Hi guys, we're going to talk about chapter two and this is going to really focus in on theories and therapies for nursing practice and I only have a few that I really want to touch on because I think these are the most important ones that you will see in your nursing career, especially if you get into more specialized psychiatric nursing. So why do we study theories? Theories provide plausible explanations why people behave. the way they behave so in this chapter we're going to talk about some of those influential psycho psychological theories with an overview of some of the treatments and the contributions so let's get started here so we've all heard of sigmund freud right he revolutionized thinking about mental health disorders he believed that mental disorders resulted from some type of unresolved issue that originated in childhood.
So there are three levels of psychological awareness that Sigmund Freud used. He also used the image of an iceberg to describe each of these levels of awareness. So if we're talking about the conscious level, that's that tip of the iceberg, that's our perceptions, our memories, our thoughts and fantasies. What is a person aware of at any time? As we move down that iceberg into that next level, that's our pre-conscious.
It's just below the surface of our awareness. We know that we can retrieve those materials easily with not a lot of effort. And then we get to the unconscious level, which is that lower part of that iceberg that's really deep. down into the water. That's where our trauma is stored.
It's really painful for us to deal with. Freud also talked about personality structure. So he talked about id, again that unconscious source. The id is totally unconscious, they're impulsive. It cannot tolerate frustration and it seeks to discharge any tension.
and return to a more comfortable level of energy. The id usually lacks the ability to problem solve and is illogical. So an example of an id is that screaming baby that is hungry, right? They're hungry, they're frustrated, and they want to try to seek discharge from that tension so that they feel comfortable again, right?
They eat and they feel comfortable again. They don't know how to problem solve, so what do they do? They just start screaming. The next personality structure is our ego.
Within the first few years of life, as the child begins to interact with others, the ego develops. The ego resides in our conscious, preconscious, and unconscious levels of awareness. The problem solver, the reality tester, the ego attempts to navigate that outside world. They are able to differentiate subjective experiences, memory images, and objective reality. So let's go back to our child that's hungry.
Now they're a little bit older, right? So the child's hungry. They have this unconscious thought or perception, oh, I'm so hungry.
They feel that tension arising. They want some food. That's that pre-conscious awareness that they know they're hungry. So now they can make a plan to eat and seek out that food, right? Their consciousness makes them the problem solver.
They go to the pantry and then they find some food and they eat. The last one is our superego. This develops between the ages of three and five, and it represents the moral component of personality.
The superego resides in the conscious, pre-conscious, and unconscious levels, again, of our awareness. The superego consists of the conscious, all the should nots that are internalized from our parents and society. The ego's ideals are all the shoulds, again, that are internalized from parents and society.
and it seeks perfection when it falls short so you could have some induced feelings of guilt if you know the should not and you choose chose anyway then you may feel guilt if you know the shoulds and you do it and you then you're going to seek perfection so again this is just another slide just going through each of those id ego and super ego Another part of Freud's psychoanalytic theory is defense mechanisms. These are methods of attempting to protect ourselves, to cope with the basic drives or the emotional painful thoughts, feelings, or events. These defense mechanisms operate on the unconscious level.
We can deny, we can falsify, or distort reality to make it less threatening for us. So let's say your doctor walks in. And he tells you you have cancer and you have six months to live.
You are probably going to, one, deny. Nope, that's not true. I don't believe you.
You're going to distort, right, that reality. You may not tell anybody about it. You may refuse to talk to anybody about it. That's your defense mechanisms kind of kicking in.
And you can use these to just ward off all of that anxiety. by preventing that conscious awareness of that threatening feeling. So classic psychoanalysis you can see here the biggest ones that I really want to focus in on this slide is those valid tools and concepts and that's that transference and countertransference.
Excuse me, transference is that unconscious feeling that a patient may put on a health care provider. It could be positive or negative. It could be affectionate or hostile. They're transferring emotions that they originally felt in childhood.
So they may say things to you like, oh, you remind me so much of my fill in the blank. Grandma, aunt, uncle, whomever. This may help you understand the relationship, the feelings, and the behaviors.
But remember, they can be positive or negative, affectionate or hostile. So let's say. oh, you remind me so much of my grandma and she used to beat me, right? So that would be a very negative hostile where that patient may put some of those unconscious feelings on you.
So being self-aware. Countertransference is just the opposite. So that's that unconscious feeling that a health care worker may put on a patient.
Again, could be negative or positive. So it's really important as a health care provider. to make sure that we are maintaining that self-awareness so that our patient receives the best care practices.
If you have a patient that reminds you of your Uncle Joe that used to talk down to you, that used to be mean to you, that used to whatever to you, you may not give your patient the best care practice because they remind you so much of that Uncle Joe. So that's where you have to maintain that self-awareness. Maybe you may have to step away from that patient.
You may have to ask for a different assignment because if they're not going to get the best care, that's unfair for that patient. But you as a health care worker have to be able to recognize that. So let's talk a little bit about interpersonal theories to nursing.
Hildegard Peplau was influenced by Sullivan. He was just another interpersonal nursing theorist, but she took it a little step further. She established the foundation.
for professional practice of psychiatric nursing but also enrich enriched psychiatric nursing and advanced nursing practice so that nurses were both seen as participants and observers for their patient populations through therapeutic communication she wanted nurses not only to observe their patients but also wanted to be able to look within themselves to be self-aware so that their focus could remain on their patient Peplau's biggest contribution was describing the different levels of anxiety, and we're going to get to that in a couple of weeks where we can talk about mild, moderate, severe, and even panic level anxiety. So she described this level of anxieties on perception and learning and wanted to promote interventions to help lower that anxiety to increase our patient's functions. Some of the behaviorist... didn't agree with Freud and believe that personality and behaviors were synonymous. If the behavior changed, so did the personality.
They also believe that behaviors can be influenced through some type of conditioning, whether that be reinforcing the behavior or diminishing the behavior based on the condition. So let's look at a couple of our behavior theories. And so we've all heard of Pavlov, right?
Pavlov. dog. This is that conditioning with a bell and food. It's kind of the same in humans, right?
If you eat something at a restaurant and you feel sick. Every time you go to that restaurant or every time you see that food, you kind of have that sick feeling, right? It's that conditioning that happens. Watson was also a behaviorist in theory. So Watson contended that personality traits and responses, the adaptive and maladaptive, were socially learned through classic conditioning.
So if you see in the book, there's kind of an audit. example in there, but it actually kind of works. So he experimented with a nine-month-old that really loved animals. He made a loud noise with a hammer. So he, sorry, he put this nine-month-old in front of a cage with a white rat.
He made a loud noise every time that infant reached for that white rat. After continuing this over and over again, right, the baby reaches, he hears this loud hammer sound. the baby takes it away. After they've done this over and over again, the infant then becomes terrified of that white rat or even white fur because of that loud noise.
He controls the environment, could control the behavior. Skinner is the next one that I think is really important to know. He has the operant conditioning theory.
So this is a method of learning that occurs through rewards and punishments. for voluntary behavior. Behavioral responses are elicited through positive and negative reinforcements, which causes a behavior to either occur more frequently, sorry, to occur more frequently.
So if we think about, if we're driving too fast, right, the police stop us and it causes us to get a speeding ticket, right? That's a negative reinforcement. So what's going to happen? We're probably not going to drive as fast, right?
So we're not going to, it decreases that chance of speeding. If you tell a joke in a room full of a bunch of people and no one laughs, how embarrassing, you're probably going to be more conscious about telling that joke again, right? It's being reinforced with, it's not being reinforced with that positive feedback. So you have negative feedback, meaning, oh, I'm not going to ever tell that joke again.
So what are some implications for nursing? we can think about our patients that are smoking maybe they're overeating maybe they're drinking alcohol what behavior therapy could we try to modify or replace those behaviors so let's look at a few of those so some of those behavioral therapies that we can think about are modeling this provides a role model for specific behavior and the patient learns to imitate it operant conditioning this is that behavior modification that uses the positive reinforcement to increase that desired behavior. Exposure therapy is a treatment for fears in which the patient might be exposed progressively to more anxiety-provoking stimuli and taught relaxation techniques.
So I want you to think about something that you're fearful of. Let's say it's a spider. So what we might do when we're doing exposure therapy is we're going to have you think about the spider.
I know you have a fear of it, but we're going to think about it. And then maybe the next time we're going to look at a picture of a spider. And then maybe the next time we're going to bring a box in that's closed, and we're going to just look at the spider that's in the box.
And then we're going to hold the box. And then we're going to let the spider crawl on the desk. And then we're going to let the spider crawl on your bare arm, right?
But as we're working through all of those things, the provider is teaching you relaxation techniques. So when we think about that spider and our anxiety gets going, right, we're going to teach you relaxation techniques while you think about that spider. And then we're going to move to the point where we can let that spider crawl on us on our bare arm and we're going to think about relaxation techniques and it's that exposure therapy. Aversion therapy is pairing a negative stimulus with a targeting behavior.
So maybe if you chew on your fingernails, remember I don't know if anybody did this. but or had this done you chewed on your fingernails and your mom put gross smelling or foul tasting stuff on your fingernails to keep you from biting it right they are trying to avert you from biting your fingernails that's aversion therapy and then biofeedback is controlling the body's physiological response to stress and anxiety so behaviorists focused on increasing decreasing or eliminating measurable behaviors but they really didn't focus on the thoughts that were involved with the behaviors. So let's look at some of our cognitive theories. And those include Ellis and Beck.
So Ellis had a rational emotive behavior theory or therapy, sorry. They wanted to remove core irrational beliefs by helping people recognize the inaccurate thoughts. So let's say you have a party that you're going to. You hate going to parties. You have to hang out with people you don't like.
You'd rather be watching that Chiefs game that's on TV. And they probably just want you to bring a gift, right? That's your belief.
So what Ellis did was try to remove some of those irrational beliefs. So he wanted you to think more along the lines of you're invited to party. You're going to go.
You're going to have a great time. You're going to meet new people. You get to go shopping to find a fun gift to be able to get.
So he just tried to eradicate those irrational beliefs and hopefully recognize those beliefs that were more accurate. If our thoughts are negative and self-deprecating because of something that happened in the past, it's going to lead to anxiety and depression. So what we want to do is change that emotive behavior.
Back on the other hand was a cognitive behavioral therapy. Cognition is based on previous experiences, and so he used therapy to reduce some of those symptoms and then change the way of thinking. So there's a really great example in your book.
So the event is while you're at a party, Corey asks me, how is it going? A few days after I was discharged from the hospital. Your feeling is anxiety.
Your automatic thought is. Corey must think I'm crazy. I must really look bad for him to be concerned. But in all reality, some other possible interpretations could be he really cares about me.
He notices that I look better than before. I went into the hospital and he wants me to know that he wants me to feel better. So it's helping that patient identify those negative thought patterns and create a worthwhile intervention. being self-aware of their thoughts of their patients. Humanistic theories, theorists thought behaviors and psychoanalysis theorists were pessimistic, dehumanizing, and they wanted to focus on the human potential and choose patterns that were supportive of personal growth.
So we should all know Maslow. You will hear about Maslow. throughout your entire nursing career. He asserts the psychology must go beyond experiences of hate, pain, misery, guilt, and conflict to include love, compassion, happiness, exhilaration, and well-being.
Human beings are active participants in life. They strive for self-actualization. When lower needs are met, higher needs are able to be emerged.
so you will see here on this triangle of matlow's hierarchy of means right we have to have those first needs met the psychological needs have to be met first before we can move up the triangle so the psychological needs mean needs that need to be met include food water oxygen sleep elimination sex all of those things need to be met first before we can move up to safety once we can meet all of those psychological needs, then we can, and they're consistently met and predictably met, then our safety needs can become in effect. Security, protection, stability, things like that. And then we just can keep moving up that.
Love and belonging can be met through healthy relationships, feeling safe physically and psychologically and emotionally, and then we can continue moving up. the triangle until we can hit that self-actualization. Once we have self-actualization, we can be relaxed, we can have fun, we can be everything that we are capable of being. But we cannot be everything we are capable of being unless we have all of those needs met below that triangle. So nursing practice is twofold.
It emphasizes, or Maslow emphasized on human potential and the patient's strengths and then prioritizing nursing actions in the nurse-patient relationship. So, for example, a nurse may need to stabilize the patient's vital signs and pain before they can collect information. If you have a patient that is in a lot of discomfort and you just start trying to ask questions, collect information, you're not meeting the patient where they are. stabilize them first then try to collect that information so make sure you're meeting the patient where they are and that concludes chapter two if you have any questions you can shoot me an email or we can chat about it in class thanks guys