Psychiatric nursing Concepts of personality development Objectives n

Psychiatric nursing Concepts of personality development

Objectives n Define personality n Discuss the major component of the following ü ü ü personality developmental theories: Psychoanalytic theory (Freud) Interpersonal theory (Sullivan) Theory of psychosocial development (Erikson) Object relations development (Mahler) Nursing model of interpersonal development (Peplau) 2

1. Psychoanalytic Theory (Freud) n Freud: Austria, neurologists, father of psychoanalysis n 1856 -1939 n Importance of early life trauma in later mental disorders n Affecting behavioral change through having patients talk about their difficulties 3

n Freud believed that all psychologic and emotional events are understandable, that childhood experiences caused adult neuroses, and that therapy provided insight into the meaning of events 4

Psychoanalytic Theory n Structure of the personality 1. Id: “pleasure principle. ” Ø Present at birth, provides infant with instinctual drives that seek satisfaction & achievement of immediate gratification. Ø Id-driven behaviors are spontaneous & may be irrational. 5

Structure of the personality 2. Ego: the rational self or “reality principle. ” It is the mediator that maintains harmony among the external world, the id and the superego. Ø Begins to develop between 4 & 6 months. Ø Ego experiences reality of the external world, adapts to it, & responds to it. 6

Structure of the personality 3. Superego: the “perfection principle. ” It derives from the rewards for “good” behaviors (egoideal) and punishment for “bad” behaviors (conscience). Ø Develops between 3 & 6 years. Ø Important in socialization of the individual because it assists ego in control of id impulses. Ø Example: a conflict between a father and his son…. 7

Psychoanalytic Theory n Categories of mental contents 1. Conscious: includes all memories that • remain within an individuals’ awareness (events that are easily remembered such as telephone numbers, dates of special holidays). Controlled by the ego, the rational & logical structure of the personality. 8

Psychoanalytic Theory 2. Preconscious: includes all memories that • • have been forgotten or not in present awareness but can be recalled with attention. Examples: addresses once known but little used; feelings associated with significant life events that occurred in the past. Controlled partially by superego, which helps to suppress unacceptable thoughts & behaviors. 9

Psychoanalytic Theory 3. Unconscious (the largest): memories that • • one is unable to bring to conscious awareness. Consists of unpleasant or nonessential memories which can be retrieved only through therapy, hypnosis, & with awareness -alteration substances. Emerges in dreams. 10

Psychoanalytic Theory § According to Freud, psychic energy is the force required for mental functioning. This psychic energy originates in the id; is used to fulfill the basic physiological needs & is called the libido. § Cathexis & anticathexis are forces within id, ego, & superego used to invest psychic energy in external sources to satisfy needs. 11

Psychoanalytic Theory n Cathexis: process by which id invests energy into object to achieve gratification (i. e. , alcohol to relieve stress). n Anticathexis: use of psychic energy by ego & superego to control id impulses (i. e. , control use of alcohol with rational thinking like “I will not drink; I already have ulcer”). n Imbalance between cathexis & anticathexis results in internal conflicts, leading to tension & anxiety within the individual. 12

Defense mechanisms n DM: mechanisms used consciously or unconsciously as protective devices for the ego in an effort to relieve mild-to-moderate anxiety in mediating between excessive demands of id, & excessive restrictions of superego. n DM become maladaptive if used in extreme degree that they distort reality. n Examples of DM include: compensation and denial. 14

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Psychoanalytic Theory § § 1. 2. 3. 4. 5. Freud described formation of the personality through five stages of psychosexual development. Freud’s Stages of personality development Oral stage--birth to 18 months Anal stage--18 months to 3 years Phallic stage--3 to 6 years (Oedipus and Electra complex) Latency stage--6 to 12 years Genital stage--13 to 20 years 19

Freud’s Psychosexual Stages n STAGE n FOCUS Oral (0 -18 months) Pleasure centers on the mouth-sucking, chewing, biting Anal (18 -36 months) Pleasure focuses on bowel and bladder elimination; coping with demands for control Phallic (3 -6 years) Pleasure zone is the genitals; coping with incestuous sexual feelings Latency (6 to puberty) Dormant sexual feeling Genital (puberty on) Maturation of sexual interest

Psychoanalytic Theory n Relevance to nursing practice n Knowledge of the structure of the personality can assist nurse to: 1. Recognizing behaviors associated with the id, the ego, & the superego will assist in the assessment of developmental level. 2. Understanding the use of ego defense mechanisms is important in making determinations about maladaptive behaviors & in planning care for the clients. 21

n In the past 40 years, psychoanalytic theory has seen a steady decline in the reliance on psychoanalytic theory and psychoanalysis. Psychoanalysis requires a person to be relatively well-functioning, introspective, and financially secure, thus creating a barrier to many mental health clients. n Basic level nurses are not trained in psychoanalysis and are not usually involved in a psychotherapeutic treatment role. n The nurse’s role has increased somewhat with long-term treatment of hospitalized clients in specific settings. 22

Psychoanalytic/Psychodynamic Therapy n It is a therapeutic process which helps patients understand resolve their problems by increasing awareness of their inner world and its influence over relationships both past and present n Understand unconscious motivation for behavior (long-term therapy) n Methods Free association n Dream analysis n 23

n Concepts important n Transference: unconscious redirection of the feelings a person has about a second person to feelings the first person has about a third person. It usually concerns feelings from an important second-person relationship from childhood, and is sometimes considered inappropriate 24

n Countertransferences the reaction to a client’s transference, in which the counselor projects his or her feelings unconsciously onto the client. How countertransference is used in therapy can make it either helpful or problematic. n A counselor may notice him or herself reacting more positively to a client that reminds them of an old friend or colleague, or may take on a more parental tone with a client who reminds the counselor of one of their children. A skilled therapist can recognize these feelings, and may even bring them up in session 25

Cognitive–behavioral theory n focuses on the present rather than the past. The theory has roots in psychology and neurophysiology. n Behavior therapy is also known as cognitive– behavior therapy. n Symptoms associated with neuroses and psychoses are identified as clusters of learned behaviors that persist because they are rewarding to the individual. 26

Classical Conditioning n Involuntary behavior can be conditioned to respond to neutral stimuli n One of the most important contributions to this framework was made by Pavlov who discovered a phenomenon he called the conditioned response in a famous experiment with a dog and a bell (1902). n The experiment found that the conditioned or learned response is the basic unit of all learning on which more complex behavioral patterns are constructed. 27

n Such construction occurs through a process of reinforcement, in which behaviors are rewarded and persist. n Response is a reaction to stimuli n If the new and different stimuli is presented with, just before, the original stimulating event, the same response reaction can be obtained n Eventually the new stimuli can replace the original one so the response can occur in reaction to the new stimuli alone n This based in “reinforcement” 28

Skinner: Operant Conditioning n Voluntary behaviors are learned through consequences of reinforcement n which says people learn their behavior from their history or past experiences, particularly those experiences that were repeatedly reinforced. 29

principles of operant conditioning n 1. All behavior is learned. n 2. Consequences result from behavior— broadly speaking, reward and punishment. n 3. Behavior that is rewarded with reinforcers tends to recur. n 4. Positive reinforcers that follow a behavior increase the likelihood that the behavior will recur. n 5. Negative reinforcers that are removed after a behavior increase the likelihood that the behavior will recur. 30

B. F. Skinner (1971) n developed psychiatric treatment approaches that represent one form of conditioning and reflect the assumptions mentioned earlier. n Operant conditioning emphasizes discovering why the behavioral response was elicited and what actively reinforces it. 31

Key assumptions of theory include The conditioned or learned response is the basic unit of all learning. n The self is the sum of past conditionings. n Behavior is the way in which a person acts. It can be observed, described, and recorded. n There is no autonomous person. People are what they do and what they are reinforced for doing by conditions in their environment. n 32

The self is a structure of stimulus–response hierarchies of habit. It is possible to know and predict conditions under which behavior will occur. n The symptoms of a mental disorder are the substance of that person’s troubles. There is no hidden motive, no underlying cause, and no internal pathogenic process. There is only the symptom or the behavior, and the aim of cognitive–behavior therapy is to change the behavior. n 33

n The therapist determines what behavior should be changed and what plan should be followed. n Change comes about by identifying events in the client’s life that have been critical stimuli for the behavior and then arranging interventions for extinguishing those behaviors. n A changed way of acting precedes a changed way of thinking. 34

Relevance to the practice n In institutional environments, nurses prescribe schedules for daily living that include behavior modification through a “token economy” where clients are rewarded by token reinforcements, such as food, candy, and verbal approval. 36

n In community-based settings, nurses also plan schedules that attempt to replace maladaptive behavior with behavior that allows people to function effectively within their natural environment. n Interventions focus on the individual and empower clients to learn new skills. 37

n The movement has attempted to replace maladaptive behavior with behavior that encourages increased functioning. n Psychiatric–mental health nurses also have a role in teaching the effective use of behaviorist principles to nonprofessional staff to assist clients when professional staff is not needed or available 38

Behavioral Therapy n Correct maladaptive behavior by rewarding and reinforcing adaptive behavior n Concept Maladaptive behavior is learned n Methods n Systematic desensitization: is a behavioral technique commonly used to treat fear, anxiety disorders and phobias. Using this method, the person is engaged in some type of relaxation exercise and gradually exposed to an anxietyproducing stimulus, like an object or place. 39

Methods CONTINUE Aversion therapy: is a form of behavior therapy in which an aversive (causing a strong feeling of dislike or disgust) stimulus is paired with an undesirable behavior in order to reduce or eliminate that behavior. n It based on classical conditioning. -undesirable behavior, such as a deviant sexual act, is matched with an unpleasant (aversive) stimulus. n The unpleasant feelings or sensations become associated with that behavior, and the behavior will decrease in frequency or stop altogether. n 40

Biofeedback n The idea behind biofeedback is that, by harnessing the power of your mind and becoming aware of what's going on inside your body, you can gain more control over your health. 41

Cognitive-Behavioral Therapy (CBT) n Modify negative thoughts, feelings, and behaviors n Methods Identify negative patterns of thinking (cognitive distortions) n Use ABC format for recording and analyzing n n n Activating event Automatic beliefs Consequences of beliefs Reformat negative thinking 42

Social–interpersonal theories n Two separate but philosophically congruent schools of thought contribute to social– interpersonal theories: interpersonal theory and general systems theory n Adolf Meyer (1948– 1952) and Harry Stack Sullivan (1953) made significant contributions to social–interpersonal theory 43

n Early interpersonal relationships are crucial for personality development n Anxiety is an interpersonal phenomenon n All behavior is aimed at avoiding: Anxiety n Threats to self-esteem n 44

Interpersonal Theory (Sullivan) n It is believed that individual behavior and personality development are the direct result of interpersonal relationships (Sullivan, 1953). n Sullivan used concepts such as anxiety, satisfaction of needs, interpersonal security (relief from anxiety), and self-system (security measures to protect against anxiety). 45

social–interpersonal theory n The self-system or self-dynamism. The self-system n n provides tools that enable people to deal with the tasks of avoiding anxiety and establishing security. The self is a construct built from the child’s experience. It is made up of reflected appraisals the person learns in contact with significant others. The self develops in the process of seeking physical satisfaction of bodily needs and security. To feel secure, the self essentially requires feelings of approval and prestige as protection against anxiety. 46

n The interpersonal school of psychiatry in general takes a developmental–interpersonal view of the self. 47

Interpersonal Theory n Components of self-system… 1) “Good me” in response to +ve feedback. 2) “Bad me” in response to –ve feedback. 3) “Not me” but someone else in response to situations that produce intense anxiety in the child. n Sullivan described six stages of personality development. 49

Social interpersonal theory includes Holistic approaches: Interrelationship of multiple dimensions increase the number of assessment factors. n Broad definition of clients: Clients are defined as part of a system–family, couple, or community. n Primary prevention: Interventions include psychoeducation, social change, and research. n 50

Therapy Goals: Gain perspective on lifestyle and environment issues, coping skills, and resources versus controlling symptoms. n Autonomous practice: Nurses are members of teams that value and move toward diffusion of roles. n 51

Interpersonal Theory n Relevance to nursing practice 1. Nurses develop therapeutic relationships with clients to help them generalize this ability to interact successfully with others. 2. By knowing the behaviors associated with all levels of anxiety, nurses can help clients achieve interpersonal security and a sense of well-being. 3. Nurses use the concept of Sullivan’s theory to help clients achieve a higher degree of independent and interpersonal functioning. 53

n In social–interpersonal theory, nursing roles include case management, social psychiatry, community psychiatry, psychoeducation, and milieu therapy. n Therapeutic interventions include programs for social change, political involvement, community organization, social planning, family support groups, and education about medications, symptom management, genetic risk, and family environment. 54

n All are associated with efforts to provide psychiatric services more efficiently to large groups of people, particularly those previously neglected, and attempt to counteract the debilitating effects of long-term institutionalization. n All are associated with a movement to address the client’s social context in providing psychiatric care 55

Interpersonal Therapy (ITP) n Guide and challenge maladaptive behavior with emphasis on relationship issues n Method n Therapist as “participant observer” n Concept n Awareness of dysfunctional patterns leads to change in behavior 56

Piaget’s Theory of Cognitive Development n Describes cognition from infancy to adulthood n Stages of cognition 1 - Sensorimotor: "extends from birth to the acquisition of language. “ n In this stage, infants progressively construct knowledge and understanding of the world by coordinating experiences (such as vision and hearing) with physical interactions with objects (such as grasping, sucking, and stepping). n Infants gain knowledge of the world from the physical actions they perform within it. n They progress from reflexive, instinctual action at birth to the beginning of symbolic thought toward 57

Constructivism n Assumption that learning is an active process of construction rather than a passive assimilation of information or rote memorization. n Credited for founding constructivism n Has had a large influence on American schools

…Piaget and Constructivism n Best known for idea that individuals construct their understanding, that learning is a constructive process Active learning as opposed to simply absorbing info from a teacher, book, etc. n The child is seen as a ‘little scientist’ constructing understandings of the world largely alone n

…. Piaget & Constructivism n believed all learning is constructed, whether it is something we are taught or something we learn on our own. n Whether or not we are taught in a “constructivist” manner, Piaget believed we are constructing knowledge in all our learning.

Piaget & Learning n Two main states – equilibrium & equilibrium disequilibrium n Believed that we are driven or motivated to learn when we are in disequilibrium n We want to understand things

Piaget & Learning • Equilibration: assimilation & accommodation • We adjust our ideas to make sense of reality • Assimilation: • process of matching external reality to an existing cognitive structure. • Accommodation: • When there’s an inconsistency between the learner’s cognitive structure & the thing being learned the child will reorganize her thoughts

Example of Learning….

Constructivism, Learning, & Education n Not interested in applying his theory to school -based education, he called this “The American question” n Constructivist educators create an environment which encourages children to construct their own knowledge. n But according to Piaget, we construct our learning regardless of how it is presented.

Piaget’s Stages of Cognitive Development n A child’s capacity to understand certain concepts is based on the child’s developmental stage

Piaget’s Four Stages n Believed that all children develop according to four stages based on how they see the world. n He thought the age may vary some, but that we all go through the stages in the same order. 1. Sensori-motor (birth – 2 years) 2. Preoperational (~2 -7) 3. Concrete operational (~7 -11) 4. Formal operations (~12 -15)

Sensorimotor Stage n Birth to about 2 years, rapid change is seen throughout n The child will: Explore the world through senses & motor activity n Early on, baby can’t tell difference between themselves & the environment n If they can’t see something then it doesn’t exist n Begin to understand cause & effect n Can later follow something with their eyes n

Preoperational Stage n About 2 to about 7 n Better speech communication n Can imagine the future & reflect on the past n Develop basic numerical abilities n Still pretty egocentric, but learning to be able to delay gratification n Can’t understand conservation of matter n Has difficulty distinguishing fantasy from reality (ex: cartoon characters are real people).

…more preoperational n Conservation of matter – understanding that something doesn’t change even though it looks different, shape is not related to quantity n Ex: Are ten coins set in a long line more than ten coins in a pile? n Ex: Is there less water if it is poured into a bigger container?

Concrete Operational Stage n From about 7 to about 11 n Abstract reasoning ability & ability to generalize from the concrete increases n Understands conservation of matter

Formal Operations n From about 12 to about 15 n Be able to think about hypothetical situations n Form & test hypotheses n Organize information n Reason scientifically

… Piaget’s Development n Development happens from one stage to another through interaction with the environment. n Changes from stage to stage may occur abruptly and kids will differ in how long they are in each stage. n Cognitive development can only happen after genetically controlled biological growth occurs.

…Piaget’s Development n Development leads to learning n Drive for development is internal n The child can only learn certain things when she is at the right developmental stage n Environmental factors can influence but not direct development n Development will happen naturally through regular interaction with social environment

Piaget & Education n Piaget did not think it was possible to hurry along or skip stages through education n Regardless, many American schools will try to teach to the stages in an attempt to accelerate development

Problems with Piaget’s Theory n Children often grasp ideas earlier than what Piaget found n Cognitive development across domains is inconsistent (e. g. better at reading than math) n Studies have shown that development can to some degree be accelerated

Abraham Maslow: Hierarchy of Needs n The most basic needs—the physiological needs of food, water, sleep, shelter, sexual expression, and freedom from pain—must be met first. n The second level involves safety and security needs, which include protection, security, and freedom from harm or threatened deprivation. 77

n The third level is love and belonging needs, which include enduring intimacy, friendship, and acceptance. n The fourth level involves esteem needs, which include the need for self-respect and esteem from others. n The highest level is self-actualization, the need for beauty, truth, and justice 78

n Maslow’s theory explains individual differences in terms of a person’s motivation, which is not necessarily stable throughout life. n Traumatic life circumstances or compromised health can cause a person to regress to a lower level of motivation n This theory helps nurses understand how clients’ motivations and behaviors change during life crises 79

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Carl Rigers: client centered therapy n First one use client n Focus on client as the healer n Successful therapeutic relationship: - Reflection: Is literally a mirroring of the client’s statement - unconditional positive regard: respect clients and their feelings, value, and goals. - Empathy - Authenticity: ability to be open, genuine, and honest in response to the client 82

3. Psychosocial Development Theory (Erikson) n Erikson studied the influence of social processes on the development of the personality. n Erikson described eight stages of the life cycle during which the individuals struggle with developmental “crises. ” n Specific tasks associated with each stage must be completed for resolution of crisis and for the occurrence of emotional growth. 83

Psychosocial Development Theory (Stages) 1. 2. 3. 4. 5. 6. 7. 8. Trust vs. mistrust: birth to 18 months Autonomy vs. shame & doubt: 18 months to 3 years Initiative vs. guilt: 3 to 6 years Industry vs. inferiority: 6 to 12 years Identity vs. role confusion: 12 to 20 years Intimacy vs. isolation: 20 to 30 years Generativity vs. stagnation or self-absorption: 30 to 65 years Ego integrity vs. despair: 65 years to death 84

Psychosocial Development Theory (PDT) n Relevance to nursing practice 1. Nurses can plan care to assist clients in fulfilling the tasks that should be performed in each developmental stage and moving on to a higher developmental level. 2. Nurses use the tasks of each stage to assess the clients’ conditions. 3. PDT incorporates sociocultural concepts into the development of personality. 87

Humanistic Theory (Rogers, Maslow) n Motivational psychotherapy (Maslow) n Hierarchy of needs approach n Basic needs must be met before progressing to higher needs 88

Theory of Object Relations (Mahler) n Focus on progression from infant’s inability to see self as separate from mother to physically and psychologically differentiated toddler n Psychological problems are result of difficulty in separation-individuation stage of development (toddlerhood) 89

Moral Development Theory (Kohlberg) n Uses Piaget’s theory applied to moral development n Describes levels and stages of developing morality n Progression from black-and-white thinking to complex, content-dependent decision making in moral issues 90

Ethics of Care Theory (Gilligan) n Uses Kohlberg’s theory with addition of feminist theory n Describes importance of relationships Banding together n Putting needs of others for whom we care above needs of strangers n 91

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Biological Model n Mental disorders believed to have physical causes n Treatments directed toward physical interventions Pharmacological n Electroconvulsive therapy (ECT) n 93

Nursing Model (Peplau) n Focus on interpersonal relationships and stages of nurses-patient relationship Preintroduction n Orientation n Working n Termination n 94

Nursing Model (Peplau) n Describes four levels of anxiety n Mild n Moderate n Severe n Panic 95

Group Therapy n Interaction among members brings about change n Concepts important Content vs. process n Stages of group development n Roles of leader and members n 96

Group Therapy n Role of nursing in group therapy n Basic level registered nurse (RN): teach psychoeducational groups n Advanced practice registered nurse (APRN): lead psychotherapeutic groups 97

Therapeutic Milieu n Setting for mental health care combining healthy environment and social structure n Goals Allow members to try out new behaviors n Increase their ability to interact adaptively n n Methods n Community meetings n Goal-setting approach 98

Family Therapy n Uses variety of theoretical models as basis for treatment of the family n Goals Reduce dysfunctional behavior and family conflict n Mobilize family resources and improve communication n Increase awareness of other members’ needs n Strengthen family coping n Integrate family into larger social system n Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 99