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What are therapeutic models?
- Framework for organizing thinking about the manifestation, the development, and treatment of disorders
- Theory attempts to establish scientific method of studying an individual as a living, social being, and contributes a language with which to examine and communicate human action
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Freud's personality structure
- Id - most primative, unconscious activity; impulse driven; goal is to satisfy self; aggressive or sexual
- Ego - rational part of self, impression of self; logic; present oriented; delays gratification; makes decisions
- Superego - last to develop; reward and punishment; "should and should not"; moral behavior
- Overdeveloped superego - feel the need to be perfect; obsessive
- Underdeveloped superego - sociopathic; reckless; lack of remorse
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Freud levels of awareness
- Conscious - awareness
- Preconscious - subconscious; info that is not readily in mind but is easily available through conscious effort
- Unconscious - repressed memories; no conscious awareness; thoughts that cannot easily pull up (i.e. memories of rape, trauma)
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Freud developmental stages
- Oral (0-1yr) - id based; trust develops (if child has trauma, they may have trust issues as an adult); fixation: passivity, gullibility, dependence
- Anal (1-3yr) - expulsion and retention phase; control develops and some sense of autonomy; fixation: anal retentiveness (stinginess, rigid thought patterns, OCD)
- Phallic (3-6yr) - genitals; sexual identity with parent of same sex; lack of successful resolution may result in difficulties with sexual identity and authority figures
- Latency (6-12yr) - develop competency; growth of ego functions and ability to care about and relate to others; fixation: difficulty identifying with others and in developing social skills, inadequacy, inferiority
- Genital (12yr+) - develop sexual relationships with opposite sex; develop identity; inability to negotiate this stage can result in difficulties becoming emotionally and financially independent
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Erikson vs. Freud
- Erikson: stressed ego; psychosocial aspects of development; considers life span development; studied healthy people; more present oriented
- Freud: stressed id and superego; psychosexual aspects of development; personality formed by age of 5; studied neurotic people
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Erikson's psychosocial stages
- Infancy (0 - 1 1/2) - trust vs. mistrust
- Early childhood (1 1/2 - 3) - autonomy vs. shame and doubt
- Late childhood (3 - 6) - initiative vs. guilt
- School age (6 - 12) - industry (competence, ability to work) vs. inferiority
- Adolescence (12 - 20) - identity vs. role confusion (submission of identity)
- Early adulthood (20 - 35) - intimacy vs. isolation
- Middle adulthood (35 - 65) - generativity (ability to give and care for others) vs. self-absorption (inability to grow as a person)
- Later years (65+) - integrity vs. despair (dissatisfaction with life; denial)
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Sullivan theories
- Interpersonal theorist
- Study personality in a social setting (relationships); thought that changes or crisis in these relationships is what therapy should be about
- Needs: satisfactions, security
- Anxiety: empathetic between child and mother; can be described, observable behaviors; individuals strive to decr anxiety
- Self system: good-me, bad-me, not-me
- Security operations: selective inattention, dissociation
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Peplau
- 1948 - wrote first textbook "Interpersonal Relations in Nursing"
- Believed in nurse-patient relationship, foundation of nursing
- Emphasized one's own behaviors and beliefs; must have self-awareness before can care for pt
- 3 phases of interpersonal process:
- Orientation: establish rapport, set boundaries, scouting phase, assessment
- Working: interventions, problem-solving, work toward goals
- Resolution: termination phase, summarize positive things that happened during interaction or any achievement pt has made
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Peplau's ideas about nursing
- Focus is on client
- Nurse is participant observer not an spectator observer (active role)
- Nurse has awareness of role
- Nursing is investigative
- Nurses use theory
- Developed process recording
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Object relations theory
- Margaret Mahler
- Disruption in object relations yields either difficulties bonding to others or difficulties seeing self as separate from others
- Ex: Pt w/ schizophrenia does not know where they end and where nurse begins
- Psychologic attachment that people get toward an object or person
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Carl Rogers: Humanistic Psychology
- Mental health is the norm
- Actualizing tendency
- Conditional positive regard
- Neurosis
- Incongruity
- Elements of a psychologically healthy person
- Sees people as good and that they are trying to fulfill their greatest potential
- Client-centered therapy: non-directive, supportive
- 3 requirements of therapists:
- Congruence: non-verbal matches verbal
- Empathy
- Respect
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Piaget: Stages of cognitive development
- Sensorimotor - 0 - 2yrs
- Preoperational - 2 - 7yrs
- Concrete operations - 7 - 11yrs
- Formal operations - 11+yrs
- Describes how cognitive development proceeds from reflex activity to application of logical solutions to problems
- Before age of 10, children are concrete and have trouble with abstract thinking, so teaching has to be much more concrete and involve modeling.
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Piaget: Schema
- Developed to organize and understand the world
- Processes used to develop:
- Assimilation - incorporate new ideas, objects, facts into framework of thoughts and they fit well
- Accommodation - change schemata to let new behavior fit
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Maslow hierarchy
- Physical health (food, water, O2, etc)
- Emotional health
- Mental health (meta-needs, intellectual)
- Spiritual health
- If lower needs not met, can't take care of higher needs (self actualization)
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Maslow's beliefs
- Needs are fulfilled by and through other humans
- A person does the best he can at the time
- With adequate understandable info, a person will make good decisions
- Man has a higher nature
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Kohlberg theory of moral development
- Level 1 Preconventional (ages 4-10) - emphasis on external control, avoiding punishment; primarily concerned with self; no empathy; needs role model
- Level 2 Conventional Role Conformity (ages 10-13) - want to please others and be considered "good"; develop social concern and conscience; don't question rules, just follow them
- Level 3 Autonomous Moral Principles (after 13, if ever) - acknowledges possibility of conflict between 2 accepted standards and tries to decide between them; acts in accord with internalized standards; sense of morality based on making sense of what society says and if it is just and moral then will follow it
- Implications for model: can use some transference (if pt in "law & order" phase, may be able to set some rules and they may be more receptive to teaching); can use level of moral pt is in to strengthen teaching
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Behaviorists
- Pavlov - classical conditioning
- Skinner - operant condition; positive or negative reinforcers (anything that is done that increases or decreases likelihood that behavior happens again; positive - praise, negative - adverse stimuli); extinction - absence of reinforcer to decrease behavior (ignoring behavior; ex: child spitting)
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Psychodynamic/psychoanalytic
- Freud
- Older technique
- Not time limited; non-directive
- Focus on internal experience, defense mechanisms, transference and past relationships
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Cognitive therapy
- Active, directive approach
- Time limited
- Goal is to change faulty thinking with correct thinking
- Therapist helps pt to recognize faulty thinking, feelings behind them, and alternatives
- Focus on thoughts/cognitions and correcting distortions
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Common cognitive distortions
- All-or-nothing - thinking in black and white, reducing complex outcomes and absolutes
- Overgeneralization - using a bad outcome as evidence that nothing will ever go right
- Labeling - form of overgeneralization where characteristic event becomes definitive and results in overly harsh label for self or others
- Mental filter - focusing on negative detail or bad event and allowing it to taint everything else
- Disqualifying the positive - maintaining negative view by rejecting info that supports positive view as being irrelevant, inaccurate, or accidental
- Jumping to conclusions - making negative interpretation despite that there is little or no supporting evidence
- Mind reading - inferring negative thoughts, responses, motives of others
- Fortune telling - assuming a negative outcome is inevitable
- Magnification or minimization - exaggerating importance of something
- Emotional reasoning - drawing a conclusion based on an emotional state
- "Should" and "must" statements - rigid self-directives that presume an unrealistic control over external events
- Personalization - assuming responsibility for external event or situation that was likely outside personal control
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Interpersonal therapy
- Focus on interpersonal relationships
- Problems: grief, role disputes, role transition, interpersonal deficit
- Therapist has active and directive role
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Behavioral therapy
- Focus on learning more adaptive behavior
- Applications: operant condition, modeling, systematic desensitization (slowly get closer to something you fear), aversion therapy, relaxation, assertiveness
- Therapist has active and directive role
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Milieu therapy
- Structuring of environment in order to promote positive behaviors in health and behavior
- Clients feel a sense of support from one another
- Clients not only interact in group, but also between groups and at meals
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Basic components of therapeutic milieu
- Basic physiological needs are met
- Physical facilities support therapeutic nature of program
- Some form of self-governance
- Unit responsibilities
- Structured program
- Community and family are included in order to facilitate discharge
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Role of psychiatric nurse in milieu
- SAFETY
- Participate in interdisciplinary plan of care
- Ensure physiological needs are met (supervisory liability)
- Medication administration and monitoring
- One-one relationship; building trust; responding to needs; modeling
- Client education
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