Theoretical Models for Working with Psychiatric

Patients
Sigmund Freud the Father of Psychoanalysis
Psychoanalytic Theories
• All human behavior is caused and can be explained
• Personality conceptualized as id, ego, and superego
• Behavior motivated by subconscious thoughts and feelings
• Ego defense mechanisms
FREUD’S PSYCHOSEXUAL THEORY
STAGE TASK
Oral Stage Explores the world by using mouth
Anal Stage Learns to control urination and defecation
Phallic Stage Learns sexual identity through awareness of genital area
Latent Stage Personality development appears to be non-active or dormant
Genital Stage Develops sexual maturity and learns to establish satisfactory relationships
with the opposite sex.
FREUD’S PSYCHOANALYTICAL MODEL
 STRUCTURES OF PERSONALITY
 ID – pleasure principle
 EGO – reality principle
 SUPEREGO – ideal principle
 LEVELS OF CONSCIOUSNESS
 CONSCIOUS – material within an individual awareness.
 PRECONSCIOUS – memories that can be recalled to conscious
level with some efforts.
 UNCONSCIOUS – memories, conflicts, experiences that have
been repressed and cannot be recalled at will.

GOAL OF PSYCHOANALYSIS: To bring unconscious to consciousness so that individual can work

through the past and understand past and present behavior.
COPING MECHANISM – are conscious efforts to deal with daily frustrations and conflicts.
DEFENSE MECHANISM – unconscious operations used to defend against anxiety or stress and
relieve emotional conflict.
 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.
 RATIONALIZATION- conscious or unconscious attempts to make or prove that one’s
feelings or behaviors are justifiable.
 INTELLECTUALIZATION-consciously or unconsciously using only logical explanations
without feelings or an affective component.
 DISSOCIATION-unconscious separation of painful feelings and emotions from an
unacceptable idea, situation, or object.
 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.
 REACTION FORMATION- a conscious behavior that is the exact opposite of an
unconscious feelings.
 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.
 PROJECTION-unconsciously or consciously blaming someone else for one’s difficulties or
 placing one’s unethical desires on someone else.
 CONVERSION-unconscious expression of intrapsychic conflict symbolically through
physical symptoms.
  REGRESSION-unconscious return to an earlier and more comfortable development level.
 FIXATION- immobilization of a portion of the personality resulting from unsuccessful
completion of tasks in a development stage.
 RESISTANCE- overt or covert antagonism toward remembering or processing anxiety-
producing information.
1. Primary focus:
 Supports the notion that all human behavior is caused and can be explained
 Individuals are motivated by unconscious desires and conflicts
THAT in order to understand the past and present behavior, is to make “the
unconscious”…“conscious

2. In a Nurse-Patient relationship, the nurse must exercise the following:

a. must recognize and understand maladaptive behaviors
b. must help patient recognize his/her maladaptive behaviors
c.must help patient choose acceptable ways of expressing their desires and drives

Psychosocial theory (Developmental model) Erik Erikson (1902-1994)

Primary Focus
0-12 trust vs. mistrust
if needs of the child are consistently met, TRUST develops …… HOPE
1-3 autonomy vs. shame & doubt
if toilet training is not hurried, AUTONOMY develops…. WILL
3-6 initiative vs. guilt
if child’s sexual curiosity is handled w/o anxiety,
INITIATIVE develops…. PURPOSES
12 industry vs. inferiority
If child’s efforts at learning is supported, INDUSTRY develops…. COMPETENCE
12-18 identity vs. role confusion
if adolescents’ vocational decision is supported,
IDENTITY develops… FIDELITY
18-25 intimacy vs. isolation
If adolescents’ decisions regarding love relationship is supported,
INTIMACY develops… LOVE
25-65 generativity vs. stagnation If an adult enjoys support from the family,
GENERATIVITY develops…CARE
65 up integrity vs. despair If the elderly has a satisfying past recollection,
INTEGRITY develops… WISDOM

 focused on social and psychological development in life’s stages, from birth to death
 Non-mastery of tasks, totally/partially, inhibits movement to the next stage
 Knowing the stages with its appropriate age help nurses ASSESS and MANAGE
BEHAVIORAL issues

Interpersonal Development Model Harry Stack Sullivan (1892-1949)

0-18 mos Infancy Develops sense of basic trust, security
and self- worth
18 mos - 6 yrs Childhood Learns language and symbols; intuition;
learns individuals have roles
6-9 yrs Juvenile Learns to accept subordinate to authority
figures outside the family.
More concept of self-status and role
9-12 Preadolescence Capable in participating if genuine love
with others.
Develop consideration and concerns
outside self.
12-14 Early adolescence Attempts to integrate sex with other
personal relationships.
Late adolescence Master expression of sexual impulses.
Forms satisfying and responsible
associations.
Uses communication skills to protect self
from conflicts with others.
 Young adulthood Learns to be economically, intellectually,
and emotionally self-
sufficient.
 inadequate or non-satisfying relationships produce anxiety and/or maladaptive behaviors;
primarily the basis of all emotional problems
 Knowing that inadequacy or non-satisfying relationships leads to maladaptive behaviors,
nurse will be able to help the patient thru CHANGE – the process of reeducation

Hierarchy of Human Need Abraham Maslow (1921-1970)

1. Primary focus:
 Totality of the person
 Hypothesized that basic needs would dominate (oxygen, water, food, sleep, sex) person’s
behavior until those needs are met

2. Relevance to Nursing practice

 a. Understanding the “Hierarchy of Needs” and its components help nurses
appropriately ASSESS and MANAGE patient maladaptive behavior/s
 b. MOTIVATION of man is based on satisfying “Hierarchy of Needs”

Cognitive Development Jean Piaget (1896-1980)

0-2 Sensory Motor reflex activity to motor learning; learns he is separate from
environment; concept of
object permanence
2-7 Pre-op stage Learns language and symbols; intuition; learns individuals
have roles
7-12 Concrete-op stage pre-logical to logical concrete thought
12 up Formal-op stage thinks abstractly; scientific method

1.Primary focus:
 believed that human intelligence progresses thru a series of stages based on age
 Piaget’s theory suggest that cognitive maturity is reached at middle to late adolescence
 Biologic changes and maturation were responsible in cognitive development
2. Relevance to Nursing practice
 Theory is more applicable when working with children

Self-Awareness Issues
 No one theory or treatment approach is effective for all clients
 Using a variety of psychosocial approaches increases nurse effectiveness
 The client’s feelings and perceptions are most influential in determining his or her
response

Legal and Ethical Issues

COMMITMENT ISSUES
1.Voluntary Commitment or Treatment – willing to seek treatment and agree to be
hospitalized.
2.Involuntary Commitment or Treatment – with legal capacity to consent to mental health
treatment but refuses to do so.
3 Criteria that allows for involuntary commitment:
 Patient poses as a danger to himself
 Patient poses as danger to others
 Gravely disabled

Right of Clients
  Mental health clients retain all civil rights afforded to all people except the right to leave
the hospital in the case of involuntary commitment
 Laws are determined by each state; know the laws of the state where you practice
 Persons detained in this way lose only the right to freedom; all other rights are intact
 Persons held without their consent must present an imminent danger to themselves or
others; this must be proven at a hearing if the person is to be committed
Release from the hospital
 Clients hospitalized voluntarily have the right to request discharge at any time and must
be released unless they represent a danger to themselves or others; if such a danger is
present, then commitment proceedings must be instituted to keep them in the hospital

 Clients who are no longer dangerous must be discharged from the hospital
Mandatory Outpatient Treatment
 Requires that clients continue to participate in treatment on an involuntary basis after
their release from the hospital into the community
 Examples include taking prescribed medications, keeping appointments with healthcare
providers for follow-up, and attending specific treatment programs or groups

 Legal guardianship is separate from civil commitment for hospitalization

 A hearing can be held to determine whether the person is competent. An incompetent
client cannot provide his or her own shelter, food, and clothing; cannot act in his or her
own best interests; and cannot run his or her own business and financial affairs. If a client
is found incompetent, a guardian is appointed to speak for the client.

Least Restrictive Environment

 Physical restraint or seclusion in a locked room can be used only when the person is
imminently aggressive or threatening to harm himself
 Restraint and seclusion, if used, must be in place for the shortest time necessary
 Many regulations govern the monitoring of clients in seclusion or restraint for their safety

 CONFIDENTIALITY

 Duty to warn a third party is an exception to client confidentiality

Clinicians must warn identifiable third parties of threats made by a client.
 Is the client dangerous to others?

 Is the danger the result of serious mental illness?

 Is the danger serious?
 Are the means to carry out the threat available?
 Is the danger targeted at identifiable victims?
 Is the victim accessible?

NURSING LIABILITY

Tort – is a wrongful act that results in injury, loss, or damage.

TYPES:
Unintentional Torts
1. Negligence - refers to the commission or omission of an act, pursuant to a duty, that a
reasonably prudent person in the same or similar circumstance would or would not do, and
acting or the non-acting of which is the proximate cause of injury to another person or his
property.
2. Malpractice - refers to a negligent act committed in the course of professional performance;
also denotes stepping beyond one’s authority with serious consequences.
Standards of care - are detailed guidelines that represent the predicted care indicated in a
specific situation.

Elements of Malpractice

ElementConcept
1.Duty- Duty is owed to a client
>Nurse fails to meet the standard of care.
>Scope of duty is within professional nursing boundaries.
2. Breach of duty- deviation from standard of care is established.
3. Injury-Financial, physical, emotional harm is established.
4. Causation Direct cause for failure to meet standard of care is clearly established.

Intentional Torts
1. Assault – involves any action that causes a person to fear being touched in a way that is
offensive, insulting or physically injurious without consent or authority.
2. Battery – Involves harmful or unwarranted contact with the client; actual harm or injury
may or may not have occurred.
3. False imprisonment – unjustifiable detention of a client.

FORENSIC EVALUATION – refer to comprehensive psychological evaluations that intersect with

the legal profession. In these matters, psychologists are called into legal proceedings to provide
objective and comprehensive psychological evaluations and to give expert witness testimony on
particular areas of psychology.

CONSERVATORSHIP – one is appointed by a court to manage the affairs of another person

found to be incompetent and unable to manage his own affairs appropriately.
DOCUMENTATION – legal records given careful attention to detail contributes to appropriate
mental health care provision and reduces liability claims in general.

Ethical Issues
 Ethics: a branch of philosophy that deals with values of human conduct (rightness and
wrongness of actions) and the goodness or badness of the motives and ends of such
actions
 Utilitarianism: a theory that bases decisions on “the greatest good for the greatest
number”

Deontology: decisions should be based on whether an action is morally right or wrong, with no
regard for the consequences
Deontological Principles
1. Autonomy: right to self-determination and independence
2. Beneficence: duty to benefit others or promote good
3. Nonmaleficence: do no harm
4. Justice: fairness
5. Veracity: honesty, truthfulness
6.Fidelity: honor commitments and contracts

Prevention of Liability
 Nurses can minimize the risk of lawsuits through safe, competent nursing care and
descriptive, accurate documentation
Self-Awareness Issues
 Talk to colleagues or seek professional supervision
 Spend time thinking about ethical issues and determine what your values and beliefs are
regarding situations before they occur
 Be willing to discuss ethical concerns with colleagues or managers
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