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Monday, November 30, 2009

Conceptual Model in Mental Health Nursing

Model

View of behavioral deviation

Therapeutic process

Roles of patient and therapist

Psychoanalytical

(S. Freud, Erikson, A. Freud, klein, horney , Fromm Reichmann, Menninger)

-Based on in adequate resolution of developmental conflicts.

-Ego defenses inadequate to control anxiety

-Symptoms results in effort to deal with anxiety and are related to unresolved conflicts

-Uses techniques of free association and dream analysis

-Identifies problem areas through interpretation of patient’s resistances and transferences

-Patient verbalizes all thoughts and dreams: considers therapist’s interpretations

-Therapist remains remote to encourage development of transference and interprets patient’s thoughts and dreams.

Interpersonal

(Sullivan, Peplau)

-Anxiety arises and is experienced interpersonally

- Basic fear is fear of rejection

-Person needs security and satisfaction that result from positive interpersonal relationships

-Relationship between therapist and patient builds feeling of security

-Therapist helps patient experience trusting relationship and gain interpersonal satisfaction

-Patient shares anxieties and feelings with therapist

- Therapist uses empathy to perceive patient’s feelings, and uses relationship as a corrective interpersonal experience

Social

(Szasz, Caplan)

-Social and environmental factors create stress, which causes anxiety and symptoms

Unacceptable (deviant) behavior is socially defined

-Patient helped to deal with social system.

-May use crisis intervention, environmental manipulation, and social supports.

-Patient presents problem to therapist, work with therapist, and uses community resources

-Therapist explores patient’s social system and resources available

Existential

(Perls, Glasser, Ellis, Rogers, Frankl)

-Life is meaningful whwn the person can fully experience and accept the self

-The self can be experienced through authentic relationships with other people

-Person aided to experience authenticity in relationships

-Therapy frequently conducted in groups

-Patient encouraged to accept self and to assume control of behavior

-Patient participates in meaningful experience to learn about real self.

-Therapist helps patient recognize value of self, clarify realities of situation, and explore feelings

Suportive therapy

(Wermon, Rockland)

-Problems are a result of biopsychosocial factors.

-Emphasis on current maladaptive coping responses

-Reality testing and self esteem enhancing measures

-Social supports are enlisted, and adaptive coping responses are reinforced

-Patient actively involved in treatment.

-Therapist warm, empathic, and allies with patient

Medical

( Meyer, Kraeplin, Spitzer)

-Behavioral disruption result from a biological disease process

-Symptoms result from a combination of psychological, genetic, environmental and social factors

-Treatment is related to diagnosis and includes somatic therapies and various interpersonal techniques.

-Treatment approach adjusted depending on symptomatic response.

-patient complies with prescribed therapy and reports effects of therapy to physician.

-Therapist diagnoses illness and prescribes therapeutic approach.

PSYCHOANALYTICAL MODEL

Psychoanalytical theory was developed by Sigmund Freud in the late nineteenth and early twentieth centuries. It focused on the nature deviant behavior and proposed a new perspective on human development. Many of Freud’s ideas were controversial, particularly in the Victorian society of that time. Objective observation of human behavior was a great contribution of the psychoanalysts, as was the identification of a mental structure. Such concepts as id, ego, super ego, and ego defense mechanism are still widely used. Most people also accept the existence of an unconscious level of mental functioning first introduced by Freud.

Id: personality process that wants to experience only pleasure, is impulsive and without morals

Ego: personality process that focuses on reality while striving to meet the needs of the Id. The ego experiences anxiety and uses defense mechanism for protection.

Superego: Personality process that is concerned with right and wrong; the consequence. It provides the ego with an inner control to help cope with the Id.

View of Behavior Deviations

Psychoanalysts trace disrupted behavior in the adult to earlier developmental stages. Each stage of development has a task that must be accomplished. If too much emphasis is placed on any stage or if unusual difficulty arises in dealing with the associated conflicts, psychological energy (libido) becomes fixated in an attempt to deal with anxiety.

Psychoanalysts believe that neurotic symptoms arise when so much energy goes into controlling anxiety that it interferes with the individual’s ability to function. They believe that everyone is neurotic to some extent. Everyone carries the burden of childhood conflicts and is influenced in adulthood by childhood experiences. Psychoanalysts in training must undergo personal analysis so that their own neurotic behavior does not hinder their objectivity as therapist.

According to psychoanalytic theory, symptoms are symbols of the original conflict. For instance, compulsive hand washing may represent the person’s attempt to cleanse the self of impulses that a parent labeled unclean during the anal stage of development. However, the meaning of the behavior is hidden from the conscious awareness of the person, who usually is upset about these uncontrollable thoughts, actions, and feelings.

Freud developed most of his theories around neurotic symptoms. His theory is less well developed in the area of psychosis. However, other psychoanalytical theorist such as Frieda Fromm-Reichmann have successfully worked with psychotic symptoms occurs when the ego must invest most or all of the libido to defend against primitive id impulses. This leave little, if any, energy to deal with external reality and leads to the lack of reality testing seen in psychosis.

Psychoanalytical Therapeutic Process

Psychoanalytic uses free association and dream analysis to reconstruct the personality. Free association is the verbalization of thought as they occur without any conscious screening or censorship. Of course, there is always unconscious censorship of thought and impulses that threaten the ego. The psychoanalyst searches for patterns in the areas that are unconsciously avoided. Conflictual areas that the patient does not discuss or recognize are identified as resistance. Analysis of the patient’s dreams can provide additional insight into the nature f the resistances, since dreams symbolically communicate areas of intrapsychic conflict.

The therapist helps the patient recognize intrapsychic conflicts by using interpretation. Interpretation involves explaining to the patient the meaning of dream symbolism and the significance of the issues that are discussed or avoided. However, the process is complicated transference, which occurs when the patient develops strong positive or negative feelings toward the analyst’s current behavior or characteristics, they represent the patient’s past response to a significant other, usually a parent. Strong positive transference causes the patient to want t please the therapist and to accept the therapist’s interpretations of the patient’s behavior. Strong negative transference may impede the progress of therapy as the patient actively resists the therapist’s interventions. Countertransference, or the therapist’s response to the patient, can also interfere with therapy if the analyst is unaware of it or unable to deal with it.

Since the therapist can temporally replace the significant other of the patient’s early life experience, previously unresolved conflicts can be brought into the therapeutic situation. These conflicts can be worked through to a healthier resolution. This release previously invested libido for mature adult functioning. Psychoanalytical therapy is usually long term. The patient is often seen five times a work for several years. This approach is therefore time consuming and expensive.

Roles of Patient and Psychoanalyst

The roles of the patient and the psychoanalyst were defined by Freud. The patient was to be an active participant, freely revealing all thoughts exactly as they occurred and describing all dreams. The patient often lies during therapy to induce relaxation, which facilitates free association.

The psychoanalyst is a shadow person. The patient is expected to reveal all private thoughts and feelings and the analyst reveals nothing personal. The analyst usually is out of the patient’s sight to ensure that nonverbal responses do not influence the patient. Verbal responses are brief and noncommittal for the most part to prevent interference with the associate flow.

The therapist uses free association (letting the patient say everything that comes to mind) so that repressed material can be identified and interpreted for patient. Dream analysis helps patients uncover the meaning of dreams, which also increases awareness about present behavior. Patient’s inconfronted. Transference that occurs in the relationship is used to encourage working through feelings that would otherwise remain unconscious

The therapist changes this communication style when interpreting behavior. Interpretations are presented for the patient to accept or reject, but rejections suggest resistance. Likewise, frustration that the patient expresses toward the analyst is interpreted as transference. By the end of therapy, the patient should be to view the analyst realistically, having worked through conflicts and dependency needs.

INTERPERSONAL MODEL

According to Sullivan the purpose of all behavior is to get needs met through interpersonal interactions and decrease or avoid anxiety. He viewed anxiety as a key concept and defined it as any painful feeling or emotion arising from social insecurity or blocks to getting biological needs satisfied. Sullivan coined the term security operation to describe those measures that the individual employs to reduce anxiety and enhance security. Collectively, all of the security operation an individuals uses to defend himself or herself against anxiety and ensure self-esteem make up the self-system.

View of Behavioral Deviations

Interpersonal theorists believe that behavior evolves around interpersonal relationship. While Freudian theory emphasizes a person’s intrapsychic experience. Interpersonal theory emphasizes social or interpersonal experience. Sullivan, like Freud, traces a progression of psychological development. Sullivan’s theory states the person bases behavior on two drives, the drive for satisfaction and the drive for security. Satisfaction refers to the basic human drives, including hunger, sleep, lust, and loneliness. Security relates to culturally defined needs such as conformity to the social norms and value system of the individual’s ethnic group. Sullivan states that when the nature of a person’s self-system interferes with the ability to attend to the need for either satisfaction or security, the person will become mentally ill.

When Peplau defined nursing as an interpersonal process, she also discussed the importance of basic human needs. Needs must be met if a healthy state is to be achieved and maintained. For Peplau, the two interacting components of health are psychological demands and interpersonal conditions.

Interpersonal Therapeutic Process

The interpersonal therapist, like the psychoanalyst, explore the patient’s life history. The crux of the therapeutic process is the corrective interpersonal experience. The idea is that by experiencing a healthy relationship with the therapist, the patient can learn to have more satisfying interpersonal relationships. The therapist actively encourage of development of trust by relating authentically to the patient. The process of therapy is process to reeducation.

The therapist helps the patient identify interpersonal personal and then attempt and more successful styles of relating. Therapy is completed when the patient can establish satisfying human relationships, thereby meeting basic needs. Termination is a significant part of the relationship that must be experienced and shared by both the therapist and the patient. The patient learns that leaving a significant other involves pain but can also be an opportunity for growth.

Roles of Patient and Interpersonal Therapist

The patient-therapist dyad is viewed as a partnership in interpersonal therap. Sullivan describes the therapist as a “participant observer” whose role is to engage the patient, establish trust, and empathize. There is an active effort to help the patient realize that other people have to speak openly. The therapist interact as a real person who also has beliefs, values, thoughts, and feelings. The patient’s role is to share concerns with the therapist and to participate as fully as possible in the relationship. The relationship it self is meant to serve as a model of adaptive interpersonal relationships. As the patient matures in the ability to relate, lie experiences with people outside the therapeutic situation can be enhanced

Interpersonal nursing roles have been identified by Peplau. These roles may be assumed by the nurse or assigned to others. The therapist helps the patient meet the goals of therapy: need satisfaction and personal growth. In addition, through role performance the nurse also experiences growth and self-discovery. Self-awareness is essential to success as an interpersonal therapist.

SOCIAL MODEL

The two preceding models focused on the individual and interpersonal experiences. The social model moves beyond the individual to consider the social environment as it affects the person and the person’s life experience. Psychoanalytical theory has been criticized for not extending to other cultures and times.

View of Behavior Deviations

According to the social theorist, social conditions are largely responsible for deviant behavior. Deviancy is culturally defined. Behavior considered is normal in one cultural setting may be eccentric in another and psychotic in a third

Social Therapeutic Process

Szasz advocates freedom of choice for psychiatric patients. People should be allowed to select their own therapeutic modality and therapists. This also implies a well-informed consumer who can base this decision on knowledge of available models of therapy. Szasz does not believe in involuntary hospitalization of the mentally ill. He questions whether any psychiatric hospitalization is truly voluntary. Szasz disapproves of the community mental health care within the reach of every American. He questions government involvement in what he views as a private concern.

Caplan, On the other hand, supports community Psychiatry, He sees the mental health professional as using consultation to combat societal problems. He believes that future psychiatric patients would benefit indirectly from positive social change.

Roles of Patient and Social Therapist

Szasz believe that a therapist can help the patient only if the patient requests help. The patient, then, initiates therapy and defines the problem to be solved. The patient also has the right to approve or reject the recommended therapeutic intervention. Therapy is successfully completed when the patient is satisfied with the changes made in lifestyle. The therapist collaborates with the patient to promote change. This includes making recommendations to the patient about possible means of effecting behavioral change, but it does not include any element of coercion, particularly the threat of hospitalization if the patient does not agree with the therapist on recommendations. The therapist’s role also may involve protecting the patient from social demands for being treated unwillingly.

Caplan believes that society it self has a oral obligation to provide a wide range of therapeutic services covering all three levels of prevention. The patient has a consumer role and selects the appropriate level of help from a wide array of available services. Ideally, effective primary preventive services would decrease the need for secondary or tertiary care.

According to this model, therapists may be professionals or nonprofessionals with professional consultation. People such as clergy, police, bartenders, and beauticians can be trained to listen and to refer people who need professional help to appropriate resources. The therapist in the social context is not tied to the office but is involved in the community. Activities may include home visits, lectures to community groups, or consultation with other agencies. The rationale for this approach is that the more involved therapist are in the community, the greater the impact on the community’s mental health. Community involvement also enhances the therapist understanding of patients who live in that environment.

EXISTENTIAL MODEL

The existential model focuses on the person’s experience in the here and now, with much less attention to the person’s past than in other theoretical models.

View of Behavioral Deviations

Existentialist theorists believe that behavioral deviations result when the individual is out of touch with the self or the environment. This alienation is caused by self-imposed restrictions. The individual is not free to choose from among all alternative behavior. Deviant behavior frequently is a way of avoiding more socially acceptable or more responsible behavior.

The person who is self-alienated feels helpless, sad, and lonely, self-criticism and lake of self-awareness prevent participation in authentic, rewarding relationships with others. Theoretically, the person has many choices in terms of behavior. However, existentialists believe that people tent to avoid being real and instead give in to the demands of others.

Existential Therapeutic Process

There are several existential therapies, all of which assume that the patient must be able to choose freely from what life has to offer. Although the approaches are somewhat different, the goal is to return the patient to an authentic awareness of being.

The existential therapeutic process focuses on the encounter is not merely the meeting of two or more people, it also involves their appreciation of the total existence of each other. Through the encounter the patient is helped to accept and understand personal history, to live fully in the present, and to look forward to the future.

Roles of Patient and Existential Therapist

Existential theorist emphasize that the therapist and the patient are equal in their common humanity. The therapist acts as a guide to the patient, who has gone astray in the search for authenticity. The therapist is direct in pointing out areas where the patient should consider changing. However, caring and warmth are also emphasized. The therapist and the patient are to be open and honest. The therapeutic experience is a model for the patient; new behaviors can be tested before risks are taken in daily life.

The patient is expected to assume and accept responsibility for behavior. Dependence on the therapist generally is not encouraged. The patient is treated is an adult. Frequently, illness is deemphasized. The patient is viewed as a person alienated from the self and others, but for whom there is hope it the therapist is trusted and directions are followed. The patient is always active in therapy, working to meet the challenge presented by the therapist.

SUPPORTIVE THERAPY MODEL

Supportive therapy is a relatively new mode of psychotherapy that is widely used in hospital and community based psychiatric treatment settings. It differs from other models in that it is not dependent on any overriding concept or theory.

View of Behavioral Deviations

Supportive therapist are psychodynamically based, an they describe behavioral deviations are neurotic, borderline, or psychotic. They subscribe to the concept of id, ego, superego and emphasize the important role of psychological defense in adaptive functioning. Compared with other models of psychiatric treatment, however, their focus is more behavior oriented. They emphasize current biopsychosocial coping responses and the person’s ability to use available coping resources.

Supportive Therapeutic Process

Supportive therapy is an electric form of psychotherapy; that is, is not based on a particular theory of psychopatology. Rather, it can draw as needed from other models and may address different symptoms with different therapeutic methods. The methods and goals of supportive therapy are equally applicable to high-functioning patients in crisis and low-functioning patients suffering from psychosis or persistent mental illness. Its emphasis is on improving behavior and subjective feelings of distress, rather than on achieving insight or self-understanding.

Roles of Patient and Supportive Therapist

In supportive therapy the therapist plays an active and directive role in helping the patient improve social functioning and coping skill. The setting for supportive therapy should allow for a moderate to high level of activity in both the patient and therapist. Communication is viewed as an active two-way process, an the use of medication or other treatments and therapist is encourage.

The therapist is involved and is willing to contribute to a true therapeutic alliance with the patient. Expressing empathy, concern, and nonjudgmental acceptance of the patient are important therapist qualities. The therapist supports the patient’s healthy adaptive efforts, conveys a willingness to understand, respect the patient as a unique human being, and takes a genuine interest in the patient’s life activities and well-being. Finally the therapist regards the patient as a partner in treatment and encourages the patient’s autonomy to make treatment and life decisions. In turn, the patient is expected to demonstrate a willingness to talk about life events, to accept the therapist’s supportive role, to participate in the therapeutic program, and to adhere to the therapeutic structure.

MEDICAL MODEL

The medical model refers to psychiatric care that is based on the traditional physician-patient relationship. It focuses on the diagnosis of a mental illness, and subsequent treatment is based on this diagnosis. Somatic treatments, including pharmacotherapy and electroconvulsive are important component of the treatment process. The interpersonal aspect of the medical model varies widely, from intensive insight-oriented intervention to brief session involving medical management of medications.

Much of modern psychiatric care is dominated by the medical model. Other health professionals may be involved in interagency referrals, family assessment, and health teaching, but physicians are viewed as the leaders of the team when this model is in effect. Elements of other models of care may be used in conjunction with the medical model for instance, a patient may be diagnosed with schizophrenia and treated with phenothiazine medication. This patient may also be participating in a token economy program to encourage socially acceptable behavior.

A positive contribution of the medical model has been the continuous exploration for causes of mental illness using the scientific process. Recently, great strides have been taken in learning about the functioning of the brain and nervous system. Thus progress has led to beginning understanding of the probable physiological components of many behavioral disorders and increasingly specific and sophisticated approaches to psychiatric care.

View of Behavioral Deviations

The medical model proposes that deviant behavior is a symptom of a central nervous system disorder. Currently the exact nature of the psychological disruption is not well understood. It is thought that the psychotic disorders such as bipolar disorder, mayor depression; and schizophrenia involve an abnormality in the transmission of neural impulses. It is also thought that this difficulty occurs at the synaptic level and involves neurochemicals such as dopamine, serotonin, and norepinephrine.

Must research currently is taking place so that the brain’s involvement in emotional response can be better understood. Another branch of research focuses on stressors and the human response to stress.

Medical Therapeutic Process

The medical process of therapy is well defined and familiar to must patients. The physician’s examination of the patient includes the history of the present illness, past history, social history, review of body systems, physical examination, and mental status examination. Additional data may be collective by significant others, and past medical records are reviewed if available. A preliminary diagnosis is then formulated, pending further diagnostic studies and observation of the patient’s behavior. This process may take place on ambulatory or an inpatient basis, depending on the patient’s condition.

Roles of Patient and Medical Therapist

The roles of physician and patient have been well defined by tradition and apply in the psychiatric setting. The physician, as the healer, identifies the patient’s illness and institutes a treatment plan. The patient may have some say about the plan, but the physician prescribes the therapy.

The role of the patient involves admitting being ill, which can be a problem in psychiatry. Patients sometimes are not aware of their disturb behavior and may actively resist treatment. This is not congruent with the medical model. The patient is expected to comply with the treatment program and to try to get well. If observable improvement does not occur, caregivers and significant others often suspect that the patient is not trying hard enough. This can be frustrating to a patient who is trying to get well and is disappointed with the lack of progress. The patient also may have difficult letting people extend care and at the same time be self-sufficient.

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References

1. Stuart, G.W. & Sundeen S.J. 1995. Principle and Practice of Psychiatric Nursing. Fifth Edition. St. Louis, Missiouri: Mosby Year Book.

2. Antai Otong, Deborah. 1994. Psychiatric Nursing : Biological and Behavioral Conceps. Philadelphia : WB Saunders Company.

3. Varcarolis, Carson, Shoemaker. 2006. Foundation of Psychiatric Mental Health Nursing, a clinical approach.

4. Cavan Frisch, E.Frisch. 2006. Psychiatric Health Nursing. Thomson ( Delmar Learning ).

5. Videbeck. 2004. Psychiatric Mental Health, Lippincott, William & wilkins