PSYCHOLOGICAL THEORIES

Mental Illness
• Historically viewed as possession by demons, punishment for religious or social
transgressions, weakness of will or spirit, and violation of social norms
• Today seen as a medical problem, although some stigma from previous beliefs remains
• Mental disorder is “a clinically significant behavioral or psychological syndrome or
pattern that occurs in an individual and that is associated with distress or disability or
with a significantly increased risk of suffering death, pain, disability, or an important loss
of freedom” (American Psychological Association [APA])
Diagnosis of Mental Illness
-Use of the Diagnostic and Statistical Manual of Mental Illness (DSM-IV)
-Provides diagnostic criteria for each mental disorder and a system of 5 axes to give a
comprehensive view of the client’s mental illness.
 Axis I: The clinical disorder that is the focus of treatment
 Axis II: Personality disorders and mental retardation
 Axis III: Medical conditions
 Axis IV: Psychosocial and environmental problems
 Axis V: Global assessment of functioning (GAF)
STRESS
 A nonspecific response of the body to any demand made upon it. (Hans Selye, 1936)
 A state produced by a change in the environment that is perceived as challenging, threatening
or damaging to the person’s dynamic equilibrium. (Smeltzer, 1992)
Adaptation
 A constant ongoing process that occurs along time continuum, beginning with birth and
ending with death. (Smeltzer, 1992)
 A continuous process of seeking harmony in an environment

THEORIES OF HUMAN DYNAMICS

 FREUD’S PSYCHOANALYSIS
 Personality
 Id
 Ego
 Superego
 Psychosexual Stages of Development
 Oral (0-18 mos)
 Anal (18mos.-3yrs)
 Phallic (3-6yrs.)
 Latency (6-12yrs)
 Genital (12-
 Defense Mechanisms

Defense Mechanisms- techniques used by the ego to keep threatening and unacceptable material out of
consciousness therefore reducing anxiety. Defense mechanisms are workings of the unconscious mind.

A number of phenomena are used to aid in the maintenance of repression. These are termed Ego Defense
Mechanisms (the terms “Mental Mechanisms” and “Defense Mechanisms” are essentially synonymous with this).
The primary functions of these mechanisms are:
1. to minimize anxiety
 2. to protect the ego
3. to maintain repression

Mechanism Definition Example

Compensation Covering up of weaknesses by A boy who cannot participate in sports studies hard and gets good
placing emphasis on a more grades.
comfortable area
A physically unattractive adolescent becomes an expert dancer.

A youth with residual muscle damage from poliomyelitis becomes

an athlete.
Conversion Unconscious expression of A student develops headache before taking a exam.
intrapsychic conflicts symbolically
through physical symptoms. A man's arm becomes paralyzed after impulses to strike another.

Denial Unconscious to admit an A man who has had a heart attack refuses to acknowledge illness and
unacceptable behavior or idea to follow prescribed therapy.

a person having an extramarital affair gives no thought to the

possibility of pregnancy.

persons living near a volcano disregard the dangers involved.

a disabled person plans to return to former activities without

planning a realistic program of rehabilitation.

Displacement Discharging pent-up feelings to a
less threatening object.
Dissociation Unconscious separation of painful
feelings from an unacceptable idea,
situation, or object.
A man who is angry at his boss comes home and yells at his wife.
A rape victim tells that she felt as if she were outside of her body
watching what was happening.

Some dissociation is helpful in

keeping one portion of one's life
from interfering with another (e.g.,
not bringing problems home from
the office). However, dissociation is
responsible for some symptoms of
mental illness; it occurs in "hysteria"
(certain somatoform and dissociative
disorders) and schizophrenia, The
dissociation of hysteria involves a
large segment of the consciousness
while that in schizophrenia is of
numerous small portions. The
apparent splitting of affect from
content often noted in schizophrenia
is usually spoken of as dissociation
of affect, though isolation might be a
better term.

Fantasy Gratifying frustrated desires by A man who fails to get a part in the play, imagines himself chosen
imaginary achievements. for the lead role.
Identification Imitating the behavior of someone A teenager dresses like that of her idolized movie star.
feared or respected.

Intellectualization Using only logical explanations A wife tells her husband that a dented car is better than a wrecked
without feeling or an affective car.
component.

The individual deals with emotional

conflict or internal or external
stressors by the excessive use of
abstract thinking or the making of
generalizations to control or
minimize disturbing feelings. 

Introjection Unconsciously incorporating other A young girl scolds her brother just like her mother would.
people’s norms and values as if they
were your own.

Projection Blaming someone else for one’s A husband forgets to pay the bill and blames his wife for not
difficulties. reminding him.

Rationalization Justification of behavior though A student fails an exam and says that the teacher did not clarify the
faulty logic. material sufficiently.

Reaction formation Acting oppositely to what the person A woman who dislikes her sister sends her gifts every holiday.
truly feels.

Regression Return to an earlier, more A 6 year old begins to wet his pants following the birth of his baby
comfortable level of functioning. sister.

Repression Involuntary and unconscious A accident victim becomes amnesic about the details of the accident,
forgetting of painful ideas, feelings but was aware at that time.
and events.

Restitution Attempting to restore unconscious A nurse who regrets not caring for her mother when she was dying
guilt feelings. because of anger chooses to work with terminal patients.

Sublimation Channeling instinctual drives into A man with excessive sexual drives becomes a successful nude
acceptable activities. painter.

Substitution Replacement of unacceptable objects A woman who wants to marry a man exactly like her dead father
or need with one that is more marries someone who looks a little bit like him.
acceptable.
Suppression Conscious exclusion of anxiety A woman says she is not ready to talk about her condition.
producing feelings or ideas from
awareness.

Symbolization An external object is made to A young woman gives flowers and chocolates to his girlfriend.
symbolize an internal feeling or idea.

Undoing Doing something to counteract or A mother spanks her child and brings home a gift for him the next
relieve guilt feelings. day.
THERAPEUTIC COMMUNICATION

Technique Definition Example

Using Silence Gives person time to think and say
more.

Accepting Receiving information in a non- Yes.

judgmental manner. Does not
necessarily indicate agreement.
Giving recognition Shows awareness of change or
efforts. Does not imply right or
wrong.
Offering self Making self available and showing
interest, concern and desire to
understand.
Uh hmm
I follow what you say
I’m with you
Good morning, Mr. Santos
I noticed you shaved this morning.
You’ve combed your hair
I’ll sit with you for a while.
I would like to spend some time with you.

Giving broad openings Clarifies that the lead is to be taken
by the client
Offering general leads Using neutral expressions to
encourage the client to continue
talking.
Placing the events in time Asking for relationships among
or sequence events.
Making observations Commenting on what is seen or
heard to encourage discussion of
feelings and thoughts. Helpful with
withdrawn patients.
Where would you like to begin?
What are you thinking about?
What would you like to discuss?
Go on.
And then.
Tell me about it.
What lead up to…?
What happened before?
When did this happen?
You seem restless.
I noticed you’re biting of lips.
You appear tense when you…

Encouraging descriptions Asking for client’s views of their What is happening to you right now?
of perceptions situation. What does the voice seem to be saying?

Voicing doubt Expressing uncertainty about the That doesn’t sound like it.
reality of client’s perceptions and Isn’t that unusual?
conclusions, used when the nurse
wants to explore other
explanations.

Presenting reality Offering a view of what is real and I know the voices are real to you, but I don’t
not, without arguing with the hear them.
client. You are not in heaven, you are in the hospital.

Encouraging comparison Asking for similarities and Has this ever happened to you before?
differences among feelings, Is this the way u felt when..?
behavior and events.

Restating Repeating the main idea expressed Pt: I can’t sleep. I stay awake all night.
Nurse: You have difficulty sleeping?

Reflecting Directing feelings and ideas back Patient: do you think I should?
to the client. Nurse: Do you think you should?
Patient: My brother spends all the money and
still has the nerve to ask for more

Focusing Concentrating on a topic until its
meaning is clear.
Exploring Looking at certain ideas more
fully. However, if the patient
chooses not to elaborate, the nurse
should not pry.
Giving information Providing information that will
help clients make better choices.
Seeking clarification Clarifying vague communications,
help clients clarify own thoughts.
Verbalizing the implied Rephrasing or putting into concrete
terms what the client implies to
highlight an underlying message.
NON-THERAPEUTIC COMMUNICATION TECHNIQUES
Technique Definition
Reassuring Closes off the communication by
giving information that is not
based on facts and truth.
Giving approval Encourages the client to continue
doing something for the sake of the
nurse’s approval rather than for
own learning.
Rejection This is a communication barrier
since the patient may avoid
expressing his or her own thoughts
/ feelings to avoid the risk of
rejection.
Disapproving Denies the client’s thoughts and
feelings by implying that the nurse
has the right to judge the client and
the client has to please the nurse.
Agreeing Provides no opportunity for the
patient to change their views.
Disagreeing Challenging the patient to defend
his/her thoughts and feelings
which serves as a hindrance in the
communication process.
Advising Fosters dependency and inhibits
the problem-solving process.
Nurse: This makes you angry?
Explain more about…
This point seems worth looking at more closely.
Tell me more about…
Can you describe it more fully?
I am…
My purpose on being here is…
This medication is for…
The rules and regulations of this ward are…
What do you mean by…?
What is the main point of what you just said?
I’m not sure I follow you.
Patient: There is nothing to do at home.
Nurse: It sounds you might be bored at home.
Patient: I can’t talk to you or to anyone. It’s only
a waste of time.
Nurse: Do you feel no one understands?
Example
Don’t worry.
You’ll feel better tomorrow.
Everything will be alright.
That is good.
Talk to the doctor about this.
That is not good.
I’d rather you wouldn’t.
That’s right.
I agree.
I disagree with that.
I think you should…
Probing Communication barriers that may Tell me about…
make the patient feel needed and Let’s talk about your family and relatives.
valued only for the information
they can give.

Testing Implies that the nurse feels that the Do you know what this drug is for?
patient needs help.

Defending Gives the impression that the client Dr. Santos is a very good doctor.
has no right to express own The hospital staff is very competent to take care
opinions and feelings. of you.

Requesting an explanation “Why” questions require analysis Why did you?

of the problem which increases
anxiety. Patient may respond
defensively.

Minimizing feelings This technique fails to explore the Patient: I wish I were dead.
feelings of the patient. Nurse: Everyone gets down once in a while.

Making stereotypical Blocks off the communication It’s for your own good.
comments process since the patient is
encouraged to have empty
responses.

Changing the subject
Fails to address the message of the Let’s discuss that later.
patient. The nurse maybe Let’s leave that and talk about…
threatened by an anxiety provoking
topic thus the perceived need to
change the subject.

Using denial Closes off the communication by Patient: I’m nothing

failing to identify the feelings and Nurse: Of course you’re something, everybody’s
thoughts of the patient. something.

 ERICKSON’S PSYCHOSOCIALTHEORY

Age Stage Activity Strength/ Factor SO

0-1 y/o Trust vs. mistrust infant takes in food Realistic hope (feeding) Mother
2-3y/o Autonomy vs. shame sense of control over Conflict (toilet training)
and doubt interpersonal
relationships and self-
control
4-5 y/o Initiative vs. guilt ability to move freely, Purpose (independence)
acquiring language skills,
curiosity, imagination
and ambition or setting
goals.
6-12 y/o Industry vs. child strives hard to read Competence (school)
inferiority and write, pursue his
hobbies and be the best
among the rest.
13-18 y/o Identity vs. role They try-out new roles Fidelity (peers)
confusion and beliefs during their
search of a sense of ego
identity
19-25y/o Intimacy vs. ability and willingness to Love
isolation share a mutual trust
26-40 y/o Generativity vs. procreation of children, Care (parents)
stagnation production of work and
creation of new ideas that
impacts a great number
of people
41-above Ego-integrity vs. intimate relationships Wisdom (reflection)
y/o despair established and caring for
others. They feel whole
and coherent

ADULT MANIFESTATIONS OF ERICKSON’S STAGES OF DEVELOPMENT

Life stage Adult behaviors reflecting mastery
Trust vs. mistrust  Realistic trust of self and others
(0-18 mos.)  Confidence in others
 Optimism and hope
 Shares openly with others
 Relates to others effectively
Autonomy vs.  Self control and willpower
Shame and doubt  Realistic self concept and self-
(18 mos.- 3 yrs.) esteem
 Pride and a sense of goodwill
 Simple cooperativeness
 Generosity tempered by withholding
 Delayed gratification when
necessary
Initiative vs. Guilt  An adequate conscience
(3-5 yrs)  Initiative balance with restraint
 Appropriate social behaviors
 Curiosity and exploration
 Healthy competitiveness
 Sense of direction
 Original and purposeful activities
Adult behaviors reflecting developmental problems
 Suspiciousness/testing others
 Fear of criticism and affection
 Dissatisfaction and hostility
 Projection of blame and feelings
 Withdrawal from others
Or
 Overly trusting of others
 Naïve and gullible
 Shares too quickly and easily
 Self doubt/self conscious
 Dependence on others for approval
 Feeling of being exposed/ attacked
 Sense of being out of control of the self and one’s life
 Obsessive compulsive behaviors
Or
 Excessive independence or defiance, grandiosity
 Denial of problems
 Unwillingness to ask for help
 Impulsiveness
 Recklessness regarding safety for self and others
 Excessive guilt/embarrassment
 Passivity and apathy
 Avoidance of activities/pleasures
 Rumination and self pity
 Assuming a role as victim/self-punishment
 Reluctance to show emotions
 Underachievement of potentials
Or
 Lack of follow-up on plans
 Little sense of guilt for actions
 Excessive expressions of emotion
 Labile emotions
 Excessive competitiveness/showing off
Industry vs.  Sense of competence  Feeling of unworthiness and inadequacy
inferiority (6-12  Completion of projects  Poor work history (quitting, being fired, lack of
yrs.)  Pleasure in efforts and effectiveness promotions, absenteeism, lack of productivity)
 Ability to cooperate and  Inadequate problem solving skills
compromise  Manipulation of others/ violation of others’ rights
 Identification with admired others  Lack of friends of the same sex
 Joy of involvement in the world and Or
with others  Overly high achieving/ perfectionists
 Balance of work and play  Reluctance to try new things for fear of failing
 Feeling unable to gain love of affection unless totally
successful
 Being a workaholic
Identity vs. role  Confident of self  Feelings of confusion, indecision and alienation
confusion (12-18  Emotionally stable  Vacillation between dependence or independence
yrs)  Commitment to career planning and  Superficial, short-term relationships with another person
realistic long-term goals Or
 Sense of having a place in society  Dramatic overconfidence
 Establishing an intimate relationship  Acting out behaviors (including alcohol and drug abuse)
 Fidelity to friends  Flamboyant display of sex role behaviors
 Development of personal values
 Testing out adults
Intimacy vs.  Ability to give and receive love  Persistent aloneness/isolation
isolation (18-25 or  Commitment and mutuality with  Emotional distance in all relationships
30 years) others  Prejudices against others
 Collaboration in work and affiliation  Lack of established vocation; many career changes
 Sacrificing for others  Seeking of intimacy through casual sexual encounters
 Responsible sexual behaviors Or
 Possessiveness and jealousy
 Dependency on parents and/or partner
 Abusiveness towards loved ones
 Inability to try new things socially or vocationally
(staying in routine/ mundane job/activities
Generativity vs.  Productive, constructive, creative  Self-centeredness/ self-indulgence
stagnation (30-65 activity  Exaggerated concern for appearance and possessions
years)  Personal and professional growth  Lack of interest in the welfare of others
 Parental and societal responsibilities  Lack of civic or professional activities/responsibilities
 Loss of interest in marriage and/or extramarital affairs
Or
 Too many professional or community activities to the
detriment of the family or self
Integrity vs. despair  Feelings of self-acceptance
(65 yrs. to death)  Sense of dignity, worth, and
importance
 Adaptation to life according to
limitations
 Valuing one’s life
 Sharing of wisdom
 Exploration of philosophy of life
and death
 Sense of helplessness, hopelessness, worthlessness,
uselessness, and/or meaninglessness
 Withdrawal and loneliness
 Regression
 Focusing on past mistakes, failures and dissatisfactions
 Feeling too old to start over
 Suicidal ideas or apathy
 Inability to occupy self with satisfying activities (hobbies,
volunteer work, social events)
Or
 Inability to reduce activities
 Overtaxing strength and abilities
 Feeling indispensable
 Denial of death as inevitable

 PIAGET’S COGNITIVE DEVELOPMENTAL THEORY

 Sensorimotor Stage (0-2) senses
 Preoperational thought stage (2-7)
 Preconceptual-learning to think in mental images (2-4)
 Intuitive- egocentrism (4-7)
 Concrete operational stage (8-12) - more logical and has concepts of morality, numbers and spatial relationships
 Formal operational (12- ) - adult logic and reason

RULES FOR PSYCHOTHERAPEUTIC MANAGEMENT

 Provide support, treat patients with respect and dignity

 Uplift patient’s self-esteem, don’t patronize
 Do not place patients in situations wherein they will feel inadequate or embarrassed
 Treat patients as individuals
 Provide reality testing
 Handle hostility therapeutically
 Provide psychopharmacologic treatment

BASIC PRINCIPLES IN DEVELOPING THERAPEUTIC NURSE-PATIENT RELATIONSHIP

 Do not reinforce or argue a patients hallucinations or delusions

 Orient patient to time, person and place
 Do not touch patients without warning them
 Avoid whispering or laughing when patients are unable to hear all of the conversations
 Reinforce positive behaviors
 Avoid competitive activities with some patients
 Do not embarrass patients
 For withdrawn patients, start with one-to-one interactions
 Allow and encourage verbalization of feelings
 Be calm when talking to patients
 Accept patients as they are but do not accept all behaviors
 Keep promises
 Be consistent
 Be honest
CHARACTERISTICS OF A MENTALLY HEALTHY PERSON

1. A mentally healthy person is free from internal conflicts. He is not at war with himself.
2. He is well adjusted. He is able to get along well with others. He is able to form effective relationships. He
is able to accept criticisms and is not upset easily.
3. He searches for an identity.
4. He has a strong sense of self-esteem.
5. He knows himself, his needs, problems and goals (self-actualization).
6. He has good control over his behavior.
7. He is productive.
8. He faces problems and tries to solve them intelligently.

CHARACTERISTICS OF MENTAL ILLNESS

1. When a person’s behavior is causing distress and suffering to the individual and/or others around him
2. Abnormal changes in one’s thinking, feeling, memory, perceptions and judgment, resulting in changes in
talk and behavior.
3. Abnormal behavior causes disturbance in the person’s day-to-day activities, job and interpersonal
relationships.

Neurosis
 Frequently talks about his symptoms
 Does not lose contact with reality
 Personality is intact
 Continue to function socially and at work
 Hospitalization is usually not required
Psychosis
 Denies that there is something wrong with
him
 Loses contact with reality
 Personality is often disorganized and
deteriorates.
 Cannot act normally in society and may
harm self and others.
 Often requires hospitalization

PREVENTION OF MENTAL ILLNESS

PRIMARY PREVENTION- involves the promotion of general mental health and protection against the occurrence
of specific diseases. Primary prevention aims to prevent the onset of a disease or a disorder, thereby reducing the
incidence (number of of new cases occurring in a specific period in time).
 Elimination of etiological agents
 Reducing risk factors
 Enhancing host resistance or interfering with disease transmission
 Reducing stress factors
 Counseling
o Student’s counseling
o Marriage counseling
o Sex counseling
o Genetic counseling
 Special centers
o Child guidance centers
o Crisis intervention center
o Geriatric center
 Mental health education

SECONDARY PREVENTION- early identification and effective treatment of an illness or disorder, with the goal
of reducing the prevalence (total number of existing cases in a year) is the aim of secondary prevention.
 Population screening
  Crisis intervention services
 Mental health education

TERTIARY PREVENTION- aims to reduce the prevalence of residual defect or disability due to illness or
disorder. It involves rehabilitation after defect and disability have been fixed. Community reintegration is also part
of tertiary prevention.

CRISIS
 Refers to the state of the reacting individual who finds himself in a hazardous situation in which the
habitual problem solving activities are not adequate and do not lead to rapidly to the previously achieved
balance state.

CRISIS INTERVENTION- means of entering into the life situation of an individual, family or group to alleviate
the impact of a crisis including stress in order to help mobilize the resources of those directly affected, as well as
those who are in the significant “social orbit.”

CONCEPT OF LOSS

GRIEF- is the process of coping with a loss.

STAGES OF DEATH AND DYING (KUBLER-ROSS)

 Denial and isolation
 Anger
 Bargaining
 Depression
 Acceptance

STAGES OF GRIEF
 Shock and disbelief
 Developing awareness
 Restitution and resolution of the loss

COPING REACTION TO DEATH THROUGHOUT THE LIFE CYCLE

 Toddler (1-3 yo)

o No specific concept of death and thinks only in terms of the living.
o Reacts more to pain and discomfort of illness and immobilization.
o Experience separation anxiety a great deal

Nursing interventions:
Focus on parents
 Assist parent to deal with their feelings
 Encourage parents’ participation in child’s care

 Preschooler (3-5 yo)

o Death is a kind of sleep. It is a form of punishment
o Life and death can change place with one another

Nursing interventions
 Utilize play for expressing thoughts and feelings
 Explain what is death that it is final and not sleep
 Permit a choice of attending the funeral

 School Age (5-12)

 o Death is personified
o Child fears mutilation and punishment
o Anxiety is alleviated by nightmares and superstition
o Death is perceived as a final process

Approaches:
 Accept regressive or protest behavior
 Encourage verbalization of feelings

 Adolescent (12-16)
 Mature understanding of death
 May have strong emotions about death, silent, withdrawn, angry
 Worry about physical changes

Approaches:
 Support maturational crisis
 Encourage verbalization of feelings
 Respect need for privacy and personal expression for anger , sadness or fear.

 Adult
 Death is disruption of the life cycle
 Death is viewed on terms of its effect on significant others.

 Older adult
 Emphasis is on religious beliefs for comfort. A time of reflection, rest and peace