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Psychotherapeutic Theory & Models
Week 2
Psychoanalytic Theory: Freud
� Topography of the Mind: Preconscious, Conscious, Unconscious
� Structure of the Mind: Id, Ego , Superego
� Drives
� Psychic energy (Libido)
� Anxiety
� Conscious Coping strategies
� Ego Defense Mechanisms (Unconscious responses)
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Psychoanalytic Theories
� Sigmund Freud: the father of psychoanalysis
� Supports that all human behavior is caused & can be explained
� Personality structure consists of three components
� Developed concept of transference and countertransference
� Current psychoanalysis focuses on
� discovering the causes of unconscious and repressed thoughts, feelings, and conflicts believed to cause the anxiety
� Help to gain insight in resolving these conflicts and anxieties
� Practiced on limited basis
� Cost
� Time constraints
Major Therapeutic Strategies
� 1) Make the Unconscious conscious
� 2) Strengthen the ego so that behavior is based more on Reality and less on instinctual drives
� Techniques: hypnosis, Free Association, Interpretation
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Interpersonal Theory:
Harry Stack Sullivan
� Key Concepts: Anxiety and Self-esteem
� “good me”, “bad me”, “not me”
� Anxiety is a “Chief disruptive force” in relationships
� Interpersonal security: sense of “total well being”
� Difficulty in living arises out of inability to satisfy needs to achieve interpersonal security
Interpersonal Theories
� Harry Stack Sullivan: interpersonal relationships
� 5 life stages: 1) infancy (birth to onset of language);
� 2) childhood (language to 5 years);
� 3) juvenile (5-8 years);
� 4) preadolescence (8-12 years);
� 5) adolescents (puberty to adulthood).
� 3 developmental cognitive modes: 1) Protaxic mode, 2)Parataxic mode, and 3) Syntaxic mode
� Therapeutic community/milieu
� Was one of primary modes of treatment but not practical now
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Gestalt Therapy (Frederick Perls)� “About the Here and Now”
� Key Concepts: People are responsible for finding their own way in life, accepting personal responsibility
� Unfinished Business creates anxiety
� Avoidance: not healthy
� Therapy techniques: Dialogue exercise, rehearsal, Exaggeration (What is the worst thing that could happen…….?)
Person Centered Therapy:
Carl Rogers
� Key Concepts: Client has potential for becoming aware of problems and means to solve them.
2) Focus is on the development of self-direction
3) Health is achieved through the congruence of the Ideal self & the Real self
Therapeutic Strategies: Openness, trust in self, genuineness, warmth, empathy, respect, active listening, reflection on feelings, unconditional positive regard
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Humanistic theories
� Maslow: Hierarchy of needs
� Theory helps nurse understand motivations and behavior change during life crisis
� 5 levels
� Basic needs foundation
� Safety and security
� Love and belonging
� Esteem needs
� Self-actualization
� Rogers: client-centered therapy
� Key to healing is the role of the client and therapist takes a supportive role
� Unconditional positive regard
� Genuineness
� Empathetic understanding
Behavioral Therapy: Pavlov, Skinner, Bandura
� Two Overriding Principles: 1) Understanding human behavior within this model differs fundamentally from a traditional psychodynamic model.
� 2) Strong emphasis on the Scientific Method to include an overt and testable conceptual framework that has measurable outcomes.
� Dialectical Behavioral Therapy: * used with Borderline Personality Disorders
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Behavioral Theories
� Pavlov: Classic conditioning
� Behavior can be changed through conditioning (external or environmental conditions or stimuli)
� Skinner: Operant conditioning
� Behavior learned through history/past experience
� If behavior could be changed thoughts and feelings would accompany
� Behavior modification therapy
� Positive/negative reinforcement
Behavioral Therapy Techniques
� 1) Problem Identification & Assessment
� 2) Role playing
� 3) Self monitoring: journaling
� 4) Behavioral Observation: used with children and parents to observe interaction patterns
� 5) Psychometric Evaluations: questionnaires & scales
� 6) Cognitive restructuring: Alter dysfunctional thinking
� 7) Assertiveness & Social skills training
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Existential Theories� Beck: Cognitive therapy
� How person perceives/interprets experience determines how feels and behaves
� Ellis: Rational emotive therapy
� Confrontation of “irrational beliefs” preventing accepting responsibility for self & behaviors
� Frankl: Logotherapy
� Help assume personal responsibility (looking for meaning in life is central theme)
� Perls: Gestalt therapy
� Focusing on identification of feelings in here and now (leading to self-acceptance
� Glasser: Reality therapy
� Focus is need for identity through responsible behavior; challenged to examine ways behavior impedes attempts to achieve life goals
Rational-Emotive Therapy:
Albert Ellis
� Key Concepts: Neurosis is irrational thinking & behaving
� Emotional problems are rooted in childhood but continue in the now
� A client’s belief system is the cause of emotional problems
� Goal of Therapy: Client gains insight into problems and then practices to change self-defeating behavior
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Therapeutic techniques: RET
� 1) Cognitive-disputing irrational beliefs through homework & changing language and thinking patterns
� 2) Emotive-Role playing & Imagery
� Usually associated with Behavior change & tailored to each individual client needs
Cognitive Behavioral Therapy
(Aaron Beck)
� Based on personality theory that asserts that how one thinks largely determines how one feels & behaves
� Goal is to alter a person’s interpretation of their situation, for example: If a patient is depressed they are only thinking in terms of hopelessness and self defeat and are likely to stay depressed.
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CBT Strategies
� Client and therapist collaborate to identify dysfunctional interpretations and try to modify them
� Guided Discovery of thinking pattern, experiences, and ways to facilitate a change in thinking patterns
� Cognitive Therapy: Highly structured and very individualized to each client , short term lasting 12-16 weeks, present centered, action oriented problem solving approach
Adlerian Theory
� Viewed human nature from a holistic, telecological, phenomenological, social, and constructivist perspective.
� Active co-creators of their world (self fulfilling prophecy)
� Therapist worked to empower the client
� Psychopathology resulted from feelings of inferiority, self-centeredness, some genetic influence and discouragement.
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Role of the Psychiatric Nurse: Peplau
� Based on Harry Sullivan’s Interpersonal theory
� Six nursing subroles of the nurse: Mother-surrogate, technician, manager, socializing agent, health teacher, counselor/psychotherapist (role most connected to Psy/mental health nurse)
� Phases of a Therapeutic Relationship:
Orientation, Working, Termination
Therapeutic Milieu (more inpatient )
� Management of the therapeutic environment to best facilitate the therapeutic process
� Involves a multidisciplinary team
� Nurses are role models
� Positive therapeutic relationships provide a model for healthy relationships
� Peer pressure and democratic structure create social skill enhancement ( especially with Adolescents)
� Allows staff to observe clients in social settings
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Conditions that promote a therapeutic
environment
� 1) Structure
� 2) Involvement
� 3) Containment: Safety first
� 4) Support: Consistency
� 5) Validation
Role of the APRN
� 1) Ensuring the physiological needs are being met
� 2) Encouraging independence
� 3) Reality orientation
� 4) Medication management
� 5) One – to- one relationship
� 6) Setting limits
� 7) Teaching
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Group therapy
� Collection of individuals with a shared interest (diagnosis), values, norms or purpose
� Types of groups: Task groups, Teaching groups, Supportive/Therapeutic, & Self help groups
� Ideal size 5-10; Membership can be Open or Closed
� Uses the principle of Universality
Yalom’s Phases of Group Development
� Yalom
� Initial or orientation phase
� Working phase
� Terminations phase
� Leadership style: Autocratic, Democratic, Laissez-Faire
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Group Therapies
� 1) Psychodrama: Members become “actors” in life situation scenarios
APRN-Provides a safe, supportive place for the character(s) to confront and resolve issues
� Family Therapy: based on four principles
A) A family is an interdependent group of people
B) Focus is on the family
C) Change in one member affects the entire family
D) The APRN facilitates communication & goal setting
Family Systems theory: Murray Bowen
� Used Genograms , Family is made up of interlocking relationships
� The more anxiety in the family the more the members will emotionally react verses thinking before acting
� Differentiation of Self is important
� Triangulation: a person focuses on another object or family member to relieve the anxiety they feel about another family member
� The more anxiety in a family, the more triangles and in turn the more dysfunction
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Therapeutic Techniques for Family
� Therapists coach family members to develop a more solid self to stand against anxiety & triangles
� Bowen focused on the family relationships and not the individuals
� Teach people to use “I think” rather than “I feel”
Structural Family Therapy:
Salvador Minuchin
� Key Concepts: Structure or Organization of the Family
� Subsystems
� Boundaries: Families with diffuse boundaries (enmeshed or blurred) have more Chaos
� Families with rigid boundaries (disengaged) have less emotional support
� Support unification, responsibilities, appropriate behavior & Open communication of family members
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Developmental Aspects of
Children & Adolescents
� Personality: deeply ingrained patterns of behavior, which include the way one relates to, perceives, and thinks about the environment and oneself.
� Behaviors from an early age may be modified in a later stage
� Stages can overlap
� Developmentally delayed individuals are “fixed” in certain developmental stages.
� Personality Disorders occur when personality traits become inflexible and maladaptive and cause distress
Developmental Contexts
� Failure to achieve developmental competencies
� Poor behavioral adaptation
� Maladaptive outcomes result from continuous malfunction in the caretaking environment
� The Parent-Child relationship and family functioning are critical to children’s effective coping with inevitable stress and/or negative forces
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Erickson’s Developmental Theory
� Trust vs Mistrust Birth to 18 months
� Autonomy vs Shame & Doubt 18 months to 3 years
� Initiative vs Guilt 3 to 6 years of age
� Industry vs Inferiority 6 to 12 years (Peer relations)
� Identity vs Role Confusion 12 to 20 years (Peer relations
� Intimacy vs isolation 18 to 25 years
� Generativity vs stagnation 25 to 65 years
� Integrity vs despair 65 to death
Cognitive Theory (Piaget)
� Based on the premise that human intelligence is an extension of biological adaptation or one’s ability for psychological adaptation to the environment
� Four Stages of Development:
� Sensorimotor: (0 to 2 years) movement & hold mental image
� Preoperational: (2 to 7 years) symbolic play
� Concrete Operational ( 7 to 11 ) value others
� Formal Operational (11-15+) abstract thinking & complex problem solving
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Piaget and Grief/Loss
� <5 Do not really understand death/ permancy
� 5-10 (concrete operational) abandonment fear that parents will die
� 10 years Understand that death happens to everyone
� Puberty (formal cognitive operations) understands death is inevitable but fear loss of control and will isolate & reject care
Stress & Anxiety
� Hans Selye: Adaptation syndrome –an emotional or physiological change due to a perceived event or “stressor”
� Adaptation is a Healthy response to stress with restoration of homeostasis
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“Fight or Flight” Syndrome
� Hypothalamus stimulates the sympathetic nervous system
� Sympathetic nervous system stimulates the adrenal medulla
� Adrenal medulla releases epinephrine and norepinephrine into the bloodstream
� Sustained Stress: Hypothalamus stimulates pituitary gland releases ACTH, which stimulates the adrenal cortex to release Glucocorticords, vasopresssin (ADH), Growth hormone, & Thyroid Stimulating hormone
Manifestations of Anxiety
� Physical: autonomic arousal
� Affective: edginess to terror
� Behavioral: avoidance to compulsions
� Cognitions: Worry, apprehension, obsessions
� Prevalence of Anxiety: Very common, more women than men, difficult to treat (treatment occurs over long time period)
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Goal of Anxiety Treatment
Not to eradicate the signal but to increase tolerance and the capacity to use and mange the
anxiety as a tool for survival.
Differential Diagnosis of Anxiety
� Rule out organic/medical illness r/t physical symptoms
� 5 factors in r/o organic causes of anxiety:
� 1) onset after age 35
� 2) lack of childhood/family anxiety
� 3) lack of any anxiety producing events
� 4) Lack of avoidant behavior
� 5) Poor response to anxiolytics
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Differential Diagnosis of Anxiety
� Some medications can cause anxiety
� Consider Substance abuse or withdraw* especially cannabis use/abuse
� Hyperthyroid can mimic panic attacks
questions
� Contact