Ajarn Taweewan Buppata Faculty of nursing BangkokThonburi University

After studying this topic, you should be able to

Explain

basic assumption or theoretical frameworks used in psychiatric mental health nursing Explain the key conceptual theories associated with behavioral deviation in human

 Discuss

the major components of the following development theories and behavioral and social theory 1. Psychoanalytic theory Freud 2. Humanistic Theory - Roger 3. Interpersonal theory Sullivan 4. Social Theory-George Mead and Gerald Kaplan

 5.Peplau

s Interpersonal Theory 6.Behavioral theory Pavlov and Skinner 7. Roy Adaptation Theory 8.Biomedical Theory
Articulate

how theories is applied to nursing practice

Basic

Assumption Key Conceptual Theory Views of Behavioral Deviations Nursing Intervention and Nurse s Role

Basic Assumption
Adolf Meyer(1866-1950) Individual as a unity which is comprised of physical, mental, social , and environment
Disease is the cause of deviant behavior Mental illness is caused by physical pathology and maladaptive to environment

Basic Assumption Emil Kraeplin believed mental illness is caused by dysfunction of human body , especially the central nervous system.

Key Concepts

Mental illness persons are the same as persons who have a physical illness Mental illness is caused by dysfunction of human body, especially the brain There are various signs and symptoms which can be diagnosed the illness The medical model focus on diagnosis and treatment of the disease Curing the disease restore normal behavior Psychiatric and Mental illness can be cured by medication treatment

 View

of behavioral deviation

Structure

and function of brain:frontal lobe Hypofrontality Hyperactivity in the limbic area (Buchsbaum,1990) Cerebral blood flow in schizophrenia

 Frontal

lobe control thinking, judgment formation ,express feeling : change in mood and character after damage this area
Limbic area(:emotional brain) associated with feeling of fear, anxiety, anger, aggression ,love, joy, hope , sexuality and social behavior

Neurotransmitter
Dopamine

Dopamine
Norepinephrin Serotonin

Mania , Schizophrenia Depression Mania,Schizo,Anxiety Depression

 Hormone

of Neuro - endocrine system -TSH : high level insomnia, anxiety, emotional liability : low level depression -ACTH: high level: mood disorder, psychosis : low level : depression - Gonadotropic Hormone high level: sexual behavior, aggression

 Genetic

or Hereditary -genetic location of schizophrenia, believed to be on human chromosomes13 and 8 -mutation of a specific gene/ change in number or structure of chromosome -Infection during the development of neuron

Treatment

Bio-Psycho-social assessment Diagnosis Treatment

Medication

treatment Brain Surgery Hormone

Nurses

Role

Data Assessment is based on past illness (which are effect to brain and hormone of neuro -endocrine system) and present condition, diagnosis and laboratory studies ,drug and substance abuse, sleeping cycle Providing care and health education

Sigmund

Freud who has been call the father of psychiatry Basic Assumption All human behavior holds a significant meaning, and not occurred by chance, but their behaviors are formed and operated by the mind

 His

theory states that deviation in human behavior result from unsuccessful task accomplishment during developmental stages. The first 5 years of a childs life to be the most important because individuals basic character had been formed.

Freuds psychoanalytic theory of behavior is built on five assumptions I. The personality consists of three structures ; id ,ego , and superego . II. Mental or psychological activity occurs on three levels ; the conscious level, the subconscious level, and the unconscious level. III. Development occurs in 5 stages which the child must master specific psychosexual conflicts to become a healthy, functioning adult ; the names of the stages reflect the body area most associated with the childs source of gratification.

IV.

Behavior is motivated by anxiety V. Behavior is always meaningful and often unconsciously motivated.

Key concepts.

I. Topography of the mind or the level of mind Freud classified all mental contents and operation into three categories -1. conscious level : all memories that remain with in an individual awareness. The conscious mind is thought to be under the control of the ego, the rational and logical structure of he personality

 2.Subconscious

level : all memories that may have been forgotten or are not in present awareness, but with attention can be readily recalled into conscious 3.Unconscious level: all memories that individual is unable to bring to conscious awareness, unconscious material consisted of unpleasant memories that have been repressed. It could be accessed through dreams and free association

Ego

Conscious level Preconscious level

Id
Unconscious level

Freuds concept of the id, ego, and superego.

II. Structure of personality

Freud organized the structure of the personality into three major component - Id : present at birth the unconscious mind, driven behavior are impulsive and may be irrational operated instinctively and without control :the pleasure principle , seek to satisfied needs, achieve immediate gratification

 Ego:

is called the reality principle /rational self :begin to develop between the age of 4-6 months :the ego develops because the id must negotiate with external reality to meet its needs, the ego mediates between id and external reality, the ego operates in reality and can solve problem

Superego:
begin to develop at the age of3- 6years is identified as perfection principle is composed of two major components The ego ideal The consciences

The

ego-ideal

Derived out of a system of rewards and punishments; when a child consistently rewarded for a good behavior, self-esteem is enhance and the behavior became part of ego-ideal It is internalized as part of his/her value system

The consciences is formed when the child is punished consistently for bad behavior The child learn what is considered morally right or wrong from feedback received from parent, society or culture

Id,

Ego , Superego are cooperated together by using psychic Energy. Psychic Energy is derived by instinct

Sigmund Freud
Human personality = an energy system

Life instinct and death instinct

Life: Eroserotic/pleasure seeking libido (acts, jokes, creativity) Death: Thanatosdestructive/ aggressive behavior

Psychosexual
Freud

development

described formation of the personality development through 5 stages of psychosexual development, he emphasis in the first 5 years of life Fixation in an early stage of development will almost certainly result in psychopathology

 Oral

stage(birth to 18 months) behavior is directed by Id The goal is immediate gratification of needs The focus of energy is the mouth The childs needs are satisfied by oral gratification; feeding, explore objects by placing them in the mouth A sense of security and the ability to trust others is derived from gratification of fulfilling basic needs during this stage

 Anal

stage(18 months to 3years)toilet training The child develops an awareness of fullness in the rectum, take pleasure in retaining or eliminating feces If this stages negotiated effectively, the child becomes an adult who can delay gratification to attain future goal If this stage is inadequate negotiated, the child becomes an adult who is either excessively rigid and conservative and obsessive compulsive and destructive

 Phallic

years

stage(Oedipal stage) 3-6

The child task pleasure in exploring and manipulating genitalia child is attracted to the opposite-sex parent, but realizes that he or she can not sexuality relate with this parent; the dilemma is resolved by identifying the same sex parent.

The

 Phallic

Stage During this stage , the superego develop and conscience is formed. If needs are adequately met during this stage, the child develop a sex appropriate identity If needs are inadequately, the child becomes an adult whose sexual identity confused

 The

latency stage(6-12 years) The child has learned to express inner drives and urges in socially acceptable way Sexual tension is sublimate into ageappropriate activities If this stage is successfully negotiated, the child become an adult who can deal with various life situation If this stage is not successfully negotiated, the child becomes an adult who can has difficulty developing social skills and who

 The

genital stage( 13-20 years) The focus is on relationship with the opposite sex The child expends energy establishing psychological independence from parent and family If this stage is completed successfully, an adult emerges whose personality is integrated, allow the development of love and work relationships

 The

genital stage( 13-20 years)

Unsuccessful

completion of this stage result in an adult whose ability to establish intimacy and a strong personality identity is greatly compromised

 Views

of Behavioral Deviations The imbalance between Id, Ego, and Superego conflicts (Ego can not maintain a balance between the impulsive behaviors of Id and the idealistic behavior of Superego) Individual use Ego defense mechanism to resolve conflicts, but unresolved conflicts at any stage of psychosexual development become fixated and remain part of the persons personality

 Inappropriate
Inadequate

defense mechanism

response to basic needs in any stage of psychosexual development The child use more psychic energy to resolve conflicts , consequently, there is a least psychic energy, and can not complete the developmental task in next stage fixation

 Understand

responses Understand the use of ego defense mechanism Provide appropriate nursing care Health education; child rearing techniques

maladaptive behavior

 Harry

Stack Sullivan and Hildegard Peplau are prominent Interpersonal Theorists Basic Assumption Human behavior and personality as a result of Interpersonal Relationship and that behavior is motivated by the avoidance of anxiety and attainment of satisfaction

 Key

concepts

1.Anxiety

-is a feeling emotional discomfort -arises out of ones inability to satisfy needs/ or to achieve interpersonal security Satisfaction of needs -is the fulfillment of all requirement associated with an individuals physiochemical environment(oxygen, food, water, warmth , tenderness, rest, activities , sexual expression : when absent, produce discomfort to individual

 Key

concepts 2.Interpersonal security when all needs have been met , individual experience a sense of total well-being(interpersonal security),no anxiety , and gain self confidence to establish interpersonal relationship Sullivan believed individual have an innate need for interpersonal security

 3.

satisfaction of needs is the fulfillment of all requirement associated with an individuals physiochemical environment(oxygen, food, water, warmth, rest, activity , sexual expression) When absent, produce discomfort in the individual

 4.self-system

Sullivan believed that the self system is designed to protect one against anxiety and allow one to obtain satisfaction. self-system is a collection of experience , adopted by individual to protect against anxiety.

It has three components Good me: is the part of the personality that develop in response to positive feedback from parent. Bad me: is the part of the personality that develop in response to negative feedback from parent.

Bad me: negative feedback from parent.( anxiety is experience; elicit feeling of discomfort , displeasure , and distress) Not me: : is the part of the personality that develop in response to situation that produce intense anxiety in the child Become not me Mental disorders

Interpersonal

stages Interpersonal growth is based on satisfying basic biological needs. To form satisfactory relationships with others , individual must complete six stages of development

development 6

 Six

stages of development 1.Infancy stage(birth to 18 months): infant learn to rely on caregiver to meet desire and needs 2.Childhood stage(18 months to 6 years): the child learn to accept not having desire and needs met immediately( a delay personal gratification)

 3.Juvenile

stage(6 -9 years) the child learn to form satisfactory peer relationships 4.Preadolescent(9-12 years) the child learn to form satisfactory relationships with person of same sex , initiating feeling of affection for another person.

 5.Early

adolescence stage( 12-14 years) The teenagers learn to form satisfactory relationship with person of the opposite sex: developing a sense of identity 6. Late adolescence stage(14-21 years) The person establishing self- identity; experiencing a close , long- lasting relationship with someone of the oppersit sex.

 Views

of Behavioral Deviations Inadequate response to basic needs, inability to establish interpersonal relationship can lead to emotion problems.

 Nurses

role The nurses must be understand their ownself and have a great deal of selfawareness. Establish a therapeutic nurse client relationship Help the client to understand his/her ownself, and self development.

 Hildegard

E. Peplau(1909-1999) Emphasized in nurses role for establishing therapeutic nurse-client relationship

She

therapist ,counsel or , socializing agent, manager , teacher.

believed that nurse serves as

Basic Assumption Individuals are different , which are comprise of a unique biologicalpsychological-spiritual- sociological structure. Peplau believed in the importance of the interpersonal environment (Interaction between person, family, parent, child , patient and nurse)

 Basic

Assumption Peplau believed in the importance of empathic linkage. The interpersonal transmission of anxiety or panic is the most common empathic linkage. The self system: self as an antianxiety system and a product of socialization.

 Peplau

proposed an interpersonal nursing theory that advanced the practice of psychiatric nursing by defined it as an interpersonal process. She proposed that nurses must promote the nurse- patient relationship to build trust and foster healthy behavior She demonstrated how nurses could use psychodynamic concept and counseling techniques with patients.

 Key

Concepts Psychodynamic nursing/Counseling Technique Nursing roles Phases of nurse-client relationship ( to built trust and healthy behavior) Peplaus psychological tasks of personality development The therapeutic use of self, promote healing

 Psychodynamic

nursing is a therapeutic nurse- client relationship which is being able to understand one s own behavior, and client s behavior, to help client understand his/her problem through therapeutic relationship. The nurse and client respect with each other , and mutually sharing, both nurse and client benefit from

 Nursing

roles Resource person Counselor Teacher Leader Surrogate

resource person: provides specific , needed information that help the client understand his or her problem Counselor: helping the client solve problem and make decisions Teacher: provide information to improve the health situation Leader: design the therapeutic direction to achieve the target goal Surrogate: as a substitute figure for another, client may view the nurse as a

Key

Concepts

Phase

of nurse-client relationship :4 phases Orientation Identification Exploitation Resolution

 Orientation
Establish

trust and rapport Establish a contract for intervention(responsibilities of both nurse and client Setting goal(mutual agreement) Develop a plan of action

 Identification

The patient describe the problem

 The nurse and the client examine the problem with in the context of the therapeutic. The client use an alternative resource to support his/her problem The nurse enhance the clients selfcare.
Exploitation

 Resolution

Summarize the progress made in resolving the problem Terminate the relationship

Major Development Stage Tasks Infancy Learning to Learning to count on communicate in various others ways with the primary caregiver in order to have comfort needs fulfilled. Toodlerhood Learning to Learning the satisfaction delay of pleasing others by satisfaction delaying self gratification in small ways.

Age

Age

Stage

Early Identifying childhood oneself Late Developing childhood skills in Participation

Major Development Task Learning appropriate roles and behavior by acquiring the ability to perceived the expectation of others. Learning the skill of compromise , competition and cooperation with other , establishment of a more realistic view of the world and a feeling of

Views
the

of Behavioral Deviations

fixation in the developmental task

maladaptive

behavior , lack of self understanding, a problem with interpersonal relationship

 Intervention

and Nurses Roles The nurses use the therapeutic use of self/self- awareness to enhance the clients growth Establish the therapeutic nurseclient relationship to help client understand his/her problem.

Theorist :Carl Rogers(1902-1987) Focus on Client Center

Theorist

: Abraham Maslow(19211970) , An American psychologist, he is best known for describing a hierarchy of needs to understand human behavior.

 Basic

Assumptions Humanistic therapist focus on a person ability to learn about him or herself, acceptance of self , and exploration of personal capabilities Holistic perspective( value of self) The personality development during the state of conscious

Key

concepts ( Carl Rogers) Empathy Positive regard

Key

concepts (Maslow) Needs Motivation

Physiological

Needs Safety and Security Love and Belonging Self Esteem and recognition Self -Actualization

3-76

 Physiologic

survival If the basic needs go unmet the person could die , meeting them only partially causes personal discomfort.

Safety , security, self preservation

Satisfying

these needs is important to provide structure and protection to the persons life these needs are unmet ,the person will experience separation anxiety and fear of self-harm

If

Love
Being

and belonging

a part of social groups and organizations , allow person to develop fulfilling relationships If unmet , will exhibit loneliness and feelings of alienation

Esteem
If

and recognition

the needs for esteem and recognition goes unfilled , a person will exhibited a feelings of inferiority and helplessness

Self-actualization
If

self- actualization needs go unmet, a person will experience loss of self-esteem and self-confidence

 Maslow

identified a hierarchy of needs the lower ones requiring fulfillment before those at higher level can be achieved He emphasized an individuals motivation in the continuous quest for self actualization.

 Maslow

described self- actualization as being psychologically healthy, fully human, and fully mature He believed that healthy or selfactualized individuals possessed the following characteristic Appropriate perception of reality Ability to accept oneself and others Ability to achieve satisfactory interpersonal relationship Ability to solve problems

Intervention and Nurses Role Focus on the nurses attitude for delivery of care Genuineness( ) Empathic understanding Unconditional positive regard

Theorists:

Ivan P. Pavlov, Edwin R. Guthric, John B. Watson, B.F. Skinner, Joseph Wope Behavioral theories attempt to explain how people learn and act.

Basic

assumption

Behaviors

are the persons action which can be observed and explain. This theory proposes that all behaviors, including mental illness is learned . Unlike other theoretical models, which focus on the patients emotions, behavioral theory focuses on the patient action.

 Basic

Assumptions Behavior that is rewarded will persist, whether the behavior is good or bad. Unwanted behaviors can be eliminated through negative sanctions, such as punishment Desired behaviors can be learned through positive sanctions, such rewards

 Key

concepts 1. Stimulus-Response Theory Ivan Pavlov

unconditioned stimulus unconditioned response (meat) (salivation) unconditioned stimulus unconditioned response conditioned stimulus (meat & ring bell) (salivation) Conditioned stimulus conditioned response (ring bell only) (salivation) It is known as classical conditioning

 2.Reinforcement
Developed

Theory B.F. Skinner(1904-1990)

an understanding of the importance of reinforcement The learning of operant behavior is also known as conditioning If a behavior occurs and is followed by reinforcement , it is probable that the behavior will recurrent.

 Views

of Behavioral Deviations Abnormal human behaviors are caused by inappropriate learning ,but abnormal behaviors can be changed through behavior modification

 Intervention

and Nurses Roles Deviated behaviors are caused by inappropriate learning Unwanted behaviors can be eliminated through negative reinforcement Desired behaviors can be learned through positive reinforcement

A number of nursing theories are applicable to psychiatric mental health nursing. The use of theories depends on the patients and their problems. For example , in people with schizophrenia who have problem related to maintenance of self care, Orems theory of self care may be useful. For example, in people with schizophrenia who have a poor interpersonal relationship problem, Peplaus theories may be appropriate when the nurse is developing a relationship with the patient.

 Developed

1976. Combined general systems theory with adaptation theory. Goal of nursing is promotion of adaptation in each of four modes of adaptation. Applicable to the home setting.

by Sister Callista Roy,

Main Concepts of the RAM Person/group/family as an adaptive system Environment: internal/external stimuli Health : becoming whole and integrated Nursing: the art and science of promoting adaptation

definition

of RAM An individual, family, or group is viewed as an adaptive system, exposed to many internal and external stimuli in the environment interfering with optimum health. Our role, as nurses, is to promote health by promoting adaptation

 I.PERSON

refer to "biopsychosocial being in constant interaction with a changing environment." (Marriner-Tomey, 1989) This concept envelops her sub concepts: cognator mechanism( ), regulator mechanism(), and the sub concepts in her four adaptive modes; physiological needs, self-concept, role function, and interdependence. These sub concepts are operationally defined by Roy and are summarized as follows.

1. The person as a living system very specifically is "a whole made up of parts or subsystems that function as a unity for some purpose." (MarrinerTomey, 1989) According to Roy, human beings use coping mechanism to adapt to both internal and external stimuli. Two major internal coping mechanism are the cognator and regulator. a. COGNATOR - a coping mechanism that functions using perception and information processing, learning, judgment, and emotion. b. The Regulator Mechanism. Refers to an individuals physiologic response to stress. Coping behavior occurs in Roy's four adaptive modes.

II. ADAPTIVE MODELS

1. Physiological - deals with a person's basic needs and adaptation processes regarding these needs. 2. Self concept is how one views themselves and is usually based on perceptions from self and other's reactions to self. These perceptions frequently direct one's behavior. 3. Role performance is the execution of ones duties in society. Most people have numerous roles that they are responsible for. 4. Interdependence is one's relations with significant others and support systems. It is in this mode where one maintains psychic integrity by meeting needs for nuturance and affection. (Marriner-Tomey, 1989)

 III.

ENVIRONMENTAL FACTORS

Roy categorizes environmental factors into three groups of stimuli: 1. Focal() - the factor that the person needs to adapt to most urgently. 2. Contextual() other stimuli present that contribute to the behavior caused by the focal stimuli. 3. Residual () factors that may be affecting behavior but whose affects aren't validated).

 IV.

Health

V. NURSING : as a science, which she defines as "a developing system of knowledge( ) about persons that observes, classifies, and relates the processes by which persons positively affect their health status"
and nursing as a practice discipline, which is "nursing's scientific body of knowledge used for the purpose of providing an essential service to people, that is, promoting ability to affect health positively." (Marriner-Tomey, 1989)

 The

goal of nursing is the promotion of adaptation in each of four adaptive modes. Physiologic Self-concept Role function Interdependence

 This

theory is used in Psychiatric Mental Health Practice as the nurse assesses the client behavior and stimuli and develops a plan of care to assist the client in adaptation in the four modes.

Dorothea

Orem: Born in Baltimore, Maryland. One of Americas foremost nursing theorists. Father was a construction worker Mother was a homemaker. Youngest of two daughters.

Studied at Providence Hospital ,school of Nursing in Washington D.C. in 1930s Got her B.S.N.E. in 1939 and her M.S.N.E in 1946 both from the Catholic University of America Got her M.S.N.E. at Catholic University of America in 1946 1958-1960 upgraded practical nursing training at Department of Health, Education and Welfare Was editor to several texts including Concepts Formalization in Nursing: Process and Production, revised in 1980, 1985, 1991, 1995, 2001

Early nursing experience included operating room nursing, private duty nursing (in home and hospital), pediatric and adult medical and surgical units, evening supervisor in the emergency room, and biological science technician. 1940-1949 Orem held directorship of both nursing school and the department of nursing at Providence Hospital in Detroit.

 1949-1957

Orem worked for the Division of Hospital and Institutional Services of the Indiana State Board of Health. Her goal was to upgrade the quality of nursing in general hospitals throughout the state. During this time she developed her definition of nursing practice.

 1959

Orem subsequently served as acting dean of the school of Nursing and as an assistant professor of nursing education at CUA. She continued to develop her concept of nursing and self care during this time. Orems Nursing: Concept of Practice was first published in 1971 and subsequently in 1980,1985, 1991, 1995, and 2001. Continues to develop her theory after her retirement in 1984

Person: An individual with physical and emotional requirements for development of self and maintenance of their well-being. Environment: Clients surroundings which may affect their ability to perform their self-care activities. Health: Structural and functional soundness and wholeness of the individual (Orem 1991). Nursing: The acts of a specially trained and able individual to help a person or multiple people deal with their actual or potential self-care deficits.

 Each

person has a need for self care in order to maintain optimal health and wellness. Each person possesses the ability and responsibility to care for themselves and dependants. Theory is separated into three conceptual theories which include: self care, self care deficit and nursing system.

 Self

care is the ability to perform activities and meet personal needs with the goal of maintaining health and wellness of mind, body and spirit. Self care is a learned behavior influenced by the metaparadigm of person, environment, health and nursing. Three components: universal self care needs, developmental self care needs, and health deviation.

 This

includes activities which are essential to health and vitality. Eight elements identified these include: air, water, food, elimination, activity and rest, solitude and social interactions, prevention of harm, and promotion of normality.

 These

include the interventions and teachings designed to return a person to or sustain a level of optimal health and well being. Examples can include such things as toilet training a child or learning healthy eating.

 This

encompasses the variations in self care which may occur as a result of disability, illness, or injury. In other words the person with a variation is meeting self care and maintaining health and wellness in a more individualize meaning.

 Every

mature person has the ability to meet self care needs, but when a person experiences the inability to do so due to limitations, thus exists a self care deficit. A person benefits from nursing intervention when a health situation inhibits their ability to perform self care or creates a situation where their abilities are not sufficient to maintain own health and wellness. Nursing action focuses on identification of limitation/deficit and implementing appropriate interventions to meet the needs of person.

 The

ability of the nurse to aid the person in meeting current and potential self care demands. Focused on person Three support modalities identified in theory including: total compensatory, partial compensatory, and educative/supportive compensatory. The clients ability for self care involvement will determine under which support modality they would be considered.

 The

nurses role in helping the client to achieve or maintain a level of optimal health and wellness is to act as an advocate, redirector, support person and teacher, and to provide an environment conducive to therapeutic development.

 The

self-care aspect of Orems theory applies to the assessment and evaluation of the nursing process. Orem emphasizes the importance of how ones own self-care is important for maintaining life, health development and wellbeing. The only restriction to this method is that the nurse can only make assessments where there is direct contact between the nurse and the client and or the family.

 The

area of self-care deficit applies to the diagnosis area of the nursing care process. Although self-care deficit is an abstract concept, it does provide a guideline for the selection of methods for helping and understanding the patient roles in self-care.

 The

third area of her theory, nursing systems, applies to the interventions of the nursing care. In order to help explain this concept, Orem also created three areas of how care can be administrated to a client depending on the physical and mental capabilities of the client. Wholly compensatory, partly compensatory and supportive-educative role

Boyd, M.A. (2005). Psychiatric nursing: Contemporary practice. (3rd ed). Philadelphia : Lippincott.
Orem,

D.E. (1991). Nursing: Concepts of practice (4 th ed.). St. Louis, MO: Mosby-Year Book Inc.

Taylor, S.G. (2006). Dorthea E. Orem: Self-care deficit theory of nursing. In A.M.
o

Townsend, M.C. (2006). Psychiatric mental health nursing: Concepts of care. (5th ed). Danvers, MA: F.A. Davis.