CONCEPTUAL FRAMEWORK FOR

PSYCHIATRIC CARE

I. PSYCHOBIOLOGY- is the scientific study of the relationship

among the structure and functions of the brain, biochemical and
hormonal process, environmental experiences and human
behavior.

NEUROANATOMY OF THE BRAIN AND BEHAVIOR

A. FRONTAL LOBE
B. PARIETAL LOBE
C. OCCIPITAL LOBE
D. TEMPORAL LOBE
 A. FRONTAL LOBE
the area around your forehead

COGNITION
HIGHEST INTELLECTUAL FUNCTION
ABSTRACT REASONING
DECISION MAKING
MEMORIES/ EMOTIONS
SPEECH
VOLUNTARY MUSCLES

DYSFUNCTION: ILLOGICAL OR PSYCHOLOGICAL

THINKING, INCOHERENT SPEECH
 B. PARIETAL LOBE
behind the frontal lobes, above the temporal lobes, and at the top back of
the brain

SENSORY FUNCTION
BODY POSITION INFORMATION

DYSFUNCTION: IMPAIRED SPATIAL ABILITY AND

BODY IMAGE. SELF CARE DEFICIT

DISORDER: SCHIZOPHRENIA, ATTENTION DEFICIT

HYPERACTIVITY DISORDER AND DEMENTIA
 C. OCCIPITAL LOBE
The occipital lobe is found in the back of the brain

VISUAL FUNCTION
OPTICALLY INDUCED REFLEXES
PERCEPTION
RECALL
VISUAL INTERPRETATION
COORDINATING LANGUAGE GENERATION

DYSFUNCTION: VISUAL ILLUSION AND HALLUCINATION

 D. TEMPORAL LOBE
The temporal lobes are found on either side of the brain and just
above the ears

JUDGEMENT
LEARNING MEMORY
SMELL SENSORY INTERPRETATION
UNDERSTANDING SOUND
AUDITORY PROCESSING

DYSFUNCTION: OLFACTORY AND AUDITORY

HALLUCINATION AND LANGUAGE ABNORMALITIES
 LIMBIC SYSTEM

A. THALAMUS
Receives and relays sensory information and plays a role in
memory and in regulating mood/ EMOTION

B. HYPOTHALAMUS
Main visceral control center of the body and is vitally important
to homeostasis, regulates ANS, body temperature, food intake,
water balance, biologic rhythms and drives and hormonal
output.
 C. HIPPOCAMPUS AND AMYGDALA
Emotional, arousal and memory

DYSFUNCTION: MEMORY LOSS IN DEMENTIA,

POORLY CONTROLLED EMOTIONS AND
IMPULSES SEEN IN PSYCHOTIC OR MANIC
BEHAVIOR
 NEUROTRANSMITTERS

A. SEROTONIN

found only in the brain

Effects: Mainly INHIBITORY
Plays an important role in anxiety and mood disorders and
schizophrenia, delusion and hallucination.
Derived from TRYPTOPHAN - dietary amino acid
Involved in control of food intake, sleep and wakefulness,
temperature regulation, pain control behavior and
regulation of emotions
- depression - anxiety disorder
 B. DOPAMINE

located primarily on the BRAINSTEM (SUBSTANTIA NIGRA)

Involve in pleasurable feelings and complex motor activities
Involve in the control of COMPLEX MOVEMENTS,
MOTIVATION, COGNITION, AND REGULATION OF
EMOTIONAL RESPONSES.
Derived from TYROSINE - a dietary amino acid.
Effects: Generally EXCITATORY
Involve in SCIZOPHRENIA AND PARKINSONS AND OTHER
PSYCHOSIS
 C. NOREPINEPHRINE

Most prevalent in the BRAINSTEM

Regulates awareness of environment, attention, learning, memory,

arousal and MOOD REGULATION

Plays a role in affect and anxiety disorder

Also known as NORE - ADRENALIN

EXCESS- Anxiety disorder

DEFICIT- memory loss, social withdrawal and depression

 D. GABA- GAMMA AMINO BUTYRIC ACID

MAJOR INHIBITORY NEUROTRANSMITTER

Nature’s VALIUM like substance

It modulates other neurotransmitter rather than

providing a direct stimulus.

Implicated in DEMENTIA, SCHIZOPHRENIA, &

ANXIETY DISORDERS
 E. ACETYLCHOLINE

Plays a role in the sleep-wakefulness cycle. Signals muscles to

become active

Can be EXCITATORY or INHIBITORY

in acetylcholine secreting neurons– ALZHEIMERS

in acetylcholine receptors- MYASTHENIA GRAVIS

 THEORETICAL BASIS

MEDICAL- BIOLOGICAL MODEL

Emotional Distress is viewed as illness

Biochemical/ genetic factors play a part in the development of

mental illness
 NEUROBIOLOGICAL THEORY

SCHIZOPHRENIA - DOPAMINE and SEROTONIN

BIPOLAR DISORDER - CATHECOLAMINES

 OTHER THEORIES

CNS INVOLVEMENT

ENDOCRINE THEORY

IMMUNE SYSTEM ABNORMALITY

CSF METABOLITES THEORY

VITAMIN DEFICIENCY THEORY

PSYCHODYNAMIC/PSYCHOANALYTIC MODEL/
PSYCHOSEXUAL

Instincts produces energy

Human behavior is determined by past experiences and

responses.

All human behavior has meaning and can be understood

Emotionally painful experiences/ anxiety motivates

behavior

Client can change behavior and responses when made

aware of the reason
 Aggregate of the physical and mental qualities
of the individual as these interacts in
characteristic fashion with his environment.
 Complex, dynamic, unique
 Expressed through BEHAVIOR.
 sum total of one’s behavior
 Behavior has meaning and is not determined
by chance.
 Behavior is goal-directed
 The unconscious play an active role in
determining behavior.
 The early years of life are important in
determining behavior
A. Psychosexual / Psychoanalytic
Sigmund Freud- early childhood experiences is
important in the development of personality.
Levels of consciousness:
1. Conscious

functions when one is awake; focus on the

here and now; concerned of thoughts, feelings &
sensations. Past experiences are recalled without
exerting effort. Corresponds to the ego or self.
2. Subconscious or Preconscious
Part of the mind in which ideas and reactions are
stored and partially forgotten; thoughts and
experiences can be recalled at will; “tip of the
tongue “experience. Acts as watchman, it
prevents certain unacceptable, disturbing,
unconscious memories from reaching the
conscious mind.
3. Unconscious
-largest part of the mind which exerts greatest
influence in one’s personality
-storehouse of all memories, feelings and
responses experienced by the individual during
his entire life.
-the memories cannot be recalled at will.
-expressed in dreams, slips of the tongue, lapses
of memories
ID
- unconscious part of the person; serves as
reservoir of primitive and biologic drives and
urges; part of personality in which we are born;
- Primitive ; demands immediate satisfaction
- No regard for rules or convention
- Functions according to the pleasure principle
- Developed during infancy
Ego
-self; I
-integrator of the personality (balances between
the ID and superego)
-part of the mind which acts with the outside
world, partly conscious, preconscious and partly
unconscious
-operates on reality principle
- Developed during the toddler period
 Superego
- The conscience

-parenteral directions which becomes

incorporated into the personality as the censoring
force
Developed during the school age.
 Strict superego-------rigid, compulsive,
unhappy person

 Weak/ defective superego---antisocial

behavior, hostility, anxiety or guilt

The EGO needs to balance between the demands

of the ID and the restrictions of the SUPEREGO.
 PSYCHOSEXUAL THEORY of the
DEVELOPMENT OF THE HUMAN
PERSONALITY

“erogenous zones”
 All human behavior is caused and can be
explained.
 Libido-sexual energy; driving force of behavior

 Repressed sexual impulses and desires

motivate much human behavior.
 Understands behavior through:

Freudian slips
Dream analysis-discussing a client’s dream to
understand their true meaning & significance
Free association-uncover the client’s thoughts
&feelings.
 A practice that is aimed to discover the causes
of the client’s unconscious and repressed
thoughts, feelings and conflicts believed to
cause anxiety
 Goal: to gain insight into & resolve these
conflicts & anxieties.
 FREUD’S PSYCHOSEXUAL and
PSYCHANALYTIC DEVELOPMENTAL STAGE

STAGE AGE TASK

ORAL 0-18 major site of pleasure and gratification

months
is through the MOUTH(erogenous
zone) ;narcissistic-self love; focus on self
BEHAVIORS: dependency, eating,
crying, sucking, biting, aggressive drives
Tension is relieved by sucking and
swallowing. Sucking need independent of
hunger. Insecurity in parting w/
breast/bottle may cause fixation.
 ID – present at birth & Directs behavior
 Infant is attached & is unable to differentiate
self from the mother figure.
 A sense of security & ability to trust others are
derived from the gratification of basic needs.
 A sense of self is only developed in
consequence of ego development. (4-6 mos)
 TASK: relief of anxiety through oral
gratification of needs
STAGE AGE TASK
ANAL 18 months Anus and surrounding areas are the
to 3 years
site of tension & sensual gratification.
TOILET TRAINING Pleasure is
through elimination and retention of
feces.
Learns INDEPENDENT BEHAVIORS:
control of holding on and letting go.
Develops concept of power and
punishment, ambivalence, concern with
cleanliness or being dirty
FIXATION: excessively neat, clean
and compulsive, frugality, stinginess ---
Dirty, wasteful and extravagant .
Reality principle is introduced(conforming
to social rules—ego development)and
beginng superego dev.
 Can stand alone
 Can walk steadily
 Can keep themselves dry in an interval of at
least 2 hours
 Can demonstrate awareness of defecating &
voiding
 Are able to use words and gestures regarding
toilet training and toilet needs
 Are desirous of pleasing the primary caregiver.
 TOILET TRAINING
“Good” Mother “Bad” Mother

Successful

Dirty Clean
- Disorganized - organized
- Disobedient - obedient
- Anti-social - O.C
- Anal expulsive - Anal retentive
 Strict & Rigid:
Retention of feces-adult  More permissive &
retentive personalities accepting- attaches
(stubborn, stingy, feelings of importance
organized) & desirability to feces
production-extrovert,
Expel Feces at
productive &
unacceptable manner &
altruistic
inappropriate
times(adult expulsive
personality)cruel,
destructive,disorganized,
untidy)
 TASK: learning independence & control with
focus on excretory functions.(anus &
surrounding areas)

 Voluntary control of anus (toilet training) is

acquired.
 STAGE AGE TASK
PHALLIC/ 3 years to pleasure is through GENITALS
6 years PENIS is the organ of interest
OEDIPAL
MASTURBATON is common
PENIS ENVY
OEDIPAL/ ELECTRA COMPLEX
Develops fear and punishment by
parents of same sex
Child becomes sexually attracted to
parent of opposite sex and fears the
parent of same sex- (CASTRATION
COMPLEX)
BEHAVIOR: masturbation
Resolution- identification of the parent
of the same sex
 Penis- organ of interest in both sexes.
 Oedipus/electra comples- unconscious &
strong desire to eliminate the parent of the
same sex & to possess the parent of the same
sex.- guilt resolved when there is +
identification with the parent of the same sex
(parent’s attitudes, beliefs and value system are
introjected by the child).
 TASK: Identification with the parent of the
same sex, development of sexual identity.
STAGE AGE TASK
LATENCY 6 years to Resolution of Oedipal Complex
12 years Sexual drive channeled into socially
appropriate activities, such as
school work and sports.
Has peers of same sex
FORMATION OF SUPEREGO
Increased intellectual activity.
Identify with teachers and peers
 TASK: sexuality repressed and focus on
relationship with peers of the same sex.

 Sexual drives channeled into socially

acceptable activities. (group activities, sports,
school work & socialization with peers.
 STAGE AGE TASK
GENITAL 12 – 20 Final Stage of psychosexual
years old development
STAGE
Begins with puberty and the biologic
capacity for orgasm
Involves the capacity for true
intimacy and establishment of
relationship w/ the opposite sex
BEHAVIORS: becomes independent
of parents, responsible of self.
Develops sexual identity, ability
to love and work.
Significant other- peer group
 Sexual behaviors evolve from self gratification
to behaviors deemed acceptable by societal
norms.
 Capacity for true intimacy is developed
 Genuine pleasure in interaction is the basis of
interpersonal relationships.
 TASK: libido reawakened as genital organs
mature & focus on relationships with members
of the opposite sex.
 PSYCHOSOCIAL THEORY of the
DEVELOPMENT OF THE HUMAN
PERSONALITY

 “developmental tasks”
 Life tasks
 ERICKSON’S PSYCHOSOCIAL MODEL
STAGE VIRTUE TASK
Trust HOPE sense of trust and confidence that the
and world is a good place; view relationships
VS
as nurturing, stable and dependable.
Mistrust DRIVE
TRUST: if needs are met consistently;
(birth-18 dependent on the consistency of maternal
months) relations
infancy
(drive, hope, realistic trust of self & others,
Confidence in others, shares openly &
relates with others effectively)

MISTRUST: needs not met, absence of

mother figure
 Drive
 Hope
 Realistic trust of self & others
 Confidence in others
 Optimism
 Shares openly with others
 Relates to others effectively
 OVERLY TRUSTING OF
SUSPICIOUSNESS
OTHERS
 testing of others  Naïve
 Fear of criticism  Gullible
 Fear of affection  Shares too quickly &
 Dissatisfaction easily
 Hostility
 Projection of blame &
feelings
 Withdrawal from others
 To develop a basic trust in the
mothering figure & to generalize it to
others.
 STAGE VIRTUE TASK
Autonomy WILL AND reasonable free choices and not
VS SELF force or shamed into doing anything
Shame CONTROL a need to establish a differentiation
between the self & its own will and the
and Doubt pressure of outside influences.
(18 months AUTONOMY: development of self
to 3 years) esteem, self control, will power, pride,
Early confidence in expressing self,
cooperativeness, and able to delay
childhood
gratification of needs
DOUBT: becomes insecure, and
learns to become ashamed of himself.
The child will no longer explore the
environment for fear of failures.
 Self control
 Will power
 Realistic self concept & self esteem
 Pride
 Sense of goodwill
 Generosity tempered by withholding
 Delayed gratification when necessary
 Self  Excessive
doubt/consciousness independence,
 Dependence on others defiance or
for approval grandiosity
 Sense of being out of  Denial of problems
control of the self & of  Unwillingness to ask
one’s life for help
 Obsessive compulsive  Impulsive, inability to
disorder wait
 Reckless disregard for
safety of others
 To gain some self control and
independence within the environment
STAGE VIRTUE TASK
Initiative DIRECTION Beginning of the development of
VS AND conscience.
PURPOSE Learns to manage conflict and
Guilt anxiety(resolution of oedipal/electra-
(+3 – 6 proper sex rule identification, failure leads
yrs.) to improper sex rule identification)
preschool Initiative to explore & reach security
outside the home could lead to guilt
INITIATIVE: imagining a future situation,
parents encourage the child to develop
his potentials, try to do something he
hasn’t done before, not afraid to try out
his ideas and voice out his mind
GUILT: parents implement inhumane
rules and restrictions, “NOTHING
VENTURED NOTHING LOST”
 To develop a sense of purpose & the
ability to initiate and direct one’s own
activities
 Adequate conscience
 Initiative balanced with restraint
 Appropriate social behavior curiosity &
exploration
 Healthy competitiveness
 Sense of direction
 Original & purposeful activities
GUILT GUILT

 Excessive  Lack of follow through

guilt/embarrasement on plans
 Passivity & apathy  Little sense of guilt for

 Avoidance of actions
activities/pleasure  Excessiveemotions

 Reluctance to show  Excessive

emotions competitiveness/
 Underachievement of showing off
potentials
 STAGE VIRTUE TASK
Industry METHOD AND Learning how to do things well
VS
COMPETENCE Emerging competence &
Inferiority confidence in activities
(6- 12 yrs.) taking pleasures in
accomplishments; produce either
School
individually or with others
age praising when they do well
INDUSTRY: seen in persons with
sense of duty, scholastic and social
competence, with perseverance and
goal directed.INFERIORITY:
Incapable of doing things, exaggerate
minor difficulties, “INFERIORITY
COMPLEX”- If at first you don’t
succeed don’t ever try again.
To achieve a sense of self confidence
 Sense of competence completion of projects
 Pleasure in effort & effectiveness
 Ability to cooperate & compromise
 Identification with admired others
 Joy of involvement in the world & with others
 Balance of work & play
 Feeling unworthy,  Overly high achieving
inadequate  Perfectionist
 Poor work history  Reluctance to try new
 Inadequate problem things for fear of
solving skills failing
 Manipulation of  Feeling unable to gain
others/violation of love or affection
other’s rights unless totally
 Lack of friends of the successful
same sex  workaholic
 STAGE VIRTUE TASK
Identity VS FIDELITY Knowing who you are and how
you fit to the rest of society.
Role
decides who he is and what kind
Confusion of person he will be.(vs role
(+12-20 confusion)
yrs.) Beginning of career choices,
puberty accept and adjust changes to body
image.INDUSTRY: allowed to make
decisions, ability to live by societies
standards
ROLE CONFUSION: not allowed to
make decisions and not made
responsible for their actions,
dysfunctional relationships; attempt to
be too many people(role diffusion)
 To integrate the tasks mastered in the
previous stages into a secure sense of self.
 Devotion, fidelity
 Confident sense of self
 Emotional stability
 Commitment to career planning & realistic
long term goals
 Sense of having a place in society
 Establishing relationship with opposite sex
 Development of personal values
 Testing out adult roles
 Lack of or giving up on
 Dramatic
goals, beliefs, values &
productive role
overconfidence
 Acting out behaviors
 Feelings of
confusion,indecision & (includes alcohol/drug
alienation abuse)
 Vacillation between Flamboyant display of
dependence & sex role behaviors
independence
 Superficial, short term
relationship w/
opposite sex
STAGE VIRTUE TASK
Intimacy AFFILIATION Able to be closer to others as a
VS AND LOVE lover, as a friend
Isolation Develops commitment to career,
(+20- and relationships
30yrs.) INTIMACY: not merely sexual
Young relationship but involves mutual
adult compassion and acceptance.
ISOLATION: occurs when
adolescent is unable to develop
lasting relationship with the opposite
sex.
Has a mastered environment
To form an intense, lasting relationship
or a commitment to another person, a
cause, an institution,or a creative effort.
 Affiliation
 Ability to give and receive love , commitment
& mutuality with others
 Collaboration in work & affiliations
 Sacrificing for others
 Responsible sexual behavior
 Persistent  Possessiveness &
aloneness/isolation jealousy
 Emotional distance in  Dependency to
all relationships parents or partners
 Prejudices against
 Abusiveness towards
others
loved ones
 Lack of established
vocation(many career  Inability to try new
changes) things socially or
 Seeking intimacy
vocationally
through casual sex
encounters
 STAGE VIRTUE TASK
Generativity CARE Being creative or productive,
VS establishing the next generation
Stagnation Extension of love into the future
(30-60 yrs.) It is a concern for the next
generation
Mid
GENERATIVITY: occurs when the
adult adult has gained enough self
sufficiency and maturity, transmission
of values to next generation, also
seen in counseling, community
services and volunteer works
STAGNATION; caring for no one,
unable to develop feelings of
adequacy, too preoccupied with his
appearance and possession
To achieve the life goals established for
oneself while considering the future
generations
 Productive, constructive, creative
 Personal and professional growth
 Parental and societal responsibilities.
 Self centeredness
 Exaggerated concern
 Too many
for appearance
Professional or
 Lack of interest in the
community activities to
welfare of others the detriment of others.
 Lack of civic & prof

responsibilities
lack of interest in
marriage &/or
extramarital affairs.
STAGE VIRTUE TASK
Integrity WISDOM own life has been worth while
VS INTEGRITY: Occurs when a person
Despair can look back and accept the course
of events, feel proud and satisfied for
(60-end) what he has accomplished, able to
Older forgive himself for the mistakes that
he made, feels ready to the end of life
adult DESPAIR: feels that his life was
wasted and finds no meaning in it.
Feels that he is not ready to die
To review one’s life & derive meaning
from both positive & negative events,
while achieving a positive sense of self.
 Feeling of self acceptance
 Sense of dignity, worth & importance
 Adaptation to life according to limitations
 Valuing one’s life
 Sharing of wisdom
 Exploration of philosophy of life &death
 Sense of helplessness,
Hopelessness,worthless  Inability to reduce
Ness uselessness &/or activities
meaninglessness  Overtaxing strength &
Withdrawal &loneliness abilities
Unable to occupy self  Feeling indispensable
Focusing on past  Denial of death as
mistakes,failures inevitable.
Dissatisfaction
Feeling too old to start
over
INTERPERSONAL THEORY
 Infant Struggles to achieve feelings of security
& to avoid anxiety.

 Met needs- infant has a sense of well-being

 Unmet needs-infant has dread & anxiety

 Modifies action to suit social demands
 Parents are viewed as a source of praise &
acceptance
 Gratification leads to positive self esteem
 Major task- formation of satisfactory
relationships with peers. Achieved with use of
competition, cooperation & compromise.
 Learns to accept subordination from authority
figures outside the family
 Learns to negotiate own needs
 More concept of self status & role
 Anxiety may result from a need to control
others
 Focus is developing relationships with persons
of the same sex
 Ability to collaborate with & show love &
affection for another person
 Develops consideration & concern for others
 Capacity for attachment, love & collaboration
emerges or fails to develop
 Major task: formation of relationships with
members of the opposite sex
 Emergence of lust
 Attempts to integrate sex with other personal
relationships
 Focus: achievement of interdependence within
the society & the formation of lasting, intimate
relationship with a selected member of the
opposite sex.
 Masters expressions of sexual impulses
 Forms satisfying & responsible associations
 Uses communication skills to protect self from
conflicts with others.
 goal of treatment- establishment of satisfying
interpersonal relationships.

Participant observer- the therapist BOTH

participates in & observes the progress of the
relationship.
 SULLIVAN’S INTERPERSONAL MODEL

STAGE AGE TASK

INFANCY 0-18 If needs are met, infant has sense of
months well being,views self as worthwhile
individual unmet needs lead to anxiety
CHILDHOOD 18 mo. Parents viewed as source of praise and
- 6 yrs. acceptance.
JUVENILE 6-9 Learn how to negotiate own needs
yrs.
PRE- 9 -12 Learn to relate to friends of same sex
ADOLESCENCE yrs.
EARLY 12 - 14 Learn independence and relate to
ADOLESCENCE friends (opposite sex)
LATE 14 - 21 Intimate relationship
ADOLESCENCE
MASLOW’S HUMAN MOTIVATIONAL NEED MODEL

HIERARCHY OF NEEDS IN ORDER OF IMPORTANCE

NEEDS
Physiologic Oxygen, food, water, sleep, sex
Safety Security, protection, freedom from
harm,order
Love & Freedom from alienation and
Belongingness loneliness; giving & receiving
affection, identification
Esteem Free from sense of worthlessness,
inferiority and
helplessness;respect;prestige

Self Actualization self fulfillment, creativity, spirituality

 ACTUALIZATION

ESTEEM

LOVE AND
BELONGINGNESS

SAFETY

PHYSIOLOGIC NEEDS
 BEHAVIORAL MODEL (PAVLOV, SKINNER)

CONDITIONED RESPONSE - pairing of stimulus

with a response

ACQUISITION - gain of learned response

EXTINCTION - loss of learned response

OPERANT CONDITIONING - a type of learning which
responses are modified as a function
of consequences of the response;
behavior operates on the
environment in some ways.
- behavior is learned from
one’s history or past experiences,
particularly from experiences that were
repeatedly reinforced.(Skinner)

a. REINFORCEMENT- consequences of behaviors that

strength or increase its frequency.
b. POSITIVE REINFORCEMENT- involves the contingent
delivery of a desired consequence; reinforcing increase
the probability that the behavior will recur. GIVING
RECOGNITION, PAY CHECK, BONUS
c. NEGATIVE REINFORCEMENT - the contingent
escapes from an aversive consequences;
increase that probability that the behavior will
recur by removal of an undesirable reinforcing
stimulus. TICKET FOR SPEEDING

d. POSITIVE PUNISHMENT - aversive consequences

decrease a particular behavior. COMMUNITY
SERVICE, IR

e. NEGATIVE PUNISHMENT - withdrawing reward

decreases a particular behavior. ALLOWANCE IN
SCHOOL, GROUNDED
 COMMUNITY MENTAL HEALTH MODEL

A. Emotional Distress stems from personal and social factors

1. FAMILY PROBLEMS (divorce, single parenthood)

2. SOCIAL FACTORS (unemployment, lack of support groups)

B. HEALTH CARE IS A RIGHT

C. Decrease need for hospitalization. Increase community care

D. Collaboration of social and health care services

E. Comprehensive services: energy care, inpatient services,

consultation and education.
Hildegard PEPLAU’S THERAPEUTIC NURSE-
PATIENT RELATIONSHIP

Interpersonal techniques is the

core of psychiatric Nursing
 THREE PHASES OF NURSE PATIENT RELATIONSHIP

1. ORIENTATION
A. Nurse explain relationship to client, defines both
roles, as well as expectations
B. Nurse contracts with clients
C. Nurse assess client and develops a plan of care
D. Limit/ termination of relationship are introduced.
E. Explanation of hospital routines and
expectations
F. Patient’s full participation is elicited.
 Trust & Rapport
 Environment (therapeutic)
 Assess Client’s strengths &Weaknesses
 Contract
 Help Communicate
2. WORKING PHASE

A. Client’s problem and needs are identified and

explored. Client and nurse develop mutual
acceptance

B. Dysfunctional symptoms, feelings or

interpersonal relationships are identified.

C. Goals are evaluated and changed as

determined by client’s progress.
 Promote positive self concept
 Realistic goal setting
 Organizing support system
 Verbalize feelings (encourage)
 Implement Action Plan
 Develop positive coping behavior
 Evaluate the result of the plan of action
3. TERMINATION PHASE

A. Relationship and growth in nurse and client

are summarized
B. Client may become anxious and react with
increase dependence, hostility or
withdrawal
C. Services are no longer needed by patient
D. Patients assumes power to meet own needs,
set new goals and so forth.
 Promote self care
 Recognize increasing anxiety
 Increase independence
 Demonstrate emotional stability
 Environmental support
 TRANSFERENCE AND COUNTER
TRANSFERENCE

TRANSFERENCE – occurs when client transfers

conflicts/ feelings from past to
the nurse

COUNTER TRANSFERENCE – Occurs when the

nurse responds to client
emotionally, as if in a personal,
not professional/ therapeutic
relationship.
 Do not reinforce or argue hallucinations or
delusions.
 Do not touch patient’s without warning them
 Avoid whispering or laughing when patients
are unable to hear all of the conversation
 For withdrawn patients, start with 1:1
interactions
 Allow and encourage verbalization of feelings
 Avoid competitive activities with some
patients
 Be calm when talking to the patients.
 Keep promises
 Be consistent
 Reenforce positive behavior
CORE CONCEPT OF THERAPEUTIC COMMUNICATION

COMMUNICATION – two way process between 2 or

more individuals. The interaction involves an exchange
of information.
ELEMENTS OF COMMUNICATION
A. SENDER
B. MESSAGE
C. RECEIVER
D. CHANNEL
E. FEEDBACK
FACTORS THAT INFLUENCE COMMUNICATION:

Attitude, Values

Sociocultural/ Ethnic Background

Past Experiences

Knowledge of the Subject Matter

Ability to relate to others

Interpersonal Perceptions
 VERBAL BEHAVIORS
 Voice quality- speaking rate,pitch range

 Vocalized pauses- um, er,ah

 NON VERBAL BEHAVIORS

 Fully attending to client

 Relaxed and unhurried manner

 Leaning forward slightly in an open body posture

 Maintaining eye contact

 Nodding periodically

 Facial Expression
FOUR ZONES OF SPATIAL TERRITORY

1. Intimate Space

 Physical contact up to 18 inches

 Comfortable for parents, with young

children or people with mutual desire

 For personal contact

 For whispering a message

2. PERSONAL SPACE
 18 inches to 4 feet
Comfortable distance when talking to a friend or family members

3. SOCIAL SPACE
 4 to 12 feet
 Formal business
For communication in social, work, and
business settings.
4. PUBLIC SPACE
 more than 12 feet
 acceptable distance between a speaker and an audience, small
groups and other informal functions
 EFFECTIVE COMMUNICATION

1. KNOW YOURSELF
2. Be honest with your feelings
3. Be secure in your ability to relate to people
4. Be sensitive to the needs of others
5. Recognize symptoms of anxiety
6. Watch out for your non verbal reactions
7. Use words carefully
8. Recognize differences
9. Recognize and evaluate your own action and responses
 SOCIOCULTURAL CONSIDERATIONS

AGE: Assess for developmental tasks and developmental

crisis
Age related problems
FAMILY AND COMMUNITY RELATIONSHIP
1. Role of the client in the family
2. Family Harmony and client’s perception of family
3. Availability of family support groups

EDUCATION

CULTURAL / SPIRITUAL BACKGROUND

 THERAPEUTIC COMMUNICATION

TECHNIQUE DESCRIPTION EXAMPLE

SILENCE Allows the client to
gather thoughts and
ponder a topic without
interruption
OFFERING Offer to provide comfort “I will stay with you”
SELF to client by presence “I am here if you are
ready to share your
story”
"I'll sit with you awhile."
ACCEPTING Indicates non NODDING
judgmental, acceptance “Yes”
of client and his “Uhuh”
perceptions
TECHNIQUE DESCRIPTION EXAMPLE
GIVING Indicate to the client “Good Morning Mr.
the awareness of his Parker!”
RECOGNI- behavior. Objective
TION “I noticed you combed
acknowledgement
your hair.
MAKING Verbalizing what you “You look sad”
OBSERVA- perceived. Subjective “You seemed annoyed.”
TION response to patients “You look happy.”
appearance and
behavior.
ENCOURAGE Ask the client to “Tell me more about
DESCRIPTION verbalize his that”
perception. Describe “Describe to me what
his or her view of an happened”
event or experience.
TECHNIQUE DESCRIPTION EXAMPLE
BROAD Encourage the client to “What would you like to
OPENINGS introduce a topic talk about?”
"Tell me what's
bothering you."
OFFERING Encourage the client So…
GENERAL to continue discussing Go on..
LEADS the topic And then? What
happened next?
REFLECTING Directing client’s Client: “Do you think I
questions/ statement should go on with this?”
back to encourage Nurse: “Do you think
expression of ideas you should go on?”
and feelings
TECHNIQUE DESCRIPTION EXAMPLE
FOCUSING Encouraging the client “Lets go back to what
to stay on the topic. you are saying.”
Concentrating on a “Let’s talk about the
single, important point difficulty with your
children.”
EXPLORING Encourage the client “Tell me more about
to express feeling and that”
idea in more depth “What kind of boat did
you see?”
CLARIFICATION Encourage the client “I am not sure I get
to express idea or what you mean.”
feeling more explicit
and understandable
TECHNIQUE DESCRIPTION EXAMPLE
PRESENTING Report events/ Patient: “I heard
situations as they someone telling me to
REALITY really are. jump off the roof.”
Nurse: “I haven’t heard
anyone, we are the
only person in the
room.”
GIVING Making available the “My name is Gloria
INFORMATION facts that the patient Diaz, I will be your
needs. nurse for today from 7
am to 3 pm.”
 BARRIERS TO THERAPEUTIC
COMMUNICATION

TECHNIQUE DESCRIPTION EXAMPLE

STEREOTYPING Offering generalized “Two-years olds are
and oversimplified brats”
beliefs about groups of “Women are
people that are based
on experience complainers”
“Men don’t cry”
“Most people don’t
have any pain after
This surgery.”
TECHNIQUE DESCRIPTION EXAMPLE

AGREEING Client’s thought is Client: “I don’t think

either right Dr. Hembra is a very
AND
DISAGREEING
or wrong. That the good doctor. He doesn’t
nurse is not in a seem interested in his
position to patients.”
judge. These Nurse: “Dr. Hembra is
responses stop clients head of the Department
from thinking through of Surgery and is an
their position and may excellent surgeon.”
cause client to become
defensive.
TECHNIQUE DESCRIPTION EXAMPLE
BEING Attempting to protect a Client: “Those night
DEFENSIVE person or health care nurses must just sit
services from negative around and talk all
night. They didn’t
comments. These answer my light for
responses prevent the over an hour.”
client from expressing Nurse:
true concerns. The “You’re not the only
nurse is saying, “You client, you know.”
Have no right to
complain.”
TECHNIQUE DESCRIPTION EXAMPLE
Giving a response that Client: “I felt nauseated
makes client prove the after that red pill.”
statement or point of Nurse: “Surely you
CHALLENGING view. These don’t think I gave the
responses indicate wrong pill?”
that the nurse is Client: “I believe my
failing to consider the husband doesn’t love
clients feelings, me.”
making the client feel Nurse: “You can’t say
it necessary to defend that; he visits you
a position. every day.”
TECHNIQUE DESCRIPTION EXAMPLE
PROBING Asking for information Client: “I was speeding
chiefly out of curiosity along the street and
rather than with the didn’t see the stop
intent to assist the sign.”
client. These Nurse: “Why were you
responses speeding?”
are considered prying Client: “I didn’t ask the
and violate the clients doctor when he was
privacy. Often asking here.”
“why” is probing and Nurse: “Why didn’t
places the client in a you?”
defensive position
TECHNIQUE DESCRIPTION EXAMPLE
GIVING Using clichés or “You’ll feel better
REASSURANCE comforting soon.”
statements
“I’m sure
of advices a means
to reassure the everything
client. will turn out all
These responses right.”
block the fears, Don’t worry.”
feelings, and other
thoughts of the
client.
TECHNIQUE DESCRIPTION EXAMPLE
REJECTING Refusing to discuss “I don’t want to
certain topics with the discuss that.
client. These “Lets discuss other
responses often make areas of interest rather
clients feel that the than the two
nurse is rejecting not problems you keep
only their mentioning.”
communication but “I can’t talk now. I’m
also the clients on may way for coffee
themselves. break.’
 Methods of attempting to protect the self
and cope with basic drives or emotionally painful
thoughts, feelings or events.

Most defense mechanisms operate at the

unconscious level of awareness, so people are
not aware of what they are doing and often need
help to see the reality.
 DEFENSE MECHANISM

DEFENSE DESCRIPTION EXAMPLE

DENIAL arguing against an Erap estrada still wanted
anxiety provoking to be called as president
stimuli by stating it after EDSA 2.
doesn't exist
DISPLACEMENT taking out slamming a door instead
impulses on a less of hitting as person,
threatening target yelling at your spouse
after an argument with
your boss
REACTION Acting the opposite having a bias against a
FORMATION of what one actually particular race or
think or feels culture and then
embracing that race or
culture to the extreme
PROJECTION placing “Its not me, its Jennifer
unacceptable who had a crush on
impulses in yourself you” (truth is she does
onto someone else have a crush on him)
RATIONALIZATION supplying a logical “ Sorry maam, I’m late,
or rational reason the traffic is so heavy
as opposed to the and the rain is pouring
real reason so hard.”
REGRESSION returning to a sitting in a corner and
previous stage of crying after hearing bad
development news; throwing a temper
tantrum when you don't
get your way
REPRESSION pulling into the forgetting sexual abuse
unconscious from your childhood due to
the trauma and anxiety
SUBLIMATION acting out Eating candy rather than
unacceptable smoking
impulses in a Drinking water instead of
socially Budweiser
acceptable way
UNDOING You try to reverse or A boyfriend giving
undo your feeling by flowers and
DOING something chocolates after
that indicates the being dishonest to
opposite feeling. It his girlfriend
may be an "apology"
for the feeling you find
unacceptable within
yourself
CONVERSION Conflicts are presented
by physical symptoms
involving portions of
the body innervated by
sensory or motor
nerves.
IDENTIFICATION Similar to without being aware
introjection, but of that he is copying his
less intensity and teacher,
completeness. The
unconscious a resident physician
modeling of one's assumes a similar
self upon another mode of dress and
person. One may manner with patients
also identify with
values and attitudes
of a group
INTELLECTUALIZATION The process of
assimilation of the
picture of an object
(as the individual
conceives the object
to be).
COMPENSATION Overachievement Napoleon complex:
in an area to offset diminutive man
real or perceived becoming an
deficiencies in emperor
another areas
DISSOCIATION Dealing with Adult remembers
emotional conflict nothing about a
by a temporary childhood sexual
alteration in abuse.
consciousness or
identity
INTROJECTION Accepting another Person dislikes
person’s attitudes, guns becomes an
beliefs as one’s own avid hunter, just
like his best friend
ISOLATION The splitting-off of the a medical student dissects a
emotional components cadaver without being
from a thought. disturbed by thoughts of
death

a bank teller appears calm

and cool while frustrating a
robbery but afterward is
tearful and tremulous.

SYMBOLIZATION An object or act a boy asks for a girl's hand (in

represents a complex marriage).
group of objects and
acts, some of which may
be in conflict or
unacceptable to the ego;
objects or acts stand for
a repressed desire
SUBSTITUTION Replacing the Woman who
desired would like to have
gratification with her own children
one that is readily opens a day care
available center.
1. Alcoholic – denial , projection and
rationalization
2. Schizophrenia – denial, projection and
regression
3. Phobia – displacement,
symbolization
4. Mood disorder – repression
5. Depression – introjection
6. Mania – reaction formation /
over compensation
 1. TCA’s to be given first unless contra
indicated

 2. Don’t use together with alcohol

 3. Expect a lag
- for TCA – 7 to 14 days
- for MAOI – 1 to 3 weeks
 TCA to MAOI – 2 weeks
 MAOI to MAOI – 10 days
 TCA to TCA – 10 to 14 days

 MAOI to surgery – discontinue MAOI first

for 10 days
 Drug of choice for hypertensive crisis –
Regitine (watch out for hypotension)
 Initial position – prone, side lying ,supine