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and Therapy
Psychoanalytic
Theories
- STRUCTURE – Personality
Structure
• All human behavior is caused and can
be explained
• Personality components conceptualized
as id, ego, and superego
• Behavior motivated by subconscious
thoughts and feelings; treatment
involving analysis of dreams and free
association
• Ego defense mechanisms
• Psychosexual stages of development
• Transference and
countertransference
Psychoanalysis focuses on discovering
the causes of the client’s
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.
Psychoanalysis is lengthy, expensive,
and practiced on a limited basis
today; however, Freud’s defense
mechanisms remain current.
Personality Structure
• ID (4-5MONTHS)
– Executive
– REALITY PRINCIPLE
– Conscious
– Competencies
– Decision Maker; Problem-Solving; Critical
and Creative thinking
• SUPEREGO
– Should not
– Small voice of GOD
– Set norms, standards and values
– MORAL PRINCIPLE
– Conscience
Imbalances between
Personality Elements
ID
M – anic
A – nti-social
SE N –arcissistic
SE
O – bsessive
ID
Compulsive
A – norexia
nervosa
EGO Schizophrenia
• During the phallic stage, what
significant development will Susan
expect of her child?
B.sexual gratification in urination and
defecation
C.sexual disinterest in the opposite sex
D.sexual and body awareness
E.sexual identification and maturity
• Answer: C
• Rationale: the child during the phallic
stage begins to explore the body and be
aware of basic sexual differences of a
girl and a boy, a reason for penis envy
and castration fear to set in. A is what
toddlers experience during the anal
stage. D is achieved during adolescence.
B. maybe a sexual dysfunction.
ORAL STAGE
• 18 months
• Cry, suck, mouth
• EGO @ 6 months
– Child cries – fed – successful
– Child cries – ignored –
unimportant - narcissistic
ANAL
• 18 months STAGE
– 3 years old
• SUPEREGO develops
• Toilet training
– Good Mother – Normal
– Bad Mother
• Clean, organized, obedient – OC (anal retentive)
• Dirty, disorganized – Anti-social (anal expulsive)
PHALLIC STAGE
• Preschooler (3 – 6 years
old)
• Parent
– Oedipus Complex
• Castration Fear
– Electra Complex
• Penis Envy
LATENCY STAGE
• 6 to 12 years old
• School
• Reading, writing,
arithmetic
• Ability to care about and
relate to others outside
GENITAL STAGE
• 12 years old and above
• Developing satisfying sexual
and emotional relationships
with members of the opposite
sex
• Planning life’s goals
• A 36-year-old client with paranoid
schizophrenia believes the room is bugged by
the Armed Forces of the Philippines and a
roommate is a foreign spy. The client has never
had a romantic relationship, has no contact
with family, and has not been employed for the
past 14 years. Based on Erikson’s theories, the
nurse should recognize that this client is in
which stage of psychosocial development?
A. autonomy vs. shame and doubt
B. generativity vs. stagnation
C. integrity vs. despair
D. trust vs. mistrust
• Answer: D
• Rationale: This client’s paranoid ideation
indicates difficulty in trusting others.
The stage of autonomy vs. shame and
doubt deals with separation, cooperation,
and self-control. Generativity vs.
stagnation is the normal stage for this
client’s chronological age. Integrity vs.
despair is the stage for accepting the
positive and negative aspects of one’s
life, which would be difficult or
impossible for this client.
Erik Erickson
• PRE-OPERATIONAL STAGE-development
proceeds from sensorimotor representation to
prelogical thought and solutions to problems
• can use these representational skills only to view
the world from their own perspective.
• Understand the meaning of symbolic gestures
– 2 to 7 years
• CONCRETE OPERATIONAL-development
proceeds from prelogical thought to logical
solutions to concrete problems
• understand concrete problems
• cannot yet contemplate or solve abstract problems
– 7 to 12 years
• FORMAL OPERATIONAL-development
proceeds from logical solutions to concrete
problems to logical solutions to all classes of
problems
• cannot yet contemplate or solve abstract problems
• can also reason theoretically
– 12 and above
Harry Stack Sullivan
(1892–1949)
• Established five life stages of
personality development that included
the significance of interpersonal
relationships
– For alcoholics
• The nurse plans to use family therapy
as a means of assisting a family to cope
with their child’s terminal illness. The
nurse’s basis for this choice is that:
A. it is more time-efficient to deal with the
whole family together
B. the entire family is involved, since what
happens to one member impacts all
C. the nurse can control manipulation and
alliances better by using this mode of
intervention
D. it will prevent the parents from deceiving
each other about the true nature of their
child’s condition
• Answer: B
• Rationale: Family therapy views the
whole (Gestalt) within the context in
which the emotional problems are
occurring. Time efficiency is not an
adequate rationale for choosing this
therapeutic approach. Option C may or
may not be true; an astute nurse can
control manipulation and alliance within
any group. Promotion of truthfulness is
a secondary gain achieved through this
mode of therapy
Assumption of Family
Therapy
• Client: Whole family
• Concepts:
– The family is the most fundamental unit of the
society.
– Adaptive or maladaptive patterns of behavior are
learned from the family
– Dysfunction in the family = dysfunction in the
individual
• Purpose
– Improve relationships among family members
– Promote family function
– Resolve family problems
ATTITUDE THERAPY
1. Paranoid – Passive Friendliness
2. Withdrawn – Active Friendliness
3. Depressed / Anorexia – Kind
Firmness
4. Manipulative – Matter of Fact
5. Assaultive – No Demand
6. Anti-social – Firm, consistent
PSYCHOSOMATIC
THERAPY
One of the chief benefits of ECT is
that it:
A. shortens the hospitalization and follow-
up periods
B. often serves as an adjunct to
psychotherapy and other treatment
C. decreases the need for medication and
psychotherapy
D. enable the client to terminate
psychiatric treatment
Electroconvulsive
Therapy
• Effective in most affective disorders
• The induction of a grandmal seizure in
the brain.
• Abnormal firing of neurons in the brain
causes an increase in
neurotransmitters
• Number of Treatments: 6-12 ,3 times a
week, about .5-2seconds
• Unilateral or bitemporal
Indications:
• Patients who require rapid response
• Patients who cannot tolerate
pharmacotherapy or cannot be exposed
to pharmacotherapy
• Patients who are depressed but have
not responded to multiple and adequate
trials of medication
Preparations for ECT:
• Pretreatment evaluation and clearance
• Consent
• NPO from midnight until after the
treatment
• Atropine Sulfate- to decrease
secretions, succinylcholine (Anectine)- to
promote muscle relaxation, Methohexital
Sodium(Brevital)- anesthethic
• Empty bladder
• Remove jewelry, hairpins, dentures and
other accessories
• Check vital signs
• Attempt to decrease patient’s anxiety
Care after ECT:
• O2 therapy of 100% until patient can
breathe unassisted
• Monitor for respiratory problems, gag
reflex
• Reorient patient
• Observe until stable
• Careful documentation.
• Male erectile dysfunction
CRISIS
• situation that occurs when an
individual’s habitual coping ability
becomes ineffective to merit
demands of a situation
Crisis Intervention
• Four stages of crisis:
– Exposure to stressor
– Increased anxiety when customary coping is
ineffective
– Increased efforts to cope
– Disequilibrium and significant distress
• Types of crises:
– Maturational
– Situational
– Adventitious
Steps in Crisis Intervention
• Identify the degree of disruption the
client is experiencing
• Assess the client’s perception of the
event
• Formulate nursing diagnoses
• Involve the patient and family if
applicable with planning
• Implement interventions- new and old
coping mechanisms
• Evaluate-reassessment, reinforcement
Crisis state lasts 4–6 weeks.
Psychological
Oblivion- Appearing numb of oblivious to the
surroundings
Shame/Silence -Often suffering in silence and
continue to experience guilt and shame
Hapless -Children come to believe that they are to be
blamed for everything
Agitation
Mistrust -They develop difficulty in trusting and
relating with others
Emotions are intense -Emotionally, they are labile,
intense, often unpredictable and may fear intimacy for
• A nursing intervention which would help
abusive parents is:
B. Allow them to relate the history of
child abuse in their family
C. Instruct them on how they can
encourage their children to obey them
D. Teach them to handle angry behavior
before it gets out of control
E. Explain to them that as the child grows
older, their needs differ.
Treatment and Intervention
• Safe place - Getting the child to a safe
place once abuse is identified
• Individual therapy for the child, play
therapy
• Family therapy
• Treatment for parents for any substance
abuse or psychiatric issues
• Social Services -Intensive involvement of
social service agencies
• Note:
Report all cases of child abuse to the
AUTHORITY.
• A nurse is performing an admission
assessment on a child and notes the
presence of old and new bruises on the
child’s back and legs. The nurse. suspects
physical abuse and would:
C. Denial B. anger
C. Bargaining D. resolution
Theories of the Grieving
Process
Kubler-Ross’s stages of grieving:
• Denial (shock and disbelief)
• Anger (toward God, relatives, health
care providers)
• Bargaining (trying to get more time,
prolonging the inevitable loss)
• Depression (awareness of the loss
becomes acute)
• Acceptance (person comes to terms
with impending death or loss)
John Harvey’s phases of grieving:
• Shock, outcry, and denial
• Intrusion of thoughts,
distractions, and obsessive
reviewing of loss
• Confiding in others to emote
and cognitively restructure
Rodebaugh’s stages of grieving:
• Reeling
• Feelings
• Dealing
• Healing
There are many similarities among
theorists about grief. Not all
clients follow predictable steps
or make steady progress.
• What is the most therapeutic initial
nursing intervention in helping a client
deal with feelings after the loss of a
spouse?
B. Help the client see the positive aspects
of the relationship with a spouse.
C. Describe the stages of the grieving
process
D. Support the client’s expression of
feelings
E. Explain that in time the hurt feelings
will lessen
Tasks of the Grieving
Process
• Undoing psychosocial bonds to
loved one and eventually creating
new ties
• Adding new roles, skills, and
behaviors
• Pursuing a healthy lifestyle
• Integrating the loss into life
Dimensions of Grieving
• Cognitive responses to grief
– Questioning and trying to make sense of the loss
– Attempting to keep the lost one present
Complicated Grieving
Disenfranchised grief is grief over a loss that
is not or cannot be openly acknowledged,
mourned publicly, or supported socially:
• A relationship has no legitimacy
• The loss itself is not recognized
• The griever is not recognized
Complicated grieving is a response that lies
outside the norm of grieving in terms of:
• extended periods of grieving
• responses that seem out of proportion
• responses that are void of emotion
Assessment (P-S-C)
• Does the client have adequate perception
regarding the loss?
– What does the client think and feel about the loss?
– How is the loss going to affect the client’s life?
– What information does the nurse need to clarify or
share with the client?