Chapter 7: Models for Working

with Psychiatric Patients

1 RECOVERY 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:
o Person-drive
o Occurs via many pathways
o Holistic
o Supported by peers
o Supported through relationships
o Culturally based and influenced
o Supported by addressing trauma
o Strength-based
o Based on respect
o 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 services

2 PSYCHOANALYTICAL MODEL

Sigmund Freud: unconscious process of psychodynamic factors is the basis

for motivation and behavior
o Self-psychology: every human being longs to be appreciated
o 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 person

2.1 CONSCIOUSNESS

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 change

2.2 DEFENSE 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

2.3 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 behaviors

3 DEVELOPMENTAL 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-acceptance

3.1 RELEVANCE

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
patient

4 INTERPERSONAL 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
o Addresses stressful social and interpersonal dynamics associated with
depressive symptoms
o Goal: improve social functioning by examining interpersonal disputes,
role transitions, grief, and interpersonal deficits

4.1 NURSES 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 months

5 COGNITIVE 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
o Challenges the automatic thoughts to help patients develop logical
thoughts and feelings
o 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
o Decreases parasuicidal behavior of self-mutilation and suicidal
attempts

5.1 NURSES 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