Exhaustive Guide to Psychological and Developmental Theories in Nursing

Psychoanalytic and Psychodynamic Theories

• The Unconscious: Sigmund Freud proposed that the unconscious mind contains thoughts and feelings that individuals "stuff back" and are not actively aware of.

• Freud's Structural Model of Personality:

  • The Id (Edge): Operates on the pleasure principle. It represents immediate desires and automatic thoughts (described in the transcript as thoughts occurring "right off the top of the bra strap"). It functions like a child, focusing on what one wants "right now," such as going to get a drink or walking out of a room.

  • The Ego: Represents reality. It acts as a mediator through compromise. It acknowledges desires but considers real-world constraints (e.g., recognizing one cannot walk out of a lecture while it is in progress).

  • The Superego: Operates on morality. It determines what is right or wrong and dictates behavior based on moral standards.

• Psychosexual Stages of Development: Freud believed personality and traits are largely sustained by the age of $5$. Subsequent experiences are primarily environmental or educational.

  • Oral Stage ($0-18$ months): Focused on oral satisfaction. Satisfied through pacifiers, hands, feet, or gnawing on objects like counters or strollers. Lack of satisfaction here can cause lingering issues.

  • Anal Stage ($18$ months - $3$ years): Focused on the private/unregulated area. Children may touch themselves as they explore new sensations of elimination (urine and feces). Potty training and explaining bodily functions are necessary to overcome this phase.

  • Phallic Stage ($3-6$ years): Children identify physical differences (penis versus clitoris).

  • Oedipus Complex: Occurs during the phallic stage ($3-6$ years). A child may develop a romantic attraction to the parent of the opposite sex. If not resolved (e.g., through proper parental boundaries and identification with the same-sex parent), it can lead to sexually inappropriate behaviors, homicidal tendencies toward the other parent or a parent's mate, or personality issues. The transcript references the movie Psycho, American Horror Story, and a vampire movie involving a mother and son as examples of unresolved complexes.

  • Latency Stage (Starts at $6$ years): Sexual instincts emerge. Education about birth and disease is crucial here to prevent inappropriate interests or risks like molestation.

  • Genital Stage (Adolescence): Focused on sexual identity. The transcript notes that children as young as $8$ to $10$ years old may engage in sexual incidents in psychiatric units. In the state of Georgia, children cannot legally consent, regardless of their own verbal agreement.

• Classical Psychoanalysis Techniques:

  • Free Association: The patient talks freely while lying on a couch.

  • Dream Analysis: Exploring symbols in dreams to understand the unconscious mind.

  • Defense Mechanism Recognition: Identifying how the patient protects their ego.

• Contemporary Psychodynamic Therapy: Focuses on the "here and now." It is best suited for the "Worried Well"—individuals who are intelligent enough to recognize they have a problem (e.g., depression or difficulty getting out of bed), motivated to change, and able to identify clear areas of difficulty.

• Transference vs. Countertransference:

  • Transference: Unconscious feelings a patient has toward the healthcare provider, often based on relationships with others (e.g., a patient calling a nurse "mom").

  • Countertransference: Feelings the healthcare provider has toward the patient (e.g., a nurse treating a patient like their own son). Nurses must maintain strict boundaries and treat all patients fairly to avoid these complications.

Interpersonal and Nursing Theories

• Harry Stack Sullivan’s Interpersonal Theory: Asserts that all behavior is aimed at getting needs met through interactions and reducing anxiety.

  • Anxiety Definition: A painful feeling or emotion arising from social insecurity or the prevention of biological needs.

  • Security Operations: Strategies used to decrease and manage anxiety.

  • Self-System: A security system or defense used to maintain self-esteem and protect against being a "scapegoat."

  • Interpersonal Therapy Usage: Best used for grief, loss, personal disputes, and role transitions (e.g., student to nurse).

• Hildegard Peplau's Theory of Interpersonal Relations: Influential in establishing nursing as a professional practice.

  • Nurse Roles: The nurse acts as both a participant and an observer. Nurses are "entitled to all the business" of the patient to facilitate care.

  • Anxiety Levels: Peplau identified different levels of anxiety and interventions to lower it, which improves a patient's ability to heal.

Behavioral Theories and Therapies

• Classical Conditioning (Pavlov): Using a stimulus to trigger a conditioned response (e.g., ringing a bell to make a dog salivate in anticipation of food).

• Behavioral Theory (Watson): Focuses on social conditioning. Aims to change maladaptive personality traits into adaptive ones.

• Operant Conditioning (Skinner): Behavior is modified through a reward and punishment system.

  • Behavior Management: Recognizing behaviors, identifying them to the patient, and replacing them with positive actions.

  • Documentation: Nurses must document behavioral changes and interventions (e.g., "Redirected the patient regarding disorganized behavior for morning group").

• Types of Behavioral Therapies:

  • Modeling: The nurse demonstrates the desired behavior for the patient to imitate.

  • Exposure Therapy: Gradually exposing a patient to their fears in small increments (e.g., helping someone afraid of stepping on cracks by moving from small tiles to larger tiles).

  • Aversion Therapy: Pairing a target behavior with a negative stimulus (e.g., using rubber bands on the wrist or ADHD "zap" bracelets that provide a small electrical pulse to discourage negative habits like face picking).

  • Biofeedback: Using monitoring equipment to show the patient their physiological responses to stress (e.g., heart rate) and teaching them how to lower those signs.

Cognitive Theories and Therapies

• Rational Emotive Therapy (Ellis): Focuses on the ABC model to handle irrational thoughts:

  • A (Activating Event): The incident that occurred.

  • B (Belief): The thought a person has about that event.

  • C (Emotional Consequence): The resulting behavior or feeling (e.g., throwing a fit and being placed in restraints after being woken up for early labs).

• Cognitive Behavioral Therapy (Beck): Identification and testing of distorted beliefs to change thinking patterns and reduce symptoms.

  • Cognitive Triad: Negative beliefs about the World ("Everyone is awful"), the Future ("Nothing will get better"), and the Self ("I can't stop doing bad things").

  • Trauma-Focused CBT (TF-CBT): Specifically adapted for victims of sexual abuse; used for all ages and involves caregivers.

• Dialectical Behavioral Therapy (DBT): A specialized form of CBT for people unable to regulate emotions.

  • Focus Areas: Core mindfulness, impulsivity, emotion regulation, and interpersonal chaos.

  • Labile Moods: Used for patients whose moods go from $0$ to $100$ instantly.

  • Target Populations: Established by Marsha Linehan in $1993$; used for chronic suicidal ideation, self-injurious behavior, borderline personality disorder, bipolar disorder, and substance use.

Humanistic and Biological Theories

• Maslow’s Hierarchy of Needs: A sequential framework where lower needs must be met before transitioning to higher needs.

  • 1. Physiological: Basic survival needs like food, water, and shelter. Homeless patients or hungry patients must have these met first.

  • 2. Safety: Ensuring the patient feels secure. In a psychiatric milieu, safety is the number one priority.

  • 3. Love and Belonging: Acceptance and identifying social resources.

  • 4. Self-Esteem: Building the patient up through resources like outpatient CBT.

  • 5. Self-Actualization/Transcendence: The final stage of reaching full potential.

• Biological Model: Focuses on the brain, genes, DNA, and chemical changes.

  • Pharmacotherapy: The use of medications. Nurses must observe benefits and overcome their own biases toward medication to encourage patient compliance.

  • Brain Stimulation Therapies (Detailed in Table $2.5$, p. $30$):

    • Electroconvulsive Therapy (ECT): Intentionally inducing a seizure under anesthesia to treat severe depression.

    • Repetitive Transcranial Magnetic Stimulation (RTMS): Using magnets on the brain.

    • Vagus Nerve Stimulation (VNS): An internal device that stimulates the nerve.

    • Deep Brain Stimulation (DBS): Invasive stimulation for severe cases.

  • Side Effects: Memory loss is a common concern with these therapies, but the benefits (preventing catatonic or severe depressive episodes) often outweigh the risks.

Developmental and Moral Theories

• Cognitive Development (Piaget):

  • Sensorial Motor ($0-2$ years): Birth to literal exploration.

  • Preoperational ($2-7$ years): Basic understanding of objects (e.g., water in a cup).

  • Concrete Operational ($7-11$ years): Figuring out how things fit together (e.g., volume and pouring).

  • Formal Operational ($12+$ years): Ability to think critically, abstractly, and use formal logic.

• Psychosocial Development (Erikson):

  • Trust vs. Mistrust ($0-1.5$ years): Developing a bond. Failure leads to an inability to bond later.

  • Autonomy vs. Shame/Doubt ($1.5-3$ years): Toddlers doing things for themselves.

  • Initiative vs. Guilt ($3-6$ years): Starting activities; shaming can lead to social withdrawal.

  • Industry vs. Inferiority ($6-12$ years): Feeling important or skilled (e.g., team sports awards).

  • Identity vs. Role Confusion ($12-20$ years): Figuring out who they are (college, sexuality).

  • Intimacy vs. Isolation ($20-35$ years): Choosing companions vs. staying alone.

  • Generativity vs. Self-Absorption ($35-65$ years): Parenting and social contribution.

  • Integrity vs. Despair ($65+$ years): Reflecting on life achievements vs. regrets.

• Other Developmental Theories:

  • Margaret Mahler ($1975$): Focused on separation and abandonment issues early in life.

  • Lawrence Kohlberg: Moral development framework including Preconventional (obedience), Conventional (social order), and Postconventional (universal ethics).

  • Carol Gilligan: Criticized Kohlberg for favoring males; proposed Ethics of Care, prioritizing the needs of those we care for over strangers.

Questions & Discussion

• Question: Did Sigmund Freud know about the frontal cortex when developing his theory?

• Response: No, but the presenter notes it is interesting how his id/ego/superego concepts align with modern understandings of the frontal lobe's function in impulse control and decision-making.

• Question: Are these slides online?

• Response: The specific slides with pictures used in the lecture are not online, but the content is available in standard slides without the images. Students were encouraged to take notes or use the video recording.