Mental Health and Mental Illness

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Mental health and mental illness Health- a state of complete physical, mental, and social wellness, not merely the absence of disease or infirmity. (Defined by WHO) Mental Health- is a state of emotional, psychological, and social wellness evidenced by satisfying interpersonal relationships, effective behavior and coping, positive self- concept, and emotional stability. Factors influencing a person’s mental health -individual or personal -interpersonal or relationship -social or cultural Mental disorder- a clinically significant behavioral of psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. (American Psychiatric Association, 2000) General criteria to diagnose mental disorder: -dissatisfaction of one’s characteristics, abilities, and accomplishments -ineffective or unsatisfying relationship -dissatisfaction with one’s place in the world -Ineffective coping with life events -lack of personal growth Diagnostic and Statistical Manual of Mental Disoerders, 4th Edition, Text revision (DSM-IV-TR) - is a taxonomy published by the APA. - describes all mental disorders, outlining specific diagnostic criteria for each based on clinical experience and research. - 3 purposes: 1. to provide a standardized nomenclature and language for all mental health professionals. 2. to present defining characteristics or symptoms that differentiate specific diagnoses. 3. to assist in identifying the underlying causes of disorders. - multiaxial classification system that involves assessment of several axes, or domains of information, allows the practitioner to identify all factors that relate to a person’s condition. • Axis I is for identifying all major psychiatric disorders except mental retardation and personality disorders. Ex. Depression, schizophrenia, anxiety, and substance- related disorders. • Axis II is for reporting mental retardation and personality disorders as well as prominent maladaptive personality features and defense mechanisms. • Axis III is for reporting current medical conditions that are potentially relevant to understanding or managing the person’s mental disorder as well as medical conditions that might contribute to understanding the person. • Axis IV is for reporting psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorder. • Axis V presents Global Assessment of Functioning, which rates the person’s overall psychological functioning on a scale of 0 to 100. Standards of care- are authoritative statements by professional organizations that describe the responsibilities for which the nurse is accountable. STANDARD: I. Assessment –collects client health data. II. Diagnosis- analyzes the data in determining diagnoses. III. Outcome Identification- identifies expected outcomes individualized to the client.


IV. Planning- develops a plan of care that prescribes interventions to attain expected outcomes. V. Implementation- implements the interventions identified in the plan of care. Va. Counseling- uses counseling interventions to assist clients in improving or regaining their previous coping abilities, fostering mental health, and preventing mental illness and disability. Vb. Milieu Therapy- nurse provides structures, and maintains a therapeutic environment in collaboration with the client and other health care Vc. Self-care Activities- nurse structures interventions around the client’s activities of daily living to foster self- care and mental and physical being. Vd. Psychobiologic Interventions- nurse uses knowledge of psychobiologic interventions and applies clinical skills to restore the client’s health and further disability. Ve. Health Teaching- assists the clients in achieving satisfying, productive, and healthy patterns of living. Vf. Case Management- to coordinate comprehensive health care services and ensure continuity of care. Vg. Health Promotion and Maintenance- employs strategies and interventions to promote and maintain mental health and prevent mental illness. VI. Evaluation- evaluate the client’s progress in attaining expected outcomes.


Self-Awareness- is the process by which the nurse gains recognition of his or her own feelings, beliefs, and attitudes. PSYCHOSOCIAL THEORIES 1. Psychoanalytic theories (Sigmund Freud- father of psychoanalysis) – supports the notion that all human behavior is caused and can be explained. -personality components: Id (innate desires, pleasure seeking behavior, aggression and sexual impulses), Superego (moral and ethical concepts, values, and parental and social expectations.), Ego (the balancing or mediating force between the id and superego.) -3 levels of awareness: Conscious (perceptions, thoughts, and emotions that exist in the person’s awareness), Preconscious (not currently in the person’s awareness, but he/she can recall them with some effort.), Unconscious (realm of thought and feelings that motivate a person even though he/she is totally unaware of them. - Dream analysis- a primary method used in psychoanalysis, involves discussing a client’s dream to discover their true meaning and significance. - Free Associations- 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 in mind. - Ego Defense Mechanisms- methods of attempting to protect the self and cope with basic drives or emotionally painful thoughts, feelings or events. Level I: The mechanisms on this level, when predominating, almost always are severely pathological.

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Denial: Refusal to accept external reality because it is too threatening; arguing against an anxiety-provoking stimulus by stating it doesn't exist; resolution of emotional conflict and reduction of anxiety by refusing to perceive or consciously acknowledge the more unpleasant aspects of external reality. Distortion: A gross reshaping of external reality to meet internal needs. Delusional Projection: Grossly frank delusions about external reality, usually of a persecutory nature.

Level II: These mechanisms are often present in adults and more commonly present in adolescence.

Fantasy: Tendency to retreat into fantasy in order to resolve inner and outer conflicts Projection: Projection is a primitive form of paranoia. Projection also reduces anxiety by allowing the expression of the undesirable impulses or desires without becoming consciously aware of them; attributing one's own unacknowledged unacceptable/unwanted thoughts and emotions to another; includes severe prejudice, severe jealousy, hyper vigilance to external danger, and "injustice collecting". It is shifting one's unacceptable thoughts, feelings and impulses within oneself onto someone else, such that those same thoughts, feelings, beliefs and motivations as perceived as being possessed by the other. Hypochondriasis: The transformation of negative feelings towards others into negative feelings toward self, pain, illness and anxiety Passive aggression: Aggression towards others expressed indirectly or passively Acting out: Direct expression of an unconscious wish or impulse without conscious awareness of the emotion that drives that expressive behavior. Idealization: Subconsciously choosing to perceive another individual as having more positive qualities than they may actually have. Level III: These mechanisms are considered neurotic, but fairly common in adults.

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Displacement: Defense mechanism that shifts sexual or aggressive impulses to a more acceptable or less threatening target; redirecting emotion to a safer outlet; separation of emotion from its real object and redirection of the intense emotion toward someone or something that is less offensive or threatening in order to avoid dealing directly with what is frightening or threatening. For example, a mother may yell at her child because she is angry with her husband. Dissociation: Temporary drastic modification of one's personal identity or character to avoid emotional distress; separation or postponement of a feeling that normally would accompany a situation or thought. Isolation: Separation of feelings from ideas and events, for example, describing a murder with graphic details with no emotional response. Intellectualization: A form of isolation; concentrating on the intellectual components of a situation so as to distance oneself from the associated anxiety-provoking emotions; separation of emotion from ideas; thinking about wishes in formal, affectively bland terms and not acting on them; avoiding unacceptable emotions by focusing on the intellectual aspects (e.g. rationalizations). Reaction Formation: Converting unconscious wishes or impulses that are perceived to be dangerous into their opposites; behavior that is completely the opposite of what one really wants or feels; taking the opposite belief because the true belief causes anxiety. This defense can work effectively for coping in the short term, but will eventually break down. Repression: Process of pulling thoughts into the unconscious and preventing painful or dangerous thoughts from entering consciousness; seemingly unexplainable naivety, memory lapse or lack of awareness of one's own situation and condition; the emotion is conscious, but the idea behind it is absent.

Level IV: These are commonly found among emotionally healthy adults and are considered the most mature, even though many have their origins in the immature level.
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Altruism: Constructive service to others that brings pleasure and personal satisfaction Anticipation: Realistic planning for future discomfort Humor: Overt expression of ideas and feelings (especially those that are unpleasant to focus on or too terrible to talk about) that gives pleasure to others. Humor enables someone to call a spade a spade, while "wit" is a form of displacement (see above under Category 3) Identification: The unconscious modeling of one's self upon another person's character and behavior

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Introjection: Identifying with some idea or object so deeply that it becomes a part of that person Sublimation: Transformation of negative emotions or instincts into positive actions, behavior, or emotion Suppression: The conscious process of pushing thoughts into the preconscious; the conscious decision to delay paying attention to an emotion or need in order to cope with the present reality; able to later access uncomfortable or distressing emotions and accept them.

-Transference –occurs when the client displaces onto the therapist attitudes and feelings that the client originally experienced in other relationships.\ -Counter transference- occurs when the therapist displaces onto the client attitudes or feelings from his/her past. -Freud’s Stages of Psychosexual Development are, like other stage theories, completed in a predetermined sequence and can result in either successful completion or a healthy personality or can result in failure, leading to an unhealthy personality. Oral Stage (Birth to 18 months). During the oral stage, the child if focused on oral pleasures (sucking). Too much or too little gratification can result in an Oral Fixation or Oral Personality which is evidenced by a preoccupation with oral activities. This type of personality may have a stronger tendency to smoke, drink alcohol, over eat, or bite his or her nails. Personality wise, these individuals may become overly dependent upon others, gullible, and perpetual followers. On the other hand, they may also fight these urges and develop pessimism and aggression toward others. Anal Stage (18 months to three years). The child’s focus of pleasure in this stage is on eliminating and retaining feces. Through society’s pressure, mainly via parents, the child has to learn to control anal stimulation. In terms of personality, after effects of an anal fixation during this stage can result in an obsession with cleanliness, perfection, and control (anal retentive). On the opposite end of the spectrum, they may become messy and disorganized (anal expulsive). Phallic Stage (ages three to six). The pleasure zone switches to the genitals. Freud believed that during this stage boy develop unconscious sexual desires for their mother. Because of this, he becomes rivals with his father and sees him as competition for the mother’s affection. During this time, boys also develop a fear that their father will punish them for these feelings, such as by castrating them. This group of feelings is known as Oedipus Complex ( after the Greek Mythology figure who accidentally killed his father and married his mother).Later it was added that girls go through a similar situation, developing unconscious sexual attraction to their father. Although Freud Strongly disagreed with this, it has been termed the Electra complex by more recent psychoanalysts. According to Freud, out of fear of castration and due to the strong competition of his father, boys eventually decide to identify with him rather than fight him. By identifying with his father, the boy develops masculine characteristics and identifies himself as a male, and represses his sexual feelings toward his mother. A fixation at this stage could result in sexual deviancies (both overindulging and avoidance) and weak or confused sexual identity according to psychoanalysts. Latency Stage (age six to puberty). It’s during this stage that sexual urges remain repressed and children interact and play mostly with same sex peers.

Genital Stage (puberty on). The final stage of psychosexual development begins at the start of puberty when sexual urges are once again awakened. Through the lessons learned during the previous stages, adolescents direct their sexual urges onto opposite sex peers, with the primary focus of pleasure is the genitals. PSYCHOANALYSIS (therapy for the wealthy) – focuses on discovering the causes of the client’s unconscious and repressed thoughts, feelings, and conflicts believed to cause anxiety and on helping the client to gain insight into and resolve these conflicts and anxiety.

2. Developmental theories -Theory of Psychosocial Development has eight distinct stage, each with two possible outcomes. According to the theory, successful completion of each stage results in a healthy personality and successful interactions with others. Failure to successfully complete a stage can result in a reduced ability to complete further stages and therefore a more unhealthy personality and sense of self. These stages, however, can be resolved successfully at a later time. Trust Versus Mistrust. From ages birth to one year, children begin to learn the ability to trust others based upon the consistency of their caregiver(s). If trust develops successfully, the child gains confidence and security in the world around him and is able to feel secure even when threatened. Unsuccessful completion of this stage can result in an inability to trust, and therefore an sense of fear about the inconsistent world. It may result in anxiety, heightened insecurities, and an over feeling of mistrust in the world around them. Virtue: HOPE Autonomy vs. Shame and Doubt. Between the ages of one and three, children begin to assert their independence, by walking away from their mother, picking which toy to play with, and making choices about what they like to wear, to eat, etc. If children in this stage are encouraged and supported in their increased independence, they become more confident and secure in their own ability to survive in the world. If children are criticized, overly controlled, or not given the opportunity to assert themselves, they begin to feel inadequate in their ability to survive, and may then become overly dependent upon others, lack self-esteem, and feel a sense of shame or doubt in their own abilities. Virtue: WILL Initiative vs. Guilt. Around age three and continuing to age six, children assert themselves more frequently. They begin to plan activities, make up games, and initiate activities with others. If given this opportunity, children develop a sense of initiative, and feel secure in their ability to lead others and make decisions. Conversely, if this tendency is squelched, either through criticism or control, children develop a sense of guilt. They may feel like a nuisance to others and will therefore remain followers, lacking in self-initiative. Virtue: PURPOSE Industry vs. Inferiority. From age six years to puberty, children begin to develop a sense of pride in their accomplishments. They initiate projects, see them through to completion, and feel good about what they have achieved. During this time, teachers play an increased role in the child’s development. If children are encouraged and reinforced for their initiative, they begin to feel industrious and feel confident in their ability to achieve goals. If this initiative is not encouraged, if it

is restricted by parents or teacher, then the child begins to feel inferior, doubting his own abilities and therefore may not reach his potential. Virtue: COMPETENCE Identity vs. Role Confusion. During adolescence, the transition from childhood to adulthood is most important. Children are becoming more independent, and begin to look at the future in terms of career, relationships, families, housing, etc. During this period, they explore possibilities and begin to form their own identity based upon the outcome of their explorations. This sense of who they are can be hindered, which results in a sense of confusion ("I don’t know what I want to be when I grow up") about themselves and their role in the world. Virtue: FIDELITY Intimacy vs. Isolation. Occurring in Young adulthood, we begin to share ourselves more intimately with others. We explore relationships leading toward longer term commitments with someone other than a family member. Successful completion can lead to comfortable relationships and a sense of commitment, safety, and care within a relationship. Avoiding intimacy, fearing commitment and relationships can lead to isolation, loneliness, and sometimes depression. Virtue: LOVE Generativity vs. Stagnation. During middle adulthood, we establish our careers, settle down within a relationship, begin our own families and develop a sense of being a part of the bigger picture. We give back to society through raising our children, being productive at work, and becoming involved in community activities and organizations. By failing to achieve these objectives, we become stagnant and feel unproductive. Virtue: CARE Ego Integrity vs. Despair. As we grow older and become senior citizens, we tend to slow down our productivity, and explore life as a retired person. It is during this time that we contemplate our accomplishments and are able to develop integrity if we see ourselves as leading a successful life. If we see our lives as unproductive, feel guilt about our pasts, or feel that we did not accomplish our life goals, we become dissatisfied with life and develop despair, often leading to depression and hopelessness. Virtue: WISDOM - Piaget’s Theory of Cognitive Development maintains that children go through specific stages as their intellect and ability to see relationships matures. These stages are completed in a fixed order with all children, even those in other countries. The age range, however can vary from child to child. Sensorimotor Stage. This stage occurs between the ages of birth and two years of age, as infants begin to understand the information entering their sense and their ability to interact with the world. During this stage, the child learns to manipulate objects although they fail to understand the permanency of these objects if they are not within their current sensory perception. In other words, once an object is removed from the child’s view, he or she is unable to understand that the object still exists. The major achievement during this stage is that of Object Permanency, or the ability to understand that these objects do in fact continue to exist. This includes his ability to understand that when mom leaves the room, she will eventually return, resulting in an increased sense of safety and security. Object Permanency occurs during the end of this stage and represents the child’s ability to maintain a mental image of the object (or person) without the actual perception.

Preoperational Stage. The second stage begins after Object Permanency is achieved and occurs between the ages of two to seven years of age. During this stage, the development of language occurs at a rapid pace. Children learn how to interact with their environment in a more complex manner through the use of words and images. This stage is marked by Egocentrism, or the child’s belief that everyone sees the world the same way that she does. The fail to understand the differences in perception and believe that inanimate objects have the same perceptions they do, such as seeing things, feeling, hearing and their sense of touch. A second important factor in this stage is that of Conservation, which is the ability to understand that quantity does not change if the shape changes. In other words, if a short and wide glass of water is poured into a tall and thin glass. Children in this stage will perceive the taller glass as having more water due only because of it’s height. This is due to the children’s inability to understand reversibility and to focus on only one aspect of a stimulus (called centration), such as height, as opposed to understanding other aspects, such as glass width. Concrete Operations Stage. Occurring between ages 7 and about 12, the third stage of cognitive development is marked by a gradual decrease in centristic thought and the increased ability to focus on more than one aspect of a stimulus. They can understand the concept of grouping, knowing that a small dog and a large dog are still both dogs, or that pennies, quarters, and dollar bills are part of the bigger concept of money. They can only apply this new understanding to concrete objects ( those they have actually experienced). In other words, imagined objects or those they have not seen, heard, or touched, continue to remain somewhat mystical to these children, and abstract thinking has yet to develop. Formal Operations Stage. In the final stage of cognitive development (from age 12 and beyond), children begin to develop a more abstract view of the world. They are able to apply reversibility and conservation to both real and imagined situations. They also develop an increased understanding of the world and the idea of cause and effect. By the teenage years, they are able to develop their own theories about the world. This stage is achieved by most children, although failure to do so has been associated with lower intelligence. 3. interpersonal theories - Harry Stack Sullivan: Interpersonal Relationships and Milieu Therapy STAGE Infancy AGES Birth to onset of language Language to 5 years FOCUS Primary need for bodily contact and tenderness; prototaxic mode dominates(no relation between experiences); primary zones are oral and anal; if needs are met, infant has sense of wellbeing; unmet needs lead to dread and anxiety. Parents viewed as source of praise and acceptance; shift to parataxic mode (experiences are connected in sequence to each other); primary zone is anal; gratification leads to positive self-esteem; moderate anxiety leads to unceratiny and insecurity; severe anxiety results in self-defeating patterns of behavior. Shift to the syntaxic mode begins (thinking about self and others based on analysis of experiences in variety of situations); opportunities for approval and acceptance of others; learn to negotiate own needs;



5-8 years

Preadolescence 8-12 years


Puberty to adulthood

severe anxiety may result in a need to control or in restrictive, prejudicial attitudes. Move to genuine intimacy with friend of the same sex; move away from family as source of satisfaction in relationships; major shift to syntaxic mode; capacity for attachment, love, and collaboration emerges or fails to develop. Lust is added to interpersonal equation; need for special sharing relationship shifts to the opposite sex; new opportunities for social experimentation lead to the consolidation of self- esteem or selfridicule; it the self-system is intact, areas of concern expand to include values, ideals, career decisions, and concerns.

Milieu Therapy- involved client’s interactions with one another, that is, practicing interpersonal relationship skills, giving one another feedback about behavior, and working cooperatively as a group to solve day-to-day problems. -Hildegard Peplau: Therapeutic Nurse-Patient Relationship STAGE Orientation DEFINITION Directed by the nurse and involves engaging the client in treatment, providing explanations and information, and answering questions. Identification Begins when the client works interdependently with the nurse, expresses feelings and begins to feel stronger. Exploitation The client makes full use of the services offered. TASKS 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. Patient responds to persons he/she perceives as helpful; patient feels stronger; expression of feelings; interdependent work with the nurse; clarification of roles of both patient and nurse. 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. 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.


The client no longer needs professional services and gives up dependent behavior. The relationship ends.

ANXIETY LEVELS MILD -sharpened sense -increased motivation -alert -enlarged perceptual field -can solve problems -learning effective -restless -gastrointestinal “butterflies” -sleepless -irritable -hypersensitive to noise MODERATE -selectively attentive -perceptual field limited to the immediate task -can be redirected -cannot connect thoughts or events independently -muscle tension -diaphoresis -pounding pulse -headache -dry mouth SEVERE -perceptual field reduced to one detail or scattered details -cannot complete tasks -cannot solve problems or learn effectively -behavior geared toward anxiety relief and is usually ineffective -feels awe, dread, horror -doesn’t respond to PANIC -perceptual field reduced to focus on self -cannot process environmental stimuli -distorted perceptions -loss of rational thought -personality disorganization -doesn’t recognize danger -possibly suicidal -delusions or hallucination possible

-higher voice pitch -increased rate of speech -gastrointestinal upset -frequent urination -increased automatisms (nervous mannerisms)

redirection -severe headache -nausea, vomiting, diarrhea -trembling -rigid stance -vertigo -pale -tachycardia -chest pain -crying -ritualistic (purposeless, repetitive) behavior.

-cant communicate verbally -either cannot sit (may bolt and run) or is totally mute or immobile.

4. Humanistic Theories Humanism- focuses on a person’s positive qualities, his/her capacity to change (human potential), and the promotion of self esteem. -Abraham Maslow: Hierarchy of needs Self-actualization Self-esteem needs (self-respect and esteem from others. Love and belonging needs (intimacy, friendship, and acceptance). Safety and security needs Physiologic needs

-Carl Rogers: Client-centered therapy –focuses on the role of the client, rather than the therapist, as the key to the healing process. 3 central concepts: • Unconditional positive regard- a nonjudgmental caring for the client that is not dependent on the client’s behavior • Genuineness- realness or congruence between what the therapist feels and what he or she says to the client. • Empathetic understanding- in which the therapist senses the feelings and personal meaning from the client and communicates this understanding to the client. 5. Behavioral Theories Behaviorism- is a school of psychology that focuses on observable behaviors and what one can do externally to bring about behavior changes. -Ivan Pavlov: Classical Conditioning- behavior can be changed through conditioning with external or environmental conditions or stimuli. -B.F. Skinner: Operant Conditioning –which says people learn their behavior from their history or past experiences, particularly those experiences that were repeatedly reinforced. Principles: a) All behavior is learned. b) Consequences result from behavior- broadly speaking, reward and punishment. c) Behavior that is rewarded with reinforcers tends to recur. d) Positive reinforcers that follow a behavior increase the likelihood that the behavior will recur e) Negative reinforcers that are removed after a behavior increase the likelihood that the behavior will recur.

f) 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. g) 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. Behavior modification- is a method of attempting to strengthen a desired behavior or response by reinforcement, either positive or negative. Positive reinforcement- giving the client attention and positive feedback. Negative reinforcement- involves removing a stimulus immediately after a behavior occurs so that the behavior is more likely to occur again. Systematic desensitization- used to help clients overcome irrational fears and anxiety associated with phobias. The client then is exposed to the least anxiety-provoking situation and uses the relaxation techniques to manage the resulting anxiety. 6. Existential Theories –believe that behavioral deviations result when a person is out of touch with himself or herself or the environment. The goal is to help the person discover an authentic sense of self. -Cognitive therapy- which focuses on immediate though processesing- how a person perceives or interprets his/her experience and determines how he/she feels and behaves. THERAPY Rational emotive therapy Logotherapy THERAPIST Albert Ellis THERAPEUTIC PROCESS A cognitive therapy using confrontation of “irrational beliefs” that prevent the individual from accepting responsibility for self and behavior. A therapy designed to help individuals assume personal responsibility. The search for meaning (logos) in life is a central theme. A therapy focusing on the identification of feelings in the here and now, which leads to self-acceptance. Therapeutic focus is need for identity through responsible behavior. Individuals are challenged to examine ways in which their behavior thwarts their attempts to achieve life goals.

Viktor E. Frankl

Gestalt therapy Reality therapy

Frederick S. Peris William Glasser

THERAPEUTIC RELATIONSHIPS Components of a therapeutic relationship: 1) Trust – builds when the client is confident with the nurse and when the nurse’s presence conveys integrity and reliability. (Congruence- occurs when words and actions match.) 2) Genuine Interest- clearly focused on the client. 3) Empathy- is the ability of the nurse to perceive the meanings and feeling of the client and to communicate that understanding to the client. (sympathy- feelings of concern or compassion one shows for another.) 4) Acceptance- avoiding judgments of the person, no matter what the behavior. 5) Positive Regard- nurse who appreciates the client as a unique worthwhile human being can respect the client regardless of his/her behavior, background or lifestyle. Self-awareness and therapeutic use of self

Self-awareness- is the process of developing an understanding of one’s own values, beliefs, thoughts, feelings, attitudes, motivations, prejudices, strengths, and limitations and how these qualities affect others. • Values- are abstract standards that give a person a sense of right and wrong and establish a code of conduct for living. Values Clarification: *Choosing- is when a person considers a range of possibilities and freely chooses the value that feels right. *Prizing- is when the person considers the value, cherishes it, and publicly attaches it to his/herself. *Acting- is when the person puts the value into action. • Beliefs- are ideas that one holds to be true. • Attitudes- are general feeling or frame of reference around which a person organizes knowledge about the world. • Therapeutic use of self- when a nurse begins to use aspects of his/her personality, experiences, values, feelings, intelligence, needs, coping skills, and perceptions to establish relationship to the clients. • Johari window- which creates a “word portrait” of a person in four areas and indicates how well that person knows him/herself and communicates with others. I. Open/public self- qualities one knows about oneself and others also know. II. Blind/unaware self- qualities known only to others. III. Hidden/private self- qualities known only to oneself. IV. Unknown- and empty quadrant to symbolize qualities as yet discovered by oneself or others. Patterns of knowing -Hildegard Peplau identified Preconceptions (ways one person expects another to behave or speak, as a roadblock to the formation of an authentic relationship. -Carper’s patterns of nursing knowledge: Pattern Empirical knowing Personal knowing Ethical knowing Aesthetic knowing Definition Obtained from the science of nursing. Obtained from life experience. Obtained from moral knowledge of nursing Obtained from the art of nursing.

Types of relationships: 1) Social Relationship- is primarily initiated for the purpose of friendship, socialization, companionship, or accomplishment of a task. 2) Intimate Relationship- involves two people who are emotionally committed to each other. 3) Therapeutic Relationship- focuses on the needs, experiences, feelings and ideas of the client only. Establishing the therapeutic relationship (Peplau’s Model of 4 PHASES) I. Preorientaion/ preinteraction Phase- begins when nurse is assigned to the patient. Major Task: develop self-awareness. II. Orientation Phase- begins when the nurse and client meet and ends when the client begins to identify problems to examine. The nurse establishes roles, the purpose of meeting, and the parameters of subsequent meetings; identifies the clients problems; and clarifies expectations. Major Task: Build trust -Nurse-Client Contract -Confidentiality- means respecting the client’s right to keep private any information about his/her mental and physical health and related care.

-Duty to Warn -Self-disclosure- means revealing personal information such as biographical information and personal ideas, thoughts and feelings about oneself to clients. III. Working Phase/ Exploitation Phase- more structured, longest and most productive phase. 2 subphase: 1) Problem identification- the client identifies the issues or concerns causing the problems. 2) Exploitation- the nurse guides the client to examine feelings and responses and to develop better coping skills and more positive self-image. Major Task: Implementation and resolution of the patient’s problem. IV. Termination Phase/Resolution Phase- is the final stage in the nurse-client relationship. It begins when the problems are resolved and ends when the relationship is ended. Major Task-: Make the client transfer what he/she has learned to others. Avoiding behaviors that diminish the therapeutic relationship • Inappropriate Boundaries • Feelings of sympathy and encouraging client dependency • Non-acceptance and avoidance Roles of the nurse in a therapeutic relationship • Teacher • Caregiver • Advocate • Parent surrogate Therapeutic Communication The nurse must be aware of the therapeutic or nontherapeutic value of the communication techniques used with the client—they are the “tools” of psychosocial intervention. Interpersonal communication is a transaction between the sender and the receiver. Both persons participate simultaneously. In the transactional model, both participants perceive each other, listen to each other, and simultaneously engage in the process of creating meaning in a relationship. The Impact of Preexisting Conditions Both sender and receiver bring certain preexisting conditions to the exchange that influence both the intended message and the way in which it is interpreted. – Values, attitudes, and beliefs. Attitudes of prejudice are expressed through negative stereotyping. – Culture or religion. Cultural mores, norms, ideas, and customs provide the basis for ways of thinking. – Social status. High-status persons often convey their high-power position with gestures of hands on hips, power dressing, greater height, and more distance when communicating with individuals considered to be of lower social status. – Gender. Masculine and feminine gestures influence messages conveyed in communication with others. – Age or developmental level. The influence of developmental level on communication is especially evident during adolescence, with words such as “cool,” “awesome,” and others. – The environment in which the transaction takes place. Territoriality, density, and distance are aspects of environment that communicate messages. • Territoriality – the innate tendency to own space • Density – the number of people within a given environmental space • Distance – the means by which various cultures use space to communicate  Four kinds of distance in interpersonal interactions: – Intimate distance – the closest distance that individuals allow between themselves and others – Personal distance – the distance for interactions that are personal in nature, such as close conversation with friends – Social distance – the distance for conversation with strangers or acquaintances

Public distance – the distance for speaking in public or yelling to someone some distance away Nonverbal Communication Components of Nonverbal Communication Physical appearance and dress Body movement and posture Touch Facial expressions Eye behavior Vocal cues or paralanguage

RULES OF THUMB FOR THE PSYCHIATRIC NURSING STUDENT(8) When asking questions there is a hierarchy. Descriptions of the experience (situations) Thoughts about the experience Feelings the experience generated HELP THE PATIENT EXPLORE THE SIGNIFICANCE OF THE SITUATION NOT SO MUCH THE SITUATION ITSELF. NEVER ASSUME ANYTHING MAKE THE IMPLICIT EXPLICIT. USE OPENENDED QUESTIONS DIRECT QUESTIONS TOWARD STATEMENTS ABOUT PEOPLE IF THE PATIENT MENTIONS PEOPLE AND THINGS. NEVER TALK IN GENERALITIES. BE CONCRETE, SPECIFIC. SPEAK ONLY FOR YOURSELF Therapeutic Communication Techniques Using silence – allows client to take control of the discussion, if he or she so desires Accepting – conveys positive regard Can you accept all communication? Giving recognition – acknowledging, indicating awareness Offering self – making oneself available Giving broad openings – allows client to select the topic Offering general leads – encourages client to continue Placing the event in time or sequence – clarifies the relationship of events in time Making observations – verbalizing what is observed or perceived Encouraging description of perceptions – asking client to verbalize what is being perceived Encouraging comparison – asking client to compare similarities and differences in ideas, experiences, or interpersonal relationships Restating – lets client know whether an expressed statement has or has not been understood Reflecting – directs questions or feelings back to client so that they may be recognized and accepted Focusing – taking notice of a single idea or even a single word Exploring – delving further into a subject, idea, experience, or relationship Seeking clarification and validation – striving to explain what is vague and searching for mutual understanding

Presenting reality – clarifying misconceptions that client may be expressing
Voicing doubt – expressing uncertainty as to the reality of client’s perception Verbalizing the implied – putting into words what client has only implied Attempting to translate words into feelings – putting into words the feelings the client has expressed only indirectly Formulating a plan of action – striving to prevent anger or anxiety from escalating to an unmanageable level the next time the stressor occurs Nontherapeutic Communication Techniques Giving reassurance – may discourage client from further expression of feelings if client believes the feelings will only be belittled Rejecting – refusing to consider client’s ideas or behavior Giving approval or disapproval – implies that the nurse has the right to pass judgment on the “goodness” or “badness” of client’s behavior Defending – to defend what client has criticized implies that client has no right to express ideas, opinions, or feelings Requesting an explanation – asking “why” implies that client must defend his or her behavior or feelings Indicating the existence of an external source of power – encourages client to project blame for his or her thoughts or behaviors on others Belittling feelings expressed – causes client to feel insignificant or unimportant Making stereotyped comments, clichés, and trite expressions – these are meaningless in a nurseclient relationship Using denial – blocks discussion with client and avoids helping client identify and explore areas of difficulty Interpreting – results in the therapist’s telling client the meaning of his or her experience Introducing an unrelated topic – causes the nurse to take over the direction of the discussion Active Listening To listen actively is to be attentive to what client is saying, both verbally and nonverbally. Several nonverbal behaviors have been designed as facilitative skills for attentive listening. S – Sit squarely facing the client. O – Observe an open posture. L – Lean forward toward the client. E – Establish eye contact. R – Relax. Process Recordings Process recordings are written reports of verbal interactions with clients. They are written by the nurse or student as a tool for improving communication techniques. Feedback Feedback is useful when it – is descriptive rather than evaluative and focused on the behavior rather than on the client – is specific rather than general – is directed toward behavior that the client has the capacity to modify – imparts information rather than offers advice – is well timed INTERVENING IN PSYCHOTIC COMMUNICATION HALLUCINATIONS - false sensory perceptions or perceptual experiences that do not really exist. Don’t deny Look for feelings and empathize Distract

Connect to anxiety Control DELUSIONS- a fixed false belief not based on reality. Empathize with feelings Give concrete tasks Refuse to discuss the delusion

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