Contemporary Psychiatric Mental Health
Nursing
3rd Edition by Kneisl Trigoboff
ISBN 0132557770 9780132557771
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Chapter 5
Theories for Interdisciplinary Care in Psychiatry
Learning Outcome 1
Discuss the major ideas of interactionism.
Concepts for Lecture
1. Theories discussed in this chapter provide the conceptual tools to formulate an understanding needed to work with psychiatric–mental health clients and to interpret important clinical data. Psychiatric–mental health nurses are concerned with the care of clients who have identified mental disorders. These concerns extend to the wide range of
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Kneisl/Trigoboff, Instructor’s Resource Manual for Contemporary Psychiatric–Mental Health Nursing, 3rd Edition
human responses to mental distress, disability, and disorder; the relationship between the individual’s optimal psychobiologic health and feelings of self-worth, personal integrity, self-fulfillment, and creative expression; and the need to satisfy basic living needs, have comfortable relationships with others, and have human rights recognized. Psychiatric–mental health nurses work for change within social and political systems, are involved in social goals that advance health holistically, and develop a philosophic and ethical framework to guide and evaluate the political outcomes of therapeutic intervention. (See Box 5-3 in the textbook.)
2. Symbolic interactionism, introduced by Herbert Blumer (1969), describes an approach to the study of human conduct. It is based on the three philosophic premises:
a. Life experiences have different meanings for different people. Because all behavior has meaning, the psychiatric–mental health nurse must develop skill in observing, interpreting, and responding to the client’s lived experiences in the hope of arriving at a common ground of negotiated meanings and authentic communication; and be wary of interventions that ignore, discount, or discredit the meaning an experience has for the client in favor of the nurse’s own definition of the situation.
b. Meanings arise in one’s social world. Meanings arise in the process of interaction with others. Psychiatric–mental health nurses must take into account each client’s social and cultural environment, and holistically assess client accounts for the interaction patterns in that person’s social world.
c. Meaning is a basis for behavior. People handle situations in terms of what they consider important about the situation. To understand clients’ actions, the
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Kneisl/Trigoboff, Instructor’s Resource Manual for Contemporary Psychiatric–Mental Health Nursing, 3rd Edition
psychiatric
mental health nurse must identify the meanings those actions have for them.
Suggestions for Classroom Activities
• Break the class into small discussion groups. Ask students to tell a story about their first day in nursing school and the meaning the experience has for them. Ask students to identify similarities and differences in their experiences and the meanings for them.
• Ask students to recall a time when they felt like an important person in their life did not understand the meaning of an experience they had. Ask them to share their experiences and feelings about the situation with each other.
• Have students observe the same activity (near the classroom area). Have each student record his or her observations. Upon return to the classroom, have each group identify similarities and differences in their observations and discuss their ideas about why there were differences.
Suggestions for Clinical Activities
• Have students develop a plan of care for a client using concepts from social interactionism.
• Have students observe clients in a group activity. Following the activity, speak with two to three clients about their experiences in the group. Compare and contrast the client stories and the meanings they associated with the group experience.
Learning Outcome 2
Discuss the major principles of humanism.
©2013 by Pearson Education, Inc.
Kneisl/Trigoboff, Instructor’s Resource Manual for Contemporary Psychiatric–Mental Health Nursing, 3rd Edition
Concepts for Lecture
1. The three premises of interactionism provide only a partial orientation. Humanism adds to the philosophic perspective. The humanistic perspective has eight central propositions (Lamont, 1967). Humanism is a philosophy of service to benefit humanity through reason, science, and democracy. The central concept of humanism is that the chief end of human life is to work for well-being within the limitations of life in today’s world. (See Box 5-2 in the textbook.)
Suggestions for Classroom Activities
• Have students recall staff and client interactions in the clinical setting. Evaluate how the eight principles of humanism were or were not evident in practice.
• Based on the assessment in the previous activity, ask students to prepare a plan of action to promote improvement in adherence to the principles.
Suggestions for Clinical Activities
• Ask students to keep a journal of interactions with clients to identify times when their interventions used principles of humanism and times where they did not. Have them list potential consequences/limitations to the therapeutic relationship that resulted from both.
• In a case conference, ask students to describe one of their clients in each of the following categories: a friend, a sister or brother, a parent, a community leader, and a hospitalized client. Ask them to describe what they learned about the individual, as a person, by viewing them in various roles.
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Kneisl/Trigoboff, Instructor’s Resource Manual for Contemporary Psychiatric–Mental Health Nursing, 3rd Edition
Learning Outcome 3
Describe the influence of the knowledge explosion in psychobiology
Concepts for Lecture
The last decades have seen major breakthroughs in knowledge about the brain, the mind, the spirit, and behavior. This knowledge explosion has been named psychobiology. Research has generated new understanding of how genetics, immunology, biorhythms, brain structure, and brain biochemistry influence mental disorders. New imaging techniques allow neuroscientists to better understand thoughts by analyzing physiological activity. New medications can correct biochemical imbalances in the brain, and psychobiologic interventions have become commonplace.
Suggestions for Classroom Activities
• Have students role-play a therapeutic conversation about the importance of medication compliance with a client newly diagnosed with bipolar disease.
• Divide students into groups and ask them to prepare an educational activity to help a group of hospitalized mental health clients understand the biologic, medical, and self-care components of depression.
Suggestions for Clinical Activities
• Have students review the nursing notes of a client’s medical record for evidence of diagnostic classification language and relate the influence of that language on the holistic components of the care plan.
• In a postclinical conference, ask students to discuss potential limitations of using classification language such as nursing diagnoses. What suggestions can they make to
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Kneisl/Trigoboff, Instructor’s Resource Manual for Contemporary Psychiatric–Mental Health Nursing, 3rd Edition
ensure client problems are addressed holistically? Have students list two goals they have for their own practice.
Learning Outcome 4
Explain how the premises of human interactionism and psychobiology relate to psychiatric–mental health nursing.
Concepts for Lecture
1. Interactionism considers human beings as having purpose and control over their lives, even if they have altered brain structure and chemistry and stressful environments. Interactionism is a philosophy of caring with a strong humanistic cast, acknowledging the interaction of psychology, psychobiology, and sociocultural contexts.
2. Humanism incorporates devotion to the interests of human beings wherever they live and whatever their status or culture, reaffirming the spirit of compassion and caring toward others. It is a constructive philosophy that wholeheartedly affirms the joys, beauty, and values of human living.
3. The humanistic interactionism considers physical and mental factors as interrelated; a change in one may result in a change in another. Healing and caring must be approached in a holistic manner. Psychiatric–mental health nurses have an expanded role, becoming involved in social goals that advance health holistically. Because psychiatric–mental health nursing has political consequences, it is essential that nurses develop a philosophic and ethical framework to guide and evaluate the political outcome of therapeutic intervention. The model for intervention and change is one of negotiation and advocacy.
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Kneisl/Trigoboff, Instructor’s Resource Manual for Contemporary Psychiatric–Mental Health Nursing, 3rd Edition
Clients and their families are not passive recipients of care given by psychiatric professionals, but rather are empowered in the process of developing new perspectives and encouraged to weigh alternatives and make self-directed choices.
4. Psychobiology has implications for psychiatric–mental health nursing practice as well. It includes a focus on the human aspects of care as well as biologic and medical aspects, bringing a contemporary holistic perspective to psychiatric–mental health care; integrating the rapidly accumulating knowledge in psychobiology; redefining the traditional art of psychiatric–mental health nursing care and caring in the new millennium; and nursing practice and research that integrates “high tech” and “high touch,” nature and nurture, and the biologic sciences and the behavioral sciences.
Suggestions for Classroom Activities
• Ask students to recall and describe a time when they felt their life circumstances affected their health in positive and negative ways.
• Have students keep a weekly journal of how their daily health and activities had an effect on their academic and social life.
Suggestions for Clinical Activities
• Ask students to keep a detailed record of activities during one clinical experience. Have them categorize each activity into “high tech” or “high touch.” Ask them to rank the high-tech and high-touch groups with a score from 1 to 5 (low to high) for feelings of personal satisfaction and for professional competence.
• Using the information from the previous activity, ask students to discuss their findings during a postclinical presentation and relate their findings to their work with a client.
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Kneisl/Trigoboff, Instructor’s Resource Manual for Contemporary Psychiatric–Mental Health Nursing, 3rd Edition
Learning Outcome 5
Compare and contrast the assumptions and key ideas of medical–psychobiologic, psychoanalytic, cognitive–behavioral, and social–interpersonal theories.
Concepts for Lecture
1. The medical–psychobiologic model is based on Emil Kraepelin’s descriptive diagnostic classification system, which included the notion that mental illness had an organic cause, that it was located in the central nervous system, that the disease followed a predictable course, and that treatment should be based on accurate diagnosis. The medical–psychobiologic position can be summarized as follows:
a. The individual has an illness or defect.
b. The illness can be located in some part of the body (usually the limbic system and the central nervous system’s synapse receptor sites). Factors include excesses or deficiencies of certain brain neurotransmitters; and genetic predispositions, or alterations in the body’s biologic rhythms, including the sleep–wake cycle.
c. The illness has characteristic structural, biochemical, and mental symptoms that can be diagnosed, classified, and labeled.
d. Mental disorders run a characteristic course and have a particular prognosis for recovery.
e. Mental disorders respond to physical or somatic treatments, including drugs, chemicals, hormones, diet, or surgery.
f. Psychobiologic explanations of mental disorders can reduce the stigma often
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Kneisl/Trigoboff, Instructor’s Resource Manual for Contemporary Psychiatric–Mental Health Nursing, 3rd Edition
associated with them, and can discourage claims that mental disorders result from a lack of willpower or moral character.
2. Sigmund Freud is considered the father of psychoanalytic theory. He shifted the focus from classification to a dynamic view of mental phenomena. Freud believed that all psychologic and emotional events are understandable, that childhood experiences caused adult neuroses, and that therapy provided insight into the meaning of events. Assumptions and key ideas include:
a. Psychic determinism states that no human behavior is accidental. Each psychic event is determined by the ones that preceded it. Events in people’s mental lives that seem random or unrelated to what went before are only apparently so.
b. The role of the unconscious any mental event that occurs outside of conscious awareness represents the unconscious region. Significant unconscious processes occur frequently in normal as well as abnormal mental functioning. Much of what goes on in people’s minds is unknown to them, and this accounts for the apparent discontinuities in their mental life.
c. Childhood experiences are related to causes of adult neuroses.
d. Psychoanalytic therapy focuses on clarifying the meaning of events, feelings, and behavior to achieve insight.
e. The structure of the mind was described in Freud’s publication of The Ego and the Id in 1923. It introduced the structural model of the mind, which describes three distinct entities: the id, the ego, and the superego. Their relationships can be depicted as an iceberg where the id is completely below the water’s surface and the superego partially below and partially above the surface. In comparison to the
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Kneisl/Trigoboff, Instructor’s Resource Manual for Contemporary Psychiatric–Mental Health Nursing, 3rd Edition
superego, the ego is more fully above the surface in the realm of conscious awareness. (See Figure 5-2 in the textbook.)
f. Freud believed that psychic energy was derived from “drives.” Instinctual aspects of a person’s mental life are explained by assuming the existence of two drives, the sexual drive and the aggressive drive. The sexual drive gives rise to the erotic component of mental activity. The sexual drive came to be known as the libido. The aggressive drive gives rise to the destructive component. (See Table 5-2 in the textbook.)
3. Cognitive–behavioral theory focuses on the present rather than the past. The theory has roots in psychology and neurophysiology. Behavior therapy is also known as cognitive–behavior therapy. Symptoms associated with neuroses and psychoses are identified as clusters of learned behaviors that persist because they are rewarding to the individual.
One of the most important contributions to this framework was made by Pavlov who discovered a phenomenon he called the conditioned response in a famous experiment with a dog and a bell (1902). The experiment found that the conditioned or learned response is the basic unit of all learning on which more complex behavioral patterns are constructed. Such construction occurs through a process of reinforcement, in which behaviors are rewarded and persist.
4. B. F. Skinner (1971) developed psychiatric treatment approaches that represent one form of conditioning and reflect the assumptions mentioned earlier. Operant conditioning emphasizes discovering why the behavioral response was elicited and what actively reinforces it. Positive reinforcement describes an event that increases the probability that the response will recur a reward for behavior. Negative reinforcement is defined as an
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Kneisl/Trigoboff, Instructor’s Resource Manual for Contemporary Psychiatric–Mental Health Nursing, 3rd Edition
event likely to decrease the possibility of recurrence because it penalizes the behavior.
Shaping is a procedure of manipulating reinforcement to bring the person closer to the desired behavior. Key assumptions of the theory include:
a. The conditioned or learned response is the basic unit of all learning.
b. The self is the sum of past conditionings.
c. Behavior is the way in which a person acts. It can be observed, described, and recorded.
d. There is no autonomous person. People are what they do and what they are reinforced for doing by conditions in their environment.
e. The self is a structure of stimulus–response hierarchies of habit. It is possible to know and predict conditions under which behavior will occur.
f. The symptoms of a mental disorder are the substance of that person’s troubles. There is no hidden motive, no underlying cause, and no internal pathogenic process. There is only the symptom or the behavior, and the aim of cognitive
behavior therapy is to change the behavior.
g. The therapist determines what behavior should be changed and what plan should be followed. Change comes about by identifying events in the client’s life that have been critical stimuli for the behavior and then arranging interventions for extinguishing those behaviors. A changed way of acting precedes a changed way of thinking.
5. Social–interpersonal theories of psychiatry grew out of a general dissatisfaction with approaches that account for mental illness in terms of either intrapersonal mechanisms (the symptoms of a disease) or individual personality dynamics such as anxiety, ego
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Kneisl/Trigoboff, Instructor’s Resource Manual for Contemporary Psychiatric–Mental Health Nursing, 3rd Edition
strength, and libido. Earlier theories neglect the crucial social processes and cultural variation involved in the development, identification, and resolution of disturbed human responses. Two separate but philosophically congruent schools of thought contribute to social–interpersonal theories: interpersonal theory and general systems theory. Interpersonal–Psychiatric Theory:
a. Adolf Meyer (1948–1952) and Harry Stack Sullivan (1953) made significant contributions to social–interpersonal theory in the first half of the 20th century.
i. The self-system or self-dynamism. The self-system provides tools that enable people to deal with the tasks of avoiding anxiety and establishing security. The self is a construct built from the child’s experience. It is made up of reflected appraisals the person learns in contact with significant others. The self develops in the process of seeking physical satisfaction of bodily needs and security. To feel secure, the self essentially requires feelings of approval and prestige as protection against anxiety.
ii. The interpersonal school of psychiatry in general takes a developmental–interpersonal view of the self.
b. Alfred Adler (1971) added the emphasis of the social and cultural conditions influencing behavior to the focus on the self and family system.
c. Erikson’s developmental theory of personality attempted to account for biologic instincts as well as cultural and interpersonal tasks that must be accomplished to move forward developmentally. This developmental theory is more optimistic than Freud’s because he believed that clients in therapy could return to a
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Kneisl/Trigoboff, Instructor’s Resource Manual for Contemporary Psychiatric–Mental Health Nursing, 3rd Edition
developmental task that had not been accomplished and relearn it.
d. Maslow’s self-actualization and hierarchy-of-needs theories proposed an order of basic human needs. Physiological needs must be met before higher-level needs such as self-esteem and self-actualization.
6. General Systems Theory:
a. Menninger (1963) views normal personality functioning and psychopathology in terms of general systems theory. His work addresses four major issues: adjustment or individual–environment interaction; the organization of living systems; psychological regulation and control, known as ego theory in psychoanalysis; and motivation, which is often called instinct or drive in the psychoanalytic framework.
b. A key concept of the theory is homeostasis (equilibrium). He asserts that the greater the threat or stress on a system, the greater the number of system components involved in coping with or adapting to it. Thus, pathology can exist at various levels: the cell and organ level (behavioral changes that follow cellular alterations due to drug use, a blood clot, or a tumor); the group level (family violence); the community level (overpopulation, pollution, homelessness, and poverty)
c. A system’s well-being depends on the amount of stress on it and the effectiveness of its coping mechanisms. Mental illness is an impairment of self-regulation in which comfort, growth, and production are surrendered for the sake of survival at the best level possible but at the sacrifice of emergency coping devices.
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Kneisl/Trigoboff, Instructor’s Resource Manual for Contemporary Psychiatric–Mental Health Nursing, 3rd Edition
Suggestions for Classroom Activities
• In small groups, have students assume the persona and theoretical position of Kraepelin, Freud, Sullivan, Maslow, Skinner, and Menninger. Have them debate the state of nursing practice in psychiatric–mental health nursing today. What do they identify as the problems and the advances in practice and how has their theory advanced nursing care today?
• Ask students to work in pairs. Each student will choose one study behavior they would like to change and prepare a plan to accomplish the change that includes positive and negative reinforcements. Have the students check in weekly to monitor each other’s progress, altering the plan as needed.
Suggestions for Clinical Activities
• Have each student develop two care plans for a client using principles from two different theories of their choosing.
• Have each student present an assessment and care plan for a client incorporating an eclectic approach from two to three theories that are appropriate for the clinical situation. Have students discuss if and how the eclectic approach enriched their interactions with the client.
Learning Outcome 6
Discuss the implications of each theory for the practice of psychiatric–mental health nursing.
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Concepts for Lecture
1. Medical–psychobiologic theories are the conceptual basis for the continued use of biologic therapies in the care of mental health clients, the hospital as the setting for care, research into the genetic transmission of mental illness, research on biochemical and metabolic variables among diagnosed psychiatric clients, and dominance of the medical doctor the psychiatrist in the mental health team. Knowledge of this framework is considered crucial. Furthermore, as long as psychobiologic knowledge expands, psychiatric–mental health nurses are responsible for translating that knowledge into care practices that recognize the biologic factors related to mental disorders. (See Box 5-3 in the textbook.)
2. In the past 40 years, psychoanalytic theory has seen a steady decline in the reliance on psychoanalytic theory and psychoanalysis. Psychoanalysis requires a person to be relatively well-functioning, introspective, and financially secure, thus creating a barrier to many mental health clients. Basic level nurses are not trained in psychoanalysis and are not usually involved in a psychotherapeutic treatment role. The nurse’s role has increased somewhat with long-term treatment of hospitalized clients in specific settings.
3. Principles of cognitive–behavioral therapy, and especially behavior modification, are complex, raising issues such as control, responsibility for behavior, and using negative or punitive stimuli. In institutional environments, nurses prescribe schedules for daily living that include behavior modification through a “token economy” where clients are rewarded by token reinforcements, such as food, candy, and verbal approval. In community-based settings, nurses also plan schedules that attempt to replace maladaptive behavior with behavior that allows people to function effectively within their natural
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Kneisl/Trigoboff, Instructor’s Resource Manual for Contemporary Psychiatric–Mental Health Nursing, 3rd Edition
environment. Interventions focus on the individual and empower clients to learn new skills. The movement has attempted to replace maladaptive behavior with behavior that encourages increased functioning. Psychiatric–mental health nurses also have a role in teaching the effective use of behaviorist principles to nonprofessional staff to assist clients when professional staff is not needed or available. (See Box 5-5 in the textbook.)
4. In social–interpersonal theory, nursing roles include case management, social psychiatry, community psychiatry, psychoeducation, and milieu therapy. Therapeutic interventions include programs for social change, political involvement, community organization, social planning, family support groups, and education about medications, symptom management, genetic risk, and family environment. All are associated with efforts to provide psychiatric services more efficiently to large groups of people, particularly those previously neglected, and attempt to counteract the debilitating effects of long-term institutionalization. All are associated with a movement to address the client’s social context in providing psychiatric care. Social interpersonal theory includes:
a. Holistic approaches: Interrelationship of multiple dimensions increase the number of assessment factors.
b. Broad definition of clients: Clients are defined as part of a system–family, couple, or community.
c. Primary prevention: Interventions include psychoeducation, social change, and research.
d. Therapy Goals: Gain perspective on lifestyle and environment issues, coping skills, and resources versus controlling symptoms.
e. Autonomous practice: Nurses are members of teams that value and move toward
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Kneisl/Trigoboff, Instructor’s Resource Manual for Contemporary Psychiatric–Mental Health Nursing, 3rd Edition
diffusion of roles.
5. Table 5-1 in the textbook provides a summary of major features of the traditional psychiatric theories.
Suggestions for Classroom Activities
• Have students watch an episode of a contemporary TV show about psychiatric–mental health issues (In Treatment, The Sopranos, etc.) Ask them to discuss the “theoretical” stance of the therapist and the pros and cons of the therapist’s style. What would they change if they were the therapist?
• Have students work in groups to develop a skit representing a client–nurse interaction using concepts from each theory
Suggestions for Clinical Activities
• In a postclinical conference, have students describe the theoretical assessment, the problem statement, treatment goal, and dominant interventions being used for the treatment plan for their assigned client(s).
• Invite advanced practice nurses who use different theoretical approaches in practice to participate in student case presentations in clinical conferences.
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Kneisl/Trigoboff, Instructor’s Resource Manual for Contemporary Psychiatric–Mental Health Nursing, 3rd Edition
