Chapter 2

Theories & Therapies

Psychoanalytic Theory

• Sigmund Freud

• A groundbreaking theory of personality structure, levels of awareness, anxiety, the role of defence mechanisms and stages of psychosexual development

Fruedian Levels of Awareness

• Iceberg Model

• Conscious: tip of the iceberg; contains all the material a person is aware of at any one time — preconceptions, memories, thoughts, fantasies, and feelings

• Preconscious: just below the surface; material that can be retrieved rather easily through conscious effort

• Unconscious: deep below the surface; all repressed memories, passions, and unacceptable urges, memories & emotion associated with trauma; the unconscious exerts a powerful but unseen effect on the conscious thoughts & feelings, need a therapist to help retrive from this part

Freudian Personality Structure

• Id: at birth; totally unconscious & impulsive, sources all drives, instincts, reflexes and needs, cannot tolerate frustration and seeks to discharge tension & return to comfort, lacks logical problem solving — “the devil”

• Ego: within a few years of life; conscious, preconscious & unconscious levels, allows you to think and plan, reality —- “mediator”

• Superego: age 3-5 develops; moral component of personality, conscious, preconscious and unconscious levels, may induce guilt if behavior falls short, thinks of shoulds and should nots, keeps impulse under control —- “the angel”

Defense Mechanisms

• Developed by the ego to ward off anxiety by preventing conscious awareness of threatening feelings

• They all (except suppression) operate on an unconscious level, and they deny, falsify, or distort reality to make it less threatening

Freudian Psychosexual Stages of Development

• Oral (0-1 year): source of satisfaction is the mouth, primary conflict is weaning, tasks include mastery of oral needs; beginning of ego development, desired outcome is to develop trust in the environment

• Anal (1-3 years): source of satisfaction is anal region, primary conflict is toilet training, tasks include beginning of dev of sense of control over drives, desired outcome is control over impuses

• Phallic (3-6 years): source of satisfaction is genitals, primary conflict is oedipus and electra complexes, tasks include sexual identity and beginning of superego dev, desired outcome is ID with parent of the same sex

• Latency (6-12 years): tasks are growth of ego and ability to care about & relate to others, desired ouctome is dev of skills needed to cope

• Genital (12+ years): source of satisfaction is genitals, tasks are dev of satisfying sexual and emotioanl relationships, eventual emancipation from parents, desired oucome is ability find pleaure in love & work

Psychoanalytic Therapy

• Classic psychoanalysis, as developed by Freud, is rarely used

• The purpose of classical psychoanalytic sessions is to uncover unconscious conflict by: free association, dream analysis & defense mechanism recognition

• Two important concepts are transference (unconscious feelings that the pt has toward a healthcare worker that were originally felt in childhood for a significant other; can be affectionate or hostile) and countertransference (unconscious feeling that the heatlhcare worker has toward the pt; again postive or negative)

Psychodynamic Therapy

Rooted in traditional psychoanalysis and uses many of the same tools and concepts however, the therapist has increased involvement and interacts with the patient more freely

• Therapy is oriented to the here and now and less on developmental origins

Interpersonal Theory

• Harry Stack Sulivan

• Effective short-term therapy

• Assumption that the psychiatric disorder is influenced by interpersonal interactions & the social context

• Goal is to reduce or eliminate psychiatric symptoms by improving interpersonal functioning and satisfaction with social relationships

• Three types of problems respond particularly well: grief & loss, interpersonal disputes, and role transition

Interpersonal Relations in Nursing

• Hildegard Peplau

• Took Sullivan’s theory and developed the first systematic theorectical frameowrk for psychiatric nursing

• Process by which the nurse helps patients to make positive changes in their healthcare status and well-being

Other Nursing Theorists

• Patricia Benner: caring as a foundation for nursing, comforting interventions, importance of nurse-pt relationship, and importance of teaching & coaching pt

• Dorothea Orem: self-care as integral part of nursing, nurse promotes self-care activities of pt

• Sister Callista Roy: continual need for people to adapt physically, psychologically, and socially and the role that nurses have to assist this adaptation and coping with the changes

• Betty Neuman: impact of internal and external stressors on equillibrium; nurses should work to discover and use stress-reducing strategies

• Joyce Travelbee: meaning in the nurse-pt relationship & importance of communication, alleviate suffering thorugh communciation skills

Classical Conditioning Theory

• Ivan Pavlov

• When a neutral stimulus is repeatedly paired with another stimulus (that normally elicits a reaction) eventually the neutral stimulus alone could elicit the original reaction

• Classicallly conditioned responses are INVOLUNTARY and are not spontaneous choices

Behavioral Theory

• John B. Watson

• Developed behaviorism: personality traits and responses, both adapative & maladaptive, were socially learned through classical conditioning

• Controlling the environemnt could mold behavior and that anyone could be trained to be anything

Operant Conditioning

• B.F. Skinner

• A method of learning that occurs through rewards and punishment for VOLUNTARY behavior

• Behavioral responses are elicited through: reinforcement (increasing the behavior) or punishment (decreasing the behavior)

  • Positive Reinforcement: adding a stimulus to increase behavior

  • Negative Reinforcement: taking away a stimulus to increase behavior

  • Positive Punishment: adding a stimulus to decrease behavior

  • Negative Punishment: taking away a stimulus to decrease behavior

• Extinction: absence of reinforcement also decreases a behavior by withholding a reward that became habitual

Behavioral Therapy

Assumes that changes in maladaptive behavior can occur without insight into the underlying cause. Works best when it is directed at specific problems and goals are well defined: phobias, alcohol use disorder, schizophrenia. Five types

1. Modeling (Bandura): therapist provides a role model for specific ID behaviors & the pt learns through imitation

2. Operant Conditioning: behavior modification & reinforcement/punishment to modify behavior, token economy system

3. Exposure Therapy: face fears and emotionally process them in a safe environment. Variations include imagining, real-world in-person confrontation, virtual reality. Often exposure therapy progresses from small to larger exposure of the fear

   1. Systematic Desensitization: incremental exposure of graded exposure along with relaxation techniques

   2. Flooding: most extreme, confronting the feared thing and then managing / processign it

4. Aversion Therapy: pairing a target behavior with a negative stimulus to extinguish undesirable behavior — bitter substance for nailbiting, use in alcohol abuse, controversial use in sexual preferences

5. Biofeedback: controlling the body’s physiological response to stress & anxiety. Helps people to make changes

Cognitive Theroies & Therapies

Cognitive theories propose that there is a dynamic interplay between the individual’s thoughts, feelings, and actions and the environment

• Rational-Emotive Therapy (Albert Ellis): Remove core irrational beliefs by helping people to recognize thoughts that are not accurate, sensible, or useful. ABC process (A- activating event, B- beliefs of event, C-emotional consequence of event), focus on present attitudes, painful feelings and dysfunctional behaviors

• Cognitive Behavioral Therapy (Aaron Beck): feelings and behaviors are largely determined by the way people think about the world and their place in it, helps pts ID, test and correct distorted thoughts

  • Automatic Thoughts: rapid unthinking responses based on schemas (assumptions about ourselves)

  • Cognitive Distortion: irrational and false assumptions and misinterpretations

    • All-or-nothing thinking, overgeneralization, labeling, mental filter, disqualifying the positive, jumping to conclusions, mind-reading, fortune-telling error, magnification/minimilzation, catastrophizing, emotional reasoning, should & must statements, personalization

  • Trauma-focused CBT was developed in the 1990s

• Dialectical Behavioral Therapy (Marsha Linehan): specific type of CBT, integration of opposites to help the patient give up extreme positions

Humanistic Theories

Humanistic Theories focus on human potential and free will to choose life patterns supportive of personal growth and emphasize self-actualization

• Human Motivation/Hierarchy of Needs (Maslow): pyramid diagram; physiological needs, safety, belonging/love, esteem, self-actualization, self-transcendence

  • Later added cognitive needs and aesthetic needs

• Self-Actualized Person: accurate perception of reality, acceptance of themselves, natural, simple, spontaneous, problem-centered, pleasure in being alone but also with active social interest, lighthearted, fair, creative, don’t conform

• Carl Rogers: a person-centered model of psychotherapy empahsizing the concepts of congruency, unconditional positve regard and acceptance and empathetic understanding

Biological Model

• A medical model

• Assumes that abnormal behaivor is the result of a physical problem

• Focuses on neurological, chemical, biological and genetic issues

• Understand how the body and brain interact to create emotions, memories and perceptual experiences

• Locates the illness / disease in the body and tartgets that site with intervetnions — drugs, diet, surgery

Biological Therapies

• Pharmacotherapy: Treat psychiatric disorders with medicine. Presented a strong alternative to past psycholocial approaches. Convinced people of the brains role in phsychiatric illness. Medicines greatly reduce the need for hospitalization and dramatically improve the lives of people suffering from serious psychiatric difficulties

• Brain Stimulation Tehrapies: electrical stimulation of the brain to treat psychiatric but also neurological disorders and pain conditions

  • Electroconvulsive Therapy (ECT): convulsive, site: cortical, disorders: depression, mania & catatonia

  • Repetitive Transcrania Magnetic Stimulation (rTMS): non convulsive, site: cortical, disorders: depression

  • Vagus Nerve Stimulation (VNS): non convulsive, site: cervical cranial nerve, disorder: depression

  • Deeb Brain Stimulation (DBS): non convulsive, site: subcortical, disorder: depression, OCD

Developmental Theories

• Cognitive Development (Piaget):

  • Sensorimotor Stage (birth-2yrs): basic reflexes, culminates with purposeful movement, spatial abilities, and hand-eye coordiantion; physical interaction with the environment stimulates this; object permanence is achieved (9 months)

  • Preoperational (2-7yrs): no abstract thought or generalizations but think in concrete fashion, egocentric thinking demonstrated, unable to conserve mass, volume or number

  • Concrete (7-11 yrs): logical thought appears and abstract problem solving is possible, take on multiple POVs, conservation possible, solution based

  • Formal (11+yrs): conceptual reasoning, abstract thought, increased problem solving

• Psychosocial Development (Erikson): role of culture and society on personality development and continues to evolve throughout the lifespan. Erikson developed eight predetermined and consecutive life stages each of which results in a positive or negative outcome and that outcome will affect the subsequent stage

• Theory of Object Relations (Mahler): emphasize past relationships in influencing a person’s sense of self as well as the nature and quality of relationships in the present

Theories of Moral Development

• Stages of Moral Development (Kohlberg):

  • Preconventional Level: Stage 1-obedience & punishment (focus on rules and authority), stage 2 - individualism and exchange (not everyone thinks the same and if you break a rule you can be punished

  • Conventional Level: stage 3 - good interpersonal relationships (children begin to view right/wrong as related to motivations, personality, and the person they’re watching), stage 4 - maintaining the social order (“rules are rules”, adopt broader view of society)

  • Postconventional Level: stage 5 - social contract & individual rights (social order is important but social order must be good to be followed), stage 6 - universal ethical principles (actions shoudl created justice, obliged to break unjust lawas)

• Ethics of Care Theory (Gilligan):

  • morality of care should replace Kohlberg’s “justice view” of morality; Gilligan emphasized forming relationships, banding togeterhe and putting the needs of those for whom we care above strangers

  • Her stages:

    • Preconventional: goal is indiviudal survival — caring for self

    • Conventional: self-sacrifice is goodness — caring for others

    • Postconventional: principle of nonviolence — balancing care for self & others