Overview of Psychiatric-Mental Health Nursing I

CHAPTER 1 Introduction to Psychiatric-Mental Health Nursing Cecelia M. Taylor CHAPTER 2 Issues and Trends in Psychiatric-Mental Health Nursing Karen A. Ballard CHAPTER 3 The Psychiatric Nursing Assessment Christine Carniaux Moran CHAPTER 4 Neurobiologic Considerations in Psychiatric Care Karan Kverno and Sherry Goertz CHAPTER 5 Psychopharmacology Beth Harris CHAPTER 6 Crises, Psychiatric Emergencies, and Disasters Winifred Z. Kennedy CHAPTER 7 Legal and Ethical Considerations Amy Wysoker CHAPTER 8 Self-Help Groups: Options for Support, Education, and Advocacy Edward J. Madara CHAPTER 9 Holistic Nursing and Complementary Modalities Jeanne Anselmo and Julia Balzer Riley CHAPTER 10 Family and Intimate Partner Violence Cynthia Mitzeliotis and Winifred Z. Kennedy

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CHAPTER Introduction to Psychiatric- Mental Health Nursing Cecelia M. Taylor 1

LEARNING OBJECTIVES

After reading this chapter, you will be able to: · Discuss the impact on psychiatric-mental · Describe the evolution of psychiatric-mental health nursing of the works of Peplau, health nursing care. Orlando, King, Orem, and Riehl-Sisca. · List the members of the contemporary multi- · Describe the characteristics of individual disciplinary treatment team and describe the therapy, family therapy, group therapy, milieu distinctive abilities of each professional therapy, crisis intervention, and somatic member. therapies. · Explain two key concepts from each of the psychoanalytic, interpersonal, and behavioral conceptual models.

KEY TERMS

Anticipatory guidance Levels of consciousness Psychosexual theory of Anxiety Milieu therapy personality development Apathy Moral therapy Punishment Behavioral model Multidisciplinary treatment Response cost Classical conditioning team Security operations Cognitive model Need for satisfaction Selective inattention Conceptual model Need for security Self-care deﬁ cit nursing theory Coping mechanisms Negative reinforcement Self-concept Crisis Neurobiologic model Situational crises Developmental crises Nurse-patient relationship Somatic therapies Dynamisms Operant conditioning Somnolent detachment Ego defense mechanisms Personality, structure of Structural family therapy Extinction Positive reinforcement Therapeutic community Family systems therapy Preoccupation Genogram Psychoanalytic model Group therapy Psychodynamic nursing Individual therapy

The use of the term patient in the ﬁ rst half of this chapter reﬂ ects historical usage.

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History The inhumane treatment of mentally ill persons peaked in the seventeenth century when Society has always adopted measures designed to petty criminals and those who were mentally ill change the behavior of persons with mental illness. were confi ned together in almshouses. Treatment In prehistoric times, those measures were likely to consisted of drastic purgings, bleedings, and have been tribal rites that, if unsuccessful, probably whippings. led to the abandonment of the ill person. During the Greek and Roman eras, the sick were treated in the temples, and treatment ranged from humane The Eighteenth and Nineteenth Centuries care to fl ogging, bleeding, and purging. In the eighteenth century, Europe, particularly The plight of mentally-ill persons continued to France, underwent political and social reform. In be poor in the Middle Ages, when their care was 1792, Phillipe Pinel, the medical director of the determined by mistaken religious beliefs. The men- Bicêtre asylum outside Paris, introduced a new tally ill were believed to be possessed by devils that treatment regimen termed moral therapy. Advo- could be exorcised by whippings and starvation. cates of moral therapy believed that mental ill- When the church stopped treating mentally ill per- ness was related to immorality or faulty upbring- sons during the sixteenth century, they were im- ing, and that a therapeutic environment could prisoned in almshouses, which were a combination correct these weaknesses. Instead of harsh con- of a jail and an asylum. Those who were violent and fi nement, patients were kept busy with work, mu- delusional were placed in jails and dungeons. King sic, or other diversions. Moral therapy required Henry VIII offi cially dedicated Bethlehem Hospital that attendants treat patients with kindness and in London as a lunatic asylum. Bethlehem Hospital keep them involved in the treatment program soon became known as the notorious “Bedlam,” (Wasserbauer & Brodie, 1992). The Quakers, un- whose hideous practices were immortalized by der the Brothers Tuke, established the York Re- Hogarth, the famous cartoonist (Figure 1-1). The treat and brought about the same dramatic re- keepers at Bedlam were allowed to exhibit the most forms in England. The development of moral boisterous patients for 2 pence a look. The more therapy and its reliance on attendants were the harmless inmates were forced to seek charity on the beginnings of current psychiatric nursing care. streets of London; the “Bedlam beggars” of Shake- The fi rst place identifi ed as a “poorhouse, speare’s King Lear were based on these prisoners workhouse, and house of correction” in the Unit- (Taylor, 1994). ed States opened in New York City in 1736. In 1756, under the guidance of Benjamin Franklin, the Pennsylvania Hospital was completed. One of the fi rst two patients admitted was described as a “lunatic.” Although patients with a mental illness were relegated to the cellar, they were assured clean bedding and warm rooms. Benjamin Rush (1745–1813), a humanitarian and the “father of American psychiatry,” began working at Pennsyl- vania Hospital in 1783. The fi rst public psychiatric hospital in Amer- ica was built in Williamsburg, Virginia, in 1773 and is known today as Eastern Psychiatric Hospi- tal. Most states, even as late as 1830, did not have facilities for treatment of the mentally ill, although a number of excellent private hospitals existed (most notably the Hartford Retreat, founded in 1818). Dorothea Lynde Dix (1802–1887) was a schoolteacher who volunteered to tutor individuals confi ned to jails and poorhouses. She was hor- Figure 1-1 Bedlam, as depicted by William Hogarth. Note the well-dressed ladies, who made social visits to the prison to rifi ed by the conditions in these facilities, and in view the spectacle of the inmates as entertainment. 1841 began a campaign to convince state legisla-

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tures that suitable hospitals, not jails, were re- patient who was hospitalized several times, wrote quired for those with mental illnesses. Twenty a book about his experiences titled A Mind That states in the United States and the Canadian gov- Found Itself. The book’s revelations led to the ernment responded directly to her appeals by au- founding of the National Committee for Mental thorizing the construction of large institutions Hygiene. The committee, for the fi rst time, es- for the mentally ill. This was the beginning of the poused the prevention of mental illness and early state hospital system in the United States. intervention. The original intent of the state hospital sys- The most signifi cant psychiatric revolution in tem was to treat those with mental illness and the early twentieth century was a direct result of then discharge them to the community or the the work of Sigmund Freud (1856–1939). Freud care of their families. Because so little was known made great contributions to the understanding of about mental illness at that time, the goals of human behavior. Before his theories were intro- treatment and discharge were not able to be duced, human behavior, particularly the behavior achieved. Consequently, state hospitals rapidly of persons with mental illnesses, was shrouded in became overcrowded with chronically mentally superstition, secrecy, and stigma. Freud brought ill patients. Paradoxically, the same state hospitals the subject of human behavior to the public’s at- that were supposed to alleviate the suffering of tention. His theories served as a springboard for violent persons who were previously imprisoned the scientifi c study of human behavior. Although contributed to the ultimate demise of moral ther- much of Freudian theory is no longer embraced apy, because this treatment could not be imple- in scientifi c circles, some of his concepts have be- mented in overcrowded settings. come so integrated into the mainstream that they In 1844, the Association of Medical Superin- have become part of everyday language (e.g., ego, tendents was formed as psychiatry began to de- conscience, unconscious). velop as a profession and as physicians became The National Mental Health Act, passed in increasingly responsible for the administration 1946, was one of the most progressive actions ad- of asylums. This organization became the Ameri- dressing mental illness the United States has ever can Medico-Psychological Association in 1851, taken. The legislation stemmed from the nation’s and was renamed the American Psychiatric As- concerns about the mental health of its citizens as sociation (APA) in 1921. It was founded by medi- a result of experiences during World War II. More cal superintendents from 13 asylums in the Unit- men in the armed forces were disabled from men- ed States (Wasserbauer & Brodie, 1992). tal disorders than from all other health problems By the 1870s, asylums were considered abys- related to military action. Immediately after the mal institutions with a terrible public image. National Mental Health Act was passed, the Na- Searching for ways to improve care, psychiatrists tional Institute of Mental Health (NIMH) was adopted the strategies already in use at general established in 1946. The NIMH provided fund- hospitals to improve patient services. These im- ing to support research into the causes of mental provements included incorporating effective illness and to provide tuition and stipends for therapies that had a scientifi c basis and using education in the four core mental health disci- graduate nurses instead of attendants. However, plines: psychiatry, psychology, psychiatric nurs- asylums were unable to attract enough nurses to ing, and psychiatric social work. Major strides improve patient care, so schools of nursing in asy- were made in increasing the number of mental lums were established. The fi rst school of this type health professionals as a result of this funding. was established at the McLean Asylum in Massa- For example, in the 1940s only fi ve to seven grad- chusetts in 1882 (Wasserbauer & Brodie, 1992). uate programs in psychiatric nursing existed; these numbers expanded greatly in the 1950s and The Twentieth Century 1960s as a result of NIMH funding. Psychiatric nursing underwent a major change At the beginning of the twentieth century, treat- when Interpersonal Relations in Nursing by Hilde- ment was still limited to restraints, isolation, wa- gard Peplau was published in 1952. Reprinted in ter bath treatments, dietary regimens, and, even- 1991 and now considered a classic, this book em- tually, early sedative drugs and shock treatments. phasized the signifi cance of the relationship be- Noticeable changes occurred in the state hospital tween the patient and nurse as a treatment modal- system in 1908 when Clifford Beers, a psychiatric ity. Dr. Peplau became the director of the graduate

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program in psychiatric nursing at Rutgers, The the centers (P.L. 89-105). These acts sought to State University of New Jersey, and is considered revolutionize mental health care by emphasizing the “mother of modern psychiatric nursing.” prevention and decentralized, local community The master’s program in psychiatric nursing treatment over institutional care, even for per- at Rutgers, along with many other programs, sons with the most severe psychiatric diffi culties. graduated hundreds of clinical nurse specialists The fi rst federally funded centers opened in 1966, (CNSs) in psychiatric nursing. These individuals initiating the deinstitutionalization of persons quickly assumed leadership positions in orga- with mental illness. nized nursing and lobbied for recognition as au- In 1973, the executive committee of the divi- tonomous practitioners of mental health care, sion of psychiatric-mental health nursing prac- specifi cally psychotherapy. Currently, many states tice of the American Nurses Association (ANA) authorize certifi ed psychiatric clinical nurse spe- published the fi rst Standards of Psychiatric and cialists and certifi ed psychiatric nurse practitio- Mental Health Nursing Practice. This document ners to prescribe psychopharmaceuticals, and has been continually revised and refl ects the cur- Medicare and most insurance plans reimburse rent, accepted levels of practice that psychiatric them for their services. nurses are expected to maintain. The most recent In 1953, the National League for Nursing, the version is Psychiatric-Mental Health Nursing: accreditation agency for schools of nursing, re- Scope and Standards of Practice (2007). quired the inclusion of psychiatric nursing clini- In the late 1980s, NIMH shifted its focus and cal experience and coursework in all basic curri- funding from education and service delivery to cula and required that these subjects be taught by research. This legislative shift resulted, in part, nursing faculty. Thus, all nursing students had from intense lobbying by the National Alliance some exposure to the practice and theory of psy- for the Mentally Ill (NAMI), an advocacy group chiatric nursing. However, it was not until the of families of mentally ill persons that demanded 1980s that the last school of nursing located in a increased research into the cause and treatment psychiatric hospital closed. of mental illness. Funding for the education of In 1955, the U.S. Congress passed the Mental mental health practitioners was abolished, re- Health Study Act. This act provided funds for a sulting in a dramatic decline in the number of 5-year study of the problem of mental illness in nurses pursuing graduate degrees in psychiatric the United States. As a result, the Joint Commis- nursing. sion on Mental Illness was established. The com- Begun in the 1960s, deinstitutionalization mission’s report, Action for Mental Health, pro- was fi nally achieved in the late 1980s and early vided the stimulus for developing more effective 1990s as a result of economic constraints and the services for people in need of psychiatric care, availability of medications and services that en- and was the basis for additional legislation. abled patients to function in the community. A revolution in care occurred in the late 1950s Currently, persons with mental illness who re- when the fi rst effective antipsychotic medication, quire hospitalization are likely to be admitted to a chlorpromazine (Thorazine), became widely avail- freestanding private hospital or a psychiatric unit able. Although many other, more effective, medi- in a general hospital. The nature of treatment has cations are currently available, none have had the also changed. An individual admitted to the hos- impact of chlorpromazine when it was fi rst intro- pital no longer has to remain for months, with duced. This medication controlled many of the most staying for less than 2 weeks (Taylor, 1994). most distressing symptoms experienced by patients, resulting in their becoming more amenable Critical Thinking Question What are the advantages to other forms of treatment and being able to func- and disadvantages for clients, families, communities, tion better both in and out of hospitals. and healthcare practitioners when short-term hospi- On February 5, 1963, President John F. Ken- talization is deemed necessary? nedy delivered a special message on mental illness and mental retardation to the Congress. He em- Finally, a major paradigm shift has occurred in phasized the goal of community care for persons understanding the causes of major mental illness, with mental illnesses. In that same year, Congress and this shift has altered the nature of psychiatric authorized the Community Mental Health Cen- treatment. As a result of increasingly sophisti cated ters Construction Act, which was followed in technology, scientists have proposed that many of 1965 by amendments to provide for staffi ng in the most severe forms of mental illness have a neu-

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Figure 1-2 An individual psychotherapy session.

robiologic basis. As a result, treatment relies heavily on the ever- expanding array of psychopharmaceuticals as well as the more tradi- tional “talking” therapies (individual psychotherapy, group therapy, family therapy; see Figure 1-2). Furthermore, because of these fi ndings, Figure 1-3 A sample Rorschach “ink blot.” many graduate programs in psychiatric nursing have revised their curricula to emphasize neurobi- ology and psychopharmacology. medications and administers other somatic therapies, such as electroconvulsive therapy. Psychia- The Twenty-First Century trists are particularly skilled in identifying and treating persons whose problems have highly in- The understanding of the causes and treatment of terrelated emotional physiological components. mental illness has increased dramatically over the Clinical psychologists have advanced educa- centuries. The availability of increasingly sophisti- tion in the study of mental processes and the cated technology ensures even more dramatic ad- treatment of mental disorders. They have partic- vances in knowledge. Because of the increasing ular expertise in the use of inferential tools de- scope and complexity of this burgeoning knowl- signed to assist in the diagnostic process and as- edge, it is necessary for the multidisciplinary treat- sessment of treatment effects. An example of such ment team to work closely together to achieve the a tool is the Rorschach test, commonly known as goals of preventing mental illness and effectively the “ink blot” test (Figure 1-3). treating those who are ill. Therefore, the psychiatric Psychiatric-mental health nurse generalists nurse in the twenty-fi rst century works collabora- and advanced practice psychiatric nurses work tively in the community with other healthcare prac- collaboratively in out-patient and in-patient treat- titioners, clients, and their families, each an integral ment settings. According to the Society for Educa- part of the multidisciplinary treatment team utiliz- tion and Research in Psychiatric-Mental Health ing a variety of treatments. Recognition of the pa- Nursing (SERPN), psychiatric-mental health tient as an integral member of the treatment team nurses are registered nurses who are educationally is refl ected in the contemporary use of the term prepared in nursing, licensed to practice in their client rather than patient when referring to the per- individual states, and qualifi ed to practice in the son in need of professional mental health services. psychiatric-mental health nursing specialty at one – In addition to clients and their families, the of two levels: basic or advanced. All nurses bring multidisciplinary treatment team includes the psy- expertise in assessing the client’s ability to engage chiatrist, clinical psychologist, psychiatric mental in activities of daily living and to assist the client to health nurse, psychiatric social worker, and activi- cope as necessary. The nurse in an in-patient set- ties therapists such as life skills, art, and music. All ting is responsible for establishing and maintain- mental health professionals share a common ing an environment that is therapeutic for the knowledge of and skill in interpersonal relation- client population as a whole. It is believed that the ships and a deep appreciation of the inextricable therapeutic nurse-client relationship is the hall- relationship between mind and body. Each profes- mark of psychiatric nursing. For a more complete sional discipline has a distinctive knowledge base discussion of these roles, see Chapter 2. and skills that enrich the treatment team. Psychiatric social workers are prepared at the Psychiatrists are physicians with several years master’s degree level and have particular skill in of supervised residency training in the medical assessing familial, environmental, and social fac- specialty of psychiatry. The psychiatrist prescribes tors that contribute to the problems of clients and

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Psychoanalytic Model Sigmund Freud is the founder of the psychoanalytic model. Freud was an Austrian physician who began his career as a neurologist. He developed an elaborate theory of human behavior based primarily on his work with persons suffering from disabling anxiety. The treatment approach derived from his theories is termed psychoanalysis. Key Freudian concepts include levels of consciousness, structure of the personality, and psychosexual development. Figure 1-4 A client engaged in painting. Source: © photobank.ch/Shutterstock, Inc. Three Levels of Consciousness Freud believed in three levels of consciousness. their families. They are also major contributors to The fi rst level of consciousness is the conscious discharge planning and the follow-up care of the mind, that part of the mind that is aware of the client. present and functions only when the person is Activity therapists have at least a bachelor’s awake. It represents the smallest part of the mind degree, and increasingly a master’s degree is re- and directs an individual’s rational, thoughtful quired in their specialty fi eld. The basis of activity behavior. therapy is the belief that persons can benefi t from The second level of consciousness is the pre- engaging in activities that focus outside of the self, conscious. The preconscious (or subconscious) is such as exercise, crafts, writing, music, or painting the part of the mind in which thoughts, feelings, (see Figure 1-4). These activities can be done either and sensations are stored. Although materials alone or in conjunction with other clients. There- stored in the preconscious mind are outside of fore, the activity therapist is skilled in the develop- awareness, they can be brought to the conscious ment, implementation, and evaluation of a highly mind with the proper stimulus, such as a direct individualized activity regimen designed to meet question. the needs of the person for whom it is designed. The third level of consciousness is the unconscious. The unconscious represents the larg- est part of the mind and is the storehouse for all Conceptual Models of the thoughts, feelings, and sensations experi- A conceptual model is a framework of related con- enced during the individual’s lifetime. The indi- cepts. Conceptual models used by mental health vidual is rarely aware of the unconscious mind, practitioners address the bases for behavior in except when it demonstrates its presence through order to direct interventions. Although some men- dreams, slips of the tongue, unexplained behav- tal health practitioners adhere strictly to one con- ior, jokes, and lapses of memory (Taylor, 1994). ceptual model, most practitioners in the United These thoughts, feelings, and sensations cannot States use an eclectic approach in which they em- be recalled at will, but nevertheless exert a pow- ploy one or more approaches from several models. erful infl uence on the person’s behavior. Belief in The most important conceptual models are the the existence of the unconscious is the basis for psychoanalytic, interpersonal, behavioral, cogni- the saying “All behavior has meaning.” tive, developmental, and neurobiologic models. We will discuss all the models in this chapter, but the Structure of the Personality last three models are discussed in more detail in The second major concept developed by Freud other chapters of this book. is the structure of the personality. Freud believed that the personality consists of three aspects, the id, the Critical Thinking Question Why would most mental ego, and the superego. The id is part of and derived health practitioners choose to use an eclectic approach from the unconscious. It is unlearned, primitive, to treatment? What are the advantages of this prac- and selfi sh. The id does not have a sense of right tice? Are there any disadvantages to this approach? and wrong, and ruthlessly insists on immediate satisfaction of its impulses and desires, which are

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geared toward avoiding pain and experiencing scious level, although an objective observer may be pleasure. The personality of newborns consists able to discern when others are using them. For ex- solely of the id, a belief that is not diffi cult to accept ample, a student who perceives herself as very intel- when one observes the behavior of infants. They ligent but who fails a test may rationalize this other- may, for example, cry lustily when hungry, regard- wise anxiety-producing outcome by telling herself less of the social appropriateness of such behavior. and others that the test was not important. Persons Even mature adults experience unceasing pressure with whom she shares this belief may be very aware from the id to satisfy its demands. The other parts that she is using the ego defense mechanism of ra- of the personality are responsible for keeping the id tionalization. Table 1-1 details commonly used de- under control. fense mechanisms. The ego develops as a result of the infant’s in- In contrast to the unconscious nature of de- teraction with its environment. It establishes an ac- fense mechanisms, coping mechanisms are con- ceptable compromise between the crude, pleasure- scious mental strategies or behaviors the individ- seeking strivings of the id and the inhibitions of the ual employs to lower anxiety. The various coping superego through reality testing. Reality testing is a mechanisms cannot be listed because their num- process the ego employs to ascertain the likely con- ber is as great as the creativity and resourceful- sequences of behavior. The ego is the practical part ness of human beings. Coping mechanisms are of the personality. As an individual matures, the ego categorized as short-term or long-term. becomes the rational, reasonable, conscious part of Short-term coping mechanisms are designed the personality and strives to integrate the total per- to address the immediate problem. For example, a sonality into a smoothly functioning, coherent person experiencing a great deal of work-related whole. In the mature adult, the ego represents the stress may drink alcohol as a means of coping. Al- self to others and individualizes the person from though this action may relieve the immediate other human beings (Taylor, 1994). anxiety, it does not address the source of the stress Chronologically, the superego develops last. or prevent the anxiety from reemerging. In con- The superego acts as the moral judge of the indi- trast, long-term coping mechanisms address the vidual based on what the person has learned from cause of the anxiety and are likely to benefi t the signifi cant others, such as parents and teachers. It individual more than short-term coping mecha- operates mostly at the unconscious level and con- nisms. Some examples are relaxation techniques, trols the id. The two aspects of the superego are the biofeedback, exercise, assertiveness training, set- conscience, which punishes individuals through ting goals, clarifying communications, visualiza- guilt and anxiety when their behavior deviates tion and guided imagery, meditation, yoga, seek- from the strict standards of the superego, and the ing out peer support, and self-hypnosis. ego ideal, which rewards individuals with feelings of well-being when their behavior achieves those Psychosexual Theory of Personality standards believed desirable by the superego. Nei- Development ther the punishing nor the rewarding functions of Freud also defi ned the developmental stages of the superego are based on the reality of the situa- personality. His theory of personality development tion. Rather, they are based on the individual’s in- is termed the psychosexual theory of personality de- ternalized standards of right and wrong and good velopment. Prior to this theory, children were seen and bad that were learned at an early age and are as miniature adults. Freud claimed that personality stored primarily in the unconscious (Taylor, 1994). is a dynamic, evolving process that develops from Freud believed that when id impulses unac- birth through young adulthood. Freud’s stages of ceptable to the superego threaten to emerge, the psychosexual development are oral (birth to 18 individual experiences anxiety. Anxiety is a diffuse, months), anal (18 months to 3 years), phallic (3 to vague sense of impending doom, and is always per- 6 years), and genital (13 years to adulthood). ceived as a negative emotion. Therefore, the person Although specifi c portions of Freud’s theory experiencing anxiety works to get rid of this feeling, are now viewed as an outgrowth of the Victorian often through the use of ego defense mechanisms, era in which he lived, his theories provided the mental mechanisms derived from the ego that are foundation for the work of subsequent theorists. designed to effect a compromise between the de- Erik Erikson expanded Freud’s theory of person- mands of the id and the superego to relieve anxiety. ality development to include the entire life span, Ego defense mechanisms operate on the uncon- and emphasized the importance of culture as a

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Table 1-1 Ego Defense Mechanisms

Defense Mechanism Definition Example Compensation Exaggerating one trait to make up for A physically small man verbally bullies his feelings of inadequacy or inferiority in employees. another dimension. Displacement Attributing feelings to a person or object A young woman kicks her cat after a telephone that are really directed at another person argument with her boss. or object. Denial Failing to perceive some threatening object A woman sets a place for dinner for her husband, or event in the external world. who has just been killed. Fixation Remaining “stuck” in a developmental A husband depends totally on his wife for most of stage. his activities of daily living. Sublimation Redirecting socially unacceptable urges An angry, hostile young man becomes a boxer. into socially acceptable behavior. Reaction formation Substituting directly opposite wishes for An adult who grew up in a very messy home is one’s true wishes. compulsively neat in his or her own home. Identification Integrating desired attributes of an A shy adolescent girl styles her hair identically to admired person to compensate for that of a popular rock star. perceived inadequacy. Introjection Incorporating another person to avoid the A psychotically depressed woman attempts suicide threat posed by the person or by one’s to kill her mother, who she states is in her own urges. stomach. Undoing Engaging in certain thoughts and A business executive studies to become a nursery actions so as to cancel out or atone for school teacher after having an abortion. threatening thoughts or actions that have previously occurred. Isolation Severing the connection between the A single parent talks unemotionally about her only thoughts and feelings associated with an child’s recent diagnosis of a malignant brain event so the event can remain conscious tumor. without undue anxiety. Rationalization Substituting a fictitious, socially acceptable “I would have helped you if I could, but I had to reason for the genuine, unacceptable take my dog to the vet.” reason for one’s wishes or actions. Repression Forcibly dismissing anxiety-producing A woman is unable to remember being raped by thoughts, feelings, or events from her brother when she was 10 years old. consciousness. Regression Returning to patterns of behavior A 6-year-old girl begins to wet the bed at night characteristic of a less anxiety-producing after her mother’s remarriage. stage of development. Projection Attributing to others an objectionable “My husband is cheating on me.” trait or feeling that really emanates from oneself. Symbolization and Using a neutral idea or object to represent A 40-year-old man has unconscious feelings of condensation an unacceptable idea or object. inadequacy as a male and spends all his money on guns and all his time polishing and cleaning them. Conversion Expressing unconscious emotional conflicts A young woman wakes up paralyzed from the waist through a physical symptom with no down on the morning of her wedding day. demonstrable organic basis. From Taylor, C. M. (1994). Essentials of Psychiatric Nursing (p. 211). St. Louis: Mosby Yearbook. Reprinted with permission.

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major determinant of personality development. believed that people defend against such anxiety by Erikson’s theory of psychosocial development is using security operations, including apathy, somno- called the Eight Ages of Man and encompasses lent detachment, selective inattention, and preoc- trust versus mistrust (infancy, 0 to 1 year), auton- cupation. Individuals use apathy by not allowing omy versus shame and doubt (early childhood, 1 themselves to feel the emotion associated with an to 3 years), initiative versus guilt (preschool, 3 to anxiety-producing event. Thus, an individual ap- 6 years), industry versus inferiority (school age, 6 pears indifferent in a situation expected to elicit a to 12 years), identity versus role confusion (ado- great deal of anxiety in most persons. Somnolent de- lescence, 12 to 18 years), intimacy versus isolation tachment is a primitive defense in which the indi- (young adulthood, 18 to 25 years), generativity vidual falls asleep when confronted by a highly versus stagnation (adulthood, 25 to 45 years), and threatening, anxiety-producing experience. More ego integrity versus despair (older adulthood, 45 common is selective inattention, in which anxiety- years to death). producing aspects of a situation are not allowed into awareness, enabling the individual to maintain Interpersonal Model a sense of stability. Finally, the security operation of preoccupation manifests as a consuming interest in a The interpersonal model was fi rst developed by person, thought, or event to the exclusion of the an American-born psychiatrist, Harry Stack Sul- anxiety-producing reality. livan (1892–1949). Sullivan believed the most Sullivan defi ned the self-concept as the result of critical factor in the development of the individ- refl ected appraisals of signifi cant others. He be- ual’s personality, and thus his or her behavior, is lieved that the development of the self-concept the person’s relationship with signifi cant others. begins in the stage of infancy and is closely related Sullivan believed that all human behavior is to the quality of the infant’s feeding experiences. If goal-directed toward the fulfi llment of two needs, infants frequently experience satisfaction and secu- the need for satisfaction and the need for security. rity from the mothering they receive during the The need for satisfaction derives from the person’s feeding process, they begin to see themselves as biologic needs for air, food, sex, shelter, and so on. worthwhile individuals; they start to develop what The need for security derives from the person’s emo- Sullivan refers to as “good me” self-concepts. How- tional needs for feeling states such as interpersonal ever, if their needs for satisfaction and security of- intimacy, status, and self-esteem. When these needs ten are not met, anxiety results and infants believe are perceived, internal tension results and the indi- they are not worthwhile; this lays the foundation vidual employs a variety of methods to meet them for the development of “bad me” self-concepts. In and thereby reduce the tension. Sullivan termed extreme cases where infants are severely deprived these methods dynamisms. He emphasized that dy- or when the majority of interpersonal relationships namisms are age-specifi c, which helps to explain are fraught with great threats to their existence, the characteristics of each stage of personality de- infants defend themselves by dissociating the velopment, from infancy (birth to 18 months), anxiety-generating experiences. As a result, because childhood (18 months to 6 years), juvenile (6 to they cannot develop a sense of self from refl ected 9 years), preadolescence (9 to 12 years), early ado- appraisals, infants develop a “not me” self-concept, lescence (12 to 14 years), and late adolescence (14 to which may lead to severe emotional problems. 21 years). During infancy, the oral cavity is used al- Once developed, the self-concept tends to self- most exclusively to meet the needs for satisfaction perpetuate because people behave in a manner (by crying to be fed) and the needs for security (by consistent with their self-concept and elicit inter- crying to be held). Therefore, the stage of infancy is personal responses from others that reinforce their characterized by the oral dynamism, because it is self-concept. Persons with good me self-concepts the means through which the individual establishes tend to relate to others in a positive way, eliciting interpersonal contact to meet needs and reduce positive responses that reinforce the self-concept. tension (Taylor, 1994). People with bad me self-concepts tend to relate to The concept of anxiety is central to Sullivan’s others in a manner that refl ects their poor view of theory. He postulated that anxiety is a response to themselves and, predictably, elicits responses that feelings of disapproval from a signifi cant adult. reinforce this view. Anxiety occurs when others’ re- These feelings of disapproval may not be based on sponses are incongruent with the person’s self- reality, and the adult whose disapproval is feared concept. People deal with this anxiety by utilizing may be real or a symbolic representation. Sullivan security operations that enable them to ignore

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differing input. This theory helps to explain why after several time outs. In response cost, a person some persons succeed against all odds and others experiences a loss or penalty as a consequence of fail despite all advantages. engaging in a certain behavior. The teenager who is “grounded” 1 day for every 5 minutes she is late Behavioral Model coming home from a date is likely to arrive home on time after several experiences of being Unlike the psychoanalytic and interpersonal mod- grounded. Extinction is the process of eliminating els, behavioral models are concerned with the here a behavior by ignoring or not rewarding it. Re- and now, not with how or why people developed peatedly ignoring a child’s temper tantrums is an the behavior they currently exhibit. Ivan Pavlov example of extinction. Efforts to increase or de- (1849–1936) was the fi rst behavioral researcher. crease behavior require a plan of treatment that His work on classical conditioning is well known is consistently implemented and avoids unin- to all students of psychology. Classical conditioning tended secondary gains, such as getting much- focuses on involuntary behaviors, such as blinking desired attention. and salivation. In classical conditioning, a person has a reaction to a neutral event because the reac- Cognitive Models tion and the event have become associated. For example, a person who exhibits the involuntary Cognitive models of development examine the symptoms of anxiety (pounding heart, rapid res- perceptual and intellectual growth of the indi- pirations) when he or she sees a picture of a tall vidual. Although individuals appear to follow a building somehow has learned to associate tall pattern in cognitive development, such time- buildings or heights with danger. tables can be very individual. Children often ap- The theory of operant conditioning has been pear to develop in one area while falling behind credited to B. F. Skinner (1904–1990) and his as- in others (e.g., learning to talk before or after sociates. Operant conditioning is concerned with walking, but not simultaneously). the relationship between voluntary behavior and An early cognitive theorist of the 1930s the environment. Skinner demonstrated that be- named Jean Piaget (1896–1980) focused on the haviors are infl uenced by their consequences; process involved in a child’s ability to know and those behaviors that have a positive consequence understand. Like Freud, Piaget’s theories are less increase in strength and are likely to be repeated, accepted by today’s therapists. However, he was whereas behaviors that result in negative conse- the fi rst theorist to postulate the different matu- quences are weakened and are less likely to be re- ration cycles involved in how children gain an peated (Stuart, Laraia, & Sundeen, 1998). awareness of self through cognitive abilities. His Increasing a desired behavior is achieved stages of cognitive development include: senso- through positive and negative reinforcement. rimotor (birth to 18 months), preoperational (2 Positive reinforcement rewards the desired behav- to 7 years), concrete operations (6 to 12 years), ior. For example, a person who receives a pay and formal operations (12 years to adulthood). raise because he or she produced more widgets is For more on this topic, see Chapter 24. likely to continue trying to produce even more widgets, assuming that he or she values an in- Developmental Models crease in pay. Negative reinforcement increases the frequency of a behavior by reinforcing the be- There are a variety of developmental models of- havior’s power to control a negative stimulus. fered by theorists that assist one in understanding For example, children quickly learn which be- how growth and development impact upon an haviors are likely to prevent their parents from individual’s mental health. These include: yelling at them. An attachment model (John Bowlby, 1907– Decreasing behavior is a more diffi cult task. 1990) based on the establishment of trust, It is achieved through punishment, response cost, bonding, and attachment as essential to the and extinction. Punishment is an aversive stimulus survival of the human species. that occurs after the behavior and serves to de- A behavior modifi cation model in which crease its future occurrence. For example, a child children are taught how to establish con- whose parents make him take a “time out” by trols from within and that there are conse- standing in the corner every time he uses a swear quences (natural, logical, and unrelated) to word is likely to decrease his use of swear words one’s behavior.

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A psychosocial model (Erik Erikson, ering to nurses and the nursing profession at a 1902–1994) based on the importance of critical time when their contributions to the care trust as a basic building block for normal of patients were not recognized. Furthermore, psychological development, that includes her theories were widely applicable to the prac- eight stages of developmental growth (see tice of nursing in all settings and with all types of Chapter 24). patients. The major concepts of Peplau’s theories are psychodynamic nursing, the nurse-patient rela- Neurobiologic Model tionship, and nursing roles. As described by Marriner-Tomey, “Psychody- In the last several decades, it has become apparent namic nursing is being able to understand one’s that an understanding of the brain and the ner- own behavior to help others identify felt diffi cul- vous system is basic to understanding the symp- ties, and to apply principles of human relations to toms, processes, and treatment of mental illnesses the problems that arise at all levels of experience” and disorders. Molecular biology is the founda- (1998, p. 327). The therapeutic nurse-patient relation for molecular psychiatry. tionship is the concept for which Peplau is best Psychiatric-mental health nurses and other cli- known. She describes an interaction between the nicians are increasingly challenged to understand nurse and patient as having four distinct yet over- neurons, neuronal transmitter brain receptors, ion lapping phases: orientation, identifi cation, exploi- channel variants, and intercellular neuronal mole- tation, and resolution. In the orientation phase cules and their effect on neural circuits, and ulti- there is a “felt need,” and professional assistance is mately, the behavior of individuals. The neurobio- sought by the patient. Identifi cation occurs after logic model and its associated psychopharmcologic the patient has clarifi ed the situation and begins to treatments will be driving forces in the next era of respond selectively to the various healthcare practi- psychiatric interventions. For most clients, phar- tioners. In the exploitation phase, the patient has macologic treatment controls the main symptoms identifi ed with a specifi c nurse and makes full use of the mental illness or disorder and is used in con- of all offered services. The resolution phase occurs junction with supportive therapies such as indi- as the patient gradually relinquishes identifi cation vidual psychotherapy, group therapy, family ther- with the caregivers (nurses and others) and is once apy, and self-help groups (see Chapter 4). again independent (Peplau, 1952). Finally, Peplau describes six different nursing Selected Nurse Theorists and Their roles that emerge in the various phases of the Conceptual Models nurse-patient relationship: stranger, resource person, teacher, leader, surrogate, and counselor. Several nurse theorists stress the interpersonal di- The roles change with the patients and the cir- mension of nursing in their conceptual models cumstances. Peplau emphasized that skill in these and believe that some form of personal interac- roles is developed only through practice and with tion with clients is the basis of the profession. A ongoing, competent supervision. brief description of some of these theorists and their models follows. Ida Jean Orlando (Pelletier) Hildegard Peplau Orlando’s fi rst book, The Dynamic Nurse-Patient Relationship: Function, Process and Principles of Hildegard Peplau has had the greatest impact on Professional Nursing Practice, was published in the development and practice of psychiatric nurs- 1961. Of all Orlando’s work, this book’s theories, ing. Although Peplau has held a number of sig- emphasizing the reciprocal relationship between nifi cant positions, she is best known for initiating patient and nurse, have had the greatest impact and developing the graduate program in psychi- on psychiatric nursing. atric nursing at Rutgers, where she was the direc- Orlando was one of the fi rst leaders of nurs- tor from 1954 until her retirement in 1974. Her ing to emphasize the elements of the nursing textbook, Interpersonal Relations in Nursing, fi rst process and the critical importance of the pa- published in 1952, signifi cantly changed psychi- tient’s participation during the nursing process atric nursing from a medical model to an inter- (Marriner-Tomey, 1998). As with Peplau’s theo- personal model in which the nurse has a major ries, Orlando’s theories apply to all nurse-patient role in therapeutic interventions. It was empow- interactions.

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Imogene King Individual Therapy Imogene King’s fi rst book, Toward a Theory for Individual therapy focuses on the person and in- Nursing: General Concepts of Human Behavior, cludes other aspects of the person’s life only as was published in 1971. King’s theory of goal at- they relate to the individual. Psychoanalysis was tainment is heavily based on systems theory. The the original form of individual therapy, although conceptual framework she formulated represents almost all conceptual models are now imple- personal, interpersonal, and social systems as the mented as types of individual therapy. Individual domain of nursing (Marriner-Tomey, 1998). therapy continues to be the most commonly used form of mental health therapy, although most Dorothea E. Orem therapists agree that treating individuals in the absence of their social support groups is the least Dorothea E. Orem’s fi rst book, Nursing: Concepts of desirable form of treatment. Practice, was published initially in 1971. Orem’s theory, termed self-care deficit nursing theory, de- Family Therapy scribes how the actions of nurse and patient are de- Although all nurses are concerned with the fami- termined by the patient’s self-care agency, “the ly’s impact on the client, only those educated as complex acquired ability to meet one’s continuing advanced practice psychiatric nurses function as requirements for care that regulates life processes, family therapists. Family therapy is based on the maintains or promotes integrity of human struc- belief that the person identifi ed as ill, the identi- ture and functioning and human development, fi ed client, exhibits symptoms that emanate from and promotes well being” (Marriner-Tomey, 1998, problems within the family system. Therefore, p. 190). Nursing is an interactive process based on treatment of the identifi ed client in isolation from the amount and kind of nursing agency needed. his or her family is doomed to failure. Two of the theoretical bases of family therapy are family sys- Joan Riehl-Sisca tems therapy and structural family therapy. Joan Riehl-Sisca applies the sociologic theory of Family systems therapy was developed by Mur- symbolic interactionism to nursing. Riehl-Sisca ray Bowen in the 1950s, and is based on the belief believes that that families are systems in which change in one as- pect of the system affects the entire system. There- . . . the nurse must view the actions of the individual as he perceives them. By role playing, explicitly or implicitly fore, when there is a change in the functioning of the nurse is able to understand why the patient does what one family member, the entire family is affected. he does and is thus better able to identify the source of Family systems theory consists of seven interlock- diffi culty, or nursing diagnosis. Then, having interpreted ing concepts. Three concepts apply to overall char- the patient’s action and studied the process recordings, acteristics of family systems: differentiation of self, the nurse is able to intervene with a plan of care. The plan triangles, and the nuclear family emotional system. of care involves helping the patient and/or family assume roles they have used in the past, or are currently using, to The other four concepts are related to the central cope with the present illness. The evaluation process is family characteristics: multigenerational transmis- then used to determine the success of this “role taking.” sion process, family projection process, sibling po- (Marriner-Tomey, 1998, p. 373) sition, and emotional cutoff (Stuart et al., 1998). Bowen believes that a member’s movement Critical Thinking Question Which of the above toward either increased emotional closeness or nursing models do you think would be most useful in distance is refl exive and predictable. The higher the practice of psychiatric-mental health nursing, the level of differentiation, the higher the level of and why? functioning. Differentiating the self from “we- ness” is the ultimate goal of treatment (Stuart et al., 1998). Family genograms are commonly used Treatment Modalities to depict the familial emotional system through generations (Figure 1-5). A genogram is a diagram Based on the conceptual models used by the ther- or map of multiple generations of a family indi- apist and an assessment of the needs of the client, cating family relationships, life events, family a treatment modality is selected, implemented, functioning, and signifi cant developmental and evaluated. The following briefl y describes the events. Men are represented by boxes, women by most commonly used treatments. circles. Other symbols and lines represent births,

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A genogram is a map of a family for several generations. It is a very useful picture that reveals multigenerational patterns. An example of a genogram is shown here.

Adopted Female (living)

Male (living) F Food disorder No longer living S Addicted to sex

Co Co-dependent G Addicted to gambling

Alcoholic W Workaholic Family conflict Identical twins d Divorce Children as surrogate parents D Addicted to Drugs Yo u C Addicted to Cigarettes

S Co

F S Co

d CVA AT 30

Co Co F

Figure 1-5 An example of a genogram.

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deaths, marriages, cohabitation, children, preg- co-leaders whose interventions must be appro- nancies, adoptions, divorces and separations, priate to the group’s development. For example, ethnic and religious origin, health and illness, risk the question “What is our purpose?” in the fi rst factors, and geographic locations. phase is likely to be an attempt to set boundaries Structural family therapy was developed by and orient group members. Therefore, a direct, family therapist Salvatore Minuchin. It is based on factual answer is most appropriate. The same understanding the individual within a social con- question asked during the next stage of group de- text. Minuchin postulated that behavior is a con- velopment is likely to represent a testing behavior sequence of the family’s organization and the in- and is best answered by refl ecting the question teractional patterns between members. Changing back to the group as a whole. the family organization and the feedback process- Group theorist Irvin D. Yalom has identifi ed es between members changes the context in which 11 operative factors that appear to account for the a person functions. Thus, the person’s inner pro- therapeutic effi cacy of groups: the imparting of cesses and behavior change (Stuart et al., 1998). information, the instillation of hope, universality, altruism, corrective recapitulation of the primary Group Therapy family group, development of socializing techniques, imitative behavior, interpersonal learn- Group therapy became a standard intervention for ing, existential factors, catharsis, and group cohe- the treatment of persons diagnosed with a mental sion (Yalom & Leszcz, 2005). illness during and immediately after World War II. A group is an identifi able system composed of three Milieu Therapy or more individuals who engage in certain tasks to achieve a common goal. The therapeutic group dif- Milieu therapy is the use of the environment as a fers from a social group because its goal is to assist therapeutic tool. The basis of milieu therapy is the individuals to alter their behavior patterns and to belief that all human beings are affected by their develop new and more effective ways of dealing physical, social, and emotional climate. Therefore, with the stressors of daily living. This goal may be the physical, social, and emotional climate may achieved through many forms of group therapy, be structured to help those who have a mental ill- including task groups, socialization groups, self- ness. For example, research has documented that help groups, psychotherapy groups, teaching and clients who are acutely ill respond best to a struc- learning groups, and supportive therapy groups. tured, consistent, and non-stimulating environ- Regardless of their type, all groups go through ment. In contrast, individuals with a mental illness four developmental phases, and certain group be- who are well enough to live in the community haviors characterize each phase. The fi rst phase is often benefi t from treatment environments they the preaffi liation phase, during which members behave actively helped to create and maintain (Tay- come acquainted with each other and develop trust lor, 1994). Therapeutic treatment settings have in one another and in the group leader. Some the following characteristics: groups are never able to move beyond this fi rst The client’s physical needs are met. phase. If the group is successful in achieving trust, it The client is respected as an individual with enters the second phase, termed the power and rights, needs, and opinions and is encour- control phase. During this phase, intragroup con- aged to express them. fl ict is experienced as members test each other and Decision-making authority is clearly de- the group leader. If this phase is successfully negoti- fi ned and distributed appropriately among ated, the group enters the third phase, termed the clients and staff. working phase. During this phase, the goal of the The client is protected from injury from self group is addressed directly. For example, in a task and others, but only those restrictions neces- group the members are now able to address the task sary to afford such protection are imposed. the group was formed to accomplish. The client is afforded increasing opportuni- The fi nal phase is the termination phase. ties for freedom of choice, commensurate Group members integrate what they have learned with his or her ability to make decisions. about themselves and the behavioral changes The staff remains essentially constant. they have made so that they can use these skills in The environment provides a testing ground the future. The success of the group is determined for the establishment of new patterns of to some extent by the skill of the group leader or behavior.

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Emphasis is placed on social interaction groups and books are common sources of antici- between and among clients and staff, and patory guidance. the environment’s physical structure and In contrast, situational crises are precipitated appearance facilitate this interaction. by unpredictable events for which people cannot Programming is structured but fl exible. prepare, such as the sudden death of a child. The therapeutic community is a type of milieu Whereas the death of one’s parent is a normal de- therapy that strives to involve clients in their ther- velopmental event, the sudden death of one’s apy, restore their self-confi dence by providing child is an untoward event for which no one can many opportunities for decision making, increase be prepared. In such events, parents have no re- their self-awareness, and focus their attention course other than general coping strategies, such and concern away from the self and toward the as their religious faith and family cohesiveness. If needs of others. This treatment modality has been these are adequate, a crisis state may be averted. most successful with groups of clients who are in If these or similar strategies do not exist or are contact with reality (Taylor, 1994). insuffi cient, a crisis state occurs. The goal of crisis intervention is to assist the Crisis Intervention individual and family to seek new and useful adaptive mechanisms within the context of the A crisis is a “state of disequilibrium resulting from social support system. The steps of crisis inter- the interaction of an event with the individual’s or vention are deceptively simple: clients must family’s coping mechanisms, which are inadequate achieve an accurate perception of the event that to meet the demands of the situation, combined precipitated the crisis state, become aware of the with the individual’s or family’s perception of the human and material resources available to assist meaning of the event” (Taylor, 1994, p. 456). Thus, them, and learn how to manage their feelings. not every untoward event precipitates a crisis state Even though these three steps seem simple, the in all individuals and families. Crisis intervention is crisis intervention counselor often spends hours of great interest to mental health professionals, be- helping clients tell and retell their experiences to cause it provides a specifi c opportunity to prevent identify the signifi cance of the events and to iden- mental illness and to promote mental health. Re- tify and plan the use of resources. This process search has documented that there are three poten- often must be repeated several times, but the re- tial outcomes to a crisis state: (1) the individual or ward of promoting the mental health of clients family may re-integrate at a lower or less healthy more than justifi es the amount of time spent and level of functioning than the one before the crisis; the fl exibility required. (2) the individual or family may re-integrate at the same level of functioning as previously; or (3) the individual or family may re-integrate at a higher, Somatic Therapies healthier level of functioning than the level before Somatic therapies are physiologically based inter- the crisis experience. This last potential outcome ventions designed to produce behavioral change. promotes mental health and is most likely to be Somatic therapies are based on the belief that an achieved with skilled intervention. inextricable relationship exists between the mind There are two types of crises, developmental and the body. In other words, the dichotomy be- and situational. The events that precipitate devel- tween mind and body and between mental and opmental crises are predictable and occur in con- physical illnesses is false. The most commonly junction with normal developmental transitions used somatic therapies are electroconvulsive with which the individual and family are not pre- therapy (ECT) and pharmacologic therapy. These pared to cope. For example, the demands placed interventions are discussed in depth in Chapters on a young couple by the birth of their fi rst child 5 and 16. may precipitate a crisis state if their idea of par- enthood was fashioned by romantic notions of baby powder and teething biscuits. Developmen- The Therapeutic Relationship tal crises may be averted by anticipatory guidance, Many consider the therapeutic relationship be- an educative process in which individuals and tween nurse and client the hallmark of psychi- families are prepared for the normal life changes atric nursing. In 1947, Nurse-Patient Relation- expected at each stage of development and are ships in Psychiatry by Helena Willis Render was told about successful coping strategies. Self-help published. Render was the fi rst to introduce the

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idea that the relationship the nurse establishes others, and other therapists; and prohibition with the client (patient) has a signifi cant thera- against socialization. peutic potential. However, it was the 1952 publication of Interpersonal Relations in Nursing by Phases of the Nurse-Client Relationship Dr. Hildegard E. Peplau that essentially revolu- tionized the teaching and practice of psychiat- There are three phases of the nurse-client rela- ric nursing in the United States. Peplau’s text tionship. The initial phase is termed the orien- focused on the therapeutic potential of the tation phase or getting acquainted phase. During one-to-one relationship at the same time that this phase the nurse and client agree on a mutu- psychotropic drugs were starting to be used, ally acceptable contract that establishes the re- enabling clients (patients) to benefi t from in- lationship’s parameters. The goals of this phase terpersonally based treatment modalities (Tay- are to develop trust and to establish the nurse as lor, 1994). a signifi cant other to the client. Although con- sistency and acceptance are desirable during all Critical Thinking Question What factors contribute phases of the relationship, these behaviors are to making the therapeutic relationship between the essential during the orientation phase. The cli- psychiatric nurse and the client the hallmark of psychi- ent learns to trust the nurse only if the nurse is atric nursing? able to convey acceptance of the client (as a parent would of a child) and exhibit consistent be- To be truly helpful to clients, nurses need to havior. Interestingly, once the client begins to understand the difference between professional trust the nurse, he or she may engage in behav- and social relationships. Social relationships are iors designed to test the nurse’s sincerity. Dur- interactions in which the needs of both persons ing this stage, clients commonly arrive late for are of equal importance. In contrast, professional an appointment. Although the nurse should relationships are those in which the needs of the not condone all the client’s behaviors, it is im- client are paramount. To engage in professional portant to consistently convey acceptance of relationships with clients, nurses must have a the client as a valued, worthwhile person. highly developed degree of self-awareness. Self- Once trust has been achieved, the second awareness means that nurses know those areas in phase of the relationship ensues. This phase is which they are emotionally vulnerable, although termed the maintenance or working phase. The they may not have an understanding of why these goal of this phase is to identify and address the vulnerabilities exist. client’s problems. Therefore, this phase is char- All intentional interactions with clients that acterized by the highly individualized nature of are helpful are considered therapeutic. However, the problems being addressed. During this not all nurse-client interactions constitute a rela- phase the nurse assumes one or more of the tionship. A relationship exists between the client roles identifi ed by Peplau—socializing agent, and the nurse only when they become signifi cant counselor, or teacher—as the nurse and client to each other (i.e., the opinion of the other makes tackle the issues facing the client. a difference in how one views oneself). When this The fi nal phase of the relationship is the con- occurs, the potential for corrective emotional ex- cluding or termination phase. The goal of this periences exists. If it is achieved, the relationship phase for both the client and nurse is to integrate becomes therapeutic. helpful experiences so that what has been learned Nurses need to be aware that boundaries are may be used in future relationships. Paradoxical- critical in maintaining a professional therapeu- ly, the more successful the relationship, the more tic relationship. At the beginning of the relation- emotionally painful is the termination. As a re- ship, an agreement or contract between the sult, both the nurse and client are tempted to deny nurse and client should be established. This is an the inevitable and pretend that their parting is excellent opportunity to establish the rules and only temporary. They may use phrases such as behaviors or boundaries that are expected be- “Keep in touch,” “I’m sure we’ll run into each tween the nurse and client, such as the time and other,” and “See you later.” These strategies are frequency of meetings; reimbursement for ser- comforting in the short term but do not help ei- vices; contact with family members, signifi cant ther in the long run.

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The therapeutic relationship remains the Taylor, C. M. (1994). Essentials of psychiatric nursing. most useful tool available to nurses who work St. Louis: Mosby-Yearbook. with a mentally ill client. However, the effective- This classic text was designed for the beginning student. ness of the relationship depends on the nurse’s It includes many approaches to dealing with problem situations. self-awareness. Wasserbauer, L. I., & Brodie, B. (1992). Early precur- sors of psychiatric nursing, 1838–1907. Nursing Summary Connections, 5, 19–25. This article provides an excellent description of the con- Historically, mentally ill persons have been ditions and events contributing to the development of poorly treated by society, suffering abandon- contemporary psychiatric nursing. ment, beatings, starvation, and imprisonment. Yalom, I. D., & Leszcz, M. (2005). The theory and practice More humane models of treatment were short- of group psychotherapy. New York: Basic Books. lived until the recent advent of therapeutic mod- This standard text about group psychotherapy covers all els of care and the availability of reliable psycho- aspects of group psychotherapy with helpful hints for ad- pharmaceuticals. Because of the current scope dressing diffi cult situations. and complexity of the burgeoning knowledge about the causes and treatment of mental illness, it is necessary for the multidisciplinary treat- Additional Resources ment team to work closely together to achieve Beers, C. (1923). A mind that found itself. New York: the goals of preventing mental illness and effec- Doubleday. tively treating those who are ill. This is Beers’s autobiographical account of his mental ill- The major conceptual models are the psy- ness, hospitalizations, treatment, and recovery. choanalytic, interpersonal, behavioral, cognitive, Carter, E., Peplau, H. E., & Sills, G. M. (1997). The ins developmental, and neurobiologic models. These and outs of psychiatric-mental health nursing and models of care are supplemented by the concep- the American Nurses Association. Journal of the tual nursing models of Peplau, Orlando, King, American Psychiatric Nurses Association, 3, 10–16. Orem, and Riehl-Sisca. The treatment modali- This article describes the profound infl uence of the Ameri- can Nurses Association on the development of psychiatric- ties commonly utilized include individual, fam- mental health nursing. ily, group, milieu, and somatic therapies, with Joint Commission on Mental Illness. (1961). Action for consideration of the need for crisis intervention. mental health. New York: Basic Books. Establishing a professional therapeutic relation- This is the fi nal report of the commission’s recommenda- ship is critical. The therapeutic nurse-client relation for the development of more effective mental health tionship is the hallmark of psychiatric nursing. services for the nation. King, I. (1971). Toward a theory for nursing: General concepts of human behavior. New York: John Wiley. Annotated References In this book, King’s fi rst publication, she proposes a theory for nursing practice based on systems theory. Marriner-Tomey, A. (1998). Nursing theorists and their work. St. Louis, MO: Mosby-Yearbook. Olson, T. (1996). Fundamental and special: The di- This text presents a discussion of the theories of all major lemma of psychiatric-mental health nursing. Ar- nurse theorists. A lengthy reference list for each theorist chives of Psychiatric Nursing, 10, 3–10. is included. This article explores the tension between defi ning Peplau, H. (1952). Interpersonal relations in nursing. psychiatric-mental health nursing as fundamental to the discipline yet also special. The formative works of New York: G. P. Putnam. Hildegard Peplau, Dorothy Mereness, and Claire Fagin This classic psychiatric nursing textbook provides the are cited. basic concepts to guide professional nurses in establishing mature therapeutic relationships with cli- Orem, D. (2001). Nursing: Concepts of practice. St. Lou- ents (patients) with all types of conditions and in all is: Mosby-Yearbook. settings. First published in 1980, Orem’s basic book explains her Stuart, G. W., Laraia, M. T., & Sundeen, S. J. (1998). self-care defi cit nursing theory. Stuart & Sundeen’s principles & practice of psychi- Orlando, I. J. (1961). The dynamic nurse-client rela- atric nursing. St. Louis, MO: Mosby-Yearbook. tionship: Function, process, and principles of profes- This comprehensive textbook on psychiatric nursing is sional nursing practices. New York: Putnam. useful for the practicing nurse as well as for the begin- This book, Orlando’s fi rst publication, explores the nurse- ning student. client relationship.

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Pickens, J. (1998). Formal and informal care of people Smoyak, S. A., & Rouslin, S. (1982). A collection of clas- with psychiatric disorders: Historical perspectives sics in psychiatric nursing literature. Thorofare, NJ: and current trends. Journal of Psychosocial Nurs- Charles B. Stock. ing and Mental Health Services, 36, 37–43. This book is a compilation of 36 articles written by lead- This article describes the historical context and current ers in psychiatric nursing prior to 1963. It provides a trends in the care of people with psychiatric disorders. unique perspective on the “roots” of the specialty. Smoyak, S. (1993). American psychiatric nursing. AAOHN Journal, 41, 316–322. Internet Resources This article provides a broad view of the work of psychiatric nurses in the United States during the past century.

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