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Chapter 3 Psychosocial Theories and Therapy Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Psychosocial Theories • Psychoanalytic (Freud) • Developmental (Erikson, Piaget) • Interpersonal (Sullivan, Peplau) • Humanistic (Maslow, Rogers) • Behavioral (Pavlov, Skinner) • Existential (Beck, Ellis, Frankl, Perls, Glasser) Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Psychoanalytic Theories: Sigmund Freud • All human behavior is caused, explainable • Repressed sexual impulses, desires as motivation for behavior • Personality components – Id – Ego – Superego Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Psychoanalytic Theories: Sigmund Freud (cont.) • Behavior motivation due to subconscious thoughts, feelings – Conscious, preconscious, unconscious – Subconscious • Ego defense mechanisms (see Table 3.1) Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Psychoanalytic Theories: Sigmund Freud (cont.) • Psychosexual stages of development – Oral – Anal – Phallic/oedipal – Latency – Genital (see Table 3.2) • Transference, countertransference Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Current Psychoanalytic Practice • Psychoanalysis – Focus on discovering causes of patient’s unconscious, repressed thoughts, feelings, conflicts related to anxiety – Free association, dream analysis, behavior interpretation used to gain insight into and resolve these conflicts, anxieties • Lengthy, expensive, practiced on limited basis today • Freud’s defense mechanisms still current Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question • Is the following statement true or false? • Freud identified three stages of psychosexual development. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer • False • Rationale: Freud identified five stages of psychosexual development: oral, anal, phallic/oedipal, latency, and genital. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Developmental Theories • Erik Erikson – Eight stages of psychosocial development (see Table 3.3) – Achievement of life’s virtues • Jean Piaget – Cognitive, intellectual development – Four stages: sensorimotor, preoperational, concrete operations, formal operations Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Interpersonal Theories: Sullivan • Five life stages: infancy, childhood, juvenile, preadolescence, adolescence (see Table 3.4) • Three developmental cognitive modes – Prototaxic (infancy, childhood) – Parataxic (early childhood) – Syntaxic (school-aged children; more predominant in preadolescence) • Significance of interpersonal relationships • Therapeutic milieu or community Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Interpersonal Theories: Peplau • Therapeutic nurse–patient relationship • Four phases: orientation, identification, exploitation, resolution (see Table 3.5) • Nurse’s roles to meet patient’s needs: stranger, resource person, teacher, leader, surrogate, counselor • Four levels of anxiety: mild, moderate, severe, panic (see Table 3.6) Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Humanistic Theories • Abraham Maslow – Hierarchy of needs – Basic physiologic, safety and security, love and belonging, esteem, self-actualization • Carl Rogers – Client-centered therapy (focus on client’s role) – Unconditional positive regard, genuineness, empathetic understanding Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Behavioral Theories • Behaviorism: focus on behaviors and behavior changes, not how mind works • Ivan Pavlov: classical conditioning • B. F. Skinner: operant conditioning – All behavior learned – Behavior with consequences (reward or punishment) – Recurrence of rewarded behavior Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Behavioral Theories (cont.) • B. F. Skinner: operant conditioning (cont.) – Positive reinforcement: increased frequency of behavior – Removal of negative reinforcers: increased frequency of behavior – Continuous reinforcement: fastest way to increase behavior; random intermittent reinforcement increasing behavior more slowly but with a longerlasting effect Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Behavioral Theories (cont.) • Treatment modalities: behavior modification, token economy, systematic desensitization Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question • Is the following statement true or false? • Abraham Maslow was the first theorist to focus on the client’s role. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer • False • Rationale: Carl Rogers was the first to focus on the client’s role in his client-centered therapy. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Existential Theories • Overall belief: deviations occur when person is out of touch with self or environment – Goal: to return person to authentic sense of self • Cognitive therapy – Focus on immediate thought processing – Use by most existential therapists Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Existential Theories (cont.) • Rational emotive therapy (Albert Ellis) – 11 “irrational beliefs” leading to unhappiness – “Automatic thoughts”; use of ABC technique • Logotherapy (Viktor Frankl): life with meaning; therapy as search for that meaning Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Existential Theories (cont.) • Gestalt therapy (Frederick “Fritz” Perls) – Emphasis on self-awareness – Identification of thoughts, feelings in the here and now • Reality therapy (William Glasser) – Focus on person’s behavior and how that behavior keeps a person from achieving life goals Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Crisis Intervention • Four stages of crisis – Exposure to stressor – Increased anxiety when usual coping ineffective – Increased efforts to cope – Disequilibrium, significant distress • Categories of crises – Maturational – Situational – Adventitious Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Crisis Intervention (cont.) • Duration: usually 4 to 6 weeks • Outcome: resolution to functioning at precrisis level, higher level, or lower level • Crisis intervention techniques – Directive interventions: assess health status, promote problem solving – Supportive interventions: deal with person’s needs for empathetic understanding Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question • Which of the following includes the concept of automatic thoughts? – A. Cognitive therapy – B. Rational emotive therapy – C. Logotherapy – D. Gestalt therapy Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer • • B. Rational emotive therapy Rationale: Rational emotive therapy focuses on 11 irrational beliefs and automatic thoughts. – Cognitive therapy focuses on immediate through processing. Logotherapy involves therapy as a search for life with meaning. Gestalt therapy emphasizes self-awareness. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Treatment Modalities • Community mental health treatment (primary mode of treatment) – Clients continue to work and are able to stay connected with family, friends, and other support systems. – Personality or behavior patterns gradually develop; unable to be changed in a relatively short inpatient course of treatment – Peer counseling, advocacy, and mentoring are showing positive results. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Treatment Modalities (cont.) • Hospital (inpatient) treatment (often last mode of treatment) – Indications: severe depression/suicidal; severe psychosis; alcohol or drug withdrawal; behaviors requiring close supervision in a safe, supportive environment Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Individual Psychotherapy • Bringing about change in a person by exploring his or her feelings, attitudes, thinking, behavior • One-to-one relationship between the therapist and the patient – Progression through stages – Relationship as key to success • Therapist’s theoretical beliefs strongly influence style of therapy Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Groups and Group Therapy • Therapist or leader and group of clients sharing common purpose • Members contribute to group with expectations of benefiting from it. • Stages of group development: – Pregroup stage – Beginning or initial stage – Working stage – Termination Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Groups and Group Therapy (cont.) • Group leadership – Formal leader usually for therapy groups and education groups; informal leader usually for support groups and self-help groups – Focus on group process, group content to be effective Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Groups and Group Therapy (cont.) • Group roles – Growth producing: information seeker, opinion seeker, information giver, energizer, coordinator, harmonizer, encourager, elaborator – Growth inhibiting: monopolizer, aggressor, dominator, critic, recognition seeker, passive follower Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Groups and Group Therapy (cont.) • Therapeutic results (Yalom, 1995): – New information or learning, inspiration or hope – Interaction with others – Feelings of acceptance, belonging – Awareness of not being alone; others share same problems – Insight into problems, behaviors, and effects on others – Altruism Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Therapy Groups • Psychotherapy groups • Family therapy • Family education • Education groups • Support groups • Self-help groups Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question • Is the following statement true or false? • Self-help groups tend to have an informal or no definitive leader. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer • True • Rationale: Support groups and self-help groups tend to have an informal leader or no leader at all. – Therapy and education groups typically have a formal leader. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Complementary and Alternative Therapies • Alternative medical systems (homeopathy, traditional Chinese medicine) • Mind–body interventions (meditation, art, music therapy) • Biologically based therapies (herbs, foods, vitamins) Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Complementary and Alternative Therapies (cont.) • Manipulative and body-based therapies (therapeutic massage, chiropractic manipulation) • Energy therapies (therapeutic touch, qi gong, pulsed fields, magnetic fields) Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Psychiatric Rehabilitation • Services to patients with persistent, severe mental illness in the community • Also known as community support services or programs • Focus on patient’s strengths • Activities involving medication management, transportation, shopping, food preparation, hygiene, finances, social support, vocational referral Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Psychosocial Interventions • Nursing activities that enhance patient’s social and psychological functioning and promote social skills, interpersonal relationships, communication • Skills used in mental health, other practice areas Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Self-Awareness Issues • No one theory or treatment approach is effective for all patients. • Using a variety of psychosocial approaches increases nurse’s effectiveness. • Patient’s feelings, perceptions most influential in determining his or her response Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins