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Review from 'The History of
Psychiatric Nursing', 1/10/00. The role of psychiatric nursing began to
unfold in the early 1950's. In 1951 J.Mellow wrote about her experiences
working with schizophrenic patients, calling it "nursing therapy".
The next contribution in 1952 was from Dr. Hildegard Peplau, was a book,
Interpersonal Relations in Nursing. This provided a description of the
skills, activities, and the role necessary for the psychiatric nurse. By the
next year, 1953, the National League of Nursing (NLN) mandated that nursing schools
were to give students Psychiatric theory and clinical experience.
By this time the major changes that had occurred since the first psychiatric
nurses were trained only in a psychiatric hospital. Linda Richards, in 1982,
was instrumental in producing the first trained psychiatric nurses in McClean
Hospital, the care was mainly custodial. These nurses were trained in a
specialty in the 2 year program that was done in the psychiatric hospital. By
1953 Nursing schools were told to include the psychiatric experience within
the regular nurses training program.
In the early 1950's, along with the beginning use of the 'social environment'
(The Therapeutic Community: A New Treatment Method in Psychiatry, M. Jones)
as therapy, came the new use of psychotropic drugs. This became a major
breakthrough for many patients. As physicians became familiar with doses and
experience, there became a decrease in the use of seclusion and restraints.
Individuals became treatable on such medications as Thorazine and Mellaril.
With this advent developed the new role of the psychiatric nurse as one who
uses the theories of human behavior and the (therapeutic) self in the nursing
process. The nurse-patient relationship is a partnership; included in this
relationship is the nurses clinical expertise, patient/family advocacy,
collaboration with other disciplines, social,legal and ethical
accountability. Todays psychiatric nurse must have a sensitivity to the
patients' social environment, financial circumstances, and the advocacy needs
of the family. Also enclosed within this structure is the most important
principle of all at risk for disease and mental illness, which is prevention,
lowering the incidence of mental illness in a community by working on the
causes of disturbance.
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Read shaded box '1-3' on page 8, Stuart & Sundeen.
The psychiatric mental health nurse is an R.N. with a baccalaureate degree
as well and has received a certification. The letter C is placed after the
R.N. ( Louise, Rausa, R.N., C.).
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The Biological Model (Medical Model) is today the dominant influence
in psychiatric care. The psychiatrist and the physician are the leaders of
the team. Other health professionals are involved in referrals, assessments,
and patient/family education. Major contributions of this model include the
continuing scientific exploration for the biological causes for mental
diseases. Research on the functioning of the brain, neurotransmitters and new
medications for better regulation and balance of neurochemistry have made
normal life possible for many. A diagnosis is made according to the
Diagnostic and Statistical Manuel of Medical Disorders, fourth edition better
known as DSM-IV. The DSM-IV names the illness, describes the symptoms, gives
an indication of the course of the illness. The major criticism of this book
is its weakness is a lack of awareness of cultural and social bias..
Important to describe here is the five axes, which are also in the DSM-IV.
These five criteria have to be described for each patient as well as
receiving a diagnosis. This is good because at one time it was realized how
difficult it was to understand what was going on with a person with a mental
illness. Being difficult to diagnose was the problem. By having a well
rounded description of what is going on with the person having the problem,
gives the physicians and therapists five different view points with which to
help in the problem solving.
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Axis I- clinical syndromes.. Includes all mental
disorders except developmental and personality disorders.
Axis II-Developmental disorders and personality disorders.
Axis III- Physical disorders and conditions.
Axis IV-Severity of psychological stressors rated on a scale of 1-6.
Axis V- Global assessment of functioning rated on the Global Assessment
of Functioning (GAF) scale that assess mental health and mental illness.
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In this traditional physician/patient relationship found in the
psychoanalytic method of therapy, the emphasis is placed on the patient
accepting the diagnosis and complying with the treatment, which includes
medications and interpersonal work.
The Psychological/ Interpersonal Model Sigmund Freud in the late
1800's did much work on developing the psychoanalytical approach to mental
illnesses. His focus was on studying the nature of 'deviant behavior'. He
brought out a new perspective on human development. His premise was that all
psychological and emotional responses were understandable. For the meanings
he looked to childhood experiences that he believed were the cause of adult
psychological and emotional disturbances. Such concepts such as the id, ego,
superego and ego defense mechanisms are still highly used. All of these
concepts have become a part of the fundamental understanding of current
psychoanalysis.
Freud's psychoanalysis can trace disturbed behavior back to developmental
stages. These stages have a task to be accomplished. Should there be a
difficulty in a person's life during a stage that prevents the accomplishment
of those tasks, conflicts and psychological disturbances could carry over to
adulthood.
Erik Erickson remolded Freud's Psychosexual Stages into psychosocial
stages that go throughout the human life-cycle. Like Freud, Erickson says
that at these stages individuals are presented with a crises to solve, that
can have either a positive or a negative outcome. Harry Stack Sullivan
(1892-1949) developed an interpersonal theory from the Freudian
framework. His work began a focus on interpersonal processes that
could be seen instead of the inner, unseen processes of Freud. Sullivan's
major premis was that the personality could only be seen and studied when the
person is acting in relation to other individuals. Personality is defined as
the way an individual relates to others. Another contribution to the interpersonal
model came from Peplau's interpersonal nursing theory. She defined
nursing as an interpersonal process. She also described the importance of
meeting basic human needs ( Maslow's heirarchy of needs, Erickson's
developmental stages) to achieve a healthy balance.
A problem with the Psychoanalytical Model is that therapy can be
complicated by 'transference', which was taught in Potter and Perry on
Therapeutic Communications. This is where the patient/client transfers
emotion from someone in their life to the therapist/nurse/physician/health
care worker. These emotions can be positive or negative, but none the less
complicate the communications as they are unrelated to the interaction
between the present individuals. Countertransference can also complicate the
therapy. This is when the therapist/nurse/physican/health care worker n has
an emotional response to the client/patient. This can interfere with therapy
unless the therapist is aware of it and knows how to handle it.
Critical Thinking: what's
missing?
1. Validation and positive reinforcement for what is healthy.
2. Human connectiveness ( patient not really listened to, not heard).
What else?
The Behaviorist Model in psychiatry has its roots in psychology and
neurophysiology (physiology of the nervous system). To the behaviorist, the
symptoms of psychoses and neuroses are clusters of learned behavior that
persist because they are in some way rewarding to the individual. One of the
most important contributions to the behaviorist model was made by Pavlov
(1849-1936). In 1902 he discovered a phenomenon 'the conditioned reflex' in
his famous experiment with a dog and a bell. Conditioned reflex: a
response is a reaction to a stimulus
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If a new and different stimulus is presented with or just
befor the original stimulating event, the same response reaction can
result.
Eventually the new stimulus can replace the origional one, so that the
response occurs to the new stimulus alone.
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The major assumption is that human are complex animals; behavior is what an
organism does. It can be observed, described and recorded. Much of the
current therapy found in large institutions caring for the mentally ill use
the behaviorists model and behavior modification help normalize the
individuals seeking treatment, both voluntarily and involuntary.
Client Centered ( Existential Model) focuses on the person's
experience in the' here and now', with less attention to the past or to other
theories. In this area of client centered therapy, it is believed that
behavioral deviation results when one is out of touch with oneself or the
environment. The person is alienated and this is caused by self imposed
restrictione. Albert Camus' The Stranger, is the best description of this
line of thought. Examples of emotions attributed to the 'self-alienated
person' are sadness, lonliness, helplessness. The client centered/Existential
therapeutic process focuses on the encounter; two or more people meeting each
other, appreciating the existence of each other, to live fully in the
present. Carl Rogers wrote several books on Encounter Groups which were very
popular in the early '70's as a form of self-help and coming back to one-self
in the here and now. The therapist is a guide and equal to the patient,
caring and warmth are emphasized.
Critical Thinking: who would
this form of therapy not work for?
Systems Theory The General Systems Theory when applied to living
systems (people) where the biological and social systems can be logically
integrated with the physical sciences. In psychiatry it offers a resolution
of the mind-matter split. An important concept from this theory ( Menninger)
is the idea of homeostasis or human balance. He presented the understanding
that the greater the threat or stress on a system, the greater the number of
parts of the system are needed to coping or adapting to it. Pathology can
exist at many levels, from the cell, to the organ, to the famiily and the
community. This quickly begins to look like Hans Seyle's General Adaption
Syndrome (GAS).which describes a continuum of psychophysiological responses.
In the system's theory the individuals well-being depends on the amount of
stress and the ability to cope or adapt to the stress. The emphasis in
therapy is on resolution of current conflicts and learning future coping
strategies.
The Cognitive Model is well described by Aaron Beck (1979). This
structured approach to treatment used for disorder such as depression,
anxiety, phobias, and pain problems. It is based on the belief that the way
an individual thinks about the world (perception) determines both affect (
response to the stimuli of life) and behavior. Their cognition
(understandings) are developed from previous experiences. Clients learn to
master problems and situations by reevaluating and correcting their thinking.
The cognitist therapist helps clients to think and act more realistically and
adaptively about their problems and thereby reduce their symptoms. The major
focus of therapy at North Coast is Cognitive. You will see a difference between
the therapy at Oakcrest and North Coast. For example, if a person interprets
all experiences in terms of whether they are competent or not, their thinking
may be mainly this:
" If I do
everything perfectly, I am not a failure."
Mental Health is defined as; including the presence of a positive attitude,
towards self, growth, development, self-actualization,integration,autonomy,
reality perception, and environmental mastery.
II. Therapeutic Modalities (chapter 31, Stuart & Sundeen) Group
Therapy The definition of a group is a collection of people who have a
relationship with one another, are interdependent, and may have a common
norm. Therapeutic group members have a shared purpose, such as to work on
self-destructive behavior. Each group has its own identity and purpose. The
power lies in the shared contributions of each member and the leader to the
group. By sharing group members solve common problems, by educating each
other, by sharing experiences and giving social support, and by listening
which relieves a feeling of isolation on the part of the individuals. Members
receive feedback from one another.
See table 31-1 Components of small groups, Stuart & Sundeen, pg. 658.
Components of small groups: Group structure includes boundries, communication
, decision making; helps regulate behavior and interaction patterns.
Preferred group size is 7-10 members, with sessions lasting 20-40 min. for
lower functioning groups and 60-120 min. for higher functioning groups. Roles
in the group are determined by behavior of the members in the group.The
Harmonizer helps to keep peace, the Encourager helps keep a positive
influence in the group. Three main catagories of roles are: Task roles,
maintenance roles, and individual roles-roles that serve to fulfill individual
needs.
See Table 31-2 Group Roles and Functions, S&S.
Group Development occurs in phases. The various phases have been well
described as The initial or orientation phase, the middle or working phase,
the final or termination phase. Also described and very descriptive of groups
is: forming, storming, norming, and performance, termination. Group
development and phases overlap and donot stay in any one order. The forming
stage is typified by an initial orientation where relationships are tested,
boundries identified. The storming phase is the initial conflict generally
done when members are resistive to the group influence. Norming is when the
resistence to group influence is overcome. What happens here is members
express intimate personal opinions, a coming together happens, a closeness
within the group. Performing is the working stage where creative problem
solving is done, solutions emerge.
The termination phase either the group ends or a member leaves the group. How
this happens is highly individual. There are health groups, task-oriented
groups, self-help groups and teaching groups, as well as support groups,
psychotherapy groups to name a few.
Curative Factors of groups include providing hope as well as
social support to its members, providing education on different things that
group members have learned or tried that have helped their particular
situation. Altrusm is another factor. Individuals end up with a
feeling of positive self-worth by giving help to others. Studies have shown
that the support and information gained in groups has given members longer
lives when dealing with cancer, heart disease, quicker recovery when dealing
with grief, traumatic stress, and major life changes such as recovery from
alcoholism and addiction. Both psychological and emotional well-being are
helped for those in specific groups.
Another curative factor is Universality . They are not alone in their
suffering. Group members are able to re-experience experiences from the past
that have been difficult. Group members are also able to learn socialization
techniques by the role modeling of other group members.
Leadership Qualities of nurse group leaders are empathy, nurturance,
genuiness, creativity, acceptance of confrontation, good communication
skills, organization and a good sense of humor. The qualities of an effective
nurse group leader are the same as in the therapeutic relationship. The
leader also has to encourage the group to look at things from different
perspectives and look at possibilities not always popular to the group. Group
leaders must work to make the group a safe place for its members to express
themselves ( confidentiality).
Leadership styles include: Autocratic: the focus is on the leader, on
whom the members are dependent for problem solving, decision making.
Production is high, morale is low.
Democratic: the focus is on the members, who are encouraged to
participate in problem solving or issues that relate to the group, including
taking action to make changes. Production is somewhat lower thanit is with
the autocratic style, but morale is much higher. Laissez-faire: there
is no focus in this type of leadership. Goals are un-defined, members do as
they please. Productivity and morale is low.
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Pharmacology Review this area for each unit on your
own.
The nurse/patient relationship This is covered well in the section
on Therapeutic Relationships in Potter and Perry, chapter 14 and the
helping relationship.
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III Concepts of Stress, Anxiety and Coping Life events are viewed as stressors
in current models of human health. The relationship of stressful life events
to the cause, onset, course, and outcomes of various psychiatric illnesses,
such as schizophrenia, depression, and anxiety, has been the focus of much
research. Issues for the individual that are related to life events as
stressors focus on the nature of the event and the magnitude of the change it
represents.
Critical Thinking: What are the norms when there are cultural and
sociological considerations to be make?
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Assignment for next week:
1/24/00
Personality Disorders (8-11)
Stuart & Sundeen, Chapter 22.
Brobyn, Laura," The Borderline Patient: Systemic Versus Psychoanalytic
Approach," in Archives of Psychiatric Nursing, Vol. I, No. 3, June
'87: pp172-82.
Vaccani, Joanne, " Borderline personality and alcohol abuse", in
Archives of Psychiatric Nursing, Vol III, No. 2, Apr. '89, pp113-119.
Gallop, Ruth, " Self-Destructive and Impulsive Behavior in Patients
with Borderline Personality Disorder," Archives of Psychiatric
Nursing, Vol VI, No. 3, June 1992: pp. 178-182.
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