PYSCHIATRIC NURSING REVIEWER

(Prelims)

CHAPTER 1: Foundations of Psychiatric – Mental  Ex. Depression, schizophrenia,

Health Nursing anxiety and addictive disorders
 Mental disorders often cause significant
MENTAL HEALTH distress and/or impaired functioning
 Difficult to define  Factors contributing to mental illness include
 No single, universal definition (but are not limited to):
 A person’s mental health is dynamic, or ever- o Individual
changing state  Biological Makeup
 If the person adapts to the challenges  Intolerable or unrealistic
appropriate to the society he/she is mentally worries or fears
healthy o Interpersonal
o If not able to adapt, he/she is mentally  Ineffective Communication
unhealthy / ill.  Inadequate social support
 It is a state of emotional, psychological, and o Social/cultural
social wellness evidenced by satisfying  Unwarranted negative view of
interpersonal relationships, effective behavior the world
and coping, positive self-concept, and  Discrimination (Stigma, racism,
emotional stability. classism, etc.)
 Influencing factors:  It is important to note that some of these
o Individual (personal) social/cultural factors can result in isolation;
 person’s biological makeup feelings of alienation; and maladaptive,
 autonomy violent, or criminal behavior.
 independence Diagnostic and Statistical Manual of Mental Disorders
 self-esteem
 capacity for growth DSM-IV-TR
 vitality  Diagnostic and Statistical Manual of Mental
 ability to find meaning in life Disorder, 5th Edition, Text Revision
 emotional resilience or hardiness  Taxonomy
 Sense of belonging  Published by the American Psychiatric
 reality orientation Association
 Coping or stress management  It describes that all mental disorder, outlining
abilities. specific diagnostic criteria for each based on
 Personal aspect of a human clinical experience and research.
being; individualism  3 Main Purposes:
o Interpersonal (relationship) o Standardize nomenclature and
 Effective communication language
 ability to help others o Present defining characteristics or
 intimacy symptoms
 Balance of separateness and o Assist in identifying underlying causes
connectedness. of disorders
 Involvement of other people  Classification:
around you that could influence o Allows the practitioner to identify all
your behavior factors that relate to a client’s
o Social/cultural (environmental) condition:
 State where a human being is  Major psychiatric disorders
involved.  Medical conditions that are
 Are non-medical factors that relevant to
influence health understanding/managing the
 How it is influenced by the person’s mental disorder
community.  Psychosocial and environmental
MENTAL ILLNESS problems that may affect the
diagnosis, treatment and
 Inappropriate behaviour is considered prognosis of mental disorders
mentally ill.
 It is a pattern, to which it can be habitual QUESTION
o You can only diagnose a person if it is Tell whether the following statement is true or false:
chronic/habitual
 Includes disorder that affect:  The definition of mental health is standardized
o Mood and universally accepted?
o Behavior  ANSWER: False
o Thinking
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o There is no single universal definition of o Together with Emil kreapelin and

mental health, which has many Eugen Bleuler
components and is influenced by myriad  He studied the mind, its disorders and their
factors. treatment.
 Emil kreapelin began classifying mental
Historical Perspectives
disorders according to their symptoms
ANCIENT TIMES s  Eugen Bleuler coined the term “schizophrenia”

 Sickness indicated as displeasure of gods is PSYCHOPHARMACOLOGY (1950S) )

considered as a:
• punishment for sins and wrong doing;  Development of psychotropic drugs
• Those with mental disorder are viewed as o Chlorpromazine (antipsychotic drug) &
demonic or divine lithium (antimanic agent) were the first
drug to be developed
Aristotle o Because of the development of drugs
 Attempted to relate mental disorders to hospital stays were shortened, many
physical disorders people become well enough to go
 Developed his theory that the amounts of home.
blood, water and yellow and black bile in the
COMMUNITY MENTAL HEALTH MOVEMENT (1963) )
body is controlled by emotions
 The four humors corresponded with  Enactment of the Community Mental Health
o Happiness Centers Construction Act
o Calmness  Deinstitutionalization
o Anger o Deliberate shift from institutional care
o Sadness in hospitals to community facilities
 Imbalances of the 4 humors were believed to  Legislation for disability income
cause mental disorders o Involves Supplemental security income
o balance restoration via bloodletting, (SSI) & Social Security Disability Income
starving, purging (SSDI)
 Changes in commitment laws in 1970s
 Early Christians’ view as possession by demons o Making it more difficult to commit
 In England (Renaissance Period) they were people for mental health treatment
distinguished from criminals against their will.
 In 1547, Hospital of St. Mary of Bethlehem was
officially declared hospital for the insane 21ST CENTURY (CURRENT STATE) )
• The mentally ill were considered
evil/possessed and were punished  51.5 million adults in the United States have a
mental illness, though only 23 million received
PERIOD OF ENLIGHTENMENT (1790s) ) treatment within the past year (National
Institutes of Mental Health, 2021)
Philippe Pinel (France) & William Tuke (England)  Nearly 11 million children and adolescents are
 They formulated the concept of asylum as a diagnosed with a mental disorder.
safe refuge or haven offering protection at  Economic burden of mental illness exceeds the
institutions where people had been whipped, economic burden caused by all types of cancer.
beaten, and starved because they were  Leading cause of disability in United States
mentally ill. Canada for those 15-44 years of age
o It began the moral treatment  1 in 4 adults and 1 in 5 children and
Dorothea Dix adolescents getting care needed.
 Began a crusade to reform the treatment of  Treatment still lagging in homeless and those
mental illness after a visit to tuke’s institution with substance abuse problems.
in England.
 She opened 32 state hospitals that offered
asylum to the suffering - Issues and concerns: -
 Believed that the society was obligated to
 “Revolving-door” effect due to
those who are mentally ill
deinstitutionalization
 She advocated adequate shelter, nutritious
o Refers to the continuous flow of client
food, and warm clothing.
being admitted and discharged in an
institution (balik, sulod)
Sigmund Freud
o Often “boarded” in emergency
 The period of scientific study, treatment of
department while awaiting inpatient
mental illness
beds.
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 Shorter hospital stays, decompensation, o Despite flaws, positive aspects making them
rehospitalization, and dual problem of both preferable for treatment
mental illness and substance abuse.
Cost Containment and Managed Care
 Homelessness (⅓ estimated to have severe
mental illness; or a chronic substance use Managed care movement (early 1970s)
disorder)  Purposely control the balance between the
 Lack of adequate community resources quality of care and the cost of that care.
Utilization review firms/managed care organizations
(1990s)
QUESTION
 To control the expenditure of insurance funds
Which statement best reflects the current state of by requiring providers to seek approval
mental health and mental illness? before the delivery of care
Case management
A. Mental health care costs exceed the costs for  Represented an effort to provide necessary
cancer care. services while containing cost.
B. Most adults and children receive adequate  Case Manager: a person who coordinates all
mental health care. types of care needed by the client.
C. Community resources for the homeless with
mental illness are adequate. Health Care Finance Administration (HCFA)
D. Deinstitutionalization has reduced the o Medicare
revolving door effect.  Covers people 65 years and older
 People with permanent kidney
ANSWER: A. Mental health care costs exceed the costs
failure and certain disabilities
for cancer care.
o Medicaid
 The economic burden of mental illness exceeds
 Funded by the federal and state
that for all types of cancer care.
governments
o Only 1 in 4 adults and 1 in 5 children
 Covers low-income individuals and
received the necessary mental health
families.
care. Community resources for homeless
 Mental health parity, insurance coverage
clients with mental illness are inadequate.
o Eliminated annual and lifetime dollar
Deinstitutionalization has led to the
amounts for mental health care for
“revolving-door” effect.
companies with more than 50 employees.

OBJECTIVES FOR THE FUTURE

- Cultural Considerations –
Healthy People 2030 objectives
 Culturally diverse population
 Cultural differences influencing mental health,
treatment of mental illness
 Changes in family structure

QUESTION

Tell whether the following statement is true or false:

 Are Community-based programs are preferable
for treating many people with mental illness?
 ANSWER: True
o Although there are flaws in the system,
Community-Based Care community-based programs have
positive aspects that make them
 Lack of appropriate number of community mental
preferable for treating many people
health centers to provide services
with mental illness.
o 2,000 community health centers that were
supposed to be built by 1980 had not
PSYCHIATRIC NURSING PRACTICE
materialized
o By 1990, only 1,330 programs provided
 Linda Richards
various types of psychosocial rehabilitation
o first American psychiatric nurse
services.
o She went to improve nursing care in
 Development of community support programs
psychiatric hospitals and organized
o Availability, quality of services highly variable
educational programs in state mental
o Inaccurate anticipation of extent of people’s
hospitals in Illinois.
needs
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o She believed that “the mentally sick should Student Concerns and Psychiatric-Mental Health
be at least as well care for as the physically Clinical Experience
sick” 1. Saying the wrong thing
 McLean Hospital, Belmont Massachussets 2. Knowing what to do
o site of first training for nurses to work with 3. Being rejected or not talking to student
persons with mental illness 4. Asking personal questions
o Expansion of role with development of 5. Handling bizarre, inappropriate, or sexually
somatic therapies aggressive behavior
 First psychiatric nursing textbook 6. Handling feeling unsafe
o Nursing Mental Diseases 7. Seeing someone known on the unit
o By Harriet Bailey 8. Dealing with similar problems or backgrounds
o published in 1920
 Johns Hopkins - Self-Awareness –
o first school of nursing to include
psychiatric nursing course (1913)  Gaining recognition of one’s own feelings, beliefs,
 National League for Nursing (1950) and attitudes
o requiring schools to include psychiatric  Everyone with unique or different values, ideas,
nursing experience beliefs
 H. Peplau  Possible conflict between personal values/beliefs,
o therapeutic nurse-client relationship those of client
o Published Interpersonal Relations in  Need to accept differences, view each client as
Nursing in 1952 worthwhile regardless of opinions or lifestyle
o Published Interpersonal Techniques: The  Self-awareness through reflection
Crux of pshychiatric Nursing in 1962
 J. Mellow QUESTION
o focus on client’s psychosocial needs, Tell whether the following statement is true or false:
strength  The National League for nursing required schools
to include a psychiatric nursing experience
before the first nursing school included a
American Nurses Association and Standards of Care psychiatric nursing course in its curriculum.
(Areas of Practice)  False
o Johns Hopkins was the first school of
nursing to include a course in psychiatric
nursing in its curriculum; this was done in
1913. It was not until 1950 that the
National League for Nursing required
schools to include an experience in
psychiatric nursing.

Key Points

Psychiatric-Mental Health Nursing Phenomena of

Concern

CHAPTER 2: Neurobiologic Theories and

Psychopharmacology

Central Nervous System

A. Brain
o Cerebrum
o Cerebellum
o Brain stem
o Limbic system
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 Norepinephrine: attention, learning,

B. Cerebrum memory, sleep, wakefulness, mood
 Two hemispheres regulation
 Four lobes:  Epinephrine: fight-or-flight response
o Frontal lobe (thought, body movement,  Glutamate: neurotoxic effects at
memories, emotions, moral behavior) high levels
o Parietal lobe (taste, touch, spatial
orientation)
- Inhibitory –
o Temporal lobe (smell, hearing, memory,
emotional expression) 1. Serotonin: food intake, sleep, wakefulness,
o Occipital lobe (language, visual temperature regulation, pain control, sexual
interpretation such as depth perception) behaviors, regulation of emotions
2. Gamma-aminobutyric acid (GABA): major
C. Cerebellum inhibitory neurotransmitter; modulation of other
 Below cerebrum neurotransmitters
 Center for coordination of movements and 3. BENZOS
postural adjustments
 Reception, integration of information from all - Excitatory or inhibitory –
body areas to coordinate movement and  Acetylcholine: sleep-and-wakefulness cycle; signals
posture muscles to become alert

D. Brain Stem - Neuromodulator –

 Midbrain: reticular activating system (motor 1. Histamine
activity, sleep, consciousness, awareness) and 2. Neuropeptides
extrapyramidal system
 Pons: primary motor pathway QUESTION
 Medulla oblongata: vital centers for cardiac, Is the following statement true or false?
respiratory function  The cerebellum consists of four lobes.
 Nuclei for cranial nerves III through XII
 False
 Locus coeruleus: norepinephrine-producing
o Rationale: The cerebrum consists of four
neurons (stress, anxiety, impulsive behavior)
lobes. The cerebellum is located below the
cerebrum.
E. Lymbic System (emotional brain; hormones,
neurotransmitters)
 Above brain stem - Brain Imaging Techniques -
 Thalamus (activity, sensation, emotion)
 Computed tomography (CT)
 Hypothalamus (temperature regulation,
 Magnetic resonance imaging (MRI)
appetite control, endocrine function, sexual
drive, impulsive behavior)  Positron emission tomography (PET)
 Hippocampus and amygdala (emotional  Single-photon emission computed tomography
arousal, memory) (SPECT)
 DIRECTLY IMPACTS MENTAL HEALTH BC OF  Limitations
EFFECTS OF HORMONES o Use of radioactive substances; expense
of equipment; client’s inability to
Neurotransmitters tolerate technique
o Changes in disorders nondetectable
 Nerves that control voluntary acts
with current techniques
 Chemical substances to facilitate
neurotransmission
 Important in right proportions to relay - Neurobiologic Causes -
messages; studies showing differences in
brains of people with some mental disorders  Genetics and heredity: play role along with
 Play role in psychiatric illness and psychotropic nongenetic factors
medications, including their actions and side o Twin, adoption, and family studies are used.
effects  Psychoimmunology: compromised immune system
 Excitatory or inhibitory (see Table 2.1) possibly contributing, especially in genetically at-
o Excitatory risk populations
 Dopamine: complex movements,  Infections: theories include viruses that alter
motivation, cognition, regulation of human genes, viruses during fetal development
emotional response o Specifically brain infections

Nurse’s Role in Research and Education

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 Ensure all clients and families are well informed • Leads to severe weight gain
 Help distinguish between facts and hypotheses o Third generation (dopamine system
 Explain if or how new research may affect client’s stabilizers; e.g., aripiprazole)
treatment or prognosis  Use: treat symptoms of psychosis
 Provide information and answer questions  Mechanism of action: block dopamine receptors

QUESTION - Side Effects –

Is the following statement true or false?  Extrapyramidal symptoms (EPSs):

 Single-photon emission computed tomography o Acute dystonia
(SPECT) is considered the best type of brain  Torticollis – neck stiffness,
imaging technique to diagnose disease. opisthotonus, oculogyric crisis
 False  Treatment: anticholinergic drugs or
o Rationale: SPECT is not considered the diphenhydramine- Benadryl (see Table
best type of brain imaging used to 2.4)
diagnose disease. In fact, many of the  Pseudoparkinsonism (stooped posture, masklike
changes in the brain are not currently facies, shuffling gait)
detectable with any of the current  Akathisia (restlessness, anxiety, agitation)
techniques.  Neuroleptic malignant syndrome (NMS)
o Severe reaction to antipsychotics
 Tardive dyskinesia (permanent involuntary
PSYCHOPHARMACOLOGY Y
movements)
 Psychotropic drugs, things to consider:  Anticholinergic side effects (e.g., dry mouth,
o Efficacy (maximal therapeutic effect) constipation, urinary hesitancy or retention)
o Potency (amount of drug needed for o Foaming dry mouth
maximum effect) o Can lead to severe medical problems
o Half-life (time it takes for half of the drug  Other side effects:
to be removed from the bloodstream) o Increased prolactin levels
 Role of the Food and Drug Administration (FDA) o Weight gain (most likely with second-
o A lot of drugs are given off-label generation agents, except ziprasidone)
 Gabapentin – anxiety, cravings o Metabolic syndrome
o Off-label use (drug may be effective for o Cardiovascular adverse effects
treating a disease different from one o Lengthening of QT interval (thioridazine,
involved in original testing) droperidol, mesoridazine)
o Black box warning (serious or life- o Agranulocytosis (clozapine  very
threatening side effects) dangerous)
o Severe monitoring (in-patient)/ check labs
daily
Principles of Psychopharmacology
- Client Teaching –
 Effect on target symptoms
 Adequate dosage for sufficient time  Adherence to regimen
 Lowest effective dose  Management of side effects
 Lower doses for older adults o Thirst/dry mouth (sugar-free candy, liquids)
 Tapering rather than abrupt cessation to avoid o Constipation (dietary fiber, exercise)
rebound, recurrence of symptoms, or withdrawal  Colace
 Follow-up care o Sleepiness/drowsiness (safety measures)
 Simple regimen to increase compliance  Actions for missed dose (take dose if within 4 hours
of usual time)

ANTIPSYCHOTIC DRUGS S QUESTION

 Antipsychotic drugs (see Table 2.3) Which drug is classified as a conventional antipsychotic?
o Conventional or first generation (e.g., A. Clozapine
chlorpromazine, fluphenazine, thioridazine, B. Risperidone
haloperidol, loxapine) C. Fluphenazine
• Cause marchasonian symptoms  D. Aripiprazole
jerking movements, drool, shuffling
(Haldol) ANSWER: C. Fluphenazine
• EPS symptoms within the first year  Rationale: Fluphenazine is classified as a
o Atypical or second generation (e.g., conventional antipsychotic.
clozapine, risperidone, olanzapine)
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o Clozapine and risperidone are  Actions for missed dose

considered second-generation o Take SSRI up to 8 hours after missed dose
antipsychotics. Aripiprazole is o Take cyclic within 3 hours of missed dose
considered a third-generation or omit the day’s dose
antipsychotic.  Safety measures  serotonin syndrome
 Dietary restrictions with MAOIs (see Box 2.1)
ANTIDEPRESSANTS DRUGS S o Tyramine
 Use: major depressive illness, anxiety disorders,
depressed phase of bipolar disorder, psychotic MOOD STABILIZING DRUGS S
depression
 Four groups (see Table 2.5):  Lithium, some anticonvulsants (carbamazepine,
o Tricyclic and cyclic compounds valproic acid, gabapentin, topiramate,
o Selective serotonin reuptake inhibitors oxcarbazepine, and lamotrigine)
(SSRIs) o You want it to be as close to 1 (0.8-1.2) as
• Try at least 3 types before moving to possible
the next level  Use: treatment of bipolar illness
o Monoamine oxidase inhibitors (MAOIs)  Mechanism of action
o Other antidepressants o Lithium normalizes reuptake of certain
 Precise mechanism is not known. EXAM! neurotransmitters.
 Major interaction is with monoamine o Valproic acid and topiramate increase the
neurotransmitter systems, especially levels of GABA.
norepinephrine and serotonin. o Valproic acid and carbamazepine inhibit
the kindling process.

- Side Effects –
- Side Effects –
 SSRIs  anxiety disorder
o Anxiety, agitation, akathisia, nausea,  Lithium
insomnia, o Nausea, diarrhea, anorexia, fine hand
o Cause sexual dysfunction tremor, polydipsia, polyuria, metallic taste
o Weight gain in the mouth, fatigue, lethargy; weight gain,
 Cyclic antidepressants acne (side effects that occur later in
o Anticholinergic effects therapy)
o Orthostatic hypotension, sedation, weight o Toxicity: severe diarrhea, vomiting,
gain, tachycardia drowsiness, muscle weakness, lack of
o Sexual dysfunction coordination
o If you are just starting lithium they can be
 MAOIs  NOT first-line treatment
much more sensitive
o Daytime sedation, insomnia, weight gain,
dry mouth, orthostatic hypotension, sexual  Carbamazepine and valproic acid: drowsiness,
dysfunction sedation, dry mouth, blurred vision
o Hypertensive crisis (with foods containing  Carbamazepine: rash, orthostatic hypotension
tyramine)  NCLEX!!!! (cheese, meat, beer)  Valproic acid: weight gain, alopecia, hand tremor
 Other antidepressants  Topiramate: dizziness, sedation, weight loss
o Sedation, headaches (nefazodone,  Periodic monitoring of blood levels
trazodone) o 12 hours after last dose taken
o Loss of appetite, nausea, agitation,  Taking medication with meals
insomnia (bupropion, venlafaxine)  Safety measures
o Priapism (trazodone)
QUESTION

Is the following statement true or false?

- Drug Interactions -
 A client who takes an SSRI with an MAOI is at
Serotonin syndrome risk for a hypertensive crisis.
 MAOI + SSRI  False
 Symptoms: Agitation, sweating, fever, o Rationale: A client who takes an SSRI
tachycardia, hypotension, rigidity, hyperreflexia with an MAOI is at risk for serotonin
 Coma, death (extreme reactions) syndrome.
 Hypertensive crisis can occur if
- Client Teaching – the client is taking an MAOI and
 Time of dosage ingests foods containing
o SSRI first thing in morning tyramine.
o Cyclic compounds at night
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ANTIANXIETY DRUGS S DISULFIRAM M

 Use: treatment of anxiety and anxiety disorders,  Use: aversion therapy for alcoholism
insomnia, obsessive-compulsive disorder (OCD),  Mechanism of action: inhibition of enzyme
depression, posttraumatic stress disorder, alcohol involved with alcohol metabolism
withdrawal  seizure o Adverse reaction with alcohol ingestion
 Benzodiazepines, buspirone (see Table 2.6)  Side effects: fatigue, drowsiness, halitosis, tremor,
o Cause seizures in withdrawal impotence
 Mechanism of action  Drug interactions with phenytoin, isoniazid,
o Mediation of GABA (benzodiazepines) warfarin, barbiturates, long-acting
o Partial agonist activity at serotonin benzodiazepines
receptors (buspirone)  Client teaching: avoidance of alcohol, including
common products that may contain it
- Side Effects - o Shaving cream, deodorant, over-the-
counter cough preparations
 Benzodiazepines
o Physical, psychological dependence
QUESTION
o Central nervous system (CNS) depression
 Respiratory depression Which drug would the nurse expect to administer to a
o Hangover effect client with ADHD?
o Tolerance/ dependence A. Disulfiram
 Buspirone B. Methylphenidate
o Dizziness, sedation, nausea, headache C. Buspirone
D. Lithium
- Client teaching –
ANSWER: B. Methylphenidate
 Safety measures  Rationale: Methylphenidate is a stimulant used
 Avoidance of alcohol to treat ADHD.
 Avoidance of abrupt discontinuation o Disulfiram is used to treat alcoholism.
Buspirone is used to treat depression.
Lithium is used to treat bipolar illness.
STIMULANTS S

 Amphetamines (methylphenidate, amphetamine, - Cultural Considerations –

dextroamphetamine)  Genetic differences rather than racial or ethnic
 Use: treatment of attention-deficit/hyperactivity background are likely to cause slower drug
disorder (ADHD) in children and adolescents, metabolism
residual attention-deficit disorder in adults,  In the future, a person’s genes may be linked with
narcolepsy the most efficacious treatment
o Great effects with stimulants
 Avoid making assumptions based on race or
 Mechanism of action
ethnicity
o Cause release of norepinephrine,
 Ask patient about own past experiences
dopamine, serotonin presynaptically
 Increased frequency of herbal medicine use
o Block reuptake of neurotransmitters
o St. John’s Wort  increases serotonin
 Dosage
o Kava
o Divided doses; higher doses for narcolepsy
o Valerian
in adults
o Ginkgo biloba
o Doses for treating ADHD vary widely (see
 Increased risk for interactions with herbal medicine
Table 2.7).

- Self-Awareness Issues –
- Side Effects –
 Clients and families need more than factual
 Anorexia, weight loss, nausea, irritability
information; they need simple and thorough
 Growth and weight suppression
explanations.
 View chronic mental illness as having remissions
- Client Teaching – and exacerbations, just as chronic physical illnesses
do.
 Dose after meals
 Remain open to new ideas that may lead to future
 Avoidance of caffeine, sugar, chocolate breakthroughs.
 Proper storage out of reach of children
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 Understand that medication noncompliance is often awareness, but they can recall them;
a result of faulty thinking and reasoning related to ex. Adult remembering their childhood
the illness, not willful misbehavior. memories.
o Unconscious – realm of thoughts and
feelings that motivates a person even
CHAPTER 3: PSYCHOSOCIAL THEORIES AND though they are totally unaware; ex.
THERAPY PSYCHOSOCIAL THEORIES Events that are too painful to
remember
PSYCHOANALYTIC THEORIES  Freudian slip
o Slip of the tongue
A. Sigmund Freud
o Indications of subconscious feelings or
 Developed in late 19th and early 20th century in
thoughts that accidentally emerge in
Vienna.
casual day-to-day conversation.
 All human behaviour is caused and can be
 Dream analysis
explainable.
o Person’s dream reflect their
 Repressed (driven from conscious awareness)
subconscious and have a significant
sexual impulses, desires as motivation for
meaning
behaviour.
 Free Association
 Personality components
o To uncover true thoughts and feelings
o Id
by saying a word and asking the client
 Reflects basic or innate desires
to respond quickly with the first thing
such as pleasure-seeking
that comes to mind.
behaviour, aggression and sexual
 Ego defense mechanisms
impulses.
o Methods attempting to protect the self
 Seeks instant gratification, causes
and cope with basic drives emotionally
impulsive unthinking behaviour
painful thoughts and events.
 Has no regard for rules or social
o Most of this operate at the unconscious
convention
level of awareness
o Superego
 Reflects moral and ethical
concepts, values and parental
and social expectation
 Direct opposite of id
o Ego
 Balancing or mediating force
between the id and superego
 Represents mature and adaptive
behaviour that allows a person
to function successfully in the
world.

 Behavior motivated by subconscious thoughts,

feelings
 3 Levels of Awareness:
o Conscious – perceptions, thoughts and
emotions that exist in the person’s
awareness; ex. Being aware of happy
feelings
o Preconscious – thought and emotions
that are not currently in the person’s
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DEVELOPMENTAL THEORIES

B. Erik Erikson
 German-born psychoanalyst
 Extended Freud’s work
 In 1950, he published Childhood and Society

Eight psychosocial stages of development

5 Stages of Psychosexual Development

C. Jean Piaget
 Cognitive and intellectual development
 He believed that biologic changes and
maturation were responsible for cognitive
development

Transference and Countertransference Four Stages of Cognitive Development

Transference

 When the client displaces onto the therapist

attitudes and feeling that the client originally
experienced in other relationships.

Countertransference

 When the therapist displaces onto the client

attitudes or feeling from their own past
 Individuals reach cognitive maturity by middle
to late adolescence
CURRENT PSYCHOANALYTIC PRACTICE

Psychoanalysis
INTERPERSONAL THEORIES
 Focus on discovering causes of client’s
D. Harry Stack Sullivan
unconscious, repressed thoughts, feelings,
 Interpersonal Relationships and Milieu
conflicts related to anxiety
 American Psychiatrist
 Free association, dream analysis, interpretation
 Extended the theory of personality
of behavior used to gain insight into and resolve
development
these conflicts and anxieties
Five Life Stages

QUESTION

Is the following statement true or false?

 Freud identified three stages of psychosexual

development.
 False
o Rationale: Freud identified five stages of
psychosexual development: oral, anal,
phallic/oedipal, latency, and genital.
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Nurses’ Role to meet the client’s needs

Four Levels of Anxiety

 He defines anxiety as the initial response to a

psychic threat

 Three developmental cognitive modes

o Prototaxic (infancy, childhood)
o Parataxic (early childhood)
o Syntaxic (school-aged children; more
predominant in preadolescence)
 He coined the term “participant observer” for
the therapist’s role
 Credited with developing the first therapeutic
community or milieu with young men with
schizophrenia in 1929.

E. Hildegard Peplau
 Therapeutic nurse–patient relationship
 Nursing theorist and clinician who built on
sullivan’s interpersonal theories
 Saw the role of the nurse as a participant
observer

Four phases

HUMANISTIC THEORIES

F. Abraham Maslow
 Hierarchy of needs
 He used the term “self-actualization” to
describe a person who has achieved all the
needs of the hierarchy
 This theory helps nurses understand how
clients’ motivations and behaviours change
during life crises
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reinforcement, either positive or

negative
 Systematic desensitization
o Used to help clients overcome irrational
fears and anxiety associated with
phobias.

QUESTION

Is the following statement true or false?

 Abraham Maslow was the first theorist to focus

on the client’s role.
 False
G. Carl Rogers  Rationale: Carl Rogers was the first to focus on
 Client-centered therapy the client’s role in his client-centered therapy.
 Focused on the therapeutic relationship and
developed a new method of client-centered EXISTENTIAL THEORIES
therapy.
o CCT – Key to healing process  Overall belief: deviations occur when person is
 He viewed the client as the expert on their life out of touch with self or environment.
o Goal: to return person to authentic sense of
Three Central Concepts self

BEHAVIORAL THEORIES

Behaviorism

 focus on observable behaviors and behavior

changes, not how mind works
 can be changed through a system of rewards
and punishment Cognitive therapy

 Focus on immediate thought processing

H. Ivan Pavlov o How a person perceives or interprets their
 classical conditioning experience and determines how they feel
 experiments with dogs and behave
 Used by most existential therapists
I. B.F. Skinner  Aaron Beck is credited with pioneering
 operant conditioning cognitive therapy in persons with depression
 One of the most influential behaviourists
 Focus on immediate thought processing
 Used by most existential therapists

J. Albert Ellis
 Rational emotive therapy
 11 “irrational beliefs” leading to unhappiness
 “Automatic thoughts”
 ABC technique

K. Viktor Frankl
 Behaviour modification  Logotherapy
o Help people change their behaviour in  Search for meaning
therapy L. Frederick “Fritz” Perls
o Method of strengthen a desired  Gestalt therapy
behaviour or response by  Emphasis on self-awareness
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 Identification of thoughts, feelings in the here  Assumptions of normal or typical may not apply
and now equally well to different racial, ethnic, or cultural
M. William Glasser backgrounds.
 Reality therapy
 Focus on person’s behavior
Treatment Modalities
 How behavior keeps a person from achieving
life goals  Community mental health treatment (primary
mode of treatment)
Crisis Intervention
o Clients continue to work and are able to
Crisis stay connected with family, friends, and
other support systems.
 A turning point in an individual’s life that o Personality or behavior patterns gradually
produces an overwhelming emotional response. develop; unable to be changed in a
 Four stages of crisis relatively short inpatient course of
o Exposure to stressor treatment.
o Increased anxiety when usual coping  Hospital (inpatient) treatment (often last mode of
ineffective treatment)
o Increased efforts to deal with stressor o Indications: severe depression/suicidal;
o Disequilibrium, significant distress severe psychosis; alcohol or drug
 Categories of crises withdrawal; behaviors requiring close
o Maturational supervision in a safe, supportive
o Situational environment.
o Adventitious/social
 Duration of crisis: usually 4 to 6 weeks Individual Psychotherapy
 Crisis resolution  Bringing about change in a person by exploring
o Functioning at precrisis level, higher level, their feelings, attitudes, thinking, behavior
or lower level  One-to-one relationship between the therapist
o Positive outcomes more likely when and the client
problem is clearly defined o Progression through stages
 Crisis intervention techniques o Relationship as key to success
o Directive interventions: assess health  Therapist’s theoretical beliefs strongly influence
status, promote problem-solving style of therapy.
o Supportive interventions: deal with
person’s needs for empathetic Groups and Group Therapy
understanding
 Number of persons who gather in a face-to-face
setting to accomplish tasks that require
QUESTION cooperation, collaboration, or working together
 Each person can influence and be influenced by
Which therapy includes the concept of automatic other members.
thoughts?  Stages of group development:
A. Cognitive therapy o Pregroup stages
B. Rational emotive therapy o Beginning stage
C. Logotherapy o Working stage
D. Gestalt therapy o Termination
Answer: B. Rational emotive therapy  Group leadership
o Formal leader usually for therapy groups
 Rationale: Rational emotive therapy focuses on 11 and education groups
irrational beliefs and automatic thoughts. o Informal leader may emerge in support
o Cognitive therapy focuses on groups and self-help groups.
immediate thought processing. o Effective leaders focus on group process
Logotherapy involves therapy as a and group content.
search for life with meaning. Gestalt  Group roles
therapy emphasizes self-awareness. o Growth producing: information seeker,
- Cultural Considerations - opinion seeker, information giver,
energizer, coordinator, harmonizer,
 Major psychosocial theorists were encourager, elaborator
o White o Growth inhibiting: monopolizer, aggressor,
o Born in Europe or United States dominator, critic, recognition seeker,
o Seldom treated outside their cultural passive follower
populations  Therapeutic results (Yalom & Leszcz, 2005):
o New information or learning
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o Inspiration or hope Psychosocial Interventions

o Interaction with others
 Nursing activities that enhance clients’ social and
o Feeling acceptance, belonging
psychological functioning and promote social skills,
o Awareness of not being alone; others share
interpersonal relationships, and communication
same problems
o Insight into problems and behaviors, how  Skills used in mental health and other practice
they affect others areas
o Altruism  Self-Awareness Issues
 No one theory or treatment approach is effective
for all clients.
- Types of Therapy Groups -  Using a variety of psychosocial approaches
1. Psychotherapy groups increases nurse’s effectiveness.
2. Family therapy  The client’s feelings and perceptions are most
3. Family education influential in determining their response.
4. Education groups
5. Support groups
6. Self-help groups CHAPTER 4: TREATMENT SETTING AND
THERAPEUTIC PROGRAMS
QUESTION
Treatment Settings
Is the following statement true or false?
Inpatient hospital treatment
 Self-help groups tend to have an informal or no
definitive leader.  Rapid assessment, stabilization of symptoms,
 True discharge planning
o Rationale: Support groups and self-help o Client-centered multidisciplinary
groups tend to have an informal leader or approach to brief stay
no leader at all. o Therapy and education o Identify long-term issues for outpatient
groups typically have a formal leader. therapy
 Short-stay clients
 Long-stay clients (severe, persistent mental
Complementary and Alternative Medicine (CAM) illness requiring acute care services)
 Complementary medicine used along with o Case management
conventional practices o Discharge planning
 Alternative medical systems used in place of Partial hospitalization programs
conventional treatment
 Integrative medicine combines conventional and  Day treatment programs
CAM practices  Eight broad categories of goals (see Box 4.1)
 Variety of therapies
Residential Settings
o Alternative medical systems (nutrition,
exercise, acupuncture)  Vary in structure, level of supervision, and
o Mind–body interventions (meditation, art, services provided
music therapy) o Group homes
o Biologically based therapies (herbs, foods, o Supervised apartments
vitamins) o Board and care homes
o Manipulative and body-based therapies o Assisted living
(therapeutic massage, chiropractic o Adult foster care
manipulation) o Respite/crisis housing
o Energy therapies (therapeutic touch, qi- o Transitional housing
gong, pulsed fields, magnetic fields)  Expectation to progress to
independent living
o Other programs serve clients for longer
Psychiatric Rehabilitation
periods of time.
 Services to people with persistent, severe mental o Respite or crisis housing
illness to help them live in the community  Short-term temporary shelter
 Often called community support services or o Opposition to group homes and
programs residential facilities
 Focus on client’s strengths
 Activities involving medication management, QUESTION
transportation, shopping, food preparation,
hygiene, finances, social support Is the following statement true or false?
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 Board and care homes are an example of a  Compared with homeless people who are not
partial hospitalization program. mentally ill:
 False • Spend more time in jail
o Rationale: A board and care home is an • Are homeless longer
example of a residential treatment • Spend more time in shelters
setting. • Have less family contact
 A day treatment program is an • Face greater barriers to employment
example of a partial  Projects for Assistance in Transition from
hospitalization program. Homelessness (PATH) program
 Center for Mental Health Services (CMHS)

PSYCHIATRIC REHABILITATION AND RECOVERY CLIENTS WITH COMPLEX NEEDS: MENTAL ILLNESS AND
PROGRAMS INCARCERATION
 Services to promote recovery process
• Emphasis on recovery, going beyond  The rate of mental illness among the incarcerated
symptom control and medication is estimated to be five times higher than the
management; includes personal growth general population.
(see Box 4.3)  Factors for placement in criminal justice system
• Reintegration into community • Deinstitutionalization
• Empowerment and increased independence • More rigid criteria for civil commitment
• Improved quality of life • Lack of adequate community support
• Higher level goals and expectations for later • Economizing on treatment for mental
recovery (see Box 4.4) illness
• Has improved outcomes by providing • Attitudes of police and society
community support services  Criminalization of mental illness
 Clubhouse model  Barriers to successful community reintegration
• Four guaranteed rights of members • Poverty
o A place to come to • Homelessness
o Meaningful work • Substance use
o Meaningful relationships • Violence
o A place to return to (lifetime • Victimization, rape, trauma
membership) • Self-harm
• Physician–client relationship is key.
• Focus on health, not illness CLIENTS WITH COMPLEX NEEDS: ACTIVE MILITARY
 Assertive community treatment (ACT) AND VETERANS
• One of the most effective approaches (see
Box 4.5)  The prevalence of posttraumatic stress disorder
• Problem-solving orientation (no problem is (PTSD) and major depression is greater than in
too small) civilian counterparts.
• Direct provision of service rather than  Increased rates of, suicide, homicide, injury,
referral physical illness
• Intense services; no time constraints  Also common:
 Information and communication technology (ICT) • Sleep disorders
• Telepsychiatry, telepsychology, telemental • Substance abuse
health, e-mental health • Cardiovascular disease
• Phone apps for web-based diary, group • Smoking
participation • Homelessness
• Videoconferencing, prescription refills • Marital and family dysfunction
 Reluctance to seek treatment
QUESTION  Lack of availability of treatment
Is the following statement true or false?  Stigma
 In the clubhouse model, the relationship  Widespread sexual traumas for both males and
between clients is most important. females
 False  Services for veterans (see Box 4.6)
o Rationale: With the clubhouse model,
the physician–client relationship is the
most important.

CLIENTS WITH COMPLEX NEEDS: HOMELESS PEOPLE INTERDISCIPLINARY TEAM

WITH MENTAL ILLNESS
1. Pharmacist
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2. Psychiatrist CHAPTER 5: THERAPEUTIC RELATIONSHIPS

3. Psychologist
4. Psychiatric nurse Therapeutic Relationship
5. Psychiatric social worker  One of the most important skills a nurse can
6. Occupational therapist develop
7. Recreation therapist  Crucial to success of interventions with clients
8. Vocational rehabilitation specialist requiring psychiatric care

 Core skill areas - Components of Therapeutic Relationship -

o Interpersonal skills (tolerance, patience)
o Humanity (warmth, acceptance, empathy) 1. Trust
 Behaviors such as caring, interest,
o Knowledge base
understanding, consistency, honesty, keeping
o Communication skills
promises, and listening (see Box 5.1)
o Personal qualities (consistency,
 Congruence
assertiveness, problem-solving)
o Teamwork skills 2. Genuine interest
o Risk assessment, risk management skills  Self-comfort, self-awareness of strengths and
limitations, clear focus
 Client can detect dishonest behavior.
QUESTION

Which discipline most likely would be included as part 3. Empathy

of the interdisciplinary team?  Ability to perceive client’s meanings and
feelings, to communicate that understanding
A. Physician’s assistant o Client and nurse giving “gift of self”
B. Physical therapist  Different from sympathy (feelings of concern or
C. Pharmacist compassion; may project nurse’s personal
D. Dietitian feelings)

ANSWER: C. Pharmacist 4. Acceptance (no judgments; set boundaries)

5. Positive regard (unconditional, nonjudgmental
 Rationale: The pharmacist would be a member of attitude)
the interdisciplinary team when medication,
management of side effects, and/or interactions Self-Awareness
with non-psychiatric medications are complex.  Know self
o A physician’s assistant, physical o Values (sense of right and wrong, code of
conduct for living)
therapist, and dietitian are not typically
 Values clarification process
involved as members of the psychiatric
 Choosing
interdisciplinary team.
 Prizing
 Acting
PSYCHOSOCIAL NURSING IN PUBLIC HEALTH AND  Beliefs
HOME CARE  Attitudes
 Cultural awareness (see Box 5.2)
 Primary prevention: stress management education
 Secondary prevention: early identification of QUESTION
mental health problems
 Tertiary prevention: monitoring and coordinating Is the following statement true or false?
psychiatric rehabilitation services  A nurse displays empathy by showing feelings of
 Clinical practice issues such as substance abuse, concern and compassion.
domestic violence, child abuse, grief, depression,  False
and many others o Rationale: Empathy is perceiving the
client’s meanings and feelings and
- Self-Awareness – communicating that understanding to
the client.
 Evolution of care away from traditional hospital-  Sympathy is showing feelings of
based goals to client-centered goals concern and compassion.
 Nontraditional settings such as jails or homeless
shelters
 Empowering clients to make their own decisions
 Awareness of frustration related to working with
clients having persistent and severe mental illness Therapeutic Use of Self
 Use of aspects of personality, experience, values,
feelings, intelligence, needs, coping skills,
perceptions to establish relationships with clients
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o Concept developed by H. Peplau  A social relationship usually involves

o Personal actions arise from conscious and communication for the purposes of friendship
unconscious responses or task accomplishment.
 True
Johari window  Rationale: A social relationship occurs for
 tool to learn about oneself friendship, socialization, companionship, or task
 Four quadrants: open/public self; achievement. It involves communication that
blind/unaware self; hidden/private self; may be superficial and shifting roles.
unknown
 Goal: move qualities from quadrants 2, 3, and 4 ESTABLISHING A THERAPEUTIC RELATIONSHIP
into quadrant 1
 Peplau’s model of three phases (see Table 5.2)
o Orientation
o Working
 Identification
 Exploitation
o Termination
 Overlapping, interlocking of phases

ORIENTATION PHASE
 Meeting nurse, client
 Establishment of roles
 Discussion of purposes, parameters of future
 meetings
 Identification of client’s problems
 Clarification of expectations
 Nurse–client contracts, confidentiality, self-
 Disclosure
Patterns of Knowing
 Preconceptions WORKING PHASE
 Ways of observing, understanding client  Problem identification
interactions o Client identifies issues or concerns.
 Four patterns of knowing (Carper, 1978; see Table  Exploitation
5.1) o Examination of feelings and responses
o Empirical (derived from nursing science) o Development of better coping skills,
o Personal (from life experiences) more positive self-image, behavioral
o Ethical (from moral nursing knowledge) change, independence
o Aesthetic (from art of nursing)  Possible transference/countertransference
 Fifth pattern: unknowing (Munhall, 1993)
o Nurse admits lack of knowledge of client or TERMINATION PHASE
client’s subjective world.  Begins when client’s problems are resolved
 Ends when relationship is ended
- Types of Relationships –  Client may feel termination as impending loss.
 Clients often try to avoid termination.
1. Social
 Purpose: friendship, socialization, AVOIDING BEHAVIORS THAT DIMINISH THERAPEUTIC
companionship, or task accomplishment RELATIONSHIPS
 Sharing ideas; shifting roles; outcomes rarely
assessed  Inappropriate boundaries (relationship becomes
2. Intimate  social or intimate)
 Emotional commitment of two persons o One of the biggest risks is nurse’s belief
 Individual needs met; assistance with helping they will not do anything nontherapeutic.
each other meet needs.  Feelings of sympathy, encouraging client
3. Therapeutic dependency
 Focus on needs, experiences, feelings, ideas of  Nonacceptance and avoidance
client only  Warning signs of abuse of the nurse–client
 Nurse’s use of communication skills, personal relationship (see Box 5.3)
strengths, understanding of human behavior
 Joint agreement on areas to work on; outcome
evaluation
 Nurse’s level of self-awareness can benefit or
hinder the relationship. QUESTION
During the working phase of a nurse–client relationship,
QUESTION which action would occur?
Is the following statement true or false? A. Expectations are clarified.
B. Nurse–client contracts are established.
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C. Feelings of loss are addressed.

D. Client’s feelings are examined.

Answer: D. Client’s feelings are examined.

 Rationale: During the working phase, the client
identifies issues or concerns and examines
feelings and responses.
 Expectations are clarified and contracts are
established during the orientation phase.
Feelings of loss are addressed during the
termination phase.

THERAPEUTIC ROLES OF THE NURSE IN A

RELATIONSHIP
 Teacher (coping, problem-solving, medication
regimen, community resources)
 Caregiver (therapeutic relationship, physical care)
 Advocate (ensuring privacy and dignity, informed
consent, access to services, safety from abuse and
exploitation)
 Parent surrogate
o Must ensure relationship remains
therapeutic (see Box 5.4)

- Self-Awareness Issues –
 Nurse’s self-awareness: crucial to developing
therapeutic relationships
 Compassion fatigue
 Helpful activities: values clarification, journaling,
group discussions, reading