NCSBN – Lesson 4: Psychosocial Integrity Study Guide
Concepts of Mental Health Diagnosing & Treating Mental Illness
• Neuroimaging through
... [Show More] positron emission tomography (PET), computed tomography (CT) and magnetic resonance imaging (MRI) allow researchers and diagnosticians to
study the brain.
• The major neurotransmitters of the brain include norepinephrine, dopamine, serotonin and gamma-aminobutyric acid (GABA).
• As a result of a better understanding of neurotransmitters and their functioning, medications are now more effective than ever before.
• Currently, no type of genetic testing can tell whether a person will develop mental illnesses. Although familial and genetic factors are known to play a part in developing some mental illnesses such as bipolar disorder and schizophrenia, there is not enough evidence to know which gene variations contribute to the development of the illness or even the degree to which other factors contributed to it.
Theories of Mental Illness
There are various psychological theories about mental illness, including Sigmund Freud's Psychoanalytic Theory, Harry Stack Sullivan's Interpersonal Theory, Erik Erickson's Psychosocial Developmental Theory, cognitive behavioral theory and behavioral theory.
Psychoanalytic Theory
• Freud believed that only part of each persona's mental functioning is conscious and that treatment of mental illness involves helping the client become aware of the unconscious structures of the id, ego and superego.
• Freud also believed that individuals unconsciously use defense mechanisms to cope with anxiety and defend the ego from conflicts between the id and the superego.
Defence Mechanism s Primitive
- Very effective short-term, but less effective over the long run
- Often used by children Less Primitive Mature
- Focused on helping a person cope and be at peace w/ themselves and those around them
Denial
• when someone treats obvious reality factors as though they do not exist because they are consciously intolerable
Ex: A woman refuses to believe her child has been diagnosed with leukemia, and states, "she just has the flu."
A functioning alcoholic denies he has a drinking problem, pointing out how well he functions in his job and relationships. Repression
• an unconscious, deliberate forgetting of unacceptable or painful thoughts, impulses,
feelings or acts
Ex. An adolescent "forgets" their appointment with a counselor to discuss final grades. Sublimation
• diversion of unacceptable instinctual drives into personally and socially acceptable areas
Ex. A young woman who hated school becomes a teacher.
A person telling a lighthearted joke about a dark fantasy that secretly causes them great shame.
Regression
• retreating to an earlier and more comfortable emotional level of development.
Ex. A 4-year-old insists on climbing into a crib with their younger sibling.
After moving to a new home, a 5-year-old starts wetting the bed Displacement
• involves transferring unacceptable feelings aroused by one object to another, more
acceptable substitute
Ex. Adolescent lashes out at his parents after not being invited to a party by his peers.
A person who gets angry at his boss, but can't express his anger for fear of being fired, comes home and kicks the dog or starts an argument Compensation
• An extra effort in one area is an attempt to offset real or imagined lack in another area; it helps
reinforce a person's self-esteem and self-image
Ex. A person who chain smokes or works out excessively in order to be able to boast about their fitness.
In order to compensate for a lack of cooking skills, a person keeps an extremely organized and immaculate kitchen
Acting out Intellectualization
• use of thinking, ideas or intellect
to avoid emotions. Assertiveness
Ex. A parent becomes extremely knowledgeable about their child's diabetes yet denies having feelings about it.
A wife of a substance abuser knows about enabling behaviors yet continues to report his absence on Monday morning as an "illness."
Dissociation
• walls off specific areas of the personality from consciousness.
Ex. An adolescent jokes about failing grades as if they belong to someone else.
People who have a history of any kind of childhood abuse often suffer from some form of dissociation. Rationalization
• justifying behaviors, emotions and motives considered
intolerable through acceptable excuses
Ex. "I didn't get chosen for the team because the coach plays favorites."
A woman who was head-over-heels in love with a guy, who then dumps her, says, "I knew he was a loser."
Compartmentalization Undoing
Projection
• unconsciously projecting one's own unacceptable qualities or feelings onto others.
Ex. A woman who is jealous of another woman's wealth accuses her of being a gold digger.
A student who has sexual feelings towards a teacher tells her friends that the teacher is "coming on to her."
Reaction formation
• expressing unacceptable wishes or behavior by exhibiting opposite overt behavior.
Ex. A recovered smoker preaches about the dangers of second-hand smoke.
A woman who is very angry with her boss and would like to quit her job, instead is overly kind and generous toward her boss and expresses a desire to keep working there forever
Interpersonal & Psychosocial Developmental Theories
The Interpersonal theory was originally developed by Harry Stack Sullivan. The theory posits that personality develops according to the client's perception of how others view them and that a healthy personality is the result of healthy relationships.
Hildegard Peplau, who is considered to be the "mother of psychiatric nursing," was influenced by this theory and
wrote Interpersonal Relations in Nursing, which became the foundation for the nurse-client relationship. According to Peplau, the nurse-client relationship is one in which the client receives unconditional acceptance, the relationship between nurse and client is client-centered and the relationship is developed according to the client's perceived readiness.
Psychosocial Developmental Theory
The Psychosocial Developmental theory was developed by Erik Erikson. This theory extends Freud's work. Erikson believed that personality develops in a series of eight predetermined stages across the lifespan and that each stage involves a crisis or conflict: trust vs. mistrust, autonomy vs. shame and doubt, initiative vs. guilt, industry vs. inferiority, identify vs. role confusion, intimacy vs. isolation, generativity vs. stagnation and integrity vs. despair.
Normal development is when a person successfully resolves the conflict; if the conflict is not resolved, then development is arrested at that stage.
CBT – Cognitive Behavioural Therapy
• is a type of psychotherapy based on the concept of pathological mental processing. The focus of treatment is on the modification of distorted cognitions and maladaptive behaviors.
• focuses on the premise that a person's thoughts control their behavior.
o If a client is feeling or behaving in an unwanted way, then it is important to
identify the thoughts that are causing these feelings or behaviors.
▪ The goal of treatment is to have the client replace current thoughts with ones that produce a more desirable outcome.
• The three major components of cognitive therapy are educational aspects, cognitive techniques and behavioral interventions.
Behavioral Therapy
• Behavioral theory believes that symptoms of mental illness are the result of learned behavior. Through the use of positive and negative reinforcement, unacceptable learned behavior can be replaced by a more desired behavior. Symptoms of phobias, sexual dysfunction and eating disorders are some of the mental illnesses currently treated using behavioral therapy. Assertiveness training and desensitization are also commonly used behavioral techniques.
Religious & Cultural Awareness
As health care becomes more complex, it is more important than ever to recognize and treat clients and their families or advocates as partners in their care. Patient- and family-centered care (PFCC) promotes effective partnerships with clients, families and health care professionals. This partnership leads to improved client safety, better health outcomes and increased patient (and staff) satisfaction.
Religion & Spirituality
Religion is an organized system of beliefs about a higher power. Spirituality relates to beliefs about the essence of being. Nurses should be familiar with some of the more common religious practices, including information about diet, daily prayer needs and beliefs surrounding death.
Being open to learning about a client's religious beliefs can help a nurse better respect their client's health care preferences.
Cultural Competence
Cultural competence is a set of skills nurses need in order to provide client- and family-centered care. This involves obtaining accurate information from the client, including cultural practices used for health and healing, and developing a mutually acceptable and culturally-relevant treatment plan for each client problem.
• Cultural Assessment Tools
o There are a number of different mnemonic devices to help you conduct a cultural assessment, such as "LEARN" and "ETHNIC". You can use either of these acronyms to help you remember the steps of a culturally sensitive assessment:
• Health Literacy
o Clients need to know and understand information about their current health status.
They also need to understand their prognosis and treatment protocol. Additionally, the client must be well informed about the processes and expectation of medical care, self-care and health promotion.
o Nurses need to be aware that even under non-stressful circumstances, a client understanding what they or other health care providers are saying can be challenging. Understanding a person's health literacy will allow the nurse to share information in ways that clients can understand and in their preferred language. Helping to ensure that clients understand their plan of care, know how to take their medications and know how to take care of themselves at home is a nursing responsibility.
Grief & Loss Loss
• is a universal phenomenon that occurs across the lifespan. While we often think of the loss of significant others such as through death or divorce, there are a variety of types of
losses, including:
o Loss of an object
o Loss of an environment, by moving to a new location, starting a new job or being admitted to a health care facility
o Loss of an aspect of oneself, which may include loss of a body part, such as amputation of a limb or a physiologic or psychological function
o A perception of loss that's felt by the person but intangible to others, such as "youth"
o Situational loss, which is the result of an unpredictable event, such as a natural disaster
• A person's response to loss depends on a number of factors, including personality, culture, previous experience with loss, values, the perceived value of the loss and the person's support system.
Grief
• Anticipatory grief
o Mental anguish caused by the impending loss of a body part, a function or a loved one.
o A person learns of impending loss and responds with processes of mourning, coping, interaction, planning and psychosocial reorganization.
• Disenfranchised grief
o A person experiences a loss that is not or cannot be openly acknowledged, publicly mourned or socially supported.
• Complicated grief
o Grief that is the result of a sudden loss.
Theories of Grief
Elizabeth Kubler-Ross (1969) Description
Denial • Unconscious avoidance which varies from a brief period to the remainder of life
• Allows one to mobilize defenses to cope
• Positive adaptive responses; verbal denial or crying
• Maladaptive responses; no crying, no
acknowledgement of loss
Anger • Expresses the realization of loss
• May be overt or covert
• Positive adaptive responses; verbal expressions of anger
• Maladaptive responses; persistent guilt or low self- esteem, aggression, self-destructive ideation or
behavior
Bargaining • An attempt to change the reality of loss; a person bargains for treatment control; expresses the wish
to be alive for specific events in the near future
• Maladaptive responses; bargains for unrealistic activities or events in distant future
Depression and Withdrawal • Sadness resulting from actual and/or anticipated loss
• Positive adaptive response; crying, social withdrawal
• Maladaptive responses; self-destructive actions,
despair
Acceptance • Resolution of feelings about death or other loss, resulting in peaceful feelings
• Positive adaptive behaviors: may wish to be alone,
limit social contacts, complete personal business
John Bowlby (1961-1980)
Four stages of separation and loss; individuals progress through these stages at their own pace, in any order, in an attempt to resolve their loss.
1. Shock and numbness
2. Searching and yearning
3. Disorientation
4. Reorganization and resolution Erich Lindemann (1944)
Describes grief as a syndrome that includes a common range of physical symptoms, i.e., tightness of throat, shortness of breath and other pain, along with a range of emotional responses. Lindemann's research is based on a sample of primarily young survivors of sudden and traumatic loss.
1. Shock
2. Acute mourning
3. Resolution of grief
William Worden (1991)
Describes four tasks in the grieving process; once these tasks have been completed, grief is assumed to have been resolved.
• To accept the reality of the loss
• To work through the pain of grief
• To adjust to the changed environment (in which the deceased is missing)
• To emotionally relocate the deceased and move on with life
Tagliaferre and Harbaugh (2002)
• Expanded on Worden's model of grief
• Proposed five tasks:
o Acknowledge the loss
o Feel the impact
o Acquire temporary substitutes
o Detach from the relationship
o Reconstruct a new life
Nursing Care
The nurse should always remember that grieving is not a linear process. Everyone grieves in their own way and there is no time limit for how long a client grieves.
Nursing care involves supporting the client and encouraging the client and/or significant other to express their feelings and concerns. Nurses should listen to the client and support effective coping mechanisms, problem-solving and decision-making efforts. Nurses can also provide resources to assist the client, including referrals to resources to help adjust to loss and bereavement.
The nurse can utilize therapeutic touch as appropriate.
The Nurse-Client Relationship
A therapeutic relationship is one that is established between a health care professional and a client for the purpose of assisting the client with problem solving, grief counseling and teaching, regarding an illness or situation. The relationship consists of the nurse who possesses the skills and ability to provide counseling, crisis intervention and health teaching and the client, who is seeking help for a problem.
Therapeutic interventions may be one-on-one, with a group and/or a family. The five basic characteristics of the nurse-client relationship include defining the relationship, goal-setting goals and establishing boundaries. Throughout the relationship, the nurse helps the client toward a resolution of the problem.
• The first stage is when the nurse establishes trust and rapport with the client.
• Many relationships begin with a contract that establishes the time, place and duration of the sessions.
• During orientation, they outline problems and expectations, including goal-setting and a plan of action.
o The nurse and client also establish the parameters for ending the relationship.
• The client is usually anxious. The nurse can help alleviate the anxiety by encouraging the client to explore and talk about these feelings.
Working Phase
• Once the boundaries of the relationship are accepted by the client and the nurse, and a therapeutic relationship is established, the nurse and the client can begin to work on the client's problems.
• The nurse will help the client identify insight into the problems and provide the client with adaptive coping and problem-solving skills.
o An ongoing evaluation of the effectiveness of the interventions is discussed at every meeting.
• The nurse uses therapeutic communication techniques and active listening skills. You can remember these skills using the acronym: SOLER.
Termination Phase
• The termination phase begins with the first session and ends when the identified treatment goals have been met.
• This is the time when the nurse and client reassess the problem and evaluate outcomes. It is also the time to encourage clients to use what they have learned and be proactive about meeting their needs independently.
• Occasionally, this is a difficult time for the client. Depending on the circumstances, the client may become too dependent on the nurse and the separation may bring up previous separation experiences and feelings of rejection, depression and/or abandonment. The nurse should reassure
the client that it's natural to feel this way and encourage the client to express any thoughts and feelings about termination.
Stress Management
Stress is a universal phenomenon that requires change or adaptation so that the person can maintain equilibrium. Stress can be considered as any physical, chemical or emotional factor that causes bodily or mental unrest.
Eustress or positive stress can help motivate people, improve performance and can even feel exciting. Eustress is usually short-term. Distress or negative stress causes anxiety or concern and is perceived to be outside of our ability to cope. It is an unpleasant feeling that decreases performance and can lead to mental and physical problems.
A stressor is anything that causes the release of stress hormones. There is a list of potential stressors, which can conveniently be placed into one of two categories: physiological and psychological. Physical stressors may include disease or physical symptoms. Psychological stressors may include feelings of unexpressed anger, isolation and loss and poor body image.
• Stage 1 – ALARM
o When the body perceives a stressor, the body reacts with a fight-or-flight
response.
▪ The stress response begins in the brain. When there's a perceived threat, the amygdala sends a distress signal to the hypothalamus. The hypothalamus oversees the stress response and will send a message to the pituitary gland and adrenal medulla.
▪ The adrenal medulla (part of the autonomic nervous system) works to maintain homeostasis. The adrenal medulla secretes the hormone epinephrine (adrenaline), which gets the body ready for a fight or flight response.
▪ Physiological reactions include:
• Increased blood pressure
• Tachycardia
• Tachypnea
• Increased respiratory rate
• Increased blood pressure
• Cold hands and feet
▪ Extra oxygen is sent to the brain, which increases alertness. Epinephrine also triggers the release of glucose and fats from temporary storage sites in
the body, which supplies the body with energy. Sight, hearing and the other senses become sharper.
▪ The next phase of the stress response system includes a series of hormonal signals to maintain the sympathetic nervous system's response. The
pituitary gland secretes adrenocorticotropic hormone (ACTH), which stimulates the adrenal glands to release cortisol. Cortisol allows the body to maintain a steady supply of glucose by releasing stored glucose from the liver.
▪ Stress also affects mood and the ability to think and process information. When someone is stressed, they may be irritable. Crying and feelings of
inadequacy may also be part of the stress response. People may become forgetful and seem preoccupied. There's a tendency to make mistakes, which decreases productivity. They may even display poor judgement.
o Adrenaline stimulates the sympathetic nervous system into action and reduces activity in the parasympathetic nervous system until the perceived threat is over.
• Stage 2 – RESISTANCE
o The body resists and compensates as the parasympathetic nervous system
attempts to return to normal levels of functioning. The body remains on alert.
• Stage 3 – EXHAUSTION
o If the stressor or stressor continue, the body becomes exhausted. There's a
decrease in the immune response, including a suppression of T-cells and dysfunction in the lymphatic system. The body is susceptible to disease and death.
Managing Stress
• Since stress is a normal part of life, it's impossible
to eliminate all stress. Instead, clients should learn how to manage distress.
• A balanced diet, adequate rest and regular physical activity helps anyone manage stress. Specific relaxation
techniques include breathing exercises, medication, progressive muscle relaxation, guided imagery, yoga, biofeedback and prayer.
• The nurse can use cognitive restructuring with the client to analyze the client's appraisal of stressors and then restructure his or her unrealistic or negative thinking.
Crisis Intervention & Suicide Prevention
Nurses will look for and assist clients and their families with events that can overwhelm their usual coping strategies.
• Crisis Intervention
o A crisis is an acute and temporary state of severe personality disorganization with an extreme state of emotional turmoil. The crisis occurs because the client's usual coping mechanisms and resources fail.
▪ A Crisis
• There are four parts of a crisis.
• First, the client must be in a vulnerable state.
• Second, there is a precipitating event.
o For example, the client could be going through a
maturational crisis, a situational crisis involving a life change, loss of a loved one or a job, or extraordinary circumstances, such as an environmental disaster or war.
• In the third or acute phase
o the client temporarily loses control and may be in a panic
state.
o The client's emotional reactions are overwhelming, and thinking is scattered.
o The client may not be able to make decisions or solve problems.
o When the client loses all effective coping skills and cannot continue to function, this is referred to as an exhaustion crisis.
▪ The shock crisis is the result of a sudden external change that causes a release of emotions that
overwhelms clients.
• The fourth or last part of the crisis
o is reorganization which takes place when a client is able to
integrate pain or loss into a new way of coping.
▪ Nursing Care
o Treatment is aimed at providing brief supportive interventions
focused on the phase of crisis.
o The objective is to help the client through the current crisis, allow free discharge of emotions and to enhance the client's cognitive thought processes.
o Often the client will need pharmacologic therapy, such as an
antidepressant or antianxiety medication.
o To assist the client in crisis, the nurse can provide a quiet, restful environment. The nurse can empower the client to solve problems by allowing the client to express his or her feelings and emotions. The nurse can also correct any misperceptions about the crisis being experienced by the client and help the client identify support systems and alternative solutions. [Show Less]