child develops the ability to express self with language,
- German-born psychoanalyst who extended Freud’s work understands the meaning of symbolic gestures, and begins
on personality development across the life span while to classify objects
- focuses on social development as well as psychological 3. Concrete Operations (6-12 years)
development in the life stages. - child begins to apply logic to thinking, understands
- In 1950, Erikson published Childhood and Society, in spatiality and reversibility, and is increasingly social and
which he described eight psychosocial stages of able to apply rules; however, thinking is still concrete.
development. 4. Formal Operations (12-15 years and beyond)
Erik Erikson and Psychosocial Stages of Development - child learns to think and reason in abstract terms, further
- In each stage, the person must complete a life task that is develops logical thinking and reasoning, and achieves
essential to his or her well-being and mental health. cognitive maturity.
- These tasks allow the person to achieve life’s virtues: hope,
purpose, fidelity, love, caring, and wisdom. ▪ Harry Stacks Sullivan (1892-1949)
- variety of disciplines still use Erikson’s eight psychosocial
- Established five life stages of personality development that
stages of development.
included the significance of interpersonal relationships
- psychosocial growth occurs in sequential phases and each
- Described three developmental cognitive modes:
stage is dependent on completion of the previous stage and
prototaxic, parataxic, syntaxic
life task.
- Believed that unsatisfying relationships were the basis for
all emotional problems
 - Described the concept of therapeutic milieu or community
Interpersonal Relationships and Milieu therapy
- The importance and significance of interpersonal
relationships in one’s life was Sullivan’s greatest
contribution to the field of mental health.
- Sullivan developed the first therapeutic community or
milieu with young men with schizophrenia in 1929.
- He found that within the milieu, the interactions among
clients were beneficial, and then the treatment should
emphasize on the roles of the client-client interaction.
- Milieu therapy is used in the acute care setting; one of the
nurses’ primary roles is to provide safety and protection
while promoting social interaction.
Sullivan’s Life Stages
Stage: Infancy - Primary need for bodily contact
(Birth to onset and tenderness
of language) - Prototaxic mode dominates (no
relation between experiences)
- Primary zones are oral and anal.
- If needs are met, infant has sense
of well-being; unmet needs lead to
dread and anxiety.
Stage: - Parents viewed as source of praise
Childhood and acceptance
(Language to 5 - Shift to parataxic mode
years) - Primary zone is anal
- Gratification leads to positive self-
esteem.
- Moderate anxiety leads to
uncertainty and insecurity;
- severe anxiety results in self-
defeating patterns of behavior.
Stage: Juvenile - Shift to the sytaxic mode begins
(5–8 years) (thinking about self and others
based on analysis of experiences
in a 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 restrictive,
prejudicial attitudes.
Stage: - Move to genuine intimacy with
Preadolescence friend of the same sex
(8–12 - Move away from family as source
years) of satisfaction in relationships
- Major shift to syntaxic mode
- Capacity for attachment, love, and
collaboration emerges or fails to
develop.
Stage: - Lust is added to interpersonal
Adolescence equation.
(Puberty to - 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.
- If the self-system is intact, areas of
concern expand to include values,
ideals, career decisions, and social
concerns.
Three Developmental Cognitive Modes
1. Prototaxic Mode:
- characteristic of infancy and childhood, involves brief unconnected
experiences that have no relationship to one another.
2. Parataxic Mode:
- begins in early childhood as the child begins to connect experiences
in sequence.
- child may not make logical sense of the experiences and may see
them as coincidence or chance events.
- child seeks to relieve anxiety by repeating familiar experiences,
although he or she may not understand what he or she is doing.
3. Syntaxic Mode:
- begins to appear in school-age children and becomes more
predominant in preadolescence, 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.
Therapeutic Community or Milieu
- Sullivan envisioned the goal of treatment as the
establishment of satisfying interpersonal relationships.
- The therapist provides a corrective interpersonal
relationship for the client.
- Sullivan coined the term participant observer for the
therapist’s role, meaning that the therapist both participates
in and observes the progress of the relationship.
Milieu Therapy
- one of the primary modes of treatment in the acute hospital
setting
- In today’s health care environment, however, inpatient
hospital stays are often too short for clients to develop
meaningful relationships with one another.
- Therefore, the concept of milieu therapy receives little
attention.
- Management of the milieu or environment is still a primary
role for the nurse in terms of providing safety and
protection for all clients and promoting social interaction.
▪ Hildegard Peplau (1909-1999)
- developed the phases of the nurse–client therapeutic
relationship, which has made great contributions to the
foundation of nursing practice today
- Leading nursing theorist and clinician: developed the
nurse–patient relationship with phases and tasks
- Identified roles of the nurse: stranger, resource person,
teacher, leader, surrogate, counselor
- Described four levels of anxiety (mild, moderate, severe,
panic) still widely used today
Therapeutic nurse-patient relationship
(The bomb diggity of nursing)
Orientation - 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.
Identification - Patient responds to persons he or
she perceives as helpful.
- Patient feels stronger.
- Expression of feelings
- Interdependent work with the
nurse
- Clarification of roles of both
patient and nurse
Exploitation - 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.
Resolution - 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 as Initial response to a Psychic threat Physical ▪ High blood pressure
a. Acute Anxiety: positive state of heightened awareness ▪ Rapid shallow breathing
and sharpened senses, allowing the person to learn new ▪ Increased Heart rate
behaviors and solve problems. ▪ Dilatation of pupils
b. Moderate: Anxiety involved a decreased perceptual field ▪ Muscle tension
(focus on immediate task only) the person can learn new ▪ Dry Mouth
behavior or solve problems only with assistance. Emotional ▪ Depression/anxiety
- Another person can redirect the person to the task. ▪ Irritability
c. Panic anxiety: Can involve loss of rational thought, ▪ Crying
delusions, hallucinations, and complete physical ▪ Suicide
immobility and muteness ▪ Deterioration of personal hygiene
- person may bolt and run aimlessly, often Mental ▪ Lack of concentration
exposing himself and others to injury. ▪ Negative thoughts
▪ Worrying
Behavioral Theories: ▪ Poor Memory
▪ For adults, receiving a regular paycheck is a constant positive
reinforcer that motivates people to continue to go to work every day Stress Management
and to try to do a good job. - Simplify Your Life
▪ It helps motivate positive behavior in the workplace. - Ask for help
- Practice Time Management
e.g. If someone stops receiving a paycheck, he or she is most likely
- Minimize Alcohol Use
to stop working.
- Humor--Take Time to Play
e.g. If a motorist consistently speeds (negative behavior) and does
- Relaxation Techniques
not get caught, he or she is likely to continue to speed.
- Get Counseling If Needed
▪ Ivan Petrovich Pavlov (1849-1936)
Alternative Management
- Pavlov (1849–1936) set out to change this salivating
- Conventional Medicine
response or behavior through conditioning.
- Counseling & psychotherapy
- He would ring a bell (new stimulus) then produce the food,
- Relaxation
and the dogs would salivate (the desired response).
- Meditation
- Pavlov repeated this ringing of the bell along with the
- Massage
presentation of food many times.
- Yoga
- Eventually he could ring the bell and the dogs would
- Aromatherapy
salivate without seeing or smelling food.
- The dogs had been “conditioned” or had learned a new
response—to salivate when they heard the bell. Their Nursing Interventions:
behavior had been modified through classical conditioning - Instruct person in relaxation techniques
or a conditioned response. - Use stressful management techniques, ex: jogging, yoga
- NOTE: behavior can be changed through conditioning with - Explore previous method of dealing with life problem.
external or environmental conditions or stimuli. - Encourage verbalization of feeling perception and fears
Stress: reaction people have to excessive pressures or other types of
demand placed upon them. Emotion:
- feeling state involving physiological arousal, a cognitive
Classic Conditioning (Behavior Theory) appraisal of the situation arousing the state, and an
Types of Stress outward expression of the state
Negative Stress Positive Stress Explaining Components of Emotions
- contributory factor in - stimulating motivation and 1. Physical
minor conditions, such awareness, providing the stimulation - psychological arousal that accompanies emotion
as headaches, digestive to cope with challenging situations. (tachycardia; dilated pupils)
problems, skin 2. Cognitive
complaints, insomnia - provides the sense of - determines specific emotion (feel, thought, belief)
and ulcers. urgency and alertness needed for 3. Behavioral
survival when confronting - outward expression of emotions (facial expression, body
- Excessive, prolonged threatening situations. posture, gestures, tone of voice)
and unrelieved stress
can have a harmful ▪ B.F. Skinner (1904-1990)
effect on mental,
physical and spiritual - ✓Behaviorism focuses on behaviors and behavior changes
health rather than on explaining how the mind works
- ✓All behavior is learned
Types of Stressors - ✓Behavior has consequences (reward or punishment)
External Stressors Internal Stressors - ✓Rewarded behavior tends to recur
- Physical - Lifestyle choices
Environment - Negative self - talk Operant Conditioning
- Social - Mind traps - Operant conditioning or learning that is controlled and
Interaction - Personality traits
responsive patterns results in shaping behavior through
- Organizational
- Major Life reinforcement of stimulus
Events - Skinner conducted an experiment:
- Daily Hassles ➢ With pigeon and rewarded them behaved properly and even
taught how to bowl in specially conducted bowling alley
Symptoms of Stress

The following principles of operant conditioning described by
Skinner (1974) form the basis for behavior techniques in use
today:
1. All behavior is learned.
2. Consequences result from behavior— broadly speaking, reward
and punishment.
3. Behavior that is rewarded with reinforcers tends to recur.
4. Positive reinforcers that follow a behavior increase the
likelihood that the behavior will recur.
5. Negative reinforcers that are removed after a behavior increase
the likelihood that the behavior will recur.
6. 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.
7. 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.
Existential Theories
▪ Cognitive therapy focuses on immediate thought processing and is
used by most existential therapists
▪ Believe that behavioral deviations result when a person is out of
touch with himself or herself or the environment.
▪ The person who is self-alienated is lonely and sad and feels
helpless.
▪ Lack of self-awareness, coupled with harsh self-criticism, prevents
the person from participating in satisfying relationships.
▪ The person is not free to choose from all possible alternatives
because of self-imposed restrictions.
▪ Existential theorists believe that the person is avoiding personal
responsibility and giving in to the wishes or demands of others.
Cognitive Therapy
- focuses on immediate thought processing— how a person
perceives or interprets his or her experience and determines
how he or she feels and behaves
ex: if a person interprets a situation as dangerous, he or she
experiences anxiety and tries to escape.
▪ Viktor Frankl
- based his beliefs on his observations of people in Nazi
concentration camps during WWII.
- curiosity about why some survived and others did not lead
him to conclude that survivors were able to find meaning in
their lives even under miserable conditions.
Viktor Frankl and Logotherapy
- Logotherapy: life must have meaning and therapy is the
search for that meaning
- search for meaning (logos) is the central theme in
logotherapy
- therapists who work with clients in spirituality and grief
counseling often use the concepts that Frankl developed
▪ Frederick “Fritz” Perls
- Founder of Gestalt therapy
- believed that self-awareness leads to self-acceptance and
responsibility for one’s own thoughts and feelings.
Gestalt Therapy
- emphasizes self-awareness and identifying thoughts and
feelings in the here and now.
- Often used to increase clients’ self-awareness by writing
and reading letters, journaling, and other activities designed
to put the past to rest and focus on the present.
▪ Albert Ellis
Rational emotive therapy: people make themselves
unhappy through “irrational beliefs and automatic thinking”—the
basis for the technique of changing or stopping thoughts
founder of rational emotive therapy, identified 11
“irrational beliefs” that people use to make themselves unhappy.
Rational Emotive Therapy
- example of an irrational belief is, “If I love someone, he
or she must love me back just as much.”
- Ellis claimed that continuing to believe this patently
untrue statement will make the person utterly unhappy,
but he or she will blame it on the person who does not
return his or her love.
- believes that people have “automatic thoughts” that cause
them unhappiness in certain situations.
- used the ABC technique to help people identify these
automatic thoughts: A is the activating stimulus or event,
C is the excessive inappropriate response, and B is the
blank in the person’s mind that he or she must fill in by
identifying the automatic thought.
▪ William Glasser
- devised an approach called reality therapy that focuses on
the person’s behavior and how that behavior keeps him or
her from achieving life goals
- developed this approach while working with persons with
delinquent behavior, unsuccessful school performance,
and emotional problems
- believed that persons who were unsuccessful often blame
their problems on other people, the system, or society.
- Believed they needed to find their own identity through
responsible behavior.
Rational Emotive Therapy
✓Reality therapy focuses on the person’s behavior and how that
behavior keeps the person from achieving life goals
✓Existential theorists believe that deviations occur when the person
is out of touch with self or environment; thus, the goal of therapy is
to return the person to an authentic sense of self.
✓Challenges clients to examine the ways in which their own
behavior thwarts
their attempts to achieve life goals.
Humanistic Theories
- Humanism represents a significant shift away from the
psychoanalytic view of the individual as a neurotic,
impulse-driven person with repressed psychic problems
and away from the focus on and examination of the
client’s past experiences.
- Humanism focuses on a person’s positive qualities, his or
her capacity to change (human potential), and the
promotion of self-esteem.
▪ Abraham Maslow (1921–1970)
✓Hierarchy of needs:
 basic physiologic needs, safety and security needs, love
and belonging needs, esteem needs, self-actualization
Maslows Hierarchy of Needs
- used a pyramid to arrange and illustrate the basic drives or
needs to motivate people
- most basic needs: physiologic needs – need to be met first
food water, shelter, sleep, sexual expression, and freedom of pain.
- Second level: safety and security needs - involve
protection security, freedom from harm or threatened
deprivation
- Third level: love and belonging needs, - include enduring
intimacy, friendship, and acceptance.
- Fourth level: esteem needs - includes the need for self-
respect and esteem from others.
- Highest level: self-actualization - need for beauty, truth,
and justice. Few people actually become self-actualized.
▪ Carl Rogers (1902–1987)
✓Concepts of unconditional positive regard, genuineness, and
empathetic understanding
- Considered: most influential psychologists of the 20th
century.
- best known for developing the psychotherapy method
called client-centered therapy and as one of the founders
of humanistic psychology.
- While still earning his Ph.D. in 1930, Rogers became the director
of the Society for the Prevention of Cruelty to Children in Rochester,
New York.
- spent several years in academia. He lectured at the University of
Rochester from 1935 to 1940 and became a professor of clinical
psychology at Ohio State University in 1940.
- In 1945 he moved to the University of Chicago as a professor of
psychology and then to his undergraduate alma mater, the University
of Wisconsin-Madison in 1957.
- 1966: Psychiatrist Carl Rogers (2R) leading a panel
discussing mental health issues.
Client-centered Therapy
- Believed that the basic nature of humans is to become self-
actualized or to move toward self-improvement and
constructive change.
- We are all born with a positive self-regard and a natural
inclination to become self-actualized.
- If relationships with others are supportive and nurturing,
the person retains feelings of self-worth and progresses
toward self-actualization, which is healthy.
- If the person encounters repeated conflicts with others or
is in non-supportive relationships, he or she loses self-
esteem, becomes defensive, and is no longer inclined
toward self-actualization; this is not healthy.
Crisis Intervention
Crisis: 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.
Four Stages of Crisis:
1. Exposure to stressor
2. Increased anxiety when customary coping is ineffective
3. Increased efforts to cope
4. Disequilibrium and significant distress
Types of Crises:
1. Maturational Crises: 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.
2. Situational Crises: 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 of family
member.
3. Adventitious Crises: social crises, include natural disasters like
floods, earthquakes, or hurricanes; war; terrorist attacks; riots; and
violent crimes such as rape or murder.
▪ Crisis state lasts 4–6 weeks.
▪ Outcome is either return to previous functioning level, improved
coping, or decreased coping.
▪ Crisis intervention techniques are authoritative and facilitative.
- Directive interventions: assess health status, promote
problem-solving
- Supportive interventions: deal with person’s needs for
empathetic understanding
▪ Crisis is described as self-limiting; that is, the crisis does not last
indefinitely but usually exists
for 4 to 6 weeks.
Three ways to resolve Crisis
▪ In the first two, the person either returns to his or her pre-crisis
level of functioning or begins to function at a higher level;
- both are positive outcomes for the individual.
▪ The third resolution is that the person’s functioning stabilizes at
a level lower than pre-crisis functioning,
- which is a negative outcome for the individual.
Persons experiencing Crisis:
▪ Usually are distressed and likely to seek help for their distress.
▪ They are ready to learn and even eager to try new coping skills as
a way to relieve their distress.
▪ This is an ideal time for intervention that is likely to be successful.
Hemingway, Ashmore, and Askoorum (2000)
Two Categories of Crisis Intervention:
Authoritative Intervention: assess the person’s health status and
promote problem-solving
- such as offering the person new information, knowledge,
or meaning; raising the person’s self-awareness by
providing feedback about behavior; and directing the
person’s behavior by offering suggestions or courses of
action.
Facilitative Intervention: 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.
**Techniques and strategies that include a balance of these different
types of intervention are the most effective.
TREATMENT SETTINGS and REHABILITATION
PROGRAMS
Inpatient Hospital Treatment
- In the 1990s, managed care shortened hospital stays;
people were sicker when admitted and were discharged
sooner, rendering milieu therapy and “talk” therapy
ineffective.
- Today inpatient units must provide rapid assessment,
stabilization, and discharge planning, and they must
accomplish goals quickly.
- A client-centered, multidisciplinary approach to a brief
stay is essential.
- Clinicians help clients recognize symptoms, identify
coping skills, and choose discharge supports.
- Once the client is safe and stable, the clinicians and the
client identify long-term issues for the client to pursue in
outpatient therapy.
Inpatient Hospital Treatment Includes:
- Scheduled intermittent hospital stays:
➢ Can be an effective part of a community-based treatment
plan.
- Long-stay patients:
➢ with severe and persistent mental illness may still require
acute care despite the current emphasis on decreased hospital
stays.
- Case management
➢ Liaison between the client and community resources, home
care, and third-party payers
➢ From accessing needed medical and psychiatric services to
carrying out tasks of daily living such as using public
transportation, managing money, and buying groceries
- Discharge planning
➢ Effective discharge planning is crucial.
➢ The better the discharge plan is, the longer the client remains
in the community.
➢ Impediments to effective discharge planning include:
✓Alcohol and drug abuse
✓Criminal or violent behavior
✓Noncompliance with medications
✓Suicidal ideation
Residential Settings
- Vary according to the level of supervision, structure, and
services provided as well as the intent of the services.
Types of residential services include:
▪ Board and care homes
▪ Adult foster homes
▪ Halfway houses
▪ Group homes
▪ Supervised apartment living
Evolving Consumer Households
- Services that emphasize recovery and going beyond
symptom control and medication management to include
personal growth
- Reintegration into the community
- Empowerment, increased independence
- Improved quality of life
- Client outcomes are improved by providing community
support services to decrease hospitalization rates and
increase community reintegration.
Rehabilitation Programs
Clubhouse Model offers:
▪ A place to come to
▪ Meaningful work
▪ Meaningful relationships
▪ A place to return to (lifetime membership)
▪ Members are given opportunities to participate in the
work of maintaining the clubhouse, leisure activities, and
employment and housing opportunities and are encouraged to use
local psychiatric services.
Assertive Community Treatment (ACT)
▪ One of the most successful types of community-based treatment,
ACT offers outreach services (going to the client instead of waiting
for the client to come to the services).
ACT programs involve:
▪ A problem-solving orientation; no problem is too small
▪ Direct provision of service rather than referral
▪ Intensity (three or more face-to-face contacts per week)
▪ A team approach rather than having one assigned case manager
▪ A long-term commitment for as long as the client needs services

Successful discharge planning occurs when: Special Populations

- Inpatient staff communicate with outpatient clinicians Homeless
prior to discharge
When compared with homeless persons who are not mentally ill, the
- Clients are able to start or visit the outpatient program
homeless mentally ill:
prior to discharge
▪ Spend more time in jail
- Family members are involved in the client’s care during
▪ Are homeless longer
hospitalization
▪ Spend more time in shelters
- Social services, day treatment, and housing programs are
▪ Have less family contact
geared toward survival in the community, compliance
with treatment recommendations, rehabilitation, and ▪ Face greater barriers to employment
independent living Prisoners
▪ Up to 15% of persons in jail or prison have severe mental illness.
Partial Hospitalization Programs ▪ Criminalization of mental illness refers to prosecuting mentally ill
- Designed to help clients make a successful gradual offenders, even for misdemeanors, at a rate four times that of the
transition to independent community living by: general population in an effort to contain them in some type of
institution.
▪ Focusing on stabilizing psychiatric symptoms
This practice is fueled by:
▪ Monitoring drug effectiveness
▪ Increasing public concern that mentally ill persons are
▪ Stabilizing living environment
violent
▪ Improving activities of daily living
▪ More stringent commitment laws
▪ Learning to structure time
▪ Lack of community support
▪ Developing social skills
▪ Deinstitutionalization
▪ Obtaining meaningful work
▪ Providing follow-up for health concerns
Interdisciplinary Team
▪ A multidisciplinary or interdisciplinary team involves the
collaboration of a variety of disciplines to provide the most
comprehensive, effective services for
clients.
Each member makes a unique contribution:
- Psychiatrist—diagnosis and prescription of treatment
- Psychologist—therapy, research, interpretation of
psychological tests
- Psychiatric nurse—holistic view of client, interventions,
evaluate care/treatment effectiveness
- Psychiatric social worker—working with families,
community support, referrals
- Occupational therapist—improving functional abilities
through arts and crafts
- Recreational therapist—constructive use of leisure or
unstructured time
- Vocational rehabilitation specialist—pursuit of school or
job, job seeking and retention skills.
Psychosocial Nursing
concerned with issues such as:
▪ Stress management education
▪ Early identification of mental health problems
▪ Monitoring and coordinating psychiatric rehabilitation services
▪ In clinical practice, public health and home care nurses encounter
substance abuse, domestic violence, child abuse, grief, depression,
and more.
Self-Awareness Issues
▪ Evolution of care away from inpatient settings into community
▪ Nontraditional settings such as jails or homeless shelters
▪ Empowering clients to make their own decisions
▪ Frustration of working with clients having persistent and severe
mental illness
Therapeutic Relationships
Developing Therapeutic Relationship in Nursing
A. Only trained staff should be allowed to interact with different
patients.
B. Those relatives and friend are allowed to meet patient who
know patients nature of illness and way to deal with.
C. Adequate time should give to understand patients’ need.
Components of Therapeutic Relationship
Trust: (nurse is friendly, caring, understanding, consistent; keeps
promises; listens; is honest)
Genuine interest when the nurse is comfortable with himself or
herself, aware of his or her strengths and limitations, and clearly
focused, the client will perceive a genuine person
Empathy (not sympathy)
Acceptance of person, not necessarily his or her behavior
Positive regard (unconditional, nonjudgmental attitude)
For example:
Acceptance
▪ An appropriate response would be for the nurse to remove his hand
and say, “John, do not place your hand on me. We are working on
your relationship with your girlfriend, and that does not require you
to touch me. Now, let’s continue.”
▪ An inappropriate response would be, “John, stop that! What’s
gotten into you? I am leaving, and maybe I’ll return tomorrow.”
▪ Leaving and threatening not to return punish the client while failing
to clearly address the inappropriate behavior.
Positive Regard
▪ If the nurse responds with “Well, that didn’t help, did it?” or “I
can’t believe you did that,” the nurse is communicating a value
judgment that the client was “wrong” or “bad.”
▪ A better response would be “What happened then?” or “You must
have been really upset.”
The nurse maintains attention on the client and avoids
communicating negative opinions or value judgments about the
client’s behavior.
Self-Awareness and Therapeutic Use of Self
▪ Self-awareness
- is a process of understanding one’s own values, beliefs,
thoughts, feelings, attitudes, motivations, strengths, and
limitations and how one’s thoughts and behaviors affect
others.
▪ Therapeutic use of self
- is when the nurse uses aspects of his or her personality,
experience, values, feelings, intelligence, needs, coping
skills, and perceptions to establish relationships with
clients that are beneficial to clients.
Johari Window is a self-awareness tool; categorizes
qualities of self as:
▪ open/public
▪ blind/unaware
▪ hidden/private
▪ unknown
Patterns of Knowing
▪ There are several patterns of knowing (ways of observing and
understanding client interactions):
✓Empirical (from nursing science)
✓Personal (from life experiences)
✓Ethical (from moral nursing knowledge)
✓Aesthetic (from art of nursing)
✓Unknowing is when the nurse admits he or she does not
know the client or understand the client’s subjective world
Example of Preconceptions that interfere with a therapeutic
relationship.
▪ Mr. Lopez, a client, has the preconceived, stereotypical idea that
all male nurses are homosexual
and refuses to have Samuel, a male nurse, take care of him.
▪ Samuel has a preconceived, stereotypical notion that all Hispanics
use switchblades, so he is relieved that Mr. Lopez has refused to
work with him.
Both men are missing the opportunity to do some important work
together because of incorrect preconceptions.
CARPER’S PATTERNS OF NURSING KNOWLEDGE
Establishing the Therapeutic Relationship
Therapeutic relationships are focused on the needs, experiences,
feelings, and ideas of the client, not the nurse.
Orientation Phase:
- nurse and client meet, roles are established, the purposes
and parameters of future meetings are discussed,
 expectations are clarified, and the client’s problems are - Both nurse and client usually have feelings about ending
identified. the relationship; the client especially may feel the
▪ Before meeting the client, the nurse has important work to do. termination as an impending loss.
▪ The nurse reads background materials available on the client,
becomes familiar with any medications the client is taking, gathers PHASES OF NURSE-CLIENT RELATIONSHIP
necessary paperwork, and arranges for a quiet, private, comfortable
setting.
▪ This is a time for self-assessment.
▪ The nurse should consider his or her personal strengths and
limitations in working with this client.
Working Phase:
- involves problem identification, where the client identifies
issues or concerns causing problems, and exploitation,
when the nurse guides the client to examine his or her
feelings and responses, develop better coping skills and a
more positive self-image, change behavior, and develop
independence.
Note that Peplau’s use of the word exploitation had a very different
meaning than current usage, which involves unfairly using or taking
advantage of a person or situation.
- For that reason, this phase is better conceptualized as
intense exploration and elaboration on earlier themes that
the client discussed.
- Testing behavior challenges the nurse to stay focused and
not to react or be distracted.
- Often when the client becomes uncomfortable because
they are getting too close to the truth, he or she will use
testing behaviors to avoid the subject.
- The nurse may respond by saying, “It seems as if we have
hit an uncomfortable spot for you.
- Would you like to let it go for now?”
- This statement focuses on the issue at hand and diverts
attention from the testing behavior.

For example:
Mrs. O’Shea suffers from depression.
▪ She continues to complain to the nurse about the lack of concern
her children show her.
▪ With Nurse Jones’ assistance, Mrs. O’Shea explores how she
communicates with her children and discovers that her approach is
usually highly critical and needy.
▪ Mrs. O’Shea begins to realize that her behavior contributes to
driving her children away.
▪ With Nurse Jones, she begins to explore how she might change her
methods of communication.

Behaviors that Diminish Therapeutic Relationship

▪ Inappropriate boundaries (relationship becomes social or intimate)
▪ Feelings of sympathy and encouraging client dependency rather
Therapeutic Relationship consists of three phases than promoting independence
▪ Transference is when clients unconsciously transfer feelings they ▪ Nonacceptance of client as a person because of his or her
have for significant persons in their life onto the nurse. behaviors, leading to avoidance of the client
▪ Countertransference is when the nurse responds to the client based Nurse self-awareness is the way to avoid such problems.
on his or her own unconscious needs and conflicts.
▪ The termination or resolution phase begins when the client’s Therapeutic Roles of the Nurse in a Relationship
problems are resolved and ends when the relationship is ended. ▪ Teacher
- It is important to deal with feelings of anger or ▪ Caregiver
abandonment that may occur. ▪ Advocate
- The termination phase, also known as the resolution ▪ Parent surrogate
phase, is the final stage in the nurse–client relationship.
- It begins when the problems are resolved, and it ends when
the relationship is ended.
Nurse–Client Contracts
 ➢ Although many clients have had prior experiences in the
mental health system, the nurse must once again outline the
responsibilities of the nurse and client.
➢ At the outset, both nurse and client should agree on these
responsibilities in an informal or verbal contract.

The contract should state:

- Time, place, and length of sessions
- When sessions will terminate
- Who will be involved in the treatment plan (family
members, health team members)
- Client responsibilities (arrive on time, end on time)
- Nurse’s responsibilities (arrive on time, end on time,
maintain confidentiality at all times, evaluate progress
with client, document sessions)

Confidentiality
▪ Confidentiality means respecting the client’s right to keep private
any information about his or her mental and physical health and
related care.

▪ Confidentiality means allowing only those dealing with the client’s
care to have access to the information that the client divulges.
▪ Only under precisely defined conditions can third parties have
access to this information; for example, many states require that staff
report suspected child and elder abuse.
▪ The nurse must be alert if a client asks him or her to keep a secret,
because this information may relate to the client’s harming himself
or herself or others.
▪ The nurse must avoid any promises to keep secrets.
▪ If the nurse has promised not to tell before hearing the message, he
or she could be jeopardizing the client’s trust.
Possible Warnings or Signals of Abuse of Nurse-Client
Relationship
• Secrets, reluctance to talk about the work being done with clients
• Sudden increase in phone calls between nurse and client or calls
outside clinical hours
• Nurse making more exceptions for client than normal
• Inappropriate gift-giving between client and nurse
• Loaning, trading, or selling goods or possessions
• Nurse disclosure of personal issues or information
• Inappropriate touching, comforting, or physical contact
• Overdoing, overprotecting, or over-identifying with client
• Change in nurse’s body language, dress, or appearance (with no
other satisfactory explanation)
• Extended one-on-one sessions or home visits

▪ In most cases, even when the nurse refuses to agree to keep

information secret, the client will continue to relate issues anyway.

The following is an example of a good response to a client who is

suicidal but requests secrecy:
▪ Client: “I am going to jump off the 14th floor of my apartment
building tonight, but please don’t tell anyone.”
▪ Nurse: “I cannot keep such a promise, especially if it involves your
safety. I sense you are feeling frightened. The staff and I will help
you stay safe.”

COMMUNICATION DURING THE PHASES OF THE

NURSE–CLIENT RELATIONSHIP