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
Definition and introduction to the personality development n Personality: patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social & personal contexts. (a dynamic and organized set of characteristics possessed by a person that uniquely influences his or her cognitions, emotions, interpersonal orientation, motivation, and behaviors in various situations. ) n Each developmental level (stage) has its own appropriate behaviors. 3
Introduction cont. n People continue to develop and change throughout their life, however, infancy and early childhood (up to 5 years old) are the major life periods for the origination of developmental changes where individual’s basic character is formed. n Developmental stages overlap & they are identified by age 4. n Environment affects developmental stages (i. e. individuals reared in dysfunctional family often have retarded ego development). n Behaviors from unsuccessfully completed stage can be modified & corrected in a later stage. 4
Introduction cont. n When personality traits are inflexible & maladaptive & cause either significant functional impairment or subjective distress, they constitute personality disorders. n Q: Why psychiatric/mental health nurses must have knowledge of personality development? n A: To understand maladaptive behavioral responses commonly seen in psychiatric clients. 5
Symbolic interactionism, introduced by Herbert Blumer (1969), n describes an approach to the study of human conduct. It is based on: 1 - Life experiences have different meanings for different people. - Because all behavior has meaning, the psychiatric–mental health nurse must develop skill in observing, interpreting, and responding to the client’s lived experiences in the hope of arriving at a common ground of negotiated meanings and authentic communication; 6
- and be wary of interventions that ignore, discount, or discredit the meaning an experience has for the client in favor of the nurse’s own definition of the situation. 7
Symbolic interactionism, 2 - Meanings arise in one’s social world. Meanings arise in the process of interaction with others. - Psychiatric–mental health nurses must take into account each client’s social and cultural environment, and holistically assess client accounts for the interaction patterns in that person’s social world 8
3 - Meaning is a basis for behavior. - People handle situations in terms of what they consider important about the situation. To understand clients’ actions, the psychiatric–mental health nurse must identify the meanings those actions have for them. 9
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the major principles of humanism n The humanistic perspective has eight central propositions (Lamont, 1967). n Humanism is a philosophy of service to benefit humanity through reason, science, and democracy. n The central concept of humanism is that the chief end of human life is to work for wellbeing within the limitations of life in today’s world 11
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the influence of the knowledge explosion in psychobiology n The last decades have seen major breakthroughs in knowledge about the brain, the mind, the spirit, and behavior. This knowledge explosion has been named psychobiology 13
n Research has generated new understanding of how genetics, immunology, biorhythms, brain structure, and brain biochemistry influence mental disorders. n New imaging techniques allow neuroscientists to better understand thoughts by analyzing physiological activity. n New medications can correct biochemical imbalances in the brain, and psychobiologic interventions have become commonplace. 14
how the premises of human interactionism and psychobiology relate to psychiatric–mental health nursing. n Interactionism considers human beings as having purpose and control over their lives, even if they have altered brain structure and chemistry and stressful environments. n Interactionism is a philosophy of caring with a strong humanistic cast, acknowledging the interaction of psychology, psychobiology, and sociocultural contexts 15
n Humanism incorporates devotion to the interests of human beings wherever they live and whatever their status or culture, reaffirming the spirit of compassion and caring toward others. n It is a constructive philosophy that wholeheartedly affirms the joys, beauty, and values of human living. 16
n The humanistic interactionism considers physical and mental factors as interrelated; a change in one may result in a change in another. n Healing and caring must be approached in a holistic manner. n Psychiatric–mental health nurses have an expanded role, becoming involved in social goals that advance health holistically. 17
n The model for intervention and change is one of negotiation and advocacy. n Clients and their families are not passive recipients of care given by psychiatric professionals, but rather are empowered in the process of developing new perspectives and encouraged to weigh alternatives and make self-directed choices 18
The medical–psychobiologic model n Psychobiology has implications for psychiatric–mental health nursing practice as well. n It includes a focus on the human aspects of care as well as biologic and medical aspects, bringing a contemporary holistic perspective to psychiatric– mental health care; n integrating the rapidly accumulating knowledge in psychobiology; n redefining the traditional art of psychiatric–mental health nursing care and caring in the new millennium; and nursing practice and research that integrates “high tech” and “high touch, ” nature and nurture, and the biologic sciences and the behavioral sciences 19
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1. Psychoanalytic Theory (Freud) n Freud: Austria, neurologists, father of psychoanalysis n 1856 -1939 n Affecting behavioral change through having patients talk about their difficulties 21
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 22
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. 23
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. 24
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…. 25
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. 26
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. 27
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. 28
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. 29
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. 30
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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. 32
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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 37
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) Latency (6 to puberty) Pleasure zone is the genitals; coping with incestuous sexual feelings 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. 39
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. 40
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. 41
Classical Conditioning 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. n Such construction occurs through a process of reinforcement, in which behaviors are rewarded and persist. 42
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” 43
Skinner: Operant Conditioning n which says people learn their behavior from their history or past experiences, particularly those experiences that were repeatedly reinforced. 44
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. 45
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. 46
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 47
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 48
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. 49
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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. 51
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. 52
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 53
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 54
2. 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). 55
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. 56
n The interpersonal school of psychiatry in general takes a developmental–interpersonal view of the self. 57
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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. 59
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. 60
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. 61
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 62
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 63
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 64
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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. 66
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 67
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 68
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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 71
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. 72
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 73
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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. 76
General system theory n Every system are maintained by mutual interaction of its parts n A system is more than the sum of its parts when things are organized into a system n This theory provides a conceptual framework For integrating the biologic and social sciences With the physical science. 77
n In psychiatry, its offer resolution of the mind- body dichotomy, an integration of biologic and social approaches to the nature of human being and an approach to psychopathology, diagnosis and therapy n Its used in understanding how families function 78
General Systems Theory: n Menninger (1963) views normal personality functioning and psychopathology in terms of general systems theory. n His work addresses four major issues: 1 - adjustment or individual–environment interaction; 2 - the organization of living systems; 3 - psychological regulation and control, known as ego theory in psychoanalysis; 4 - and motivation, which is often called instinct or drive in the psychoanalytic framework. 79
A key concept of theory is homeostasis (equilibrium). n He asserts that the greater the threat or stress on a system, the greater the number of system components involved in coping with or adapting to it. Thus, pathology can exist at various levels: n the cell and organ level (behavioral changes that follow cellular alterations due to drug use, a blood clot, or a tumor); n the group level (family violence); n the community level (overpopulation, pollution, homelessness, and poverty). 80
n A system’s well-being depends on the amount of stress on it and the effectiveness of its coping mechanisms. n Mental illness is an impairment of selfregulation in which comfort, growth, and production are surrendered for the sake of survival at the best level possible but at the sacrifice of emergency coping devices. 81
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