Clazre G.

WaughJic
 Fifth Edition
I .'; ----7
-

Mental
This book is dedicated to ny ehildre~
Evfick- Anne,Malik, and Jan@.
 $teti&& ,,, ranfrontaeion
b&&m modBcarion
@Q
o p e r a mnditioning
&cematie d a x a t i ~ n negative condit~onlng
dmemitization positiw conditioning
implosive therapy %@wive
modebg passive
rol~-p1ayin& assertive

a Differentiae the &aracteristim d &ay, fear, pwi~a d

aggression
I
I& seven symptoms of seaae anxiety.
D State four wp of redudng anxiety
Discuss urnsing actionslinterventi~m for @e anxious client
D Zxplajn modeltng, role-pIayiq,confrontation, and behavior
modBcation as techniques for changing bebaviars,
D List three elements afpassive, aggressive, and assertive behav-
ior.
Desensitization
ImpIosiveTherapy
Problem Solving S t r a is a nonspe&c response to any demand made on the body,
These demandis w 4 e d stressors. People are constantly affmed by
Rchiques for Changing Behavior ph@cal and psTfch~10gicalS ~ S O ~ Adaptation
S . urmally goes unno-
Modeling ticed rmless the stressors are severe or prolonged. How strew is per-
Bole-Playing ceived by the person detesmines whether the stpess produces anxiety
in that individuaL It also determines the degree of atMdety psoduced
Confbntation We bave become a harried people with stmsors rapidly accelerating
Behavior MoMsation wd eontrjbuting 10bincreased anxi* in our environment and daily
Assertlvmess Tr- life. Anxiev&ts thm constant To live is to experience anx-
ious moments, but @ety C a n stimu1ate personal $ravtk
ANXIETY: MILD, MODERATE, SEVERE
Amd- is a vague, uneasy f e w of discomfbrt It is a term used to
describe reaction to s ~ e s swhen the source is Weved to be threaten- LNXIETY PERCEPTION PHYSIOLOGICAL
ing but is not obviow. The source of anxiety is usuallywithin the per- BEHAVIOR
CHANGES
son's intend environment &ety is diffaent from fear in that fear is
the reaction to a known and usuaUy e x t e t d threat E w ~ ~ experi-
IL~
ences anxiety at some point in their lives. In fact some W t y is nee
essary. Withogt it, people would be apathetic and disinttxsted in their
s u r r o u n ~
Anxiety mag occur at mytime during the life cycle. It may be the
resrilt of a de~el6~mental or situational saessor. S i t i o n a l strossors
slre cfismptiire changesin ow's life such as divorce, serious i l l n a the
death of a loved one, or lass of a job. Although anxi* is often acute
and ofsbort duration, there are people wtm consistentlyh with a cer-
tain level ofanxi* This is called chronic,or long-term, &a. People
with cbmnic anxiety may additionally experience acute episodes of
anxiety.
Amiety canbe mild, &te, or severe Mild anxiety warns the
body to m o m its form to handle an impending threat It increases
the energy level a8d alertness. The irtdiidnal is then better rrble to
a u k , analyze,draw condusions, and solve problans Cable 5-11.
Moderate d e + g decrea~esperceptim The p o n fonnes atren-
tion on the particular task or problem This 3s called selective inatten-
fion 0th-voices or events witbin the room may not be miiced

Severe anxiety decreases pemption to an even greater extent

Theperson selects only p of an experience and focuses a11 attention
on ?t.Abstract thinking js lost Some concrete directions nury be fol-

pulse and m&ations; a rise in blood pressure; dry mouth. s p e d 1

ences intolerable seess. The physiological changes caused by M e V

are inmased. Attention is focusad em a miaute detail that is often
b 1 0m ~ t of proportion Speech is wuaIly incoherent and u~mnuni:
 Relievfns Anxiety PIfl
A
-
--
A

I/
coping
selected Rapid pulse Mei?RanMm I
focus of attention

tense muscles

posture
\ \ Increased
biood preswve

respiration
I

Mod'crate anxietp: aWentibn

Speech focwed on getting to work on tlme

FIGURE 5-1 Physical and mental responses to sBvere anxfety.

Anxiety-pmdueing situations are not the same for all people A situs-
tion that is unimportant to m e person may cause andety in another
(EguE 543. A situation that is seen as a chanage to one person may
cause panic in another person The followfng are emmplee of anxi*-
producing situations.
Joyce was broqht up in a family that considered time very
importmt She was mntinually admanshed ts, h w and
was punished for being late. She internalized thi?. value !~f
being on time and coatinued to function under its shess.
l o p coped with && I stress by being M y aware of tim%
organizing h a activkb by the clock,and allovving added
W e for possible delays.
One morning Joyce overslept She handled this added
~treSsor hunying. At the last minute, she discovered her
car kevs were miss&. She felt omwhelmed and no fozxger
ab~e rely on her usual coping me-sms. Her muscles
Severe anxiety: loss of control.
no coping mechanisms
FlOURE 5-2 A seemingly insignfmant sttuation can lead m severe
anxiew Tfthe person views the situation as a severe Mlreat,
b e a e f e w her thinIeing was disorgmhed, and she feIp
- helplas. I-laving excw en-& nor lolowing what to do,
she moved from place to place, becornin$ bs aware ofher
e n k o m t She kltEke smeambg or crying. SSh looked
, at her keys mvefztl times bm did not we them.As h a a m -
ieygrew, thee w;rsa greater dispuptieninprocestngstim-
tdi firom hei senses. When samepne eIse fotad the k m
p 3 hai~dedt h m tc, 4% the severam&e%g ended. Ex this
cham5

time, Joyce had already spent a @at deal Of ad@% en=-

&y.
..II
Karen a straight 4. studwt, was known as a "brainP Her
dmmates b e l i d amdie6 wera. easy fi3.r her. They did not
m a k the high En'en paid fm her achievement
Karen m e fmm a family that p?tized sac- Rer father
w a p&du@t aml Lter mother a c o w @sar.
When other ch3dren praised for good wark she *S
aitidmd fm not dQTxg mom Notlntng lessl than the best
m toleratad. She began to &eI inferiw To &a but was
$till lmder the ufcomtanfly having to acbieya Earen
&me $ muId make gmd gr& by re*
she lemm
owaand Corneq'uentl~ she spmtmmy extm h o w in
studp and many dety-f?Dd days bt&e each examina-
fion. Wahm time far &ends a d ofher a e b i t i , %en
w a I& alone. Tb prom her &-esteem an8 compemate
for her laek affkknnds,IZ;aren achieved h%gh grades.
& r d s d e is an m p k of dominz~tiun.m y time
domimition I s a fa~de; the pemn using it is insecure
The td- person mu& project an km@of
md m n y ~ e t Karen
a @mdmedm the &roonlt but
others may project dm&am% in gener;il The dominant
person mmt make dlofthed e 6 . Depensency-mses em
ietybeeuse -in o h m has mer davetop,edForcedinro
a dep&q position, the dominant p"sm my def3tthe
rules, c o m p l d m a b a u t i n c o ~and
, &saditothersin
or& fnremain supt3ia.
.I.
Iahn, tool k d i o n e d under stress. B e m e of his back-
ground,he viewed all &en& with mental illnws not asfhey
were but as be @ a d &em to be. Re reartea to the
e x p a t i o m &at had been e8zabMhed in his youtk &om
the time John auld member, hi6 &milyftetpent].y t-tlked
about Wa$ Aunt Suzy: %heshould be locked up. She can
not be tnrsted You never how what she is goin$ to do:
Even though John nwer met his Armt Swy or ilny other
-
person wi& mental m,be formed opihm9 about -
th~m These spinons lay aonnant b e n r k his awaWses.9.
fohn%ventinto nmsing ftom high school Hewas well W
by his okssmate4 aria &cult$
Dming the fbtsemww, Johnd&ved sbhoWc stle
cess wtthsut &cnl& IJurfng the8econd semeten hewas
 RelievingAnxietv "121

.mm
One evening, Jack was cWViq car doslg a da"Bmw
mountain road. eight-mold son was sitting
him.m e was:hmvy in tbe opposite direction and most
of &led to dim their h&gh&. JaOk WaS driv-
@1dy,but the dnvm bebind him semed to be in a
h m . mey f~uowedclosely behind and honked
horn. Jack began calJbg tbe other He Pm
posefuny turned on his bright lights whenever a
appIm&ed when bit: Yaung S O n BZXRaPkd that his dad
seemed awfully tense, the father responded by shuin&
~~~~t gau $lare my a w a d If it was not for gou, I w d d
hmad, so yon jm k e q*~
not be on t
mn
waysin which people tend to hmdk a stres$ful6kua- Desensitiiation
tion and lessen anxiety include dependenmt domhtioni withdrawid, hother method used by therapisrs to r&me a r ~ d * is && des--
and a m a & n ~oycevgas dependent mr Me. More w d l g , one thflon Desensitization is a way of conditioning a to be non.
depends on omer people In a time of is MpfuL but It. re@Ponsive to a stimulus. This technique is usuaIly done by counselors,
b e e o m a pmblem when the dependence P s i s @and is mane. I
nurse w-, and psy~hologists,but other health w e tyopkers
Dependent perrple are inseaup.and C ~ X K J ace*~ that thyhaw should be kmjliax with the method Cliem arefirst trained muscle
bilitia, mey are mhly ~et&tive ~~%idsm, @w& Or *tion They are then asked t6 identi& (13 the &etpprodueing

-
mily be v i m d iqection For this reason dependant pea~le sfmad- *itaatio21;(2) a place iusually home) in which theg feel safea d seem;
1~f o l l the
~ d-ds of othd, men if those denan& canflict with and 13) another place or situation that is rekxing, such lying on the
their mwishes. , b e d C k n t ~ then asked to imagine the &ey-pmdudng
ji~p, John Jack were in a crisis, A crisis OClXJ3 when fie fion while tbe therapist desixibes it in some detail men &ts feel
p r o w that produced the M e t @ and @ * d m p the16wts@ of w e % a pmmmged signal,such as mov$lg
ing m e h e ape not effecave,Helping a person a a The description of the stressful evene is stopped and the am-
helpin$ the solve problems, Par PIVblm sol*g to n g safe haven When clients fed seme they
aPist be@ d e ~ ~ 1 i i fbg
OCCw,m e t y be latvered to a l e d at which learning are taken, thmugh imagination, to tbe re- situ&on m e n dents
p r a .~& ~ p t i n gto help Joyce, John or Jack p r o a m in their WYr&e& the entire process r e p e a e
state ofsevere a m wuld ha% been Wtl-3. Su~posebundergoes desensitization. The therapst might
ask Karen to * e e.
hemeIf in a specific s i t u a t i ~as he H~
%ht begin saying You are now sitting m the ~ s r o o myow . desk
RELIEVING ANXIETY is chred. Your p m d is out You are ready to take the exam. he pro-
fessor walks in the room. He has papers under his a m He
Systematic Relaxation O m to clear their desks. The test papeas are passed out you reeive
~ystemaflc
-tian is one method fodopsd by hehwioral psZT- Papa and look it over. There are some questiom ym do not
a01*ts to relieve d e t y . It is based on the faa that M e V and remember ever d i s e u a . You are trplng to think offhe ansrnrerbut ft
-tiOn ea&at ge~axationexercises stem from the *that
awareness of a tense mvde wables one to that musch is Fh?n might & h~ froger at this point The therapht immd-
not easy to do and consums &art must be used afiou$h the atel~ with, "OX,YOII ant now out ofthe- classroom you are
of -ety begin to ltnuer immdiatdy, total relaxation take @ h-e with YO^ MY. you are sitting at the p*. your is
seved w e . gw and YoW father is smokiog his favorlte pipe. m e dog lies near-.
-
 @Thereis a ~ i n t h e f h p l a c e a n d t h e ~ f i . a m % f egood
& from avmeneh. Time .is mated on srrper6.M W w while the
Ynur father d i e s as he lrstens ro gou play:* real probLem gQ%. W:c&wdIf J Q wen: ~ && her pB1m
When Karen app- more mlaxed, the thempist &t continue vm, she prokwy would .wm&, UI axmot find ,mykepac or.UIfI wdd
~"N~wyouarelying~thebeach.ThewfiiCesandiswarm~t L find my keys, I w@ddnot h a pmblem? mnld no W b t gay
your skin You ean hew the quiet q~kshhgof the waves a m the Pr-have ta make an Ann-@&test' &en ifshecould not *lain why.,
*The sun is warm. YOU ean feel youpmdes rek&g as the J e h muld be qe.et@ to rampkin ofphysical d i m &en ifI&
sa$s umlm ea& p a + &ds k@, EU%J gets M.&and J o b 5 abd&I &em&m is
The therapist d e n takes baok to tbe dibssmorn wh84 sh@ f e l i e ~ dthe undefllying problems-the o m th.a am the d e t y
appears relaxed MTau have nsw handed in the test pap&. YOUhimst0 the first placeiaresrilldm.These am upbrl$ng probIw thatneed
wait* the grade. Ypn have no idea hawyou did, but you are wcirzkd
about the questiom you did not r e m e . ! The f6h.~~shformati011about Karen rmght hdprbe. team &
The entire proms is repeated aver d over, mtflhtaren n@ .W&? pmlem and assess the sbatim
lower elrperiendes amiety&tt,?hbk&% about t b me6sful-t

Implio&e therapy is in direct c0mt.t to desemifid-ion B s @ ~ s k

Has ICaren f@ wemh&ed & ~I&cIc$
therapy attempts to arouse as much anxiety in theindmidual possi- did, what the sttuarien? \What 7 q i n g m-ms , a d tide
ble. Relaxation is srnetimes used but only at thew end ofthe s w i o ~ , theaT Wwe they &ediv&
' What we ken!s R~tmmgoaIs?
Calrtio~This technique re@m a prof&onanp uaiaedU1mpIst
Wbat is hw relatiamhip vvith hex f d y ?
Relamiion And desensitization are not the only meam af &uc-
ing arude, In worlrtng wEeh 0th- the nurse will ikd &at a &atti- , H C h whom docs she call for help? Ma she ask W w o n ' s
mde and quiet music can have a soothing $fmt Warm bathS or hot help at:the- of fkpblem? Did the p~tim wbnd?
drinks s~m&rieahelp. k s i o n a l actkith have also been used suc. In w h m does Karen confide?'
cessfdly to relieve anxiety. Qnce anxiety ia l m r e d to a manageable
level, th~problemthat caused the anxiety mu@be sobed. Phatis Karen's dmbpmcntal level?
~ S Wt-oW these questions vviU hdp the fwmrach somemdqions
~ ~ , of the anduBiom thqmigbt wch are
& O ~ U T ; ~Sarae
PROBLEM SOLVING S k m k s ;las pmr s ~ E G Q - ~ ~
Solving a problem may involve sel@&% other aptions, cchaneSlng
b&& about an event, &m@rngbehaviot or kdQ'a more e$e*
coping m e w % Problem solving involves a change. Before apmb-
lacan be solved, the person mutit remgniag the needfar c ~ X @ and , S k ha,spoor p r d b l e m ~ osW.
l~
know that he or she has the &abili$y to m' SXte does not use adapti* @*dm.
Very fewproblems have dearcut solutiom In-g a deckion
it is necessary to weigh possible $a&f&ctioma g e t padBible and
corn. its.imea l l ihat aftkt an action cannot he conuoUeck it is
imgossible to know whether the c$osendecision da a y e d u c e
the plwned result However, a M i o n must be made It Mlill be a
more &e& solution ifthe entire health team, as well as the client is
hvi&$& tlze process.
step pblem. salw is to problem.
k mt.ssthe ~. si'roa* his w., m m . m e REAL ~sob&m is hiddm
give direction to the nursing care m e n will receive.PmsibIe ggoals for

43 Help Karen become mare a w e of her situation.

.i Qach Karen prablem-solvinp ~kill.9.

I& Teach her more adaptiee coping ra$asures.

,a &&t her in setthg more reabtic goals fof herself.

_ Tea& her assertlw skills. Nursing Intewentlon6

1% Fl&.de a stlpporflvem e - la Protliddg a supprnfive
d k t reTatiomhip inwM& t l o W p gives Chris the
I - Care Plan: '
Nursing ChriswiIIfdfrrl:tcwenf sense a f ~ ~ t ys t oh
lifeSituatiom and stwsm*
The Client with Anxiety and Stress

a thiq-rrineytx~~ld lawIpram@in m m a C y headaches, deaeaaed consen*

m&icd fkWy stawg fhat be b4ls b e f l o m 4 tratfon, e p l g e p a i n , and
=II& dblood flxthe~ast few days. He r&tes to the n m c0
-ri-
se one^ bathe has been q&* wmptcm of hem-
bum and epig&~ pain f a the pas^ ma* vial si&ware when symptom develop.
m p w a ~ 98& e puke 9D, wpiratr,q rate and U m d
m~ ~ # S D . Dtnimg the W asswrnent interyiewu;, be comV=hg session@g i w
TATS that hjg vvife ~ k % ford a dieorce &m&s ago became Cbrb an oppo* tc

-
l a g m-hours and time a ~ a liam
y the WY He pnxess sbessffil&mti~m.
st&s mt he also is in the M 1 e of a d & d t & X k & d
suit He & a ~ ~ & x e abl t q of~thmaricattack. Zie wiuhave an oppo&~~-
A complete blaod m t and an uppet gas-
@e d e e d for the next morning. The mm p d t f m -
ap x o m & W s see a clinfcaI s p d s t in ps)rchi-
n ~ i n gtb &CUBS the S~IXSWS in his Me The initial 2b-~ p ~ b 1 ~ m - ~ o dI v i-
n $ Zb. LeamLFle, ~mbIan.go~ving
e g ri~aalsthat he is expepieneingsymptome of m 0 h - +-%Iqllesencpurageu Chris
ate to -8 anxiety. ws ha agreed to an extended d m - W seepofBible opticm~ and
tion &er the inttial fntemie~Chris elates that he b de-es
ap&en&g fkquent headaches and is fmdbg it @cult to
2c Qlristo keep a 2c. J g d wring provih an
c o n e a t e on his corn Wed
d * ~ o ~ o f ~omnritpf"orCMst€l
~ ~
methods of so* m& pooeess I@ situations.
NURSING MOM-8 1
28. ~eardhmetho& ofrelie* $tress.rn- m4w
SEWS f.%, -dse, y@or
feIaxa,tianante.&q@e@.
, I ~va~uation I
I Chris is wmd&g three timesa week @,ndpfactiices ~ h -
I ation teehnquea wheA he hcomm t w e . He fs BPI*
amepmble5ns&ving tdmiqrres in iAs daily Bfk
I
I

D e & d @ a d elated to &%kof losing at the

q e w e d f o c c u p ~ t i p n d m p ~ sewndaaf
eg to pmi- .Modeling is a method used to imp~.oveinterpersonal wmmunication
bfe m n z as znmifwted by m-t af wife skills. The nurse, acting a.9 the teacher, dc~nonstnrteshow K m n might
divare due m C W : a . ~ p a t i o Ms e s p o ~ b s i band
~
medical sppttxm (@eat headachess,inr- ma-
cehrn& and epga@tPic *).

1 1 outcome Identification
I I Qz& will &ate pafehtldl oEtcameg of divorct?aEtd OCOU-
paziuaal mpoetiea and prlo~izeresults uuithin one I
N u Y S I ~Interventions
~

RoIe-pIs\yinmctiomwith
f i d y a d work modatea
nee and mim.
-
ati ion ales
Dlrms Chrlfi'S exgeECatioliti Dwssing ~ e m o d
, o&upatjId -a-
ofmagiage and c m h p ~ t i i ~ ~and
tiam asgIsrS in vd-

&Itrplaying prcwide~oppoP-
Wty to identifywith otheri+
.fee- &ndt b o ~ g b .
I7iscuw possible behavior
&ages as needed.
I $ Chapter 5

confrontatlon 'wdeatisw ham &cam& $&

rewar& Wbix the awn ,a very
C0mn-n is a method of e~mmunication
to bok at inconsweneie~ Eeehg md vo&atiom.
~b.
that fo- the client
It t a means of
m A n n i e i i u t t o t h e d&*
bzh&&I ,fitappe&
her, Wys -*
began wring j $ i q s gctian, and

helping the p W n validate reality. The nurse might wnfront Karen

with the following: Tou told me your father q e c t s you to get a&. '~om&es a u?itten met @ in b- m,diftca.tioa
can y.ou relate one incidence m which your father told YOU this?"
'i"clientand n m e R@W ia w~itinga the dew,^ mir we
rhe r d to lae'recehd d e n isa&&. ne&&
W i8 dated and sighed by Bo&~ and & me [m j-~].
Benavior Modiflcatlon
Beha* rn~dtfication is a technique b a t d on &e hetheory b t
b W r must be rewarded or reinfed to mntinueThis t a m e
bas been used kquently with children but i s d d v e with age
groups. Behaoior iS determined by the reinforment pattern the in&-
ddual & learned throughout his hi h a her' fe. is knbnown aS o p e
t, &wad@ anundesirable behavior is known as
Assertiveness warning
?mPle m y respond to situations in an
t @ ~ e r t imanner.
out regard
~e &pssion implies meeting &S - S her avn
otherg. The passive pasm S U P P ~ ~ or
desires in h r o f others. ~ssertiwbehavior implie -~ing on&s
*a-
or

-monfng; reinfarein$ a desirable G W m is called Own needs, but unlike m a n , it & ~ . m c ~ ~ il d e~s i~nthe
g ,other
conmoning.~ehavibr, whether sodally acceptableor not
is continued for a reason. The individual the bbehavior sees S d y , ,women were wnaoned to be p&ve J' -)&
reason as g o d , no matter howdbtwdng it may s e e m to 0tha8. were aught to s y p r a their needs. The pawiye person is
change an undesirable behavior, the reward for the behavior oftentaken ah- of ~ & e peopleem be counted onto do w&t
is - ~ d . ~o a-engthen an acceptable behavior, the behavior is
rewarded. It souads simple,but inactual practice it is not easy. Not all
beh&~Tsare wntinued by the same reinfarc-t and not aILpeople
respond to the same reward
Tf a behavior is to be ehnged, must- be speci6edlyidenti-
fied The beh~xiormustbe stated inconmte t m . A baseline is then
estabIished by obsming the bhvior to be changed and rec~rdingthe
n w e r of times it ouws. This provides a basis for d e t w the
effectivenessof modifiealtion attempts.
~ nofthee most d@I&t aspects of behavior modificationiS to dis-
mvtr the rewanl the individual is mxiving ,&m the behavior. DDuring
the baseline observations, events before and after their behavior
This fnay give a clue to tfie reward the individtd is mitrjng
from the WOI. In the htillowhg examfle, it is evident that the
an &&rewives i&J from a behavior is not alway~0bhllS.
On sL*(ieTBIoccasioas, M y hit Annie Mthile playing in the
4 Chanter 5

is asked of them but t h e y q raent i t They can bemnie very w,

but ange~is seldom - W e d openly. Ifthey do express an$,&,
they fed g d Q and mu@make arnends. Passive people hawe d great
need ta be liked Their self-mnqt is vulnerable to the comments of
othars, GomsequeatIp &q are not seI€-dbctin$ and have & c d ~
feel@ p o d about themsek.
Men in our sodetg. have EaaifiomIIy b&n fa@t €0 be openiy
aggresm. Tomen have been encow-d to be wewive anly in a
msaiwe sense. Passive-oarafa to a manip&tive type of behau-
lor. The mmlipuhtor %mpts tn get his or her b a y by inflicting guilt
on the receiver. 'The following is an example of manipulative lxhavinr.
It is all right if you want to go t~ your party a d Leave me
all done. Enjoy po!melf and not @vea thon@Lt to yoaf
paormoher in this big house wfth n&hg to da. I stapd
home Mthyou whw you wae small because I laved you,
but I do .at want youto fdahligated. You go tojrowr party
and hve aacod t h e .
Thiskind of statement is &e&ve for getting whatis desired by inflict-
ing; guilt fdirlgs.
Asse&m requasts .we made in a n ~ tonedof miee.They afe
spefftic md reasonr;ble and hcludc three elements:
Q~sbdetationofthe other pezwn9sk e h g s
0understand how you feel)
11I A stawnent of one's own Peelings
I W is the way ifed,)
The request itself
Ehis ia whae f would W.3
,. . . ,* ..
The following emmpte 8Iustratx-x the dB3ence bemeen ggraske, PASSIVE ..-i: .~A:,;:-:
passim and l~ssertive~espoflse~.
Sitaatiatt: Jane is a nurse workjag in a twaty-bed corn-
I BEHAVIOR i L
ASSERTIVE
' w-@ $+; BEHAVIOR
AGGRESSIVE
BEHAVIOR

p 1 e t e ~ T~k rt e i s a k e a d n m
RN, and an aide Jane hirs been a s w e d &$it
cIienb, the RP6 has five clients, a d Phe aide
bas s e w 4 Jane f& she cannot give adequate
~ t 0 ~ a a d t h i t' t ~ tisuidw
&ee ;;he has taka &z? =*at
dI week Slxe decides to tak ta the head nurse
a b u t the &wtPDn The head amst ~esponds,
*I m somy Them i9 nothing I can do. The
 Eelieuing Anxiety
~~

)REV1EW
--
mow AND C O M ~ P R E H ~
& MuMpk &ice* 6el@ the one Bpst
x ~ ~ p & , ~ fn~~t ~-3* . g ~
Q lZPa*ans.res~tBtBfrsmp&$&,J
0 B . .~~ , h $ d l ; s . i S . mF
;
A
..
,

p C,,%&@\@
~

>eUS,.&;&k
p D.,>Z~* :$$?= or g .- w
2. ; . fJ$tw@&:w d = e I &.&&,&p
& @g ne~,&@
~~b~~
0 B. fdkge~~ mtj$f@~
Q Q ~ ~

Q a mrn~-;
: , " ,

"a. A,&&$p.*~ @
-,$-

a A. mm & , o m . & & ,$dprnm&@.$hi

SUGGESTED ACTIVITIES
Consider the ds-r undw whi&yo~become d o u s .
Do yo8 usually respand byh"oz&g dependent witMraw
@gcessive, or &mt?
T q ~d the feeling9 evoked in you when you are a r o d
someone uiho is e x p & m moderate or severe anxietyty
Pmctb fhe relaxation ezergsw d w d e d in this chapter for
twmly to thkgr minutesa day.
a m e a crtmdous &-to Mm b&r&your next ~sni&+@a.
D- be.enam,tr~a d m p w &eUnp;g. q m &q d i f ?
h-w . , mw& ,duringan w t s o n y
183E Chapter 5

i! The b-or digplayed by a buspitalked dent who mnstant

ly compkin! and defies rules Is
R dependence.
Lt B.withdrawal
Q C, donina'tion
n.
o -ssion.

r n L Y YOUR LEARiuma
A. MuEtiple choice. Sdeetthe one bedt ansnier.
1.A n m e has worked a shift fm Eor weekends so that
fbe peer could have time ofTfor reamtiowl &ties. The
per says to therurr^je,"Im d ~ o u m w&for~nextw&-
end, too." Choose an meptive response fw the nurse to give
ta fbg co-worker,
d A,Y~~dthaty~uhavep~forthe~eelren&hutI
lave plan9 also. Sfnce Pae already WQW three week-
ends for you, please mk komeone elsew
P B. ? had made p h fax the h e n d but realize 2 s ImpDx-
tant tg help yon Sur& Ill work nwt we%kendfor paa
0 C,~o~bahiMtysaskingmetoryarkforyo~ Youneedg,
agk m e b o d y else.{
Lt D. m y do you k q askUl;e: me fa work for you? Dodt
youthWTba&lkkT"
2. The anme gathers data fivm a new client adWted with
Genera&ed lX8arder. Which statement the client
wouId hcfkate the client uses pasame beha16m i n-tape-
sonal lalapimhips7
3 d Y've b e e n m m my &ter do my h o n m r k fm me:
4
She d o a t have a job and might as ;well help me."
D B, "I dwnp put my Mdrenasand spouse's nee.& first but
itdytiresmemta,adit'shardmkeegupwithwhat
fhey wantu
D C. JI think I talfe good care dmf*sselE I'm proud of my
professiand work and hawe a d g dationskip
with my BenndsP
P D.'"L'~&gotto~valcecareafmy6e1Pbearusewb~&~ia
$0- @ '&lve them an inch md
to tfait. I d ~ y say,
b y ' U ale a mile."
 5. fear

D. Briefly answer the fonawing.

..
1. Create a table listing each letd of anxiety and an exmplle,oe
Row you have e q e r i e ~ d each l e d What ~ y l
n
2. %%atare fm ways ta relieve anxiety?
 of OoncUtlpnWre- for ourvent bahavr6~
f!eXeS &Used UY h@@
prevlaus e v e m l t " psrsan & w e
' can be unlearned th&Deh;?Yior
and replam by
new, more aDpror
DriBte b%hav(gr
~~-UIUS -
by W V h g ttlb

Cllkil't. E~ewpemonwants Help the<pgrson

OBJPCTWES centered to BChwVebBlf- b&ome semware tenslan, and
-- aherapy actuatlzatlon and so that-hevr she deewbeness by
AAee studyin$'this chapter, d e the~den€shauld be able m. MI6 drwefs the a n changenrs or provlutng a
Derson's mottue hsr own behavtor nojmiflgrnentat
r IdemS.f3ifhe theories of three pqdmtkrapim. fop action and improve envipnwnt
SBif.ConGewt Ref;leEtwllngs
wdmicpm wedby each we of psych*apist
nti Ide~tify
TI 8 Accept psrson as is
D e h e r a m ? fteqwntly used in psyCh0thmp~ Rgktate person's
l& of rnm&wness of tke id, ego, and thought5 sna
m State the functFon feelings
" A

The mind conceives Help the person orem exQerlences

- experiencesas a become more Leamtng s*
El @lain how seIfdwareness helpti to Solve mental problems. whole: when an aware SO he or awareness
expefleflce 1s she completes Relaxation
Incomplete,a experience.;, Presanttzlng
problem may r s u R accepts reswn. FantaWng
sibillty for hls or mageration
There are many methods wed to mt mental b e probIenfsenfS her iBe, anq eo~ves
M&& wed dIre&y on the body are called somatic therapies. Problems
oVlrea the d o n m e n t is chargd or c@d& the m w t is
PSYCho. Abnormal aenavrafts Brina repressed
r e f 4 to as &eutherapy. P@&empyum vetbal anaqrea- anaksis a result M e-I-
Themptgt
s& tecbaicpm to hhp clients resolve i~lflepW&C@ and ma* expenances to the ~ntwaretatlonof
ences that have beran Oomctaus mind statements
barn. repfessed Into the wherethey can Free assocla$ion
&mi& Rogers, and Perb ark just a few of the people who have perSon's unwn- be resolved cathauls
develop4 psr;.hother@ies. Egch af theta men has coatribwed infor- serous mlnq HY~no$IS
matipn us& ia d e~ sta m and trw human behavior pmb- oream anelysls
lems. Rational Behavlorls due to Help the person ta
'Be nurse bee& to h v e some howledge of the techniques emotive what peoule bellevs amteue a more real.
emp- the t d o I o & s rn d and thebasic belie&miler@% each f?eraoy about an event and rflc bellef svstem

j" -,
p&&apy mble 61). Althoq$ t kheN is not apsychothWpW not $he event itself and to know that he MUSCle PelMtlOR
the LWN inrwam with &ens who arp beirrg treated by +&empu or me hss tns a111lty Problem solving
to Cope WIM events Asslsoeg readings
and therefore, should mde&and the prindpb ofthe p@otherapY x and actlwtles
 ..

,.,
'PSVC~O*~~~~~~
~-

Tp? aggres~iana n d ~The ~ ~id .opmtes at the u n w , m ,level ais

ruled @ the pleasme prineipIe. W e ?s. no sense of right or w o n i $
the id,On?ythe seeking pr dem@ding dEdEimmedizt& satisfacfion,
Theego i S the w3nsdous seE It is through the ego thatthoqhts,
f em.atians, ~ ,and compxomirrs a. famed. The ego sw& to
control the pleasure prindpie of the id by substituting the r d t y pjm-
+lee This means t h s the ego seeks u,delay the drim &the id until
they ran be releaged through appmpriate bebvicu,
The ego WWS to Control and to guide the actions of an indlvid?
U@. It is a mediator between the &cfw &vm of the id and th@
afsearie& It develops through internebion With the enuimn-
~faent, DeveIopmmt of the ego begins during the six to eight
month ,oflife. ~t about rhe age of two lt ism^ fairly
dm10ped
The .aperego dwelop later, usuallgaround the age of three or
fm.It eS genmally fairly well dewdoped at the age often years. m e
SaptTego i6 the i n t e W e d parental value system &d the con-
s c i w S t i s concerned withthe demands.of society and a d o r e con-
I trob i m ~ u that k would mdager stieie~It is responsible for help
ing; the individual to d i g n i s h rtght &om mng. The supeEgo
wbrh iitboth the m&ns.md u n c ~ m ~lev& i ~ ~but
s p- at
the uncc~nsciousi&
~SYCHOII.NALVSIS,
ferndhril@m
Q#& -dilt&,h~ STAGES OF PsYcHBS~$Lib@JgLop~&q~
'*
h a

*& v:-m*2.hieve
@-@ miad g ImYimg Libido refas to the sexual dIf'vp. P i e d pz-opr~sedb\tthe lib$&,
be$ins ta deoelap at birth imd & & @ ~ ! ~ ~ ~ t a g the mih
,&t@%
g&@pa&&
bmp&
.
,*
ts, @ '-&US
hb W OD
%&it%i.:aR!
mw& ,d a
,
life of the individual rable 6-31.The
&DU@
~ hstage
t of
is from birth to e i p ; h months. This is & o m m &the
libido devilop-t
st
a s
t3 @ m t& m
,,, ,
because the idint recziva all of his or her pleas- h u g h the
I*hknri$*f&~ @ $ ~ t a W , , - & g b%mB&- , 2! @&tFy
& mouth The second stage is the anal we,whi& oecm Between the
%
-,
,a ,*,
*a&,W @+@@ma
&m& *- 3*.-,
not tare w
-$' :,
@r-;f,i.i@
g p e n t iiWHSs,
~'erma88&
rn @the 8ab%o*%
fl-j
W m of one and Three. It is in this period that toilet V
very ~bportant The third stage is^ the p h a c %a$e.
be@ to develop a wxwd idenBty and becomes aware ofhis or her
q become
&e child
4 9 w m w & e &wm&yd &;anytw"
body, espealIygenitalia
d &w.
* *
Mris ail
.mi e a t p e , t saima a a~bf, m & w q y.@ n a g the W d stage, the child develops stsong feelings towad
Incwe,g-Mee&ne
,*
+.*
@~w-:@,'@g
,& dae@
& , a m *f@&
&e,-~
@gl:w.adbred,
sw

id &@@&.-, bP1'&,& p@ &&e

-@&
&,;tnd;tndInS'mM
m't
+w,
&&&a&&@ $
@@&qi$y ~ 3 Qj
WQla"iQup

~&s@, a
Tfre
x?:@
$l
PSrenf ofthe opposite sex The boy 6Us in love'with
and becomes jealouiofhis f&m. The $irl grows doser €0her father
a d kames jealoou8ofher mother. This behavior, n e c p s s fa
dweIopment is mned me Oedipus conplw
e @ a complex in females. The Oedipus: comple m d &m the
x_ inmales
~ mother

~ nor-
and
@

&gidla &"*. m*. as.& :I& w*" mythical 1%~ ~

mother:
~ &, p who W ldlled h@ Gther and w e d his
~ ~ + ~ w ~ g ~ o m
~ vea
~; , i%@,,~d@%
& e

--
anrc stage %ma1 ~r&ntltybwlns to develop. he Plea-
,5 zone 1s the genT&l area. The rdVld
rirr~lalnnsm w n s feeLlhss forthe parent W
- - - - ~ ~~,
i7vy"-,-.'---
.-;
the opposite sexand w&ts:that
.. p e w all t@r J
:?
,
stwe ends w h m me c ~ i l d5 t a ' ' ~8 ,
hrmself. ~ t w
to Identlfy wi&.ttwparentof m e same sex. 1 '
&ency stage netween the qges OF six and eleven, sexual U@
ings are gomant. The child paitlclpates m
more soclallv approved actlvmes. OrOUP tnt* I , . I
action IS very Important.
oenttal stage mi. IS t h e m 1 phase and I a reawakening o w
sexual urges. The stage begins with adoles. ; (;
cence and moves toward sexual maturanon~, 1 $
and sexual relatlonshtPS.
It should be noted that same experts do not believe that all chil
dren experience Ereud's swes of libjdo development krtheraore,
these stages are not accepted by all a u t h m a .
Accalding to Freud, psychologid pmblem may occur because
of anrested d d o p n e n t of the libido. The therapist attempts to dis
r n where the libido stopped developing and why It is beIieved thaj
this information is in the unconscious. Through psychoanalysis, tbic
idormation is raised to wnseious level where it canbe dealt with
Free association, c a W i s , hypnosis, and dream analysis are tech
dques used in psychodysis. Free associatton d e r s to a proms
of counselingin which the person says aloud whatever c o r n to mind
The t h q i s t listens and interprets the person's statemenu
&thmia is a method of fecaUing to memory an experience that i
caw a problem and helping the personto eqresv it Hypnosis i
an w y induced state in which there is maeased responsimes
to swaestion In dream analysis, the therapist interpreB th
imagery that occurs dming sleep.
Witance and transference are a h terms frequently used i
psychoanalysis. Resistance ocnus when the person tdes to p M
the movlng of infarmation from the unconscious to the consdo1
level. UnIess the w o n is able to work through this fesistanc
pmgress wiU not confinue. Transferenre occrrrnt when the persan
gm% the tlierapist characbisties of signi6cant orhem in the person's
past lifo. Thi&process is thought to be n e w q for mwmq
Psycbmnalysis is a very sl~~process.
ReCovexy m y require fmm
om to many yeam of intensfivetreatment
CLIENWCEMERED THERAPY
I.
: Elient-centered or nondirective therapyww developed by Carl Rogers,
a wntemperary psychologist Accordfag to Rogen, the actuakhg ten-
, dencg i# the person's motive for action. He b&eves that under the
propet cDndifiow, people have a natural tendency to progress to self-
actualimtion.
Rogers does not Gee terms suchas ~ c o m d o uors libida. He does
not beliem iE is helpful to interpret past experiences. Instead he uses
, terms such 49 8 e l ; F - a w m and achdimdon temlardes. Rogers
bekern that anention sbould be centered on the person3 pf%6on&ty
and feelings at the present
A poor seEmcept can prevent seIf-a&dization. When people
, see themdives as Merent b m what they are actually experiendng,
they become incongruent b c - intemal harmony). They distort
- .f and deny anything that is not consistent with their self-concept
incongruence causes them to become anxious. The purpose of client-
eenrered therapy fs to help people i n w e && selfawareness and
thm Improve their seIf-wncept By beeomiag self-me, people can
view their problems more re&tidy Tbis enables themTo begin to
accept themeIves and their enwonmentts.
%chiques med by the thempist are based on the belief that the
person has a strang drive for serf-achldizarionThe therapist @la to
help the pepson reduce anxie9 tension, and defensiveness that block
this drive by pmviBmg a nonjudgmentaI e n v i r o m t in which the
pewen actadp heIps himself or he- A noniudgmental envkon-
merit helps the person ta feel safe and nnderstood Wheh d&enses are
Eelaxed, amore redistic concept of self and the environment can dewl-
5p. The therapist accepts the person as he or she is and does not try to
%e him or her.The therapist promotes an e~lvjronmentin which
the person can change himself or hersel£ The client is encouraged to
-1:~s his or her feelings. The theraptst listens, tries to understand,
then restates the person's thonghts and feelings. In this way, the
person is able to hear his or her own Teelings expressed This leads to
increased self-awareness Dnce a person is aware of-howhe os she feels
and what makes the person feel that w a he ~ or she can begin to
*rove the behavior Rogers' a ~ r o a c hto psychology is humanistic
and hop&.
7& Chapter 6
- -
.
I
Tbe zttinule of b e therap?& is af primary concern to hgk+.
Rogers b b v m rhat the therapbt mmt have thee basic qnatitim to
bring about behavioral change €T&path~, pmitive regard, d genuine-
ness. The meet i m p m t Ofthwe 13 m g . knpathg is the quali-
ty df fur$ undersyandhg Zbe person b o q I& or her ex@eriences,
and tqing to &eethe world as the client $mit Empathy is under-
stmding the person's fediap, even h s e b e h awareness The sw-
ond, quatily, positive regar& mwns that the thempist must accept the
pmon as he or she iS,The therapist w%er judge%interprets, a probes.
The cIient is mtstedto ma-ka the change mssaty iar m e I f ~rhW-
self. -eness is thethird q d i @ For chage to o m thetheraipist
must w m a @ t eSincerity .to the pwon.
Behawinpism is a type of therapy that examine RarZnal and a b w ~
mal hehadior a8 a result of mdiri[~nedreflexes It i$ppNarily used fw
p q i e in anxiety states or vvitb &eah disodpps. It ts Geldom rised
with a thaught-d.isodered perso% Joseph %1pe hits d m muebwork
III beha4orism.
Behaviolism is based an the bewthat a11 aaion { r a p m l is
mused by a p d o u s m t ( s h ~ lb.p o n s a are learned durjng
-. m m . %%en a stindm o'ccnps, a pasgn wponds in a m y
life
Wt @wes plea8um or pnts hurf. Tor exdmplle, each time a W
$a= near a glass w e , the mother sap M with it @ at Of purdshment
This is the thetsndm. The cbild stops to save or hm1P from
h e This is the rspnnw When the child Iearns that stoppin$ is the
safest bebvior, this behavier continues 6h e the sthuh mcm'9.
BvenfuaDythe response becomea automatic The child is &en safd to
be c~ditbnedAll rwonsm M e both pnsitiw and negative aspects.
The childls respoase saves him qr her &omp i i s h e n &but itdenis
the plmwe of twi%ng the was& If arespome has more positim tban
ne&tive aspects, it is said to be nrlaptive.
childten m y respond to &mulus with temper tan-. .-.
Efhe
tan€mmrestrlt &them getting what thep wsnt Gin this we, han-
the vilse3,tl~ey;o\Fi2tmiauausing this behavior H ~ Fa tan,-
ws& in terms of en=, so &isconsidered a maladaptive rmpme.
is
Once a beha8ior h;?s been learned, it may result £ruma s t b d u s
similar to a associated wi& the orlghd one. Tbis iS calledgetlemliaa-
&sf For axample, a a m n dev8Iops a fear &plane tdps beawe of an
a
w.
acdaeht. EarentuaIly, this faar may p m l i a e to other The I T S
mag feel anxiery when he goes to rhe airport to mea a friend.72ssmf
and s m d of a pl&e msy b q distress.Eoen t%llbddings ma$"c aw
him €0&el uneasy
Some terms m m m n in belraviorlsm are eztinctiolr, displace-
me- r e i $ m m and conflid E3tinrrion occurs when a conditioned
response is stopped. To Frend, displacanent mmeant taking our hostili-
ty on someane orher than the one for whom it is intended ?t, beha*-
i o m , dispkmmmt is the act of engaging in %&stitUte behavim
Reir&ormrwt is &e saiefaction one gets from a @ d a r respon9e. It
is why the behabehavior continues. Con$& as wed by the behaviorist,
re& to a situation in which two conditioned respomes oppose each
o*het Por example, Jane's boyfriend has requested that she we= a par-
ti& dress on a spedal date. U n f o r t ~ ~ ~ tJane + , hih(i gllined weight
and the dress no longer firs.Jane has been cqditbned to please her
boytitend so she goes an a dlet She also has been conditioned .to sat-
isfy frustration & eating.If Jane becomes Eutratexl while diettag?she
is faced with c&ct bemuse she must give up one conditioned
respame to satispYanother.
Maladaptive w o n s e s mult fmm e a r h wents, but the behav-
ioral there 'st& net interested in exploring the cIienfs prast It is the
current be ravior and its eurreut stimulus that interest fhe thefapi&
Behavior conrinues only as 104% as it js reh%orcedced The stimulus or
rein%ommust be determhed and stopped, an avmive comequmce
added, or a difkent b e h a w reinfor~dfor change PO o c m
Dm@ the first sea$iOn,the them@&takes a derailed his,tory,The
brstory includes such hhemsw the client's age, marital status, edueat~n,
and occupation as well as & a her relations@s with athers, U d
behavion, activities, and hkes and dis- also are & ~ s e dat this
tim% The focus is on the hehavior the dent wishes to chan$;e The
k a p f s t may ask the client to keep a The &'tory and d i q help
the therapist determine the maladaptive behavior, the extent of the
behaPior, and the stimulus for and consequences o f d e behavior.
The behiorisst is primarily a teacher of new behavia=. Arti~ix
are oriented totvcird a goal fh;lt is stated in specific, m u r a b l e tams.
Helping a permn to impme his or her personality is not a measura-
I ble god because it is too vague Success of the therapy cannot be deter-
mined bya vague goal, Gods musf be specificAn example of a sp&c
goal is Teach the client musele relamion exercim .she can use ro
relieve a m i q r before examhatiom:
The technique used by the behaviorist depends on the sitllrrtion
'i
and the consent of the client. Tkchaiqaes include
" Modeling to demonstrate appropriate behavior.
Q Desensitization.
': Maselerelaxation
13 Assertiveness training.
Role pb@ngq
Behawirk modification.
I'M-,Chapter 6
RATIONAL EMOTIVE THERAPY
Rational emotive therapy, known as RET, is related to behauiorism
Wonal refers to the person's abBy to think; to emote is to express
feelings. Its founder, Albert EUis,was convinced that aperson's behav-
ior is dne to his or her avn thinking, Problems are not caused by spe-
cific events but are a direct m u k ofwhat theperson belimes about the
events.
Por example, Karen expects all A@but receives a E on a test As a
result, Karen becomes depressed and leaves schooI. Sup&%dy, it
seems that the grade caused the depression. Ellis, however, would take
the pasition that it- not the grade but how W e n viewed the went
that cansed the depression. To Karen, the B meant failwe She tells her-
self that she is an awful person because she did not get an A. This
makes the event a disaster that Karen cannot handle If the p d e had
not been al-important, the depression would not have occnrred Ellis
calls this type of thinking mas&* and says it is the cause of all
mental health problems.
In RET there are no m C s or shaulds. There is only the reality of
the situatian Oae shouId not demand hut oirly desire. It is not sation-
a1 to believe that one must get all As. It is irrational to demand that 0th
~-
~- ~ ~
crs respond in a certain wvay. Some ~!~ents arc impc~rtant,hut none are
important, Some events ?re unrlcsirill~lt.rjr ~ncc~nvellierlt. hut none
are b t r o u s .
To Ellis, whep a person sees an went as awful or tenible, he or
she is aa@IizinJ; or c a t a s f m p w . Catastrophizing results in a
lass of caanol over behavior. 'W~thoutconboL there is no problem
solving. The consequen- may be s&-defeating or maladaptit-e.The
philosophy of rational emowe therapy is expressed in the phrase %'
the world gives you almon, make lanowdcNIt is not what happens
to a petson but what theperson does about the event that counts.
Since problems are a result of masturbatory rhinking, the thera-
pbt wbally attacks the &leafs thinkjng ~r belief system Though
other techniques are used, this wnfsontation or attack is the 6ne m e ,
basic RET technique. The therapist might say something such as
Where is the law that says you must always get an A?" "%ow me The
proof that you are an awfd stdent' Throuph this technique, the dm-
apist tea- the person to thmk realistfcally.Realistic thinking leads to
problem solving or to the ability to cope uith situations that cannot be
chanffed.Many RET thefipists ehffluragetheir clients to live bythe fol-
God grant me the serenity to accept the things I cannot
change, the muage to c h q e the W g s I can, and thewis-
dom to h o w the difference
COONltIVE-BEHAVIORAL THERAPY
Today, eognitivebehaviod therapy CCBTI, adapted Emm the
wark of A;aon Be& is a current, sucwsful fmof' psy&other"py,
espeoially in outpatient5-s Eor both indivldual and group th-.
In GET, the dient is cmfhnted with inationaL negafive beliefsand
attitudes that drive faulty, negafive and emotiom. The goal is
to recognize the mnnection between predpitxting even@, tbaugh~,
m d actions. The "I shaWwuld/woulAiought toirnght W if'onkf
thou@ts are reframed into T WP la positive tho@% producing a
pasition astiori).The mdt is an inneased abaty TO adjust and func~
eion eEecridy, whish I=& to m9re m-firfactbn with life
Style of disordeM m g includa eatastraphizing,ovwgene~
abatio~, and a l l o t - n w thinlang.
1 Catastrophizing: exaggerating the importance of negative
aspects and pla.ving donm the jtnportance of positive things.-
?eg& 'thought: I am done in the world
r: Positme thought: I knaw and love many people.
t Ooergmerdzation: maP;ing a gemal nrle fmm one idstance.
- Negative rbo&t:: 1am a &taI B.ot at math
*- Positiw thonght: I'm h aw a W d t time r4gat how-
eve?, I I fmpr- mymsth scorn now fhat I bat% a tutor.
3 All-o~mthhg thmk.ing' things are black or white, good or b9d,
-
ohm is no midTEle ground.
Nqdve thought: I am not perf- I an a rmal W m
Posirhte thought I have imperfections, sa dodoes eoerJrone I
am making an effort to feel good about myself
&lapfed $om Buras, J3.fi98D). Feelingped. Mew %irkSignet.
GESTALT THERAPY
Gest;llt therapy w a developd by Pritz MIS. It t 5 my cornplat
tern based on the theory that the mind conceives Brperiences as a
whole When an cqmime is inmmpl&e, a pmblem may rmIt The
goal of the Gestalt thm@$t.is to help the pemn complete rha experi-
ence and incrwe au\mreness. A wmpleted eqedenee is &d a
Zb the Gestalt themprst homfflsktiiebalanOe between the person
a d ltis or hez imimmentis inrponmt tahealth. Theh d y person
is in b h e e w i d tbe enairarmern and rnathted by an awareness of
needs, ~ ~ u r c eas d, re&-&
i ans. This avwenes8 makes choiw avail-
able and allm the pason to take fflnml of his or her Me.Problem
-- ~ -
~
I I
3
-
-~-
s;, Chapter 6
1
result from a disturbance in homeostasis+Symptoms anse as a result
of the body's attempt to maintain the stam quo.
Fqmknce and awareness are thetwo most important.aspem of
Wtalt ~ P J " Only . the preswt r t m because only tIuc present can
be experienced. C d f s that were inmxnplete in the past mwt be
brought to the present in order to be completed. Each person has the
ability to complete his or her etlperience and relieve the prqblem. The
thempbt acts as a guide in helping-the p m became m m aware ~ helps to inwease awaenms. Through the pleexce, she is
GestaIt therapy is used to treat people in anxiety states and tho*
with somaticand affective disorders. It can alsa he used to enhanceliv-
ing Eor the mentally heal* person. Three common techniques in
Gestalt therapy are exaggeration, f a n t q and ppesentiEin$.
Ezgp&n i5 a technique used to help the persat become
aware of his or her body hguageI verbal language, or frEa6ine;s. For
exampl~the student jvst baught herself anew dress. She spent a great
deal of money onit, but now she does not like it The problem is that
she dues not know why. The qtudent is mld to Iaok at the dress and
tdlthedress she does aotlike it Shemaybe agked ta rep& the wards
several times, meh time saying tbem iwder and more f o d u l $ Soon
will o e m if the student is listening to her feelings instead
of just her wards.
Ettggeratian is &o used when a person is unaware of his or he2
body lang~~+$eIffhe dient wwm his h a d while talking,the therapist
might ask him fo waggerate the movement by waving his atm in an
ever-widening arc. Since fhe movement is cxagpated, awaxenes of
the m o m e n t increases. When a person is aware of behaviorr be or
she can control it
When ;Fan&ng, the &eat is asked to b d g the futufe to &e
here and now. The student wan@to buy a nay car and has tQ choose
hemeen two possib&ies. Oae is a baghfly eolored sporty caf and the
othef is a much less q x p e n s i a e wmpact She conTindy uaciIlates
betareen the two md just m o t make up her mind. Ta help her, the
tbarapist agks the student to fantasize that she has each ofthe w,obe
at a time She is ask& to pretend that she is 8-g in them, dslYing
them and meeting herfrienh, Then she trm on each situation she is
asked to concentrate on how each fek,
Presentkingis a means o f b r h g i i a past went into tbe pment
as &own in the follomg example.
A student come8 to the M p b t bemuse she f& @lty.
She bad been invited to yisit her great aunt but went 8ut
with her Bends. The avnt djnd suddenly and the student:
cannot forgive W The therapist encowages a dialogue
bemen the aunt and the student A n empty chair is plat&
in &wt of the h e E The stadeat pretends -rt.leaunt is
e a t e l inthe chair. She is then asked to converse wfth the
mt The student alternawiakm t M part of her asmi and
hers* dxqing chairs whea appmpriate. $be is enegm-
aged to say w&Ww c m s to her while pkBrng each
part, She is ah0 encouraged to be aware of her fadings
while playing each This d i a l m e is a fmtasy, but it
able to b a m e amre of her fedhgs toward hergreat annt
Ammess is usually sudden as if a 14ght has been fumed
onw& m e a s comas wnW. The student Ls thenable
to rid hm@ofhff gt&"feelin@.
Por Gestalt thempgrto be effective9 tbe perma m m ~think t dw
fn$- presentizinp,hPasiz&g, ar ~ ~ t ihe or o h e~is jusr
, to ape-
rienee &dingis. Peehgs amthe matar Tancern.Forthe person to
riencefdhgss,it is neeessuy to be selfdware.A great d d oftime m y
he qent b y a e thaapist inhdping tb.~hecfteat increase his ox hw selP-
awapqness The therapist map dracy amtionto the &en& pasture o?
tone of voice, 13rether%pWsawnfee&@+ doubts, fadatasld &en*
also be expressed.
D r m are a dfmmttmtion of an ?.xompl& e q m r i m ~U~&,
Freud, the G e s W t daes wt attempt to d e m a n d or malye
dreams The &erapi& helps the &eat expalent% the &am and
increase awmeness. &periencees are taken at fa&vaIue. The Gestalt
therapist feels &at meanings emerge by tbemsdves with time. TIE
&.era@t uses &ed and p w o m &qua. AU te&miqnes are
geared to hdp the person in-e his is her self-a-m, qai-
enee *s, am3 complere previouS2gii~~mglete experiences.
REALITY THERAPY
WlEiam Glaasef8 waby thesapyfs one of the newresf psychotherapies.
Itsp q s e is to M p people gee themselves aamatel. 6ce re&$, and
I fhEU their q ~ ~eeds.
n Glasser beliweg that each pawn fias a mpm-
II sibility for his mher owm k W r . A pason's prmmt behaoior mmot
be blamed oar what wcumd in t k p m RediQtherapy has been used
Wensiveipin the rehabilitatfon o f j u v a e delinquents and with W-
who h&ie&led in ~ a o iIt. has &o succmfdy berrn used tu
@duncethe lives ofpegpie during m&d eonnicts, &es, and in treat-
ment for chemical d q e n h Reality therap has been sukwWp
applied by parents, teachers, and nder Ia~tpeopLe
The xed+@ dmm@t must be a warm, conceined person who js
real and genuim %%en sppmpriate,thmapIstsdismss their anm ape
13enm,achnitpezmd faults, an$ are w iQ n& W m
&&%ewS M-
lm@dMost impwtmtl$ the th!m@t truly $y~mthe 32ent
The reakfy therapst is soneemed a b m b e W r , r&w tb*ur
feeIings ar tb.&ghts, G ~ M belie=
Z thatpeople h&e Emkd 1-
~wtErej,fe&@adthaZon&beba~canbechaqkd.Ifrhepon
~ p h i m of @t kelings, the thefapi6tmjgbt ask the peruj@nis
doing to ma?& himself or herself fed &?"; This &w%@ ehe cum-
p M t b m a feeling ra a behauio~It also f6euses zesponsibj%@&r the
guilton the p m . CMgthe present i s impmE4nI;~epast is $one and
m e . t be changed. Ethe past & d&emsed at allr it is to &cover the
p.s@onlssmm$u. The strm$ths 81% zhen dated m mmmt behavior.
Each p m m has a respomiblitg to e Y a I W his or her awn
beh&r, This ~aalmttwnis essential bewnse behavior m n ~ mbe
changed unlessthepersonis comrmeed4batthebebaaimi-~harrnfvlto
hiin or bee The &&pist m y e x p ~ e 8 sp m a l vdae.9 bat daw not
attanpi to f m p gt3m.1on tbe hew pemon
behavier is eduated and a d&im sS nliiae to change a
sp&c behavlm?a pLBn is daielopd Eor chn@% that behaylor. Mu&
ofthe therapist's time Ss spent in helping ?heperson make p h For ~ desired results far
W change.Tfie next step is k r Ore client to eomaithims&ar herself
to eaqylng out tEIE plBn EsSentid to d t y t h q p the cofmnim%ent
may be verbal or in the form ofa &%ea c~ntiati.It is u s e ma&
to sweane @her than the dfent Glassm b&eoes m1$ fdil
. bec~me
theycmn&makeca gp&mxits to themelm,
Tf a plan &hno excuse is accept& S a m d m a the p m n is
asked whether be er ,she ininrendad to Tu16I1 f.hcommitment
gometimes &atmay be wked &en he or she intends t@do w b t
wa px0mif.d At other rimes,the&nmaprtlqui*.e m 5 o n Abmluttely
~is~ptable,memadismt~Thisis&em~importtant
to d t y therapy. An An talcst ~srespansfbiliqfrorcl the pet%&arrd
etnpha&zes failure thaapy duag at prwiding suaf%
Verbal arphysioslptmishenf is never med by th&i-tdky t h e -
pi& I;lasser aq1oysr w& he terms the ~~ E O of
ma&. Por exampIe, a a d my ammi$himSe!for hw& to pmottQ
the d m every day in exhn@ f o r p I @ ~ x Ifttu:
a child f& tQ pxac-
ticec he or she does not get ta play Thi6 is the B B WmquenCe
~ W dddrsn me hvdved with rihmb and coafxmitr:
b m m e it w;ls mntually agreed on b&m the act Wty therapists
belie vet hi^ rmp&mis the ssame as mmtiil hdfh. Ifpeople aet in
a responsible way, they atlain @& happiness, a d sueass.
fRANGACtIONAL ANALYSIS
'Itansactional ilnalysis was dnzlloped by Fkc Rcrne in the 1950s. 'me
atm of tzansactional analysis is to help people impme their 1h.e.s.It has
m e mmm!yb&&ypeopk .a& as &o$e &
& eep ~ w i e s , w-
+&~ld
~i4~m+m&&&edim&&&,~~&
a@.;wi~ p w i l p ~11-d gr~qs~
&me beii- that each persen a m && ta .a &pt or
qtnjtesuipt mnntfmaipt t h e s f k n parental S a m w . The
sCr& is-Weniby the individual at .avefy esu1~tage and is bas4 5n a
deisiop. fhe hedbidgd makw &om self and othem. AemnIime; to
tran$8crlanal analJsis, a &soA mice 'me of four d e o a :
a y$n O.K., yotrtre Q.KU
T m O.K, yodre not OKP,
I "I'm no€OE, pu'm O.K*
H Trn not QX, yunOU'le not 0.E
The aachlal ricLipt i~ patlelped r5n the We of a s i ~ c aother.
t ~ At
flm, it is an outhe, hut @add& it is m&ed md detailed.
Even~aL1-p; itlmwmes the s d p t that M u e n w t hpawn's life.
A pason ensum the oatsome ofhis or her script tbroup;h garnc
pky*. A game is a sedw t ~ifn w o n a l r e l a ' t i a w & I&& to
game player A script based on "I'm nat. O,Kr
m r r ~ ciall for fhe h e d u r i l to get hurt V pmple do not a~tamatiCany
hurt him or her, the person engages in behmim &at will Eerm fhm
to do 80. This behaviar is wharkme c;rlls g p r pla)riw~ T h e errdremlt
&a game is the cement ofthe person'$ %sling about self:
Tkmwtiod analysis recogaizes three ega statepi:the pawat the
child, and the adult These three ego stares &st simdtaneously in aR
people; M e a on& one is dombmt at a time.Behmlas beloqg&g
to the tbw ego states rn learned by chWm $-om th& a'@~Bcult
othelis. Pam& contain all the rules and adnxooiti~wchildren have
h e ~ dthe i look# o f h and the dmppf~vdseen on the mother's %a,
t-he Ieflder hug8 and the severe pw&n@ fhe &Id has received
P,nIscanbeeithernuzturbg~rcritimL
w drenhold alltkefeekngs and map be mt~ml or adaptive,joy
~ sad,~ or miscbievo~s. ~ Izaattd children behave by ku@&g, smik~@
P- w.
d %are fmpd* aild sporrtaneous. They fee1
i% a.
s a m w guilC and Natural dbildra are ~reatme,Whaeasadap
The adult processes and andpea arimut'i Itis the adult wko asks
cluestion?, mans, plans, and make$ dedsiolls (Table 6-31.
Feople mlip~ndi n my iraeraction through one of these ego
States. A husband coma home from work and asks in his %ddY
* m e nwiU dinner be ready? Ilis wife may respond by saying "Is k t
~yauthInkIhavetodo?I ' o u m n I d d o s o m e ~ s ~ m d h e r e ~
help. Then mybe yon muld have your dinner on tfmpt" Ehe would
be responaing in her"&Hcal p m t e Had she %lie& CIt uriU be rmdy
 EIlo state Eao state
Of
Of
husband

"Wllen wit
dinnep Be
ready?"
*
4

"In one hour"

flCURe 6-1 A slmple uncrossed tran9action. Three ego states

exist in all People simultaneously. Peaple respond in any interac
tion through one of these ego states. If the resDonss 1s In the
same ego state as addressed, a simple uncrossed transaction
occurs and communscation conffnues.

in a few minutps. You fust sit dowa thee and put your feet up. Gee
honey,you look SO tired," she would be responding in her " u d n g
parentn Her 'child e g mmight have s&d " k f sgo out and eat to-hp
- that
nr 4* -- vou fc:am mey Ha "adulf would have simply said
'Dinnet d ire reah in a half hour."
Jn any tl:a.nsaction one m o t predict the ego state in whi&
another p e r s o n d respand. Iftheresponse is in the same ego state a6
 „ go state sgm state
Of
-
1
1- IWE bf tpe ppwm tips p r ~ b l k ~ a be h m e t to
can
of the ebmtioua migm Wile@, it w be d d t w%&The id, w, and
husband wife
sup&zB;o balance eaCh oibw to check behavior. P~yehoanalyskis a

E l-
aery lang p m w , some- taKing-y yeare.
CIientcenteed thff~apyis based on the belief that peoplenat-
Parent
m a y gww t u w d seEa~twht%on under the rigla canditiuns. It is
"when wUl Tranbfemd the p p s e afthe h a @ to praide these conditfons. The @ax-
dinner be to parent pist provides an accqTtng, nonnjagmmtal environment aimed at
ready?" for reducftlg the client% m$iety and clefemsea that block ?his driwe.
response
Client9 are m u r a g e d to ~ r e z their
s f-ge and i n m their
self-awamaesa When people are amre of howthey feel an6 what
"IF you W O U I ~hem . ... makes them feel fiat way, they can wowork on improxdng behaxioe
me, you might Empathy, positive regard and g a u h m w are dhmctedstirs that
have dinner the client-oriented therapist mwt show the client
on the." kh;wjorism is a school of therap that believes actioIbg m
ChiId
caused by past even- Behadom mnthue only if they are aceampa-
nied by a ward m e n a learned response becomes a m &
people am M d to be canditioned to tlre response- ThaapWme ptlr
FII;URE &2 Crossed transaction. The husband asks a question in m y teachem of new behaviom m u s e a d y of te&nique
his adult ego state, but tne wlfe responds in her ctltEal parent. t~eliminate rewards for und&ble Behavior or in- m i l s
The critical parent directs her statement to the child; thus, the Ew d&able behavior.
transaction is crossed. CrQsseatransactions are often destructive. Ra?iorlal emotive therapy is related to b&vimism Its fmder,
&rt Ellis, w u wvinced tbat a person's behwkr is due to his or
Others, though, feel that the vanous schools ofp~ychologyhave her her tbhkmg. Prabierns are not caused by evenfa .that happen
samethig to offer, but none has the entire an?.= Thwe therapbts but are a result of wha B e p a o n b e b s about the eyents.
Therapy is aimed at h @ p g the pwon's belief s g a k and t e d -
are known as eclectics. They pick and c h o w techniwes from any
~~epersonthatheorshehas'theab~toc~pe~anye~enf
school that seem to fit the siD1ation They might d y z e relationships
with one client and use fantasy with ano€her. They may confront one CogniGive-behawid therapy is a+ted ftom the work of
AaronBeck It is a cum&zt and successful form of therapy in ouLpa-
client and use the word assouation with another. Mmy times these
b t Bettings. a i m ate wnf5onted with hatio~lgLnegative beli&
therapists have two or threefavorire therapies that they usemost oftw
but they use none exclusive&. end a W e 8 and learn how their belie% influence thefr thongbts,
iWin@,d a c t b m .
Gestalt theram is hued onrhe theory Bat the mind conceives
SUMMARY -
---
--: ---- e?rperiences a whole. When an experience is hwmplete, a pmb-
Iem may mirlt Tl?e gml of the Gestalt tke~tpististo help tke client
Psychotherapy is a method of trea?ingmental illness in which ver- m p l e t e the expaknce though awareness. ExpMendng and
bal ana expressive techniques are used W help the person resolve awweness am the two =st irtlpmant aspem of k a p y . ma
inner c&cts and m o d e behavior. Mmy techniques are used, wmes9,the person canchange his or her a o ~ behavim n The t h e
including psychodysis, client-centered therapy, behavio&m, apkt ~pendsmuch tjme help* people hacome more anrafe.
rational emotive therapy, Gat& thepapy, and transactid mdpis. ReaEQ Therapy ahas to wsiat people €0 see themseha accu-
Psyhoanaly~isis based on the work of Siptmd Freud The rately, ro fam reaIi@, and to bXlll peFsanal nee&. Individuals are
thempist obtains hformation about past and present eacpefa~es mpomible far t b k own behior; present behavior cannot be
that have been repressed in the client's subcomkious mind By b k e d on past events. The r e w aerapbt is concerned wiih
 3. A Gestalt therapist assists s client in acting out a manary af
b&+r, r&@ ;@Q fw*. :@tpare @ % a g e d @@uate _> a tra-atic childhood experience vvfth m abusive family
&& bkvi~r o m f13@&g?q inahtdap!@eb-@cr: The
wrq&t helps @ &&e,pI@m for fhat &~&t$r @@a* member. Which technique'is tbe rhmpist using?
tl A. fantasizing
p*; h&epp. &;lt rwm$$ig &, M e :@mend&ealrh, tl B. presentizing
pmP&d
-&+-&&.*
wusipn,
i s g . 9th~~py~@@hud

o,X,,ym9te-QXK
~ ~
agd ;@,id@ maitg *:
Ifhelps pe~-
D G resistance
Ll D. awareness
& &tapBt wegg&Biqgea from mme than one B. Erwd d&ed the O&pm avnplea aswhich of the foUmving?
sch00I &pq&oiO@ O A. an abnormal hahador in developing gii-IB
a&& ~ d e@&trpn&$ &Q%@8to o 3. a f e e k g of inferior+tyassociatedwith familg.relation-
a a t & ~e w&
@f&e &.en@ may .red&@ The
a
me ,- cwnmonlly nsed d . & e g& Qf Q C. a strong; f w of doseness a child has for the p w n t
the rherapies mimes migilt rn.WUDlW. of the appasitesa
-..,
.., .
8- =J * L.x,;~I . Q D. a smng feeling of doseness a child has for the p p n t
of the same sex
5.The term Ebidu refers to which afthe following?
SUGGESTED ACTIVlTlES
-
Q A. canseience
m Wth a small groupr make and play word b i o . M e several
o B. setf-conoept
Q C. available sexual enexgy
bingo car& with d W m 0fpyehuthmpji terms, A d e r
0 D. m d t i o reapme
~
caIks Qttt the thnns. Ea& player alea to &d the ddW%onon
h& or hm d T h firstplayer to mer the definitions m e t - ?-rt
6. Which phrase c m C t l y defhe8
&*, O A moving wwmcious thmgha to the consworn level
hhkv a 4 fk fm the yadoug p6ychOthmapie8. Lrstthe p w Q B. anributing b c f M e S of a sigmEcant other to the
choth.ewpy, its intended goal,andthe techntgaes used to
P C. substituting one behavior for m d e r
aamnpbh this gad 0 D. verb- fPelin$s af@ and anxiety
9 Whkh situation accurately identifies incongruencs? Clients:
REVIEW Q k see themselves as different &amwhat theg m
earperienefng.
KNOW rn C O ~ m m 0 B,play m a n i p W Y e gslnes to aadsfy internd drives.
k Maltiple choice, Select the one b& answer. 12C. respond t6 a message in a cbild-Wnemarmer.
CI D. change their behavior inresponse to a repeated
1. C o n d i W r@m f~ a term aswciated with whi& ofthe
m n h g psycho€herapiie9? stimuIus.
o k b&Wwm 3. Which therapist W d use dwensitimtion and r~laxation
o B. Getitdt *ob@ te~hniques?
0 C,~ Z c e n ~ D A behavioriet
D. reality t h e r m Q B. client-entered therapist
a. According to Preud whit& ofthe f o U o W controls and P c. psy&oan*t
guides the actions afa p w a d 0 D, reality therapist
P tl ego Q C, libido
Q B.id 0 D. superego
 niques? mend gsychothwpy sessIcms trs help me with my problemsj
D A, dient-ceatered therapist a. .. but I'm n a going. I've s m examplea of paychoan&ysfsin
e e s md th&s nat fos me? Whtch response by the nurse
P B. Gestalt therapist .Im t .
0 C. transactional analyst I . would be most apEnapPiate?
C;I k Tsychoanalysis would be y a y efferpive for pour prob-
U D.behado&
lems You should follaw your doctor's r e m d -
10. Accarding to Freud's Stag'& of libido developx~ntwhich tion"
stage develops fist? !2 a 'T9ychoanalysis is j ~ m one
t type ofpayeho&erap~
U k anal "Iclyour therapist can dedlde WMch approach i s bem for
a B. phallic yau?
0 C superego U C. %a have the right to d&de w h a e r or not to follow
O D. osal your doctor'sr e c c n n m d a t i ~ ~ . "
R D. '"It does% 5 m d &e yanr doam is o~eringhelpful rec-
mmendatim. Terhap9 you s h d d w e docto&
APPLY YOUR LEARNING
4. Thg nurse assists a client daring an acts and cr& group. The
B.Multiple cboie Seled the one best answer. client sagis, Tm jlSst no gomi at fhis stuff I don" t o w why I
1.The nurse is assigned to care for a nwly admitted adult cEw keep coming to rh- $roupkV The clients plan of m e also
on the ps'ychiatric unit The n&s physical features and indudes c o ~ ~ h e h a v i o rth
aal w swsions Wee il week
mane@rns are similar to those ofthe client's motha, who Fhi& wsnment by the n m e would be qprckre of the
was physically abusive during the client's childhood. Which planofwe7
factor below is most likely t~ affect the nurse-client relation- O A /? notieed yoa srayed for the entire arb anti crafts group
ship? and were encoxmgbg to
O A. transferenw D B. "What typm of activities d d appeal to you more tban
O B. disphcement a m and cr&T
CJ C, game playing O C. Tou &odd uy hanler to &b the a& projects you
a D. ca6amis start You give up too
2. A client diagnosed with an anxiev disorder is involved* U D. "GOeasiex on pornelf: Aas and 6is just a 6imple
Gestalt psychotherapy. 73% client attends sessions twi- wm- aeiiw
week with the psychotherapist In w W of the following 5. A &entin a psy.chiatric unit who i s also a suctressful inmt-
ways would the practical nurse most appropmte1y suppm ment dm%, sap te the nurse Y'm nmr going ro bemmt: a
the pyehatherapy? partner at my wmpans I jm can't predict ibanda].trends
Q A. Have the client describe the dis&on from each a=- Eke other &ys@.I The hoqital uses problem-ariated
sion with the psychotherapist progress notes, Beside which ofthc fdnowing problem state-
D B. Use exaggeration, fantrtsiz'i and presentiang tech- ments would the n m e doeament the &e&s d m n m n t ?
niques in the nurse-client interactions. Ci A, defmkve coping
01 C. Ask the client to deswibe dreams and hdp the client a B. impaired adjmtment
interpret the dreams' meanings.
u D. Assist the client to attend the psydmthempy sessions
U c. altered role petfonnance
R D. self-esteemdistwban-ce
regularly and to be on time.
 3. Name three essenW awbutes of the dient-ed therapist,

1. Bsinging exp&*ncas repreraed is a. Behaxiorism

de~ a c w d o m to the mnscious C&ntcentered 4. How does selfawarema help a person to solve a meatal
level therapy problem?
2. Baviding an acrepting, c @ s M t therapy
nonjudgmmtd enxdronmmt kfmed
at redwing the &&'P met$
and def- tha*block self-
acmaI&aerntendencies 3. rk-xribe the PcTicalivocatianal nurses role keg*
3. Kmoving or inmming a reward P.%cMtberapy.
to cbxilge mnditioned r a p e s
4. frrarional beliefs are refrmed
into a post& thaught producing
a p o w e action
5. Therapy M on the b M ~ a t
p r o B b s are c a i e d by what a
person belie- about an event
and not the event itself
6. Iiclping the dient to complete
an incomplete experience
7. Helping the &nf m see himself
or herself acwa€dpItD face reali$,
andtomatGepbt0-e
maladaptive bdavior
5. &@up therapy inwbich CHents
m Mped to a d p their
mnsamons with others

D, Brief* mwt~ the finowins

I- Define psychotherapy

2, State the function ofthe id, ego, aad superego,Indicate the

l e d of Cansdousne8s at wHch each opera*.
 Phurmcologcal bter/entions induded for chapters on Humq s and
Geriaaic MentalZIealth @

us in each chaptn encourage analysis and developmtnt

I
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