Chapter 7: Models for Working with Psychiatric PatientsRecovery Model Focus is on improving a persons competencies, not just alleviating symptoms Movement toward a meaningful way of life; doesnt involve a cure Patient strives to improve his or her own health and wellness Striving to achieve full potential of life Ten guiding principles: Person-drive Occurs via many pathways Holistic Supported by peers Supported through relationships Culturally based and influenced Supported by addressing trauma Strength-based Based on respect Emerges from hope Collaborating with patients instead of telling them what to do Encourage them to try new things Patients take responsibility for their own care Setbacks are not considered failures Create atmosphere of hope Person is not identified by his or her illness Patients develop meaningful roles in their communities, not with the mental health system Support systems include family, peers, and community; peer support is essential Patient is incorporated in every level of planning, delivery, and evaluation of mental servicesPsychoanalytical Model Sigmund Freud: unconscious process of psychodynamic factors is the basis for motivation and behavior Self-psychology: every human being longs to be appreciated Object relations theory: individuals relate to others based on expectations formed by early experiences If early parental relationships are secure and loving, the child grows up secure in relationships Disruptions in early parent-child relationships leads to future relationship problems; distorts perceptions of others Transference: unconscious distortion in the relationship; a patient displaces distrustful feelings for her father onto her male psychiatrist and refuses treatment Projective identification: unconscious relationship-oriented mental mechanism that when one person projects to the second person, who reacts to the projection, the reaction elicits a response from the first personConsciousness Consciousness: material within a persons awareness Unconsciousness: memories, conflicts, experiences, and material that have been repressed and cannot be recalled at will Preconsciousness: memories that can be recalled to the consciousness with some effort Insight into the meaning of symptoms facilitates changeDefense Mechanisms When anxiety becomes too painful, defense mechanisms are used to protect the ego and diminish anxiety Excessive use prevent the person from problem solving They are unconscious but some are within voluntary control Denial: unconscious refusal to admit an unacceptable idea or behavior Repression: unconscious and involuntary forgetting of painful ideas, events, and conflicts Suppression: conscious exclusion from awareness of anxiety-producing feelings, ideas, and situations Rationalization: conscious or unconscious attempts to justify ones feelings or behaviors Intellectualization: conscious or unconscious logical explanations without an affective component Dissociation: unconscious separation of painful feelings and emotions from an unacceptable situation, object, or idea Identification: conscious or unconscious attempt to model oneself after a respected person Introjection: unconsciously incorporating values and attitudes of others as if they were your own Compensation: consciously covering up for a weakness by overemphasizing or making up a desirable trait Sublimation: consciously or unconsciously channeling instinctual drives into acceptable activities Reaction formation: conscious behavior that is the exact opposite of an unconscious feeling Undoing: consciously doing something to counteract or make up for a transgression Displacement: unconsciously discharging pent-up feelings to a less threatening object Projection: unconsciously or consciously blaming someone else for ones difficulties Conversion: unconscious expression of intrapsychic conflict symbolically through physical symptoms Regression: unconscious return to an earlier more comfortable developmental level Relevance to Nursing Practice Nurse must recognize and understand the maladaptive defense mechanisms, share observations regarding the defense mechanisms, assist the patient to increase their awareness of using the defense mechanisms, and increase the use of adaptive behaviorsDevelopmental Model Eriksons theory: Every person must pass through eight interrelated stages over the life cycle Failure to complete a stage results in reduced ability to cope psychologically Trust vs. Mistrust: (0-18 months) develop realistic trust of self and others Autonomy vs. Shame (18 months 3 years) developing self-control and willpower Initiative vs. Guilt (3-5 years) developing an adequate conscience Industry vs. Inferiority (6-12 years) sense of competence Identity vs. Role (12-20 years) confident sense of self Intimacy vs. Isolation (18-30 years) ability to give and receive love Generative lifestyle vs. Stagnation (30-65 years) product, constructive, and creative activity Integrity vs. Despair (65-death) feelings of self-acceptanceRelevance to Nursing Practice Patients with psychiatric disorders demonstrate partial mastery of developmental stages Nurses conduct assessment on the patients level of function to identify the degree of mastery of each stage up to the patients age Assessment reveals issues that need to be addressed while working with the patientInterpersonal Model Sullivan: believes that interactional is more important than intrapsychic Healthy person: social being with ability to have relationships Mental illness: lack of awareness or lack of skills in relationships Relationships are viewed as sources of anxiety, maladaptive behavior, and negative personality formation Interpersonal psychotherapy (IPT): used for treatment of depression and other mood disorders Addresses stressful social and interpersonal dynamics associated with depressive symptoms Goal: improve social functioning by examining interpersonal disputes, role transitions, grief, and interpersonal deficitsNurses Role Focus on current interpersonal relationships and experiences Develop mature and satisfactory relationships relatively free from anxiety Focus on interpersonal issues and distortions due to past experiences Nurse corrects distortions with clear communication, consensual validation, warm collaborative relationship Present the patient as worthwhile and respect the patients rights, dignity, and valuable abilities Focus of sessions: loneliness, fear of rejection, clarifying emotions, using anxiety to learn about self and other Therapy is time limited, usually for 3 monthsCognitive Behavioral Models Becks cognitive therapy and Ellis rational-emotive therapy models: focus on thinking and behavior rather than on expressing feelings Cognitive approach: ability to think, analyze, judge, decide, and do Irrational and illogical beliefs are responsible for causing problems Cognitive therapy: examines distorted perceptions by reality testing and problem solving aimed at correcting the distorted processes Challenges the automatic thoughts to help patients develop logical thoughts and feelings CBT: builds on cognitive therapy with learning principles Motivational Enhancement Therapy: enhances the patients readiness and willingness to change habits and relation to addictions using motivational interviewing Dialectical Behavioral Therapy: treats borderline personality disorder and complex PTSD Decreases parasuicidal behavior of self-mutilation and suicidal attemptsNurses Role Humor used to confront ineffective thinking Focus on therapy is on the present Patients learn to take responsibility for irrational thoughts, feelings, and behavior to replace with more productive ones Assist the patient to learn from mistakes Patients who project blame are shown that theyre responsible for their behaviors