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Psychosocial Theories

and Therapy
Psychoanalytic
Theories

• Pioneered by Sigmund Freud (1856–


1939) in Vienna
• Father of Psychoanalysis
- “Your behavior today is directly
or indirectly affected by your
childhood days or experiences.

- 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)

– Impulsive / Instinctual drive


– I want to… PLEASURE PRINCIPLE
– I want to… PHYSIOLOGIC NEEDS
– I want to… PRIMARY PROCESS
• EGO

– 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

Psychosocial Theory of Development


0-18 mos. Trust vs. Mistrust

-attachment to mother which lays


foundations for later trust in others
-conflict: general difficulties relating
to others. suspicion, fear of the
future
• 18 m0s – 3 yrs Autonomy vs.
Shame/Doubt

• Gaining some basic control of self and


environment
• Conflict: independence-fear conflict,
severe feelings of self-doubt
3 yrs – 6 yrs Initiative vs. Guilt

-becoming purposeful and directive


-conflict: aggression-fear conflict; sense
of inadequacy and guilt
6 yrs – 12 yrs Industry vs.
Inferiority
• Developing social, physical and school
skills, competence
• Conflict: sense of inferiority; difficulty
learning and working
• 12 yrs – 20 yrs Identity vs. Role
Diffusion
• Making transition from childhood to
adulthood; developing a sense of
identity
• Conflict: confusion of who one is,
identity submerged in relationships or
group memberships
21 yrs – 35 yrs Intimacy vs. Isolation
-establishing intimate bonds of love and
friendship
-conflict: emotional isolation
35 yrs – 55 yrs Generativity vs.
Stagnation

-fulfilling life’s goals that involve family,


career and society, developing concerns
that embrace future generations
-conflict: self-absorption. Inability to
grow as a person
• 55 yrs – above Integrity vs. Despair
• Looking back into one’s life and
accepting its meaning
• Conflict: dissatisfaction with life, denial
of or despair over prospect of death
Jean Piaget
Cognitive Theory of
Development
Jean Piaget (1896–1980)
Described cognitive and
intellectual development in
children in four stages:
sensorimotor, preoperational,
concrete operations, formal
operations
• SENSORIMOTOR STAGE-development
proceeds from reflex activity to representation
and sensorimotor solutions to problems
– 0 to 18 months

• 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

• Described three developmental cognitive


modes: prototaxic, parataxic, syntaxic

• Believed that unsatisfying relationships


were the basis for all emotional problems

• Described the concept of therapeutic


milieu or community
Hildegard Peplau (1909–1999)
• Leading nursing theorist and
clinician: developed the nurse–
patient relationship with phases and
tasks
• Identified roles of the nurse:
stranger, resource person, teacher,
leader, surrogate, counselor
• Described four levels of anxiety
(mild, moderate, severe, panic) still
widely used today
Humanistic
Abraham Theories
Maslow (1921 –1970)
• Hierarchy of needs: basic physiologic
needs, safety and security needs, love
and belonging needs, esteem needs, self-
actualization
Carl Rogers (1902–1987)
• Client-centered therapy
• Concepts of unconditional positive regard,
genuineness, and empathetic
understanding
IvanBehavioral Theories
Pavlov (1849–1936)
B. F. Skinner (1904–1990)
• Behaviorism focuses on behaviors and
behavior changes rather than on
explaining how the mind works
• All behavior is learned
• Behavior has consequences (reward or
punishment)
• Rewarded behavior tends to recur
• Positive reinforcement increases the
frequency of behavior
• Removal of negative reinforcers
increases the frequency of behavior
• Continuous reinforcement is the
fastest way to increase behavior;
random intermittent reinforcement
increases behavior more slowly but
with longer-lasting effect
• Treatment modalities based on
behaviorism include behavior
modification, token economy, and
systematic desensitization
Existential
• Cognitive Theories
therapy focuses on immediate
thought processing and is used by most
existential therapists
Albert Ellis
• Rational emotive therapy: people make
themselves unhappy through “irrational
beliefs and automatic thinking”—the basis
for the technique of changing or stopping
thoughts
Viktor Frankl
• Logotherapy: life must have meaning and
therapy is the search for that meaning
Frederick “Fritz” Perls
• Gestalt therapy emphasizes self-
awareness and identifying thoughts
and feelings in the here and now
William Glasser
• Reality therapy focuses on the
person’s behavior and how that
behavior keeps the person from
achieving life goals
Existential theorists believe that
deviations occur when the person is
out of touch with self or environment;
thus, the goal of therapy is to return
the person to an authentic sense of
self.
Treatment Modalities
Community (outpatient) mental
health treatment
• The client can often continue to work
and can stay connected with family,
friends, and other support systems
while participating in therapy
• Personality or behavior patterns
gradually develop over the course of a
lifetime and cannot be changed in a
relatively short inpatient course of
treatment
Hospital (inpatient) treatment
• Severely depressed and suicidal
• Severely psychotic
• Experiencing alcohol or drug
withdrawal
• Exhibiting behaviors that require
close supervision in a safe,
supportive environment
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
• The therapist’s theoretical beliefs
strongly influence his or her style
of therapy
SEVEN SUBTYPES
1.CLASSICAL PSYCHOANALYSIS
• Based on Freud’s theory
• To uncover unconscious feelings and thoughts
that interfere with the client’s living a fuller
life
• Free association- client is encouraged to say
anything that comes to mind, without
censoring thoughts or feelings
• Dream analysis
• Working through (transference)-process of
repeated interpretation to the person of his
or her unconscious processes has the effect
of bringing about change
2. PSYCHOANALYTICAL
PSYCHOTHERAPY
• Uses DREAM ANALYSIS, TRANSFERENCE
and FREE ASSOCIATION AND
COUNTERTRANSFERENCE
• Therapist is much more involved and interacts
with the client more freely
• Done through intimate professional
relationship between the nurse/therapist and
the client over a period of time (introductory,
working and termination phase)
3. SHORT TERM DYNAMIC
PSYCHOTHERAPY
• Indication-persons with specific
symptom or interpersonal problem that
he/she wants to work on
• Therapist directs the content
• Use of transference and dream
analysis, NO FREE ASSOCIATION
• Weekly sessions (total number-12 to 30)
• Successful for highly motivated
individuals who have insight and with
positive relationship with the therapist
4. TRANSACTIONAL ANALYSIS
• Eric Berne
• Each person has three ego states and change from
one to another frequently
• Parent-concepts of standards of behavior and how
things should be done e.g. “Go and take out the
garbage.”
• Adult-rational thinking and data analyzing part of
the personality e.g. “Would you please take out the
garbage”
• Child- feelings associated with persons, things or
incidents represent the need-gratifying aspects of
the personality. E.g. “Is that why you married
me?To be your garbage man?”
• For group, family and individual
• Client to identify ego states for each given
situation
• Rewarding of positive or negative behaviors with
strokes
• Client work through these behaviors
• A nurse teaches a client to control his
panic by countering his negative
thoughts of “I’m a failure, I can’t pass
any examinations,” with “I have passed
most examinations and I’ll try my best
to pass the next test.” This is an
example of:
A. psychoeducation
B. distraction
C. positive self-talk
D. panic control treatment
• Answer: C
• Rationale: Positive self-talk is an
intervention the client can learn to
counter fearful or negative thoughts
that occur when faced with increased
anxiety and panic. These are
preplanned, rehearsed statements
that give the client an area to focus on
when symptoms of panic begin.
5. COGNITIVE PSYCHOTHERAPY
• Restructuring or changing ways in which
people think about themselves
3 steps:
1.Thought stopping
2. Positive self-talk
3. Decatastrophizing
• Therapists help patients identify these
thoughts
6. BEHAVIORAL THERAPY
• Changes in maladapted behavior can occur
without insight into the underlying cause
• Based on learning theory (B.F.Skinner, Pavlov)
• Modeling
• Operant conditioning
• Self-control therapy- combination of
cognitive & behavioral approaches “talking to
self”
• Systematic desensitization
• Aversion therapy
• Token economy
7. GESTALT THERAPY
• Emphasis on the “here and now”
• Only present behavior can be changed,
not history
• Uncover repressed feelings and needs
• Techniques: have a person behave the
opposite of the way he/she feels,
presuming that a person can then come
in contact with a submerged part of
the self; in dreams, person is ask to
play the roles of persons in the dream
to get in touch with different
repressed feelings
• During the meetings of a therapy group one
member tends to monopolize the group
discussion and no one is confronted this
behavior. This nurse would best handle this
situation by:
A. saying to the client, “You use too much
time in our sessions.”
B. Ignoring the behavior because the client
may become upset if confronted
C. Encouraging the members of the group to
do more talking by calling on various silent
member
D. Saying the group. “ I’m wondering why the
group is so willing to let this client do so
much of the talking.”
Group Therapy
• Group therapy involves a therapist or
leader and a group of clients sharing
a common purpose; members
contribute to the group and expect to
benefit from it.
• Types of groups include:
• Psychotherapy groups, family
therapy, family education, support
groups, self-help groups, education
groups
• Stages of group development
– Pregroup stage
– Initial stage
– Working stage
– Termination stage
• Group leadership
– Therapy groups and education
groups: formal leader
– Support groups and self-help
groups: no formal leader
Effective group leaders focus on
group process as well as group
content
• Group roles
– Growth-producing roles:
information-seeker, opinion-
seeker, information-giver,
energizer, coordinator,
harmonizer, encourager, and
elaborator
– Growth-inhibiting roles:
monopolizer, aggressor, dominator,
critic, recognition-seeker, and
passive follower
The therapeutic results of group therapy
(Yalom, 1995) include the following:
• Gaining new information or learning
• Gaining inspiration or hope
• Interacting with others
• Feeling acceptance and belonging
• Universality -Becoming aware that one is not
alone and that others share the same
problems
• Gaining insight into one’s problems and
behaviors and how they affect others
• Altruism - Giving of oneself for the benefit
of others
Psychosocial
Interventions
Psychosocial interventions are nursing
activities that enhance the client’s
social and psychological functioning
and promote social skills,
interpersonal relationships, and
communication.
These interventions are used in
mental health and other practice
areas.
• The nurse recognizes that the focus of
milieu therapy Is to:
B.role-play life events to meet individual
needs
C.use natural remedies rather than drugs
to control behavior
D.manipulate the environment to bring
about positive changes in behavior
E.allow the clients freedom to determine
whether or not they will be involved in
activities
Milieu Therapy
Milieu Therapy
• Total environment has an effect on the
individual’s behavior
• Components
– Physical Environment
– Interpersonal relationships
– Atmosphere of safety, caring, and
mutual respect

– 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.

Outcome is either return to


previous functioning level,
improved coping, or decreased
coping.

Crisis intervention techniques are


authoritative and facilitative. A
balance of both types is most
effective.
Anger, Hostility, and
Aggression
Anger is a normal human
emotion.

Hostility and aggression are


inappropriate expressions of
anger.
Anger
Anger is a strong,
uncomfortable, emotional
response to a provocation,
either real or perceived.
It results when one is
frustrated, hurt, or afraid
and energizes the body for
defense (fight or flight).
• Denying or suppressing angry
feelings can lead to physical or
emotional problems
• Anger that is expressed
inappropriately can lead to hostility
and aggression
• Appropriate expression of anger
involves assertive communication
skills that lead to problem solving or
conflict resolution
• Venting angry feelings by
engaging in safe but aggressive
activities (punching bag, yelling)
is called catharsis. However,
research has shown that
catharsis may increase rather
than alleviate angry feelings
• Clients with depression may have
anger attacks when they feel
emotionally trapped
• Which nursing intervention is most
important when restraining a violent
client?
A. reviewing facility policy regarding
how long the client can be restrained
B. preparing an as needed dose of the
client’s psychotropic medication
C. checking that the restraints have
been applied correctly
D. asking if the client needs to use the
bathroom or is thirsty
Hostility and
Aggression
Hostile and aggressive behavior may
occur suddenly without warning, but
often stages or phases can be
identified:
• Triggering
• Escalation
• Crisis
• Recovery
• Postcrisis
Hostility is an emotion expressed
by:
• Verbal abuse
• Lack of cooperation
• Violation of rules or
norms
• Threatening behavior
(verbal aggression)
Related Disorders
Most psychiatric clients are not
aggressive, but some exhibit angry,
hostile, or aggressive behavior caused
by:
• Paranoid delusions
• Auditory (command) hallucinations
• Dementia, delirium
• Head injury
• Intoxication with alcohol or drugs
• Antisocial and borderline personality
Intermittent Explosive Disorder:
Rare psychiatric diagnosis involving
discrete episodes of aggressive
impulses resulting in serious injury
or property damage
Episodes are out of proportion to
any provocation, and the person is
remorseful and embarrassed
afterward.
Acting Out
An immature defense mechanism
in which the person deals with
emotional conflict or stress by
actions rather than reflection or
feelings; the person is trying to
feel less powerless or helpless by
acting out.
Etiology of Hostility and
Aggression
• Neurobiologic theories:
decreased serotonin, increased
dopamine and norepinephrine;
damage to frontal or temporal
lobes
• Psychosocial theories: failure to
develop impulse control and
ability to delay gratification
Treatments and
Medications
Treatment often focuses on
treating the underlying or
comorbid psychiatric
diagnosis such as
schizophrenia or bipolar
disorder.
Aggressive Clients
• Lithium for bipolar disorder, conduct
disorder, or mental retardation
• Carbamazepine (Tegretol) or valproate
(Depakote) for dementia, psychosis, or
personality disorders
• Atypical antipsychotics such as clozapine
(Clozaril), risperidone (Risperdal), and
olanzapine (Zyprexa) for dementia, brain
injury, mental retardation, and personality
disorders
• Benzodiazepines for older adults with
dementia
• Haloperidol (Haldol) and lorazepam (Ativan)
for clients with psychoses
Assessment
• Early assessment and intervention
needed when clients are angry or
hostile to avoid physically
aggressive episodes
• Nurse must assess both individual
clients and the therapeutic milieu or
environment
• Assessment and intervention are
based on five phases of aggression
Data Analysis
Common nursing diagnoses:
• Risk for Other-Directed
Violence
• Ineffective Coping
Intervention
Interventions are most effective and
least restrictive when implemented
early in the cycle of aggression.
• Managing the milieu includes:
– Having planned activities; informal discussions
– Scheduled one-to-one interactions; letting clients
know what to expect
– Helping clients with conflicts to solve their
problems, including expression of angry feelings
• Managing aggressive behavior includes:
– Triggering phase:
• Approach in nonthreatening, calm
manner
• Convey empathy
• Listen
• Encourage verbal expression of
feelings
• Suggest going to a quieter area, or use
of PRN medications
• Physical activity such as walking
– Escalation phase:
• Take control
• Provide directions in firm, calm voice
• Direct client to room or quiet area for
time out
• Offer medication again
• Let client know aggression is unacceptable
and nurse or staff will help
maintain/regain control if needed
• If ineffective to that point, obtain
assistance from other staff (show of
force) to get client to take time out or
take medication
– Crisis phase:
• Staff must take control of situation as
determined by facility or agency policy
(trained in techniques for behavioral
management)
• Use restraint or seclusion only if
necessary
– Recovery phase as client regains control:
• Talk about the situation or trigger
• Help client relax or sleep
• Explore alternatives to aggressive behavior
• Provide documentation of any injuries
• Staff debriefing
– Postcrisis phase:
• Client is removed from any restraint
or seclusion and rejoins the milieu
• Calm discussion of behavior; no
lecturing or chastising; return to
activities, groups, and so forth
• Focus is on appropriate expression
of feelings, resolution of problems
or conflicts in nonaggressive manner
Community-Based Care
• Regular follow-up appointments,
compliance with prescribed medication,
and participation in community support
programs help the client to achieve
stability
• Anger management groups
are available to help clients
express their feelings and
learn problem-solving and
conflict-resolution techniques
Self-Awareness Issues
• How nurse handles own angry feelings
• Comfort with expression of anger from
others
• Ability to be calm, nonjudgmental
• Nurse must have assertive communication
skills, conflict resolution skills, ability to
see that client’s behavior/anger is not
personal or a sign of nurse’s failure, and
ability to deal with own fear when clients
are aggressive or threatening
Abuse and Violence
Clinical Picture of Abuse and
Violence
• Abuse is the wrongful use
and maltreatment of another
person…
…can be child, spouse, partner,
or elder parent
Victims of abuse and trauma can have
both physical and psychological injuries,
including:
• Agitation anxiety, silence
• Suppressed anger or resentment
• Shame and guilt
• Feelings of being degraded or
dehumanized; low self-esteem
• Relationship problems; mistrust of
authority figures
Characteristics of Violent
Families
• Social isolation
• Alcohol and other drug abuse
• Power and control by abusive
person
• Intergenerational
transmission process
Spouse or Partner Abuse
• Involves the mistreatment of one
person by another in the context
of an intimate relationship
• 90% to 95% of domestic violence
victims are women
• Pregnancy escalates domestic
violence
• Abuse can occur in same-sex
relationships
Battered Wife Syndrome
Psychodynamics
• Often done by the husband to his wife
• Abusive husband believes that he owns
his wife (as one of his possessions) and
starts to be violent and abusive when
the wife shows signs of being
independent (like having her own job)
Profile of the Abuser
• Inadequate
• With low self-esteem
• Poor problem-solving and social skills
• Immature
• Needy
• Unreasonably jealous
• Possessive
• He longs for power and a sense of control,
which he is able to have when he bullies and
punishes the family physically
Profile of the Abused
• Dependent
• Low self-esteem
• Perceives herself as unable to function
away from her husband
• Equates success with her blind loyalty to
her husband
• Fear of being killed by the abuser if
they try to escape
Cycle of Abuse and Violence
• Initial episode of violence
• Honeymoon period: abuser promises it
will never happen again, gives gifts and
flowers, is affectionate
• Tensions begins to build with arguments,
silence, complaints
• Violence occurs again
• This cycle repeats over and over
Battered Wife Syndrome
When preparing to present a community
program about women who are victims
of physical abuse, which of the
following would the nurse stress about
the incidence of battering?

a. Death from battering is rare.


b. Battering is a major cause of injury
to women.
c. Lower socioeconomic groups are
primarily affected.
d. Battering rarely involves pregnant
women.
Assessment
• It is necessary to identify victims of
abuse in all settings, since they often
do not seek treatment directly
• SAFE questions can be used to assess:
– Stress/Safety- What stress do you experience in your
relationship? Do you feel safe in your relationship?
– Afraid/Abused- Have there been situations in your
relationship where you have felt afraid
– Friends/Family- Are your friends aware that you have
been hurt? Do your family/siblings know about this abuse?
– Emergency plan – Do you have a safe place to go and
the resources you & your children need in an emergency?
Treatment and Intervention (cont’d)
• Injuries -Assessment for physical injuries immediately
after the episode of violence

• Communication -The nurse must never indicate that


he or she thinks the woman should leave the relationship;
need to keep the door open for further communication

• Information -Providing women with information


about shelters, services, and so forth is essential
Effect of Violence on the Children
The violence the children experience
has a great impact on their health and
development.

They tend to be more aggressive and


have greater risk-taking behavior.
A 3-year-old client is bought to the emergency
room with a fractured wrist and suspicious
bruising on his arms. The step-father claims
the boy fell out of bed. What is the most
important criterion for the nurse to consider
when deciding to report suspected child abuse?
a. Inappropriate parental concern or the degree of
injury.
b. Absence of parents for questioning about the
injury.
c. Inappropriate between the history and injury.
d. Incompatibility between the history and injury.
Child Abuse
Child abuse is intentional injury of a
child, including:
– Physical abuse or injuries
– Sexual assault or intrusion
– Neglect or failure to prevent harm
(failure to provide adequate physical or
emotional care or supervision;
abandonment)
– Psychological abuse
• Julia, 6 years old the youngest of 4 daughter of
Mr. & Mrs. Gomez was brought to the
emergency room with bruises all over the body
and lacerations on her face.
• During the initial interview with the parents,
they gave a typical description of an abused
child when they say that Julia:
A. has always been different from her sisters
B. does not show respect for others
C. tends to lie frequently
D. always displays temper tantrums
Parents who abuse children:
(psychodynamics)
• Knowledge- Have minimal parenting knowledge and
skills
• Unmet needs -Are incapable of meeting their
own needs, much less those of a child
• Transmission- Often raise their children the
way they were raised, including corporal
punishment and abuse
• Unrealistic expectations -Expect the child
to meet all their needs for love and affection
• Emotions -Are emotionally immature and needy
Assessment
Suspect child abuse when there
are:
• Delays in seeking treatment; old injuries
that were not treated
• Unusual injuries such as scalding and
cigarette burns
• Multiple, unexplained bruises
• Inconsistent history, or illogical
explanation for the injuries
• Urinary tract infections; red, swollen, or
bruised genitalia; tears of vagina or
Types of Child Abuse
Physical Abuse
• Involves the performance of a severe corporal
punishment of hitting or beating child victims
• These acts include biting, burning, cutting,
poking, twisting limbs, or scalding with hot
water
• Signs and symptoms:
– Untreated fractures
– bruises of various ages
– injuries not explained adequately by caregivers
Sexual Abuse
• Involves sexual acts committed by an
adult towards an individual below 18
years of age

• This may involve incest, rape, sodomy,


exposure, rubbing or fondling of the
victim’s genitals

• This also includes sexual exploitation of


involving minors in acts of pornography or
in doing obscene acts
Neglect

Intentional or ignorant withholding of physical,


emotional, or educational needs for the
improvement of the child’s well-being

May be in the form of:


• refusal or delay in seeking medical treatment
• abandonment
• inadequate supervision
• recklessness with the child’s safety
• spouse abuse in the child’s presence,
• failure to enroll the child in school
Psychological Abuse
Abuse which adversely affects the child’s
emotional make-up
These may include:
 verbal abuse
 blaming
 screaming
 name-calling
 constant family
arguments resulting to fighting and
yelling
withholding of affection and
experiences that promote love,
security, and self-worth

This could also be in the form of parental


Changes in the Victims and Survivors of
Abuse
Physical
 Injuries in the form of fractures or burns
 Sexuallty-transmitted diseases

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:

a. File charges against the mother and the


father of the child
b. Report the case to legal authorities
c. Ask the mother to identify the individual
who is physically abusing the child
d. Tell the child that she will need to go to a
foster home until the situation is
straightened out.
Elder Abuse
Elder abuse is maltreatment of
older adults by family members
or caretakers, including:
– Physical, sexual, or psychological abuse
or neglect
– Self-neglect
– Financial exploitation
– Denial of adequate medical treatment
• 60% of perpetrators are spouses,
20% adult children, 20% others

• People who abuse elders are


almost always in a caretaker role

• Elders are reluctant to report


abuse because they fear the
alternative (nursing home)
Assessment
Possible indicators of physical abuse:
• Malnourished, dehydrated
• Rashes, sores, lice
• Smell of urine, feces, dirt
• Failure to keep needed medical
appointments
• Untreated medical condition
Possible indicators of emotional or
psychological abuse:
• Reluctance to talk openly
• Helplessness
• Withdrawal or depression
• Anger or agitation
Possible indicators of self-
neglect:
• Inability to manage own
finances
• Inability to perform activities
of daily living
• Inadequate clothing
• Signs of malnutrition or
dehydration
Possible indicators of abuse by
caregiver:
• Caregiver speaks for the elderly
person
• Caregiver shows indifference or anger
• Caregiver blames elderly person for
physical problems
• Caregiver shows defensiveness
• Caregiver and client give conflicting
accounts
Possible indicators of financial
exploitation:
• Recent changes in will that client
could not make
• Different signatures on checks
• Unusual activity in bank accounts
• Missing valuables
• Inability to manage money
Treatment and Intervention
Treatment and intervention may
involve:
• Providing adequate support and
respite for the caregivers
• Changing caregiving
arrangements
• Moving the elderly person to a
safe environment
Rape
Rape is a crime of violence and
aggression expressed through
sexual means. The act is
against the victim’s will or
against someone who cannot
give consent.
• A female victim of a sexual assault is being
seen in the crisis center for a third visit.
She states that although the rape occurred
nearly 2 months ago, she still feels “as
though the rape just happened yesterday.”
The nurse would respond by stating:
b. “What can you do to alleviate some of
your fears about being assaulted again.”
b. “Tell me more about those aspects of the
rape that cause you to feel like the rape
just occurred.”
c. “In time, our goal will be to help you move
on from these strong feelings about your
rape.”
d. “In reality, the rape did not just occur. It
has been over 2 months now.”
• The victim can be any age
• Half of rapes are committed by
someone known to the victim
• Rape is underreported to the
police
• Same-sex rape can occur
between partners but is most
common in institutions
Male rapists have been
categorized as:
• Sadists- Sexual sadists aroused
by pain of victim
• Anger -Those who rape as a
displaced expression of anger
and rage
• Predators- Exploitative
predators
• Inadequate men
Physical and psychological trauma to
rape victims is severe:
• Medical problems: victims are
significantly less healthy; pregnancy,
STDs, HIV are concerns
• Psychological Trauma -Victims may
feel frightened, helpless, guilty,
humiliated, and embarrassed; may
avoid previously pleasurable activities
• Relational Problems -Relationship
problems may occur, mistrust
Treatment and Intervention
• Immediate support to
ventilate fear and rage
• Care by persons who believe
that the rape happened
• Coordination of all needed
services in one location
• Giving the victim control over
choices whenever possible
• Prophylactic treatment for
STDs
• Referral to therapy services;
counseling; and groups for
longer-term help
Psychiatric Disorders Related
to Abuse and Violence
Two psychiatric disorders are
associated with histories of
violence and abuse:
2. Posttraumatic stress disorder
(PTSD)
3. Dissociative disorders
PTSD
Disturbing behavior resulting
after a traumatic event at least
3 months after the trauma
occurred
Up to 60% of persons at risk
(combat veterans, victims of
violence and natural disasters)
develop PTSD.
Dissociative Disorders
Dissociation is a subconscious defense
mechanism that helps a person protect
the emotional self from recognizing the
full impact of some horrific or
traumatic event by allowing the mind to
forget or remove itself from the
painful situation or memory.
Dissociation can occur both during and
after the event and becomes easier
with repeated use.
Self-Awareness Issues
• Becoming comfortable asking all women
about abuse (SAFE questions)
• Listening to accounts of abuse from
clients and families
• Recognizing client’s strengths, not just
problems
• Working with perpetrators of abuse;
dealing with own feelings about abuse
and violence
• Which of the following statements made
by a client whose husband has just died
would be the most important in
determining whether her response is
normal or delayed or extended?

C. “My husband died 1 week ago.”


D. “I feel sad and want to cry all the time.”
E. “We were married for 40 years.”
F. “We grew apart during the later years.”
Grief and Loss
Grief refers to the subjective
emotions and affect that are a
normal response to loss.
Grieving, also known as bereavement, is
the process of experiencing grief.
Anticipatory grief is facing an
imminent loss.
Mourning is the outward sign of grief.
Experiences of grief and loss are essential and
normal in the course of life; letting go,
relinquishing, and moving on happen as we grow
and develop.
Grief and loss are uncomfortable.
Types of Losses
Losses may be planned, expected, or
sudden. Loss of a loved one is
probably the most devastating type
of loss, but there are many other
types of losses: (Maslow’s)
• Physiologic (loss of limb, ability to
breathe)
• Safety (domestic violence,
posttraumatic stress disorder,
breach of confidentiality)
• Security/sense of belonging
(relationship loss [death,
divorce])
• Self-esteem (ability to work,
children leaving home)
• Self-actualization (loss of
personal goals, such as not going
to college, never becoming an
artist or dancer)
The Grieving Process
Nurses must recognize the signs of
grieving to understand and support
the client through the grieving
process.
The therapeutic relationship and
therapeutic communication skills are
paramount when assisting grieving
clients.
• 52 year old Renee Sandoval comes to
the mental health clinic and related
that since the death of her husband
she feels really miserable. She says in a
loud voice, “How could he leave me? I
can’t deal with this!” Which of the
following stages of the grief reaction is
she most likely displaying at this time?

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

• Emotional responses to grief


• Spiritual responses to grief
• Behavioral responses to grief
• Physiologic responses to grief
Nurse’s Role
The nurse must encourage clients to
discover and use effective and
meaningful grieving behaviors:
• Praying
• Attending memorials and public
services
• Performing rituals
• Staying with the body
Disenfranchised Grief or

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?

• Does the client have adequate support?

• Does the client have adequate coping


behaviors?
Intervention (P-S-C)
• Regarding perception of the loss
– Explore perception and meaning of the loss

• Regarding adequate support


– Help the client reach out and accept what others want
to give

• Regarding adequate coping behaviors


– Shift from an unconscious defense mechanism to
conscious coping
– Compare and contrast past coping
– Encourage the client to care for self
Essential communication and interpersonal
skills to assist grieving: (BUTTONS)

• Beliefs- Respect the client’s personal


beliefs
• Uniqueness -Respect the client’s unique
process of grieving
• Touch -Appropriate use of touch indicates
caring
• Trust -Be honest, dependable, consistent,
and worthy of the client’s trust
• Offer Smile -Offer a welcoming smile and
eye contact
• Name- Refer to a loved one or object of
loss by name (if acceptable in the client’s
culture)
• Simple - Use simple, nonjudgmental
Self-Awareness Issues
• Examining one’s own
experiences with grief and
loss
• Taking a self-awareness
inventory and reflecting on
the results may be helpful.

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