Theories of

Psychiatric Nursing
Practice
Penny Applegarth, RN, MSN,
FNP
Psychoanalytic
Theories & Therapies
Sigmund Freuds Psychoanalytic
Theory
Conscious part of the brain:
involves perceptions, memories,
thoughts, fantasies & feelings
Sigmund Freuds
Psychoanalytic Theory
Preconscious: awareness that is
below the level of conscious
retrieval, but can be accessed
with conscious effort

Unconscious: repressed memories,

passions, & unacceptable urges
Freuds Personality
Structure
Three distinct interactive systems
Id: all drives, instincts, genetic
tendencies / inheritances, capacity
to respond
Ego: problem solver, reality tester
Superego: the moral component of
personality
Defense Mechanisms &
Anxiety
Anxiety: natural part of living
Defense mechanisms: ego develops to
ward off intense anxiety or other
overwhelming feelings by preventing
the conscious awareness of
threatening feelings
Operates at the unconscious level
Can cause distortions in the individuals
perceptions of reality
Defensive Mechanism
Compensation: Counterbalance for
deficiencies in one area by excelling in
another area
Denial: Refusal to perceive or face
unpleasant reality as it actually exists
Displacement: The discharge of pent-
up feelings (frequently hostility) unto
something or someone else in the
environment that is less threatening
than the original source of the feelings
Defensive Mechanism
Identification:
Incorporates the image of an
emulated person, then acting,
thinking & feeling like that person
Intellectualization:
The overuse of abstract thinking or
generalization to control or minimize
painful feelings
 Defensive Mechanisms
Minimization:
Not acknowledging the significance on
ones behavior
Projection
Attributing ones own unacceptable
motives or characteristics to another
person or group
Rationalization:
Use of a contrived socially acceptable &
logical explanation to justify unpleasant
material & to keep it out of consciousness
Defensive Mechanisms
Reaction Formation:
Prevention of awareness or expression
of unacceptable desires by adoption of
opposite behaviors in an exaggerated
way
Repression:
Disturbing thoughts, wishes, or
experiences are expelled from
conscious awareness
Defense Mechanisms
Regression:
Returning to an earlier level of
adaptation

Sublimation:
Modification of an instinctual but
socially unacceptable impulse into a
constructive acceptable behavior
Defensive Mechanisms
Splitting:
Failure to integrate positive & negative
aspects of self or others, resulting in
polarized images of self & others as all
good or all bad
Suppression:
Conscious inhibition of an impulse,
idea, or affect. The person is usually
fully aware of the behavior
Freuds Five
Psychosexual Stages
of Development
Developmental stages from
infancy to adulthood
Main focus is on the first five years
of lifes experiences &
development
Freud believed that all mental
illness was a result of early intra-
psychic conflict
Important Terms
Transference: the clients feelings are
projected onto the nurse or therapist
that were originally held toward a
significant other in their life
Countertransference: the health care
workers unconscious personal
feelings are projected onto the client
Feelings Displaced in
Transference
Desire for affection
Desire for gratification of
dependency needs
Love
Hostility
Jealousy
Competitiveness
Resistance
Psychoanalysis:
Process in which the ego opposes
the conscious recall of unpleasant
experiences

Therapy:
Client puts road blocks to dealing
with identified issues
Erik Eriksons Ego
Theory
Describes eight stages of development
from infancy to late adulthood
Stressed development influenced by
the mother-child-father triangle (like
Freud), but also felt cultural & social
influences were very important
Didnt feel the personality was fixed
by age 5
Eriksons Model in
Nursing
Used to identify developmental
level for age
Can help with the development of
the care plan, to keep goals
realistic
Harry Stack Sullivans
Interpersonal Theory
Defined personality as behavior that
can be observed within
interpersonal relationships
Premise: the purpose of all behavior
is to:
Meet needs through interpersonal
interactions
To decrease or avoid anxiety
Psychotherapeutic
Environment
Group psychotherapy, family
therapy, & educational / skills
training programs can be
incorporated into the clients
treatment
This is used in residential & day
hospital settings today
Psych Nursing
Sullivans theory is the foundation
for Hildegard Peplaus nursing
theory of interpersonal relationships
Participant observer: the
professional helpers cannot be
isolated from the therapeutic
situation if they are to be effective
Hildegard Peplaus Theory of
Interpersonal Relationships in
Nursing
In 1952, established a systemic
theoretical framework for
psychiatric nursing
Identified psychiatric nursing as
an essential element of general
nursing & as a specialty
Nurse Patient
Relationship
First nursing theorist to describe the
nurse- patient relationship as the
foundation of nursing practice
An evolving process through three
distinct interlocking & overlapping
phases
1. Orientation phase
2. Working phase
3. Termination phase
Boundaries

A limit or edge that defines

you as separate from others
Physical
Emotional
Sexual
Relational
Boundaries

Rigid or flexible
Transparent or opaque

Close or Distant

Culturally Determined
 The nurse is planning care for a client
i-clicker?:
with anxiety who will be admitted to the unit
shortly. Which nursing action is most
important?
a. Consider interventions that will
increase the clients sense of value
b. Choose a roommate that could
develop a friendship with the new
client
c. Identify a room where the client will
have comfortable surroundings
d. Plan methods of decreasing stimuli
that could cause heightened anxiety
Behavioral Theories /
Therapies
Conditioning: pairs behavior with a
condition that reinforces or diminishes
the behaviors occurrence
Ivan Pavlovs Classical Conditioning
Theory
John B. Watson: behaviorism-
personality traits & responses were
socially learned through classical
conditioning
B. F. Skinners Operant
Conditioning Theory
Operant conditioning:
voluntary behaviors learned
through consequences
Reinforcement: the behavior
responses elicited occur more
frequently when reinforced
Reinforcement
Positive reinforcement:
consequence is a pleasant or
pleasurable experience
Negative reinforcement:
removal of an objectionable or
aversive stimulus
Behavioral Therapy
Based on the assumption that changes
in maladaptive behavior occur without
insight into the underlying causes
Successful in treatment for phobias,
alcoholism, schizophrenia
Modeling: therapist provides a role
model, demonstrates more effective
behaviors to help client cope
Cognitive Theories &
Therapies
Rational- Emotive Behavior Therapy
(REBT)
http://www.youtube.com/watch?v
=73hzaaSlNr0&feature= fvwrel
Cognitive- Behavioral Therapy
(CBT)
http://www.youtube.com/watch?v
=GqW8p9WPweQ&feature=related
Cognitive Therapy

Eliciting automatic thoughts

Testing automatic thoughts

Identifying maladaptive
underlying assumptions
Testing the validity of the
assumptions
Humanistic Theories
Abraham Maslows Humanistic
Psychology Theory
Hierarchy of Needs
Emphasis on human potential & the
clients strengths as key to success
for the nurse- client relationship
Establishes priorities for nursing
interventions
Hierarch of Needs

Maslow:
Self Actualization Needs
Esteem & Recognition
Love and Belonging
Safety Needs
Physiological Needs
 Which behavior, seen in a 30 y.o. client
i-clicker?:
would alert the nurse that the client is not in
the appropriate developmental stage according
to Erickson?

a. States he is happily married

b. Frequently requests to call his
brother just to check in
c. Looks forward to visits from a
co-worker
d. Says Im still trying to find
myself
Biological Theories/
Therapies
Focuses on neurological,
chemical, biological, & genetic
factors
Focuses on how the body & brain
interact to create emotions,
memories, & perceptual
experiences
Biological Theories/
Therapies
View abnormal behaviors as a
symptom of the psychiatric
disease process
Targets the site of the illness
using interventions (drugs, diet,
surgery)
 Implications for
Psychiatric Nursing
This model incorporates all the basic
nursing strategies (therapeutic
relationship, communication) along
with the importance of
understanding the bio-chemical
implications of the mental illness
Psychiatric Nursing
Increases the importance of
understanding the effects of
medications on the brain
functioning

Wholistic approach
Other Therapies
Milieu therapy focuses on the
total environment as an element
of treatment
Incorporates the people, setting,
structure, & emotional climate as
elements of treatment
Therapeutic
Community
May use a variety of different
therapeutic modalities from
behavioral, structured,
spontaneous, humanistic oriented
Psychiatric Nursing
Roles
Instrumental in providing the
structure, framework, &
implementation of interventions
to reach goals of the milieu model
Examples: provide safety for
suicidal clients, do crisis
intervention strategies, run
groups, one to one counseling
 Therapeutic
Relationships
Between nurse & client established
to enhance client growth
Focuses on client issues, problems, &
concerns
Communication techniques used to

identify & explore clients needs, set

goals, assist in development of new
coping skills, & encourage behavioral
changes
Factors Enhancing Growth
in Others

Genuineness
Congruence between verbal
content & affect/ behaviors
Empathy
Understanding ideas expressed &
feelings present in the other
Factors Enhancing
Growth in Others
Positive Regard
Implies respect: attitudes & actions
(attending, suspending value
judgments)
Helping
Clients Develop
Resources
Awareness, encouragement shown
toward positive behaviors
Positive Regard
Behaviors
Mutually establishing times to
begin & end time for talking or
activities
Being on time to all scheduled
meetings
Listening (actively) to client
Neutral comments; nonjudgmental
responses
Factors Hampering
Relationships
Lack of nurse availability or
lack of contact
Lack of nurse self-awareness

Nurse negative feelings about

client; nonverbal expression
leeks through
Factors Beneficial to
Relationships
Being honest & congruent
Letting client set the pace
Listening to client concerns
Consistent, regular, & private interactions
with client
Positive initial attitudes & preconceptions
Promoting client comfort & balancing control
Client demonstrating trust & actively
participating in relationship
Phases of the Nurse-Client
Relationship
Pre orientation

Planning for the first interaction

with client

Identifying nurse concerns &

decide how to address them
Orientation Phase

Orientation
Establish boundaries of relationship
Role/responsibilities of nurse/client
Establish Confidentiality agreement
Formal/informal contract
Time, place, date, duration of meetings
Mutual goals
Assessment & Care plan
Termination terms
Working Phase: Tasks
Maintain relationship
Gather further data
Promote client problem-solving skills,
self-esteem & communication
Facilitate behavioral change
Overcome resistance behaviors
Evaluate problems & goals, redefine prn
Practice & express alternative adaptive
behaviors (role play)
Termination: When

Symptoms improved
Social functioning improved

Goals achieved

Impasse in therapy

Insurance runs out

Change of staff
Termination: What

Deal with intense feelings

regarding the experience
Summarize goals & objectives
achieved
Review client plans for future

Finalize termination