CHAPTER 3: Psychosocial Theories and Therapy

Chapter 3: Psychosocial Theories and Therapy

Key Terms:
o Alternative Medicine: therapies used in place of traditional or conventional medical practices
o Behavior Modification: a method of attempting to strengthen a desired behavior or response by
reinforcement, either positive or negative
o Behaviorism: a school of psychology that focuses on observable behaviors and what one can do
externally to bring about behavior changes; it does not attempt to explain how the mind works
o Client-centered Therapy: focused on the role of the client, rather than the therapist, as key to the healing
process
o Closed Groups: structure to keep the same members in the group for a specified number of sessions
o Cognitive Therapy: focuses on immediate thought processing: how a person perceives or interprets his or
her experience and determines how he or she feels and behaves
o Complementary Medicine: therapies used in conjunction with traditional or conventional medical
practices
o Countertransference: occurs when the therapist displaces onto the client attitudes or feeling from his or
her past; process that can occur when the nurse responds to the client based on personal, unconscious
needs and conflicts
o Crisis: a turning point in an individuals life that produces an overwhelming emotional response; life
circumstances or stressor an individual is confronting that cannot be managed through customary coping
strategies
o Crisis Intervention: includes a variety of techniques, based on the assessment of the individual in crisis, to
assist in resolution or management of the stressor or circumstance
o Dream analysis: a primary method used in psychoanalysis; involves discussing a clients dreams to
discover their true meaning and significance
o Education Group: a therapeutic group; provides information to members on a specific issue, for instance,
stress management, medication management, or assertiveness training
o Ego: in psychoanalytic theory, the balancing or mediating force between the id and the superego;
represents mature and adaptive behavior that allows a person to function successfully in the world
o Ego Defense Mechanisms: methods of attempting to protect the self and cope with basic drives or
emotionally painful thoughts, feelings, or events
o Family Therapy: a form of group therapy in which the client and his or her family members participate to
deal with mutual issues
o Free Association: a method in psychoanalysis used to gain access to subconscious thoughts and feelings
in which the therapist tries to uncover the clients true thoughts and feelings by saying a word and asking
the client to respond quickly with the first thing that comes to mind
o Group Therapy: therapy during which clients participate in sessions with others; the members share a
common purpose and are expected to contribute to benefit others and to receive benefit others and to
receive benefit from others in return
o Hierarchy of Needs: a pyramid used to arrange and illustrate the basic drives or need that motivate
people; devoted by Abraham Maslow
o Humanism: focuses on a persons positive qualities, his or her capacity to change (human potential), and
the promotion of self-esteem
o Id: in psychoanalytic theory, the part of ones nature that reflects basic or innate desires such as pleasure-
seeking behavior, aggression, and sexual impulses; the id seeks instant gratification; causes impulsive,
unthinking behavior; and has no regard for rules or social convention
o Individual Psychotherapy: a method of bringing about change in a person by exploring his or her feelings,
attitudes, thinking, and behavior; it involves a one-to-one relationship between the therapist and the client
o Integrative Medicine: combines conventional medical therapy and CAM therapies that have scientific
evidence supporting their safety and effectiveness
o Milieu Therapy: the concept that involves clients interactions with one another, that is, practicing
interpersonal relationship skills, giving one another feedback about behavior, and working cooperatively
as a group to solve day-to-day problems
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o Negative Reinforcement: involves removing a stimulus immediately after a behavior occurs so that the
behavior is more likely to occur again
o Open Groups: an ongoing group that runs indefinitely; members join or leave the group as they need to
o Operant Conditioning: the theory that says people learn their behavior from their history or past
experiences, particularly those experiences that were rapidly reinforced
o Parataxic Mode: begins in early childhood as the child begins to connect experiences in sequence; the
child may not make logical sense of the experiences and may see them as coincidence or chance events;
the child seeks to relieve anxiety by repeating familiar experiences, although he or she may not
understand what he or she is doing
o Participant Observer: this term has been coined for the therapists role, meaning that the therapist both
participates in and observes the progress of the relationship
o Positive Reinforcement: a reward immediately following behavior to increase the likelihood that the
behavior will be repeated
o Prototaxic Mode: characteristic of infancy and childhoods that involves brief, unconnected experiences
that have no relationship to one another; adults with schizophrenia exhibit persistent protoxic experiences
o Psychiatric Rehabilitation: services designed to promote the recovery process for clients with mental
illness; not limited to medication management and symptom control; includes person growth reintegration
into the community, increase independence, and improve quality of life
o Psychoanalysis: focuses on discovering the causes of the clients unconscious and repressed thoughts,
feelings, and conflicts believed to cause anxiety and helping the client to gain insight into and resolve
these conflicts and anxieties; pioneered by Sigmund Freud; not commonly seen today
o Psychotherapy Group: the goal of the group is for members to learn about their behaviors and to make
positive changes in their behaviors by interacting and communicating with others as members of a group
o Self-Actualization: describes a person who has achieved all the needs according to Maslows hierarchy
and has developed his or her fullest potential in life
o Self-Help Group: members share a common experience, but the group is not a formal or structured
therapy group
o Subconscious: thoughts or feelings in the preconscious or unconscious level of awareness
o Superego: in psychanalytic theory, the part of a persons nature that reflects moral and ethical concepts,
values, and parental and social expectations; therefore, it is in direct opposition to the id
o Support Groups: organized to help members who share a common problem to cope with it
o Syntaxic Mode: begins to appear in school-aged children and becomes more predominant in
preadolescence; the person begins to perceive himself or herself and the world within the context of the
environment and can analyze experience in a variety of setting
o Systematic Desensitization: behavioral technique used to help overcome irrational fears and anxiety
associated with a phobia
o Therapeutic Community or Milieu: beneficial environment; interaction among clients is seen as
beneficial, and treatment emphasizes the role of this client-to-client interaction
o Therapeutic Nurse-Patient Relationship: professional, planned relationship between client and nurse that
focuses on clients needs, feelings, problems, and idea; interaction designed to promote client growth,
discuss issues, and resolve problems; includes the three phases of orientation: working (identification and
exploitation) and termination (resolution); also called therapeutic nurse-patient relationship
o Transference: occurs when the client displaces onto the therapist attitudes and feelings that the client
originally experiences in other relationships; it is common for the client to unconsciously transfer to the
nurse feelings he or she has for significant others
Objectives:
o Explain the basic beliefs and approaches of the following psychosocial theories: psychoanalytic,
developmental, interpersonal, humanistic, behavioral, existential, and crisis intervention
Psychoanalytic Theories:
Sigmund Freud: The Father of Psychoanalysis:
o Developed psychoanalytic theory in the late 19th and early 20th centuries in
Vienna
o All human behavior is caused and can be explained

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CHAPTER 3: Psychosocial Theories and Therapy
o Believed that repressed (driven from conscious awareness) sexual impulses and
desires motivate much human behavior
o Personality Components: Id, Ego, and Superego
o Behavior Motivated by Subconscious Thoughts and Feelings:
Believed that the human personality functions at 3 levels of awareness:
Conscious: perceptions, thoughts, emotions that exist in the
persons awareness, such as feeling happy or thinking about a
loved one
Preconscious: thoughts and emotions are not currently in persons
awareness, but can recall with some effort
Unconscious: realm of thoughts and feelings that motivates a
person even though there totally unaware
Believed that much of what we do and say is motivated by our
subconscious
Freudian Slip: term used to describe slips of the tongue; believed these
slips werent accidents or coincidences, but indications of subconscious
feelings or thoughts that accidently emerge in causal day-to-day
conversations
o Freuds Dream Analysis:
Believed that a persons dreams reflect subconscious and have
significant meaning, although sometimes meanings are hidden or
symbolic
Free association, used to describe subconscious feelings or thoughts
o Ego Defense Mechanisms:
Ego Defense Mechanisms Table 3.1 pg 43
Most defense mechanisms operate at the unconscious level of awareness;
so, people are not aware of what they are doing and often need help to
see reality
o Five Stages of Psychosexual Development:
Based theory on belief that sexual energy (libido) was the driving force
of human behavior
Freuds Developmental Stages Table 3.2 pg 45
Psychopathology results when a person has difficulty making the
transition from one stage to the next or when a person remains stalled at
a particular stage or regress to an earlier stage
o Transference and Countertransference:
Transference patterns are automatic and unconscious in the therapeutic
relationship
Nurses can deal with countertransference by examining their own
feelings and responses, using self-awareness and talking with colleges
Current Psychoanalytic Practice:
o Analytic theorists use techniques of free association, dream analysis, and
interpretation of behavior
o Still practiced today but on a very limited basis; length, weeks long or more
frequent sessions for several years; costly and not covered by conventional health
issuance; known as therapy for wealthy
Developmental Theories:
Erik Erickson and Psychosocial Stages of Development:
o German-born psychoanalysis
o Extended on Freuds work on personality development across the life span while
focusing on social and psychological development in life stages
o Published Childhood and Society, described the 8 psychosocial stages of
development

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CHAPTER 3: Psychosocial Theories and Therapy
o People must complete a life task that is essential to well-being and mental health
in each stage; tasks allow the person to achieves life virtues such as hope,
purpose, fidelity, love, caring, wisdom
o Eriksons Stages of Psychosocial Development Table 3.3 pg 46
o Used in a variety of diciplines
o Occurs in sequential phases, and each stage is dependent on completion of the
previous stage and life task
Jean Piaget and Cognitive Stages of Development:
o Explored how intelligence and cognitive functioning developed in children
o 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
o Strongly believed that biologic changes and maturation were responsible for
cognitive development
o 4 stages:
Sensorimotor: birth-2 years; childe develops sense of self as separate
from environment and concept of object permanence; begins to for
mental images
Preoperational: 2-6 years; childe develops ability to express self with
language, understands meaning of symbolic gestures, begins to classify
objects
Concrete Operations: 6-12 years; child begins to apply logic to thinking,
understands spatiality and reversibility, is increasingly social, able to
apply rules
Formal Operations: 12-15 years and beyond; child learns to think and
reason in abstract terms, further develop logical thinking and reasoning,
and achieves cognitive maturity
o Theory suggests that individuals reach cognitive maturity by middle to late
adolescents
o Useful when working with children
Interpersonal Theories:
Harry Stack Sullivan: Interpersonal Relationships and Milieu Therapy
o American psychiatrist who extended the theory of significance of interpersonal
relationships
o Believed that ones personality involves more than individual characteristics,
particularly how one interacts with others
o Thought that inadequate or unsatisfying relationships produce anxiety, he saw as
the basis for all emotional problems
o Five Life Stages:
Established 5 life stages: infancy, childhood, juvenile, preadolescence,
adolescence
Sullivans Life Stages Table 3.4 pg 27
Describe 3 developmental cognitive models of experience and believed
that mental disorders are related to persistence of the early modes;
prototaxc mode, parataxic mode, syntaxic mode
o Therapeutic Community or Milieu:
Envisioned the goal of treatment as the establishment of satisfying
interpersonal relationships therapist provides a corrective interpersonal
relationship for the client
Coined the term participant observer
Developed first therapeutic community or milieu with yang men with
schizophrenia
Milieu therapy was one of the primary modes of treatment in the acute
hospital setting

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CHAPTER 3: Psychosocial Theories and Therapy
Management of milieu, or environment, is still primary role for the nurse
in terms of providing safety and protection for all clients and promoting
social interaction
Hildegard Peplau: Therapeutic Nurse-Patient Relationships:
o A nursing theorist and clinician who built on Sullivans interpersonal theories
and saw role of the nurse as a participant observer
o Developed concept of therapeutic nurse-patient relationship, which included 4
phases; orientation, identification, exploitation, and resolution phase
o Peplaus Stages and Task of Relationships Table 3.5 pg 48
o Roles of the Nurses in the Therapeutic Relationship:
Wrote about the roles of nurses in the therapeutic relationship and how
these roles meet the clients needs
Primary roles:
Stranger: offering client same acceptance and courtesy that the
nurse would any stranger
Resource Person: providing specific answers to questions within
a larger context
Teacher: helping client learn formally or informally
Leader: offering direction to the client or group
Surrogate: serving as a substitute for another such as parent or
sibling
Counselor: promoting experiences leading to health for the client
such as expression of feeling
Believed that the nurse could take on many other roles: consultant, tutor,
safety agent, mediator, administrator, observer, researcher
o Four Levels if Anxiety:
Defined anxiety as the initial response to a psychic threat
Describe 4 levels:
Mild Anxiety: positive state of heightened awareness and
sharpened senses, allowing person to learn new behaviors and
solve problems; can take in all avail stimuli
Moderate Anxiety: involved decreased perceptual field; the
person can learn new behavior or solve problems with
assistance; another person can re-direct to task
Severe Anxiety: involves feelings of dread or terror, person
cannot be redirected to a task, focuses only on scattered details
and has physiologic symptoms of tachycardia, diaphoresis, chest
pain; may go to ER believe they are having heart attack
Panic Anxiety: can involve loss of rational thought, delusions,
hallucinations, complete physical immobility and muteness; may
bolt and run aimlessly, often exposing self of injury
Anxiety Levels Table 3.6 pg 49
Humanistic Theories:
Represents significant shifts 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 clients past experiences
Humanists consider the persons past experiences, but direct more attention toward
present and future
Abraham Maslows: Hierarchy of Needs:
o American psychologist who studied the needs or motivations of individuals
o Focused on total person, not just one facet of the person and emphasized health
instead of simply illness and problems
o Formulate hierarchy of needs

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o Most basic needs: psychological- food, water, sleep, shelter, sexual expression,
freedom from pain; must be met first
o Second: safety and security- protection, security, freedom form harm or
threatened deprivation
o Third: love and belonging- enduring intimacy, friendship, acceptance
o Fourth: esteem needs- include the need for self-respect and esteem form others
o Highest: self-actualization- need for beauty, truth, justice
o Theory explains individual differences in terms of person motivations, which
isnt stable throughout life
o Theory helps nurse understand how clients motivations and behaviors change
during life crisis
Carl Rogers: Client-Centered Therapy:
o Humanistic American psychologist who focused on the therapeutic relationship
ad developed a new method of client-centered therapy
o One of the frit to use term client instead of patient
o Believed that each person experiences the world differently and knows his or her
own experiences
o Takes a person-center approach, a supportive role, rather than a directive or
expert role because he viewed the client as the expert of their life
o 3 central concepts:
Unconditional Positive Regard: a nonjudgmental caring for the client that
is not dependent on the clients behavior
Genuineness: realness or congruence between what the therapist feels
and what he or she says to the client
Empathetic Understanding: the therapist senses the feelings and personal
meaning from the client and communicated this understanding to the
client
o Believed that the basic nature of humans is to become self-actualized, or to move
toward self-improvement and constructive change
Behavioral Theories:
Behaviorism grew out of a reaction to introspection models that focused on the contents
and operations of the mind
Behaviorist believe that behavior can be changed through a s system of rewards and
punishment
Ivan Pavlov: Classical Conditioning:
o Laboratory experiments with dogs
o Behavior can be changed through conditioning with external and environmental
conditions or stimuli
o Would ring a bell, produce food, and dogs would salivate, process would repeat
itself and eventually the bell would ring and the dogs would salivate without food
being produced, a conditioned response
B. F. Skinner: Operant Conditioning:
o One of the most influential behaviorists, American psychologist, developed
theory of operant conditioning
o Following principles of operant conditioning:
All behavior is learned
Consequences result from behavior- broadly speaking, reward and
punishment
Behavior is rewarded with reinforcements tend to recur
Positive reinforces that follow behavior increase the likelihood that the
behavior will recur
Negative reinforces that are removed after a behavior increase the
likelihood that the behavior will recur

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CHAPTER 3: Psychosocial Theories and Therapy
Continuous reinforcement is the fastest way to increase that behavior, but
the behavior will not last long after reward ceases
Random intermittent reinforcement is slower to produce an increase in
behavior, but the behavior continues after the reward ceases
o Behavior modification
o Positive reinforcement
o Negative reinforcement
o Conditioned responses, such as fears or phobias can be treated with behavioral
technique
o Systematic desensitizing
Existential Theories:
Existential theorists believe that behavioral deviations result when a person is out of
touch with himself or herself or the environment
Believe that the person avoiding personal responsibility and is giving in to the wishes or
demands of others
Emphasize personal responsibility for ones self, feelings, behaviors, choices
Encourages person to live fully in the present and to look forward to the future
Care Rodgers is sometimes grouped here
Cognitive Therapy:
o Many existential theorists use
o Basic emotions of sadness, elation, anxiety, and anger are reactions to
perceptions of loss, gain, danger, and wrongdoing by others; Aaron Beck is
credited with pioneering cognitive therapy in persons with depression
Rational Emotive Therapy:
o Albert Ellis is founder, identified 11 irrational beliefs that people use to make
them self selves unhappy
o Believes that people have automatic thoughts that cause them unhappiness in
certain situations
ABC technique to help people identify:
A: activating stimulus or event
C: excessive inappropriate response
B: blank in persons mind that they must fill in by identifying
automatic thought
Viktor Frankl and Logotherapy:
o Based beliefs on observations of people in Nazi concentration camps during
WWII
o Counselors and therapists who work with clients in spirituality and grief
counseling often use logo concepts the Frankl developed
Gestalt Therapy:
o Founded by Frederick Fritz Perls, emphasizes identifying the persons feelings
and thoughts in the here and now
o Believed self-awareness leads to self-acceptance and responsibility for ones own
thoughts and feelings
Reality Therapy:
o William Glasser founder, focuses on the persons behavior and how that behavior
keeps them from achieving life goals
o Developed approach while working with those with delinquent behavior,
unsuccessful school performance, emotional problems
o Believe those who were unsuccessful blamed others for their problems
o Challenges clients to examine the ways in which their own behavior thwarts their
attempts to achieve life goals
Crisis Intervention:
Caplan identified stages of crisis:

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o The person exposed to a stressor, experiences anxiety, and tries to cope in a
customary fashion
o Anxiety increases when customary coping skills are ineffective
o The person makes all possible efforts to deal with stressor, including attempts at
new methods of coping
o When coping attempts fail, person experiences disequilibrium and significant
distress
Crisis occurs in response to a variety of life situations and events that fall into 3
categories:
o Maturational Crisis: developmental crisis; predicable events in normal course of
life, such as leaving home for the first time, getting married, having a baby,
beginning career
o Situational Crisis: unanticipated or sudden events that threaten individuals
integrity, such as death of loved one, loss of job, physical or emotional illness in
the individual or family member
o Adventitious Crisis: social crisis; natural disasters, war, terrorist attacks, riots,
violent crimes
Aguilera identified their factors that influence whether or not an individual experiences
crisis: individuals perception of the event, availability of emotional supports, availability
of adequate coping mechanisms
Crisis is described as self-limiting; crisis doesnt last indefinitely but usually exists 4-6
weeks
Those experiencing crisis usually are distressed and likely to seek help for distress
Directive Interventions: assess persons health status and promote problem-solving such
as offering the person new information, knowledge, meaning; raising self-awareness via
feedback of behavior; directing behavior by offering suggestions or course of action
Supportive Interventions: deal with persons need for empathetic understanding
o Describe the following psychosocial treatment modalities: individual psychotherapy, group
psychotherapy, family therapy, behavior modification, systematic desensitization, token economy, self-
help groups, support groups, education groups, cognitive therapy, milieu therapy, and psychiatric
rehabilitation
Individual Psychotherapy:
Involves 1:1 relationship between therapist and client
Seek this kind of therapy based on desire to understand self, and behavior, to make
personal changes, improve interpersonal relationships, get relief from emotional pain or
unhappiness
Relationship between therapist and client procedure through stages similar to those of the
nurse-client relationship: introduction, working, termination
Client must select a therapist whose theoretical beliefs and style of therapy are congruent
with client needs and expectations of therapy; select a therapist carefully and should ask
about therapist treatment approach and are of specialization
Groups:
Number of people who gather in a face to face setting to accomplish tasks that require
cooperation, collaboration, or working together
Group Content: what is said in context of group (education material, feelings and
emotion, discussion of projects to complete)
Group Process: behavior of the group and individual members (seating arrangements,
tone of voice, who speaks to whom, who is quiet.)
Stages of Groups Development:
o Pre-group Stages: members are selected, purpose or work of group identified,
group structure addressed
o Beginning Stage: initial stage; commences as soon as group begins to meet;
member introduce self, leader is selected, group purpose discussed, rules and
expectations for group review
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o Working Stage: begins as members begin to focus their attention on the purpose
or task the group is trying to accomplish; several; group characteristics may be
seen; cohesiveness is a desirable group characteristic and its associated with
positive group outcome ; in a therapy group members dont give one another
feedback if group is overly cohesive; competition can be destructive for group,
when conflicts are not resolved members become hostile or groups energy is
diverted from accomplishing its purpose
o Final Stage: termination
Group Leadership:
o Formal Leader: usually identified based on education, qualifications, experience;
support groups and self-help groups usually dont have identified formal leaders,
all members are seen as equals
o Informal Leaders: generally, members recognized by others as having
knowledge, experience or characteristics that members admire and values
o Effective group leaders focus on group processes as well as on group content
Group Roles:
o Not all members are aware of their role behavior and changes in members
behavior may be a topic that the group will need to address
o Growth Producing Roles: info seeker, opinion seeker, info giver, energizer,
coordinator, harmonizer, encourager, elaborator
o Growth-Inhibiting Roles: monopolize, aggressor, dominator, critic, recognition
seeker, passive follower
Group Therapy:
o Members Share a common purpose and are expected to contribute to the group to
benefit others and receive benefit from other
o Being a member of a group allows clients to learn new ways of looking at
problems or ways of coping with or solving problems, also helps to learn
important interpersonal skills
o Therapeutic results of group therapy include:
Gaining new info or learning
Gaining inspiration or hope
Interacting with others
Feeling acceptance and belonging
Becoming aware that one is not alone and that others share same
problems
Gaining insight into ones problems and behaviors and how they affect
others
Giving of oneself for the benefit of others (altruism)
o Therapy groups vary with different purposes, degrees of formality, and structures
o Psychotherapy Groups:
Open groups
Closed groups
o Family Therapy
o Family Education:
National Alliance for the Mentally Ill (NAMI) developed 12-week
Family-to-Family Education Course taught by trained family members
Focuses on schizophrenia, bi-polar, clinical depression, panic
disorder, OCD
Discusses clinical treatments and teach knowledge and skills that
family member need to cope effectively
NAMI also conducts Provider Education Programs taught by two
consumers, two family members, and a mental health professional who is
also a family member or consumer

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CHAPTER 3: Psychosocial Theories and Therapy
Designed to help providers realize the hardship families and
consumers endure and to appreciate courage and persistence it
takes to live with and recover from mental illness
o Education Groups
o Support Groups
o Self-Help Groups
Complementary and Alternative Therapies:
The National Center for Complementary and Integrative Health (NCCIH) a federal
government agency for scientific research on complementary and alternative agency; part
of the National Institutes of Health in the Department of Health and Human Services
Alternative medicine
Integrative medicine
NCCIH studies a wide variety of commentary and alternative therapies:
o Alternative Medical Systems: homeopathic medicine and naturopathic medicine
in Western cultures, and traditional Chinese medicine (herbal and nutritional
therapy, restorative physical exercises [yoga and Tai chi], mediation,
acupuncture, remedial massage
o Mind-body Interventions: meditation, prayer, mental healing, creative therapies
that use art, music, dance
o Biologically Based Therapies: substances found in nature (herbs, food, vitamins);
dietary supplements, herbal products, medicinal teas, aromatherapy, variety of
diets
o Manipulative and Body-based Therapies: based on manipulation or movement of
one or more parts of body (therapeutic massage, chiropractic or osteopathic
manipulation)
o Energy Therapies: two types; biofield therapies, intended to affect energy fields
that are believed to surround and penetrate the body (apeutic touch, qi gong,
Reiki); bioelectric-based therapies, involving convectional use of electromagnetic
fields (pulsed felids, magnetic fields, AC or DC field)
Important for nurses to ask clients specifically about the use of herbs, vitamins, or other
health practices in a nonjudgmental way
Psychiatric Rehabilitation:
Programs often called community supportive services or community supportive programs
Focuses on clients strengths, not just on illness
Client actively participates in program planning
Designed to help client manage the illness and symptoms, gain access to needed services,
live successfully in the community
Assist with clients ADLs and IADLS
Provides opportunities for socialization
Vocations referrals, training, job coaching, and support are available for clients who want
to seek and maintain employment
Offering services that meet each clients most important goals can significantly improve
quality of life and promote recovery and well-being

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