Chapter 3

Model for Working with Psychiatric Patients

Psychiatric-Mental Health Nurses Association of the Philippines, Inc. (PMHNAP)

Learning Objectives
Compare and contrast major therapeutic models that contribute to the understanding of psychiatric patients and their behaviors. Identify key concepts of the major therapeutic models. Describe the relevance of each therapeutic model to psychiatric nursing practice.
Keltners Psychiatric Nursing Philippine edition

Therapeutic Model
Psychoanalytic
Sigmund Freud emphasized the unconscious process or psychodynamic factors as the basis for motivation and behavior. Personality consists of three processthe id (pleasure and principle), ego (focuses on the reality principle and strives to meet the demands), and superego (concerned with right and wrong).

Keltners Psychiatric Nursing Philippine edition

Therapeutic Model
Defense Mechanisms
Denial - Unconscious refusal to admit an unacceptable idea or behavior Repression - Unconscious and involuntary forgetting of painful ideas, events, and conflicts Suppression - Conscious exclusion from awareness anxiety-producing feelings, ideas, and situations
Keltners Psychiatric Nursing Philippine edition

Therapeutic Model
Rationalization - Conscious or unconscious attempts to make or prove that ones feelings or behaviors are justifiable Intellectualization - Consciously or unconsciously using only logical explanations without feelings or an affective component Dissociation - The unconscious separation of painful feelings and emotions from an unacceptable idea, situation, or object
Keltners Psychiatric Nursing Philippine edition

Therapeutic Model
Identification - Conscious or unconscious attempt to model oneself after a respected person Introjection - Unconsciously incorporating values and attitudes of others as if they were your own Compensation - Consciously covering up for a weakness by overemphasizing or making up a desirable trait Sublimation - Consciously or unconsciously channeling instinctual drives into acceptable activities
Keltners Psychiatric Nursing Philippine edition

Therapeutic Model
Reaction formation - A conscious behavior that is the exact opposite of an unconscious feeling Undoing - Consciously doing something to counteract or make up for a transgression or wrongdoing Displacement - Unconsciously discharging pent-up feelings to a less threatening object

Keltners Psychiatric Nursing Philippine edition

Therapeutic Model
Projection - Unconsciously (or consciously) blaming someone else for ones difficulties or placing ones unethical desires on someone else Conversion - The unconscious expression of intrapsychic conflict symbolically through physical symptoms Regression - Unconscious return to an earlier and more comfortable developmental level
Keltners Psychiatric Nursing Philippine edition

Therapeutic Model
Developmental Model Erick Ericksons developmental model spans the total life cycle from birth to death. He believed that each of the eight stages of developmental afforded opportunities for growth, even up to the acceptance of the persons own death.
Keltners Psychiatric Nursing Philippine edition

Therapeutic Model
Stages of Development Trust vs. mistrust (018 months) realistic trust of self and others, confidence in others Autonomy vs. shame and doubt (18 months3 years) self-control and will power Initiative vs. guilt (35 years) an adequate conscience, initiative balanced with restraint Industry vs. inferiority (6 12 years) sense of competence, completion of projects. Identity vs. role diffusion (1218 or 20 years) confident sense of self, commitment to peer group values
Keltners Psychiatric Nursing Philippine edition

Therapeutic Model
Intimacy vs. isolation (1825 or 30 years) ability to give and receive lobe, commitments, and mutuality with others Generative lifestyle vs. stagnation or selfabsorption (3065 years) productive, constructive, creative activity, personal and professional growth Integrity vs. despair (65 years to death) feelings of self-acceptance, sense of dignity, worth and importance, adaptation to life according to limitation
Keltners Psychiatric Nursing Philippine edition

Therapeutic Model
Interpersonal Model
Harry Stack Sullivan (1953) developed a comprehensive examination of interpersonal and inter-group relationship called the interpersonal theory of psychiatry. He believed that interactional was more important than the intrapsychic.

Keltners Psychiatric Nursing Philippine edition

Therapeutic Model
Hildegard Peplau (1952, 1963) played a significant role in applying Sullivans original concepts regarding interpersonal relationship to nursing practice. She elaborated on and applied Sullivans concepts of degrees of anxiety, severe anxiety, panic, terror states, and pure anxiety. She saw the nurses role as helping patients decrease insecurity and improve functioning through interpersonal relationship.

Keltners Psychiatric Nursing Philippine edition

Therapeutic Model
Cognitive Model Jean Piaget (1896 1980) developed a stage theory of cognitive development that explained how intelligence and cognitive functioning developed in children. He believed that this process of understanding and changes involves assimilation, accommodation and organization.

Keltners Psychiatric Nursing Philippine edition

Therapeutic Model
Cognitive Development
Sensorimotor (birth to 2 years) develops sense of self as separate from the environment and the concept of objects Preoperational (26 years) develops the ability to express self with language Concrete operational (612 years) apply logic to thinking Formal operations (1215 years and above) learns to thinks and reason in abstract terms
Keltners Psychiatric Nursing Philippine edition

Therapeutic Model
Cognitive-Behavioral Models Aaron Becks cognitive therapy (CT) and Albert Elliss rational emotive therapy (RET) models focus on thinking and behaving rather than on expressing feelings.

Keltners Psychiatric Nursing Philippine edition

Therapeutic Model
Cognitive-behavioral therapy (CBT) builds on CT by incorporating techniques based on learning principles and behavioral therapy techniques, including exposure, response prevention, skills training, and reinforcement. The goal is to work on directly changing behaviors as well as changing faulty thinking.

Keltners Psychiatric Nursing Philippine edition

Therapeutic Model
Stress Models Hans Selye (1956) defined stress as wear and tear on the body. He developed his framework to explain the physiologic response to stress.

Keltners Psychiatric Nursing Philippine edition

Therapeutic Model
Three stages of general adaptation syndrome (GAS) Alarm reaction preparation for fight or flight Stage of resistance strive to adapt to stress Stage of exhaustion defense is exaggerated and dysfunctional, and personality becomes disorganized, thinking becomes illogical, and decision making becomes ineffective
Keltners Psychiatric Nursing Philippine edition

Therapeutic Model
Richard Lazarus focused on the psychological aspects. Psychological stress is a relationship between the person and the environment that appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being.

Keltners Psychiatric Nursing Philippine edition