therapies, theories and a bunch of bullshit
Psychoanalytic therapy: Freud
· Believed behaviors are determined by unconscious motivations and instinctual drives – Psychodynamic theory:
o All behavior has meaning
o Principle of Psychic Determinism: all behavior is motivated by unconscious mental content
§ Example: A person forgets where he parked his car because he really does not wish to go where he was going
o Childhood experiences shape adult personality
o Id, ego, superego
§ Id: Pleasure principle: immediate satisfaction
· Unconscious drives
· “I want”
§ Ego: concept of external reality: rational mind, operates on reality principle
· Mediates between the demand of drives and environmental realities.
· Responsible for the use of defense mechanisms
· “I think, I evaluate.”
§ Superego: evaluates right from wrong:
· Aspirations, ideals, and moral values
· Regulated by guilt and shame
· Develops around age 6
· “I should, I ought.”
· Psychodynamic therapy promotes the development of greater insight and awareness of maladaptive defenses
· Past development and psychodynamic factors are part of what shape present behaviors.
· Defense mechanisms (frued): conflict is normally dealt with through the use of defense mechanisms witch: are a function of the ego, are unconsciously called into action, are used to reduce anxiety, become part of the personality, maintain a cell sense of safety, promote self-esteem and sell sense of well-being, may be used episodically or habitually, and may be used constantly and become fixed, as seen in neuroses.
o Denial: avoidance of unpleasant realities by unconsciously ignoring their existence
§ Example: an alcoholic who denies they have a problem after job loss
o Projection: unconscious rejection of emotionally unacceptable personal attributes, beliefs, or actions by attributing them to other people, situations, or events
o Regression: return to comfortable thoughts, behaviors, or feelings used in earlier stages of development in response to current conflict, stress, or threat
§ Ex: child wets the bed after divorce
o Repression: unconscious exclusion of unwanted, disturbing emotions, thoughts, or impulses from conscious awareness
§ Ex: child cannot remember abuse
o reaction formation: often called overcompensation; unacceptable feelings, thoughts, or behaviors are pushed from conscious awareness by displaying and acting on the opposite feeling, thought, or behavior
§ ex: treating someone you dislike in a friendly matter in order to hide true feelings
o rationalization: justification of illogical, unreasonable ideas, feelings, or actions by developing an acceptable explanation that satisfies the person
§ Ex: Student blames professor for bad test after failure
o undoing: behaviors that attempt to make up for or undo an unacceptable action, feeling, or impulse
o Splitting: aspects of a person are only seen in extremes and not integrated
§ Ex: wife only views husband as all goo or all bad
o intellectualization: attempts to master current stressor or conflict by expansion of knowledge, explanation, or understanding
§ Ex: terminal illness patient learns deeply about disease and treatment to avoid reality
o suppression: conscious analog of repression; conscious denial of a disturbing situation, feeling, or event
§ Ex: put aside a bad day to enjoy daughter’s wedding- can be good
o sublimation: unconscious process of substitution of socially acceptable, constructive activity for a strong unacceptable impulse
§ Ex: when angry – workout- good defense mechanism
o altruism meeting the needs of others in order to discharge drives, conflicts, or stressors
· Psychosexual stages: used for discharging drives (sexual and aggressive) and obtaining gratification, age-related behaviors: primary means of discharging drives and achieving gratification:
o Oral (0-18 months): sucking, chewing, feeding, crying
o Anal (18 months - 3 years): sphincter control, expulsion/retention
o Phallic (3-6years): normal for 6 year old to touch genitals, oedipal conflict (attraction to parents)
o Latency: (6-puberty): socialization, motor skills
o Genital: (puberty on): integration of earlier stages
Cognitive therapy: external events do not cause anxiety or maladaptive behaviors, BUT the person’s expectations, perceptions, and interpretations of events cause anxiety.
· Exams central cognitive distortions
· GOAL: change irrational beliefs, faulty perceptions and cognitive disortortions
Behavior Therapy: change bad behaviors by techniques such as exposure, relaxation, problem solving, and role-playing.
DBT: used in borderline personality disorder treatment
· Focuses on emotional regulation, tolerance for distress, self-management skills, interpersonal effectiveness, and mindfulness, with an emphasis on treating therapy-interfering behaviors
· Goals: decrease suicidal behaviors, therapy-interfering behaviors, emotional reactivity, self-invalidation, crisis-generating behaviors, and passivity; and increase realistic decision-making and accurate communication of emotions and competencies.
Existential therapy: reflection of life and self-confrontation is encouraged
· Logotherapy (therapy through meaning)
· Accepting freedom and making responsible decisions
· Focus on present and personal responsibility
· Who am I, why am I here?
Humanistic Therapy: person-centered therapy
· Unconditional positive regard
· People are born with the capacity to direct themselves toward self-actualization
Interpersonal Therapy: focus on interpersonal therapies that are causing distress
· Effective for adults and adolescents with depression
· Based on attachment theories
· Has also been applies to treat other disorders such as bipolar, substance use, and eating disorders
EMDR: form of behavior and exposure therapy
· Bilateral stimulation: moving eyes or tapping hand on knees.
· Mostly used in PTSD
· Goal: achieve adaptive resolution
· Phases:
o Desensitization phase: The client visualizes the trauma, verbalizes the negative thoughts or maladaptive beliefs, and remains attentive to physical sensations. This process occurs for a limited time while the client maintains rhythmic eye movements. He or she is then instructed to block out negative thoughts, to breathe deeply, and then to verbalize what he or she is thinking, feeling, or imagining
o Installation phase: the client installs and increases the strength of the positive thought that he or she has declared as a replacement of the original negative thought
o Body scan: the client visualizes the trauma along with the positive thought and then scans his or her body mentally to identify any tension within
GROUP THERAPY:
· Benefits: increased insight about one’s self, increased social skills, cost-effective, sense of community
· Yalom developed the first theoretical perspective on group therapy work and identified 10 factors that differentiate group therapy from individual therapy:
1. Installation of hope: hope to create a different life; members are at different stages so this gives others hope on where they could be
2. Universality: others have similar problems and they are not alone
3. Altruism: sharing oneself with another and heling another
4. Increased development of socialization: new social sills are learned and bad ones are corrected
5. Imitative behaviors: increase skills by imitating others
6. Interpersonal learning: Interacting with others increases adaptive interpersonal relationships
7. group cohesiveness: participants develop an attraction to the group and other members as well as a sense of belonging
8. catharsis: participants experienced catharsis as they openly expressed their feelings, which were previously suppressed
9. existential factors: groups enable participants to deal with the meaning of their own existence
10. corrective refocusing: participants reexperience family conflicts in the group, which allows them to recognize and change behaviors that may be problematic.
· Group phases: By tuckman (6 phases)
o Pre-group phase: leader considers direction and framework of the group
o Forming phase: members are concerned about sharing and being rejected. Goals are identified and boundaries are established
o Storming phase: members are resistance and begin to use testing behaviors
o Norming phase: resistance to the group is overcome by members.
o Performing phase: group work becomes more focused.
o Adjourning phase: preparation to end the group is made
Family therapy: There are many different types of family therapy
· Family Systems concepts:
o A system is any unit structured on feedback
o The family system is the process by which members of a family operate
o Family Systems Theory: cannot understand the individual without understanding how members of the family operate together (system).
o Operate on a set of rules that may be overt or covert
o Boundaries: are barriers that protect and enhance the functional integrity of families, can be physical or psychological.
§ Boundaries can be rigid, leading to distance relationships and disengagement
§ Clearly defined: maintain separateness while emphasizing belongingness
§ Diffuse boundaries are blurred and indistinct, leads to enmeshment
o Circular casualty: ongoing feedback loop
o Family homeostasis: families will resist change to maintain a steady state
o Morphogenesis: families will adapt to change when necessary
o Morphostasis: family remains stable in the midst of change
· Family Systems Therapy by Bowen: A person's problematic behavior may serve a function or purpose for the family or be a symptom of dysfunctional patterns
o focus is on chronic anxiety within families
o treatment goals are to increase the family's awareness of each members function within the family and to increase levels of self-differentiation (the level at which one's sense of self-worth is not dependent on external relationships, circumstances, or occurrences)
§ Triangles: lower the level of family adaptation, more likely for triangle to form.
§ Nuclear family emotional system: level of differentiation is of parents is equal to level of differentiation of family
§ Multigenerational transmission: dysfunction is across generations
§ Family projection process: parents transmitting their own level of differentiation on the most susceptible child.
§ Emotional cutoffs: attempting to break contact with family of origin
§ Sibling position: influences interactions and personality characteristics
· Structural Family Therapy by Minuchin: emphasis on how, when, and to whom family members relate in order to understand and then change the family’s structure
o Person’s symptoms are rooted in the context of family transaction patterns. The symptom is a function of the health of the whole family and is maintained by structural problems in the system
o the main treatment goal is to produce a structural change in the family organization to more effectively manage problems; changing transactional patterns in family structure
§ Family structure: an invisible set of functional demands that organize the way members interact with each other, made up of subsystems (e.g., marital, parental, sibling), coalitions (two members joining forces against a third member), and boundaries.
§ Structural mapping (genogram): mapping relationships using symbols to represent over involvement, conflict, coalitions, and so forth
§ Hierarchies: distribution of power
· Experiential Therapy by Satir: behaviors is determined by personal experience and not by external reality.
o Focus is on being authentic, on freedom of choice, on human validation, and on experiencing the moment.
o Treatment goals are to develop authentic, nurturing communication and increased self-worth of each family member; the overall goal is growth rather than symptom reduction alone.
· Strategic therapy:
o Symptoms are viewed as metaphors and reflect problems in the hierarchical structure
o Symptoms are a way to communicate metaphorically within a family
o Goal is to help family members behave in ways that will not perpetuate problem behaviors
o Interventions are problem-focused rather than structural therapy
o Techniques:
§ Straightforward directiveness: Tasks that are designed in expectation of the family members' compliance
§ paradoxical directives: a negative task that is assigned when family members are resistant to change and the member is expected to be non-compliant (use with caution)
§ reframing belief system: problematic behaviors are relabeled to have more positive meaning.
· Solution-based therapy: the goal is to rework the present situation, and solutions that have worked previously
o Treatment goal is effective resolution of problems through cognitive problem solving and use of personal resources and strengths
o techniques include the use of miracle questions, exception finding questions, and scaling questions
§ miracle questions: “If a miracle had happened tonight while you were asleep, and tomorrow morning you woke up to find the problem no longer existed, what would be different? How would you know the miracle took place? How would others know?”
§ Exception finding questions: directing clients to a time in their lives when the problem did not exist, which helps them move towards solutions by assisting them in searching for any exceptions to the pattern. Was there a time when the problem did not occur?
§ Scaling questions: on a scale of 1 to 10, with 10 being very anxious and depressed, how would you rate how you are feeling now?” This is useful for highlighting small increments of change
Legal Considerations:
· Malpractice insurance: does not protect NPs from practicing out of their legal scope of practice
· Four elements of negligence must be established for malpractice:
o Duty: NP had a duty to exercise reasonable care when providing treatment to the client
o Breach of duty: NP violated the applicable standard of care in treating the client's condition
o Proximate cause: there is a causal relationship between the breach of duty and the client’s injuries
o Damages: client experiences permanent and substantial damages as a result of the breach in the standard of care
Therapeutic relationship: Assumes the client and the nurse enter into a mutual, interactive, interpersonal relationship specifically to focus on the identified needs of the client
· The following are a few characteristics of a therapeutic relationship:
o genuineness, acceptance, non-judgmental, authenticity, empathy, respect, and professional boundaries
· transference and countertransference are key concepts in the nurse-client relationship
o if identified, countertransference is usually dealt with through the supervisory process and talking with coworkers about the issues
§ provided in a peer-to-peer or peer-supervisor relationship
§ examines interpersonal dynamics inherent in the SNP's relationship with clients
· There are three phases of a therapeutic nurse-client relationship
o Introduction: orientation
§ Nurse actions: Creating a trusting environment, establishing professional boundaries, establishing the length of anticipated interaction, providing diagnostic evaluation, setting mutually agreed upon treatment objectives.
· Common client behavior: initial hesitancy by the client to participate fully in assessment and treatment planning (approach avoidance)
o Working (identification and exploitation):
§ nurse actions: clarifying client expectations and mutually set goals, implementing treatment plan, monitoring health, undertaking preventative health care, measuring outcomes of care, evaluating outcomes of care, reprioritizing plan and objectives as indicated
· common client behavior: transference, countertransference, client resistant to care practices, client resistant to change
o termination (resolution):
§ nurse action: reviewing the client's progress towards objectives, establishing a long-term plan of care, focusing on self-management strategies, disengaging from the relationship, referring the client to other services as needed
· common client behavior: client resistance determination, regression, reemergence of symptoms or problems.
Eriksons Developmental Stages: 8 stages
· Infancy: Trust vs mistrust (0-1years):
o Developmental mastery: Ability to form meaningful relationships, hope about the future, trust in others
o Developmental failure: Poor relationships, lack of future hope, suspicious of others
· Early childhood (1-3)
o Developmental mastery: self-control, self esteem, willpower
o Developmental failure: Poor self-control, low self esteem, self doubt, lack of independence
· Late childhood (3-6)
o Developmental mastery: self-directed behavior, goal formation, sense of purpose
o Developmental failure: lack of self initiated behavior, lack of goal orientation
· School-age (6-12)
o Developmental mastery: ability to work, sense of competency and achievement
o Developmental failure: sense of inferiority, difficulty with working and learning
· Adolescents (12-20)
o Developmental mastery: personal sense of identity
o Developmental failure: identity confusion, poor self identification in Group settings
· Early adulthood (20-35)
o Developmental mastery: committed relationships, capacity to love
o Developmental failure: emotional isolation, ecocentrism
· Middle adulthood (35-65)
o Developmental mastery: ability to give time and talents to others, ability to care for others
o Developmental failure: Self absorption, inability to grow and change as a person, inability to care for others
· Late adulthood (65+)
o Developmental mastery: fulfillment and comfort with life, willingness to face death, insight and balanced perspective on life's events
o Developmental failure: bitterness, sense of dissatisfaction with life, despair over impending death
Conflict resolution: win-win solution directed by a third party
· Negotiation: discussion among 2 or more people with the goal of reaching an agreement.
· Mediation: third party help facilitate discussion to reach an agreement
· Arbitration: third party reviews evidence from both sides and make a decision to settle the case
· Professional civility: behavior that shows respect toward another person
PICO questions:
· P= patient, population, problem
· I=intervention
· C=comparison (another treatment or placebo)
· O=outcome
Systematically search for relevant research evidence
· Critique research evidence
o Qualitative hierarchy
§ RTCs, meta-analysis, systematic review
§ EB guide based on systematic review
§ Evidence based on RCT without randomization
§ Etc….
o Quantitative hierarchy
§ Evidence from systematic reviews of descriptive and qualitative studies
§ Single descriptive and qualitative
§ Etc…
Concepts on interpreting research
· Internal validity: the independent variable (the treatment) caused a change in the dependent variable (the outcome)
· external validity: the sample is representative of the population and the results can be generalized
· descriptive statistics: used to describe the basic features of the data in the study; numerical values that summarize, organize, and describe observations; can be generated by either quantitative or qualitative studies
o examples include
§ mean: average of scores
§ standard deviation: indication of the possible deviations from the mean
§ variance: how the values are dispersed around the mean the larger the variance the larger the dispersion of scores
inferential statistical values include the following:
Analysis of variance (ANOVA): tests the difference among three or more groups
Probability is the likelihood of an event occurring
An impossible event has a probability of 0, while a certain event has a probability of 1.
Pearson's r correlation: tests the relationship between two variables
t-test: assesses whether the means of two groups are statistically different from each other
P-value: also known as the level of significance, describes the probability of a particular result occurring by chance alone
The National Committee for Quality Assurance has developed Health Effectiveness Data Information Sets (HEDIS) to measure health outcomes. Currently, 11 HEDIS measures exist for behavioral health:
· antidepressant medication management
· follow-up care for children prescribed ADHD medication
· follow up after hospitalization for mental illness
· diabetes screening for people with schizophrenia and bipolar disorder who are using antipsychotic medications
· diabetes monitoring for people with diabetes and schizophrenia
· cardiovascular monitoring for people with cardiovascular disease and schizophrenia
· adherence to antipsychotic medications for individuals with schizophrenia
· use of multiple concurrent antipsychotics in children and adolescents
· metabolic monitoring for children and adolescents on antipsychotic medication
· use of first line psychosocial care for children and adolescents on antipsychotic medication
· mental health utilization
Health care policy four components
· Process: formulation, implementation, and evaluation
· policy reform: changes in programs and practices
· policy environment: arena the process takes place in the government, media, and public
· policymakers: key players and stakeholders
Health policies are developed through law and regulations
· branches of law executive (implement law), legislative (initial formulation), and judicial (interpret law
Nurse Practice Act:
· Provides title protection (who may be called a NP)
· Defines advance practice
· State laws that define scope of practice (what NPs may do)
· Places restrictions on practice
· Sets credentialing requirements (educational, certification)
· States grounds for disciplinary action
· May require collaboration with physician
Credentialing
· Process used to protect the public by ensuring a minimum level of professional competence
Certification
· Provides title protections
· Determines scope of practice (Who NPs can see and what they can treat)
· The process by which a professional organization or association certifies that a person licensed to practice as a professional has met certain predetermined standards specified by that profession for specialty practice
· assures the public that a person has mastery of this specified body of knowledge
· assures that the person has acquired the skills necessary to function in a particular specialty. The ANCC is the only certifying body for advanced practice psychiatric nursing privacy protection act
standards of practice
· authoritative statements regarding the quality and type of practice that should be provided
· provide a way to judge the nature of care provided
Confidentiality
· Requires that a provider obtain a signed medical authorization and consent form to release medical records and information when requested by the client or another healthcare provider
· Exceptions to guaranteed confidentiality:
o when appropriate persons or organizations determine that the need for information outweighs the principle of confidentiality
o if a client reveals an intent to harm self or others
o information given to attorneys involved in litigation
o releasing records to insurance companies
o answering court orders, subpoenas, or summons
o meeting state requirements for mandatory reporting of diseases or conditions
o Tarasoff principle: duty to warn potential victim of imminent danger of homicidal clients
o child or elder abuse
HIPAA
· privacy protection act
· guarantees clients for fundamental rights
o to be educated about HIPAA protection
o to have access to their own medical records
o to request an amendment of their health information to which they object
o to require their permission for disclosure of their personal information
Ethics: Ethical principles:
· Justice: doing what is fair
· Beneficence: promoting well-being and doing good
· Nonmaleficence: Doing no harm
· Fidelity: Being true and loyal
· Autonomy: doing for self
· Veracity: telling the truth
Complementary and alternative therapies
Mind-body interventions are therapeutic practices that focus on the interaction between mental and physical processes, including techniques like biofeedback, meditation, yoga, and guided imagery to promote holistic health.
The following examples are appropriate for using biofeedback:
Stress-related symptoms such as anxiety
Pain
Insomnia
Neuromuscular problems
Neurobehavioral disorders
Enhancement of hearing
Athletic and work performance
Biologically-based therapies
Herbal products
Vitamins
Supplements
Aromatherapy
Manipulantive and body based therapy
Acupressure and acupuncture
Massage
Reflexology
Aromatherapy
Analgesic, psychological and antimicrobial benefits
Olfactory stimulation used to elicit feelings or memories during psycho therapy