THEORETICAL FOUNDATIONS OF PSYCHIATRIC c.
unconscious - is the realm of thoughts and
NURSING
1. PSYCHOANALYTIC THEORIES
Sigmund Freud (1856–1939)
The Father of Psychoanalysis
He developed psychoanalytic theory
Psychoanalytic theory supports the notion that all
human behavior is caused and can be explained
(deterministic theory). Freud believed that
repressed (driven from conscious awareness)
sexual impulses and desires motivate much human
behavior.
Personality Components: Id, Ego, and Superego
The id is the part of one’s nature that reflects basic
or innate desires such as pleasure
seeking association, in which the therapist tries to uncover
behavior, aggression, and sexual impulses. The id
seeks instant gratification, causes impulsive
unthinking behavior, and has no regard for rules or
social convention.
The superego is the part of a person’s nature that
reflects moral and ethical concepts, values, and
parental and social expectations; therefore, it is in
direct opposition to the id.
The ego is the balancing or mediating force
between the id and the superego. The ego
represents mature and adaptive behavior that
allows a person to function successfully in the
world. Freud believed that anxiety resulted from
the ego’s attempts to balance the impulsive
instincts of the id with the stringent rules of the
superego.
Behavior Motivated by Subconscious Thoughts
and Feelings
. Expression of an emotional conflict through the
Freud believed that the human personality
functions at three levels of awareness:
a. conscious - refers to the perceptions, thoughts,
and emotions that exist in the person’s awareness
b. preconscious - thoughts and emotions are not
currently in the person’s awareness, but he or she
can recall them with some effort
feelings that motivates a person even though he or
she is totally unaware of them
Freud’s Dream Analysis
Freud believed that a person’s dreams reflect his
or her subconscious and have significant meaning,
though sometimes the meaning is hidden or
symbolic. Dream analysis, a primary technique
used in psychoanalysis, involves discussing a
client’s dreams to discover their true meaning and
significance. For example, a client might report
having recurrent frightening dreams about snakes
chasing her. Freud’s interpretation might be that
the woman fears intimacy with men; he would
view the snake as a phallic symbol, representing
the penis. Another method used to gain access to
subconscious thoughts and feelings is free
the client’s true thoughts and feelings by saying a
word and asking the client to respond quickly with
the first thing that comes to mind. Freud believed
that such quick responses would be likely to
uncover subconscious or repressed thoughts or
feelings.
Ego Defense Mechanisms
Freud believed that the self, or ego, uses ego
defense mechanisms, which are methods of
attempting to protect the self and cope with basic
drives or emotionally painful thoughts, feelings, or
events.
Compensation
Overachievement in one area to offset real or
perceived deficiencies in another area
• Napoleon complex: diminutive man becoming
emperor
Conversion
development of a physical symptom, usually
sensorimotor in nature
• Teenager forbidden to see X-rated movies is
tempted to do so by friends and
develops blindness, and the teenager is
unconcerned about the loss of sight
Denial
Failure to acknowledge an unbearable condition;
failure to admit the reality of a situation or how
one enables the problem to continue
• Diabetic person eating chocolate candy Substitution
Displacement Replacing the desired gratification with one that is
Ventilation of intense feelings toward persons less more readily available
threatening than the one who aroused those • Woman who would like to have her own children
feelings opens a day care center
• Person who is mad at the boss yells at his or her Suppression
spouse Conscious exclusion of unacceptable thoughts and
Dissociation feelings from conscious awareness
Dealing with emotional conflict by a temporary • Student decides not to think about a parent’s
alteration in consciousness or identity illness to study for a test
• Amnesia that prevents recall of yesterday’s auto Undoing
accident Exhibiting acceptable behavior to make up for or
Fixation negate unacceptable behavior
Immobilization of a portion of the personality • Person who cheats on a spouse brings the spouse
resulting from unsuccessful completion of tasks in a bouquet of roses
a developmental stage
• Never learning to delay gratification
Identification
Modeling actions and opinions of influential others
while searching for identity, or aspiring to reach a
personal, social, or occupational goal
• Nursing student becoming a critical care nurse
because this is the specialty of an instructor she
admires
Rationalization
Excusing own behavior to avoid guilt, responsibility,
conflict, anxiety, or loss of self-respect
• Student blames failure on teacher being mean
Reaction Formation
Acting the opposite of what one thinks or feels
• Woman who never wanted to have children
becomes a supermom
Regression
Moving back to a previous developmental stage to
feel safe or have needs met
• A 5-year-old asks for a bottle when new baby Five Stages of Psychosexual Development
brother is being fed
Repression Freud based his theory of childhood development
Excluding emotionally painful or anxiety-provoking on the belief that sexual energy, termed libido, was
thoughts and feelings from conscious awareness the driving force of human behavior.
• Woman has no memory of the mugging she
suffered yesterday Psychoanalysis focuses on discovering the causes
Resistance of the client’s unconscious and repressed thoughts,
Overt or covert antagonism toward remembering feelings, and conflicts believed to cause anxiety
or processing anxiety-producing information and on helping the client gain insight into and
• Nurse is too busy with tasks to spend time talking resolve these conflicts and anxieties. The analytic
to a dying patient. therapist uses the techniques of free association,
Sublimation dream analysis, and interpretation of behavior.
Substituting a socially acceptable activity for an
impulse that is unacceptable Transference occurs when the client displaces onto
• Person who has quit smoking sucks on hard the therapist attitudes and feelings that the client
candy when the urge to smoke arises originally experienced in other relationships.
Countertransference occurs when the therapist
displaces onto the client attitudes or feelings from
his or her past.
2. DEVELOPMENTAL THEORIES
Developmental Theories Erik Erikson (1902–1994)
 was a German-born psychoanalyst,
 he extended Freud’s work on personality
development across the life span while
focusing on social and psychological
development in the life stages.
 In 1950, Erikson published Childhood and
Society, in which he described eight
psychosocial stages of development.
 In each stage, the person must complete a life
task that is essential to his or her well-being and
mental health. These tasks allow the person to
achieve life’s virtues: hope, purpose, fidelity, love,
caring, and wisdom.
Erikson’s eight psychosocial stages of
development are still used in a variety of
disciplines. In his view, psychosocial growth occurs
in sequential phases and each stage is dependent
on completion of the previous stage and life task.
Cognitive Stages of Development - Jean Piaget
(1896–1980)
 Explored how intelligence and cognitive
functioning develop in children.
 He believed that human intelligence
progresses through a series of stages based on
age, with the child at each successive stage
demonstrating a higher level of functioning
than at previous stages.
 Piaget strongly believed that biologic changes
and maturation were responsible for cognitive
development.
 The child learns to think and reason in
abstract terms, further develops logical
thinking and reasoning, and achieves cognitive
maturity.
Piaget’s theory suggests that individuals reach
cognitive maturity by middle to late adolescence.
Piaget’s theory is useful when working with
children. The nurse may better understand what
the child means if the nurse is aware of his or her
level of cognitive development. Also, teaching for
children is often structured with their cognitive
development in mind.
3. INTERPERSONAL THEORIES
Interpersonal Relationships and Milieu Therapy -
Harry Stack Sullivan (1892– 1949):
 was an American psychiatrist who extended
the theory of personality development to
include the significance of interpersonal
relationships.
 Sullivan believed that one’s personality
involves more than individual characteristics,
particularly how one interacts with others.
 He thought that inadequate or non-satisfying
relationships produce anxiety, which he saw as
the basis for all emotional problems.
 The importance and significance of
interpersonal relationships in one’s life is
probably Sullivan’s greatest contribution to the
field of mental health.
Therapeutic Community or Milieu.
Sullivan envisioned the goal of treatment as the
establishment of satisfying interpersonal
relationships. The therapist provides a corrective
interpersonal relationship for the client. Sullivan
coined the term participant observer for the
therapist’s role, meaning that the therapist both
participates in and observes the progress of the
relationship.
In the concept of therapeutic community or
milieu, the interaction among clients is seen as
beneficial, and treatment emphasizes the role of
this client-to-client interaction. Until this time, it
was believed that the interaction between the
client and the psychiatrist was the one essential
component to the client’s treatment.
The concept of milieu therapy, involved clients’
interactions with one another, including practicing
interpersonal relationship skills, giving one another
feedback about behavior, and working
cooperatively as a group to solve day-to-day
problems.
Therapeutic Nurse–Patient Relationships -
Hildegard Peplau (1909–1999)
 was a nursing theorist and clinician who built
on Sullivan’s interpersonal theories and also
saw the role of the nurse as a participant
observer.
 Peplau developed the concept of the
therapeutic nurse–patient relationship, which
includes four phases: orientation,
identification, exploitation, and resolution.
1. The orientation phase is directed by the nurse
and involves engaging the client in treatment,
providing explanations and information, and
answering questions.
2. The identification phase begins when the client
works interdependently with the nurse, expresses
feelings, and begins to feel stronger.
3. In the exploitation phase, the client makes full
use of the services offered.
4. In the resolution phase, the client no longer
needs professional services and gives up
dependent behavior. The relationship ends.
Roles of the Nurses in the Therapeutic
Relationship.
Peplau write about the roles of the nurses in the
therapeutic relationship and how these roles help
meet the client’s needs. The primary roles she
identified are as follows:
• Stranger - offering the client the same
acceptance and courtesy that the nurse would do
to any stranger
• Resource person — providing specific answers to
questions within a larger context
• Teacher — helping the client learn either
formally or informally
• Leader — offering direction to the client or group
• Surrogate — serving as a substitute for another,
such as a parent or sibling
• Counselor—promoting experiences leading to
health for the client, such as expression of feeling

Four Levels of Anxiety.
Peplau defined anxiety as the initial response to a
psychic threat. She described four levels of anxiety:
mild, moderate, severe, and panic. These serve as
the foundation for working with clients with
anxiety in a variety of contexts.
4. HUMANISTIC THEORIES
Humanism represents a significant shift away from
the psychoanalytic view of the individual as a
neurotic, impulse-driven person with repressed
psychic problems and away from the focus on and
examination of the client’s past experiences.
Humanism focuses on a person’s positive qualities,
his or her capacity to change (human potential),
and the promotion of self-esteem. Humanists do
consider the person’s past experiences, but they
direct more attention toward the present and
future.
Abraham Maslow (1921–1970)
 was an American psychologist who studied the
needs or motivations of the individual.
 He differed from previous theorists in that he
focused on the total person, not just on one
facet of the person, and emphasized health
instead of simply illness and problems.
 Maslow (1954) formulated the hierarchy of
needs, in which he used a pyramid to arrange
and illustrate the basic drives or needs that
motivate people.
 Maslow hypothesized that the basic needs at
the bottom of the pyramid would dominate
the person’s behavior until those needs were
met, at which time the next level of needs
would become dominant.
 Maslow used the term self-actualization to
describe a person who has achieved all the
needs of the hierarchy and has developed his
or her fullest potential in life. Few people ever
become fully self-actualized.
Client-Centered Therapy - Carl Rogers (1902–1987)
 was a humanistic American psychologist who
focused on the therapeutic relationship and
developed a new method of client centered
therapy.
 He was one of the first to use the term client
rather than patient.
 Client-centered therapy focuses on the role of
the client, rather than the therapist, as the key
to the healing process.
 Rogers believed that each person experiences
the world differently and knows his or her own
experience best.
 According to Rogers, clients do “the work of
healing,” and within a supportive and
nurturing client–therapist relationship, clients
can cure themselves.
 Clients are in the best position to know their
own experiences and make sense of them, to
regain their self-esteem, and to progress
toward self-actualization.
 The therapist takes a person-centered
approach, a supportive role, rather than a
directive or expert role, because Rogers
viewed the client as the expert on his or her
life.
 The therapist must promote the client’s self-
esteem as much as possible through three
central concepts:
o Unconditional positive regard—a
nonjudgmental caring for the client
 that is not dependent on the client’s  He maintained that if the behavior could be
behavior changed, then so could the accompanying
o Genuineness—realness or congruence thoughts or feelings.
between what the therapist feels
and what he or she says to the client The following principles of operant conditioning
o Empathetic understanding—in which described by Skinner (1974) form the basis for
the therapist senses the feelings behavior techniques in use today:
and personal meaning from the client and
communicates this 1. All behavior is learned.
understanding to the client 2. Consequences result from behavior—broadly
speaking, reward and punishment.
5. BEHAVIORAL THEORIES 3. Behavior that is rewarded with reinforcers tends
to recur.
Behaviorism grew out of a reaction to
4. Positive reinforcers that follow a behavior
introspection models that focused on the contents
increase the likelihood that the behavior will recur.
and operations of the mind. Behaviorism is a
5. Negative reinforcers that are removed after a
school of psychology that focuses on observable
behavior increase the likelihood that the behavior
behaviors and what one can do externally to bring
will recur.
about behavior changes. It does not attempt to
6. Continuous reinforcement (a reward every time
explain how the mind works. Behaviorists believe
the behavior occurs) is the fastest way to increase
that behavior can be changed through a system of
that behavior, but the behavior will not last long
rewards and punishments.
after the reward ceases.
7. Random intermittent reinforcement (an
Ivan Pavlov: Classical Conditioning
occasional reward for the desired behavior) is
slower to produce an increase in behavior, but the
 Classical Conditioning Laboratory experiments
behavior continues after the reward ceases.
with dogs provided the basis for the
development of Ivan Pavlov’s theory of
These behavioral principles of rewarding or
classical conditioning:
reinforcing behaviors are used to help people
 Behavior can be changed through conditioning
change their behaviors in a therapy known as
with external or environmental conditions or
behavior modification, which is a method of
stimuli.
attempting to strengthen a desired behavior or
o Pavlov’s experiment with dogs involved
response by reinforcement, either positive or
his observation that dogs
negative.
naturally began to salivate (response) when
they saw or smelled food (stimulus).
Positive reinforcement - by giving the client
attention and positive feedback.
B. F. Skinner: Operant Conditioning
Negative reinforcement - involves removing a
stimulus immediately after a behavior occurs so
 One of the most influential behaviorists was
that the behavior is more likely to occur again.
B.F. Skinner (1904–1990), an American
psychologist.
Behavioral Therapy - Behavioral theory considers
 He developed the theory of operant
how reinforcement influences behavior. Through
conditioning, which says people learn their
reinforcement, a person learns to perform a
behaviors from their history or past
certain response (behavior) either to receive a
experiences, particularly those experiences
reward or to avoid a punishment.
that were repeatedly reinforced.
 Skinner did not deny the existence of feelings
6. EXISTENTIAL THEORIES
and needs in motivation; however, he viewed
behavior as only that which could be observed, • Existential theorists believe that problems result
studied, and learned or unlearned. when the person is out of touch with the self or
the environment. The person has self-imposed
restrictions, criticizes him or herself harshly, and
does not participate in satisfying interpersonal
relationships.
• Founders of existentialism include Albert Ellis
(rational emotive therapy), Viktor Frankl
(logotherapy), Frederick Perls (gestalt therapy),
and William Glasser (reality therapy).
• All existential therapies have the goal of
returning the person to an authentic sense of self
through emphasizing personal responsibility for
oneself and one’s feelings, behavior, and choices.
Cognitive therapy is based on the premise that
how a person thinks about or interprets life
experiences determines how he or she will feel or
behave. It seeks to help the person change how he
or she thinks about things to bring about an
improvement in mood and behavior.
7. PSYCHOBIOLOGIC THEORIES
Psychobiology describes the interaction between
biological systems and behavior. Striving to
understand how psychological and biological
connections shape the human experience.
Psychological and biological processes merge
within the mother-infant interaction. Both infants’
behavior and physiology regulated by the caregiver.
Certain components of the mother-infant
interaction regulate the infant’s behavior and
physiological system. Loss of these regulators in
maternal separation can produce behavior a
physiological change in infants leading to pattern
change known as protest and despair.
 Bio-criminology - a field of study that has
made attempts at linking violent or disruptive
behavior to eating habits, vitamin deficiencies,
genetics, inheritance, and other conditions
which impact body tissues.
Characteristics of Psychobiological Theories focus
is on the relationship of the following to criminal
behavior: DNA, environmental contaminants,
nutrition, hormones, physical trauma and body
chemistry in human cognition and behavior.
8.PSYCHO-SPIRITUAL THEORIES
Focus: Relationship of Man with God
 Man’s relationship with God is destroyed
because of sin.
 Restlessness (anxiety) is because man is
separated from God.
 Sin produces fear. Sin separates man from
God
 The only way to have peace is to reestablish
relationship with God through Jesus Christ
(Christianity).
Spirituality
 Things beyond biological experience
 Give depth and meaning of life
 Presence of higher power
 Higher purpose
 Higher principles
 Spirituotherapy - to establish relationship with
God.
Nursing application
 The nurse should first assess her own
relationship with God.
 Praying and reading the gospel with the
patient is one of the functions of the nurse.
 The nurse must respect his/her patient’s
belief but need not sacrifice his/her salvation.
Basic Concepts
 Apart from God, man is not whole
 God can forgive past experiences (Intrapsychic)
and erase painful experience in the past.
 The only way man can learn to do good is
through God’s grace (unmerited favor).
 It is not by might, not by power but my spirit,
says the Lord. (the Bible)
9. ECLECTIC APPROACH
Incorporates a variety of therapeutic principles and
philosophies to create the ideal treatment program
to meet the specific needs of the client.
Example:
Combining medication (anti-depressant) with
different types of psychotherapy such as cognitive
and behavioral therapy to treat depression.