Chapter 7: Psychoanalysis, Psychotherapy, and Behavioral Therapies

Chapter 7: Psychoanalysis, Psychotherapy, and Behavioral Therapies

These therapies address mental health issues through various methods and theoretical approaches.

Nursing Responsibilities

• Not usually performing therapy: Nurses typically collect and assess data rather than deliver the therapy.

• Key roles:

  • Gather initial assessment data

  • Recognize the client’s need for therapy

  • Evaluate symptoms and treatment progress

  • Advocate for client’s right to treatment

• Being familiar with therapy types supports the client’s engagement in treatment.

Client Education

• Explain benefits of different therapy types

• Identify diagnoses each therapy can help manage

Classical psychoanalysis vs Psychotherapy

Therapy to uncover unconscious thoughts/feelings and resolve conflict via discussion with a psychoanalyst.

• Sessions span months to years.

Limitations

• Time-consuming and costly → rarely sole therapy today.

• Developed by Sigmund Freud; focuses on early childhood experiences and internal conflicts.

• Primarily used to explore past relationships and uncover unconscious conflicts.

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More verbal therapist–client interaction

Builds a trusting relationship to explore problems.

Transference

Client projects feelings from early significant relationships onto the therapist.

Countertransference

Therapist projects unconscious feelings about people from their past onto the client.

Therapeutic Tools (3)

Free association: Spontaneous, uncensored verbalization of thoughts.

Dream analysis & interpretation: Dreams reflect unconscious urges/impulses.

Defense mechanisms: Unconscious strategies to manage internal conflict.

Psychotherapy

More verbal therapist–client interaction than psychoanalysis.

Builds a trusting relationship to explore problems.

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Types

• Psychodynamic psychotherapy: Similar to psychoanalysis but focuses on the client’s present state rather than early life. Often longer in duration than other therapies.

• Interpersonal psychotherapy (IPT): Targets specific problems in relationships, communication, and bereavement; aims to improve interpersonal/social functioning to reduce psychiatric symptoms.

• Cognitive therapy: Focuses on how thoughts influence feelings and actions. Used for depression, anxiety, eating disorders, etc., by changing thinking patterns.

Behavioral Therapy

Developed by Pavlov, Watson, and Skinner in response to Freud; emphasizes changing behavior to treat disorders.

Behavior is learned and has consequences

• Abnormal behavior results from avoiding painful feelings.

Change occurs without needing insight into root causes.

Techniques: Relaxation training, modeling, exposure therapy, activity scheduling.

Effective for phobias, substance use, and other disorders.

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Types

• Eye movement desensitization and reprocessing (EMDR): Reprocesses traumatic memories in a safe, structured environment using adaptive coping strategies.

• Cognitive-behavioral therapy (CBT): Combines cognitive and behavioral approaches; addresses anxiety management by targeting how thoughts influence feelings and behaviors.

• Dialectical behavior therapy (DBT): Form of CBT for personality disorders and self-injury behaviors; emphasizes gradual behavior change, acceptance, and validation.

Types and Uses of Behavioral Therapy

Modeling

• Therapist or others act as role models; client imitates behavior to improve skills.

• Nursing use: Demonstrate appropriate behavior in stressful situations to help clients improve interpersonal skills.

Operant Conditioning

• Positive reinforcement for desired behavior.

• Nursing use: Example—tokens for good behavior exchanged for privileges/items.

Systematic Desensitization

• Gradual exposure to anxiety-provoking stimuli while using relaxation techniques.

• Nursing use: Start with relaxation mastery → gradual exposure (real or imagined) → reduce anxiety response. Effective for phobias.

Aversion Therapy

• Pair maladaptive behavior with unpleasant stimulus to discourage it.

• Nursing use: Punishments (e.g., bitter taste, mild electric shock) for harmful behaviors; requires supervision.

Relaxation & Mind–Body Techniques

• Meditation, guided imagery, diaphragmatic breathing, muscle relaxation, biofeedback.

• Used to control pain, tension, and anxiety (e.g., during labor or anxiety episodes).

Other Behavioral Therapy Techniques

Flooding

• Prolonged exposure to an undesirable stimulus (with therapist present) to reduce anxiety response.

Response prevention

• Preventing compulsive behavior to decrease associated anxiety.

Thought stopping

• Teaching client to interrupt negative or compulsive thoughts by saying “stop” (out loud or silently) and replacing with positive thoughts.

Trauma-Focused CBT

• Combines trauma education with coping strategies; gradual re-exposure to trauma memories to process them adaptively.

Validation therapy

• For neurocognitive disorders; acknowledges and respects client’s feelings in their perceived reality.

Virtual reality exposure therapy

• Uses VR to treat depression, anxiety, phobias, PTSD, and attachment issues by controlled exposure in a simulated environment.

A nurse is assisting with systematic desensitization for a client who has an extreme fear of elevators. Which of the following actions should the nurse implement with this form of therapy?

a

Demonstrate riding in an elevator, and then ask the client to imitate the behavior.

b

Advise the client to say “stop” out loud every time they begin to feel an anxiety response related to an elevator.

c

Gradually expose the client to an elevator while practicing relaxation techniques.

d

Stay with the client in an elevator until the anxiety response diminishes.

c Gradually expose the client to an elevator while practicing relaxation techniques.

Systematic desensitization is the planned, progressive exposure to anxiety-provoking stimuli. During this exposure, relaxation techniques suppress the anxiety response.

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Demonstration followed by client imitation of the behavior is an example of modeling.

Teaching a client to say “stop” when anxiety occurs is an example of thought stopping.

Exposing the client to a great deal of an undesirable stimulus in an attempt to turn off the anxiety response is an example of flooding.

A nurse is caring for a client who has a new prescription for disulfiram for treatment of alcohol use disorder. The nurse informs the client that this medication can cause nausea and vomiting when alcohol is consumed. Which of the following types of treatment is this method an example?

a

Aversion therapy

b

Flooding

c

Biofeedback

d

Dialectical behavior therapy

a Aversion therapy

The nurse should identify that aversion therapy pairs a maladaptive behavior with unpleasant stimuli to promote a change in behavior and is used for a client who has a new prescription for disulfiram for treatment of alcohol use disorder.

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Flooding is planned exposure to an undesirable stimulus in an attempt to turn off the anxiety response.

Biofeedback is a behavioral therapy to control pain, tension, and anxiety.

Dialectical behavior therapy is a cognitive-behavioral therapy for clients who have a personality disorder and exhibit self-injurious behavior.

dialectical

(adj) relating to the logical discussion of ideas and opinions

(adj) concerned with or acting through opposing forces.

A nurse is teaching a client who has an anxiety disorder and is scheduled to begin classical psychoanalysis. Which of the following client statements indicates an understanding of this form of therapy?

a

“Even if my anxiety improves, I will need to continue this therapy for 6 weeks.”

b

“The therapist will focus on my past relationships during our sessions.”

c

“Psychoanalysis will help me reduce my anxiety by changing my behaviors.”

d

“This therapy will address my conscious feelings about stressful experiences.”

b “The therapist will focus on my past relationships during our sessions.”

The nurse should identify that classical psychoanalysis is a therapeutic process that requires many sessions over months to years and places a common focus on past relationships to identify the cause of the anxiety disorder.

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The nurse should identify that classical psychoanalysis is a therapeutic process that requires many sessions over months to years.

Classical psychoanalysis focuses on identifying and resolving the cause of the anxiety rather than changing behavior.

Classical psychoanalysis assesses unconscious, rather than conscious, thoughts and feelings.

A nurse is discussing free association as a therapeutic tool with a client who has major depressive disorder. Which of the following client statements indicates understanding of this technique?

a

“I will write down my dreams as soon as I wake up.”

b

“I might begin to associate my therapist with important people in my life.”

c

“I can learn to express myself in a nonaggressive manner.”

d

“I should say the first thing that comes to my mind.”

d “I should say the first thing that comes to my mind.”

When taking action, the nurse should identify that free association is the spontaneous, uncensored verbalization of whatever comes to a client’s mind.

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Dream analysis and interpretation are therapeutic tools. However, they are not an example of free association.

Associating the therapist with significant persons in the client’s life is an example of transference rather than free association.

Learning to express feelings and solve problems in a nonaggressive manner is an example of assertiveness training, rather than free association.

Cognitive Reframing

Identifies and changes negative thoughts that cause anxiety.

Examines causes and replaces negative self-talk with supportive ideas.

Example: Changing the thought “I’m a bad person” to “I’ve made bad choices, but I’m not a bad person.”

Types

• Priority restructuring: Focus on important tasks and pleasurable activities.

• Journal keeping: Write stressful thoughts; improves well-being.

• Assertiveness training: Express feelings and solve problems calmly and directly.

• Monitoring thoughts: Increase awareness of negative thinking patterns.

A nurse is preparing to implement cognitive reframing techniques for a client who has an anxiety disorder. Which of the following techniques should the nurse include in the plan of care?

Select all that apply.

a

Priority restructuring

b

Monitoring thoughts

c

Diaphragmatic breathing

d

Journal keeping

e

Meditation

a Priority restructuring

b Monitoring thoughts

d Journal keeping

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Diaphragmatic breathing is a form of behavioral therapy rather than a cognitive reframing technique.

Meditation is a form of behavioral therapy rather than a cognitive reframing technique.