Introduction to Psychiatric-Mental Health Nursing:

●​ Nursing students may feel a mix of excitement, uncertainty, and anxiety when starting in this
field.
●​ The chapter covers the history, treatment advances, current issues, and the psychiatric nurse's role.

Mental Health and Mental Illness:

Mental Health:

●​ Definition: WHO defines health as physical, mental, and social wellness, not just the absence of
disease.
●​ Mental health characteristics: Emotional stability, satisfying relationships, effective behavior,
positive self-concept, and coping ability.
●​ Factors influencing mental health:
○​ Individual: Biologic makeup, self-esteem, resilience, coping skills, sense of belonging.
○​ Interpersonal: Communication, intimacy, balance between independence and
connectedness.
○​ Social/Cultural: Community support, adequate resources, acceptance of diversity,
realistic worldview.
●​ Mental health is dynamic and influenced by interactions among individual, interpersonal, and
social/cultural factors.

Mental Illness:

●​ Includes disorders like depression, schizophrenia, anxiety, and addictions.

●​ Symptoms: Mood, behavior, and thinking disturbances causing distress or impaired functioning.
●​ Contributing factors:
○​ Individual: Biologic vulnerabilities, unrealistic fears, inability to distinguish reality, loss
of life's meaning.
○​ Interpersonal: Poor communication, social withdrawal, inadequate support.
○​ Social/Cultural: Violence, poverty, discrimination, lack of resources.

Debate: Questions persist about whether certain behaviors signify illness or are simply "bad behavior."

Diagnostic and Statistical Manual of Mental Disorders (DSM-5):

●​ Published by the APA, with major revisions in 2013.

●​ Purpose:
○​ Standardize language for mental health professionals.
○​ Define diagnostic criteria for disorders.
 ○​ Help identify underlying causes of mental conditions.
●​ Classification includes:
○​ Major psychiatric disorders (e.g., depression, anxiety).
○​ Relevant medical conditions.
○​ Psychosocial/environmental issues affecting diagnosis and treatment.
●​ While student nurses don’t diagnose, the DSM-5 is a helpful resource for understanding
psychiatric conditions.

Psychiatric Nursing Practice:

Historical Development:

●​ Linda Richards (1873): First American psychiatric nurse; emphasized equal care for mentally
and physically ill.
●​ First psychiatric nurse training (1882): McLean Hospital, Belmont, Massachusetts. Care was
custodial, focusing on nutrition, hygiene, and activity.
●​ Advancements in care: Use of medical–surgical principles expanded with treatments like insulin
shock therapy (1935), psychosurgery (1936), and ECT (1937).
●​ Nursing milestones:
○​ First psychiatric nursing textbook: Nursing Mental Diseases (1920).
○​ Psychiatric nursing added to curriculum at Johns Hopkins (1913).
○​ NLN required psychiatric nursing experience in schools (1950).

Influential Theorists:

●​ Hildegard Peplau: Developed the therapeutic nurse-client relationship model and emphasized
interpersonal dimensions in psychiatric care.
●​ June Mellow: Focused on clients’ psychosocial needs and strengths, particularly in daily
activities and severe mental illness contexts.

Standards of Practice:

●​ Developed by: American Nurses Association (ANA) and American Psychiatric Nurses
Association (APNA).
●​ Purpose: Define nursing responsibilities, guide acceptable practice, and ensure quality care.
●​ Phenomena of Concern: Include mental health promotion, managing psychiatric symptoms,
addressing societal factors (e.g., violence, poverty), and ensuring client recovery (Box 1.2).
●​ Practice Areas (Box 1.3):
○​ Basic-level functions: Counseling, crisis intervention, teaching, behavior modification,
milieu therapy, psychobiologic interventions, health promotion.
○​ Advanced-level functions: Psychotherapy, prescriptive authority, program management,
clinical supervision.

Student Concerns:
1.​ Saying the wrong thing:
○​ Listen carefully, show genuine interest, and restate if necessary.
2.​ Role in mental health settings:
○​ Tasks are less physical and more focused on therapeutic communication and
trust-building.
3.​ Fear of rejection by clients:
○​ Reclusive clients may behave the same with experienced staff; being available and
willing to listen is key.
4.​ Asking personal questions:
○​ Build rapport first. Personal questions in the context of trust and therapeutic
communication are not prying.
5.​ Handling inappropriate behavior:
○​ Monitor emotional responses; clarify boundaries with guidance from instructors or staff.
6.​ Safety concerns:
○​ Most clients are not violent; aggressive situations are managed by trained staff. Students
should avoid physical restraint and remain in open spaces when needed.
7.​ Encountering someone known:
○​ Confidentiality is critical. Notify the instructor to handle the situation appropriately.
8.​ Relating to clients’ problems:
○​ Students may share similar issues; understanding these parallels is part of developing
empathy and professional insight.
9.​ Eclectic Approach in Mental Health Treatment:
○​ Combines concepts from multiple theories and strategies.
○​ Integrates psychosocial theories and medical neurobiologic theories.
10.​Types of Psychosocial Theories:
○​ Include psychoanalytic, developmental, interpersonal, humanistic, behavioral, and
existential theories.
11.​Freud's Psychoanalytic Theory:
○​ Deterministic View: Suggests all behavior is caused and explainable.
○​ Developed through work with women exhibiting "hysterical" symptoms without a
physiological basis.
○​ Key idea: Repressed childhood traumas and unmet needs can cause neurotic behaviors.
12.​Personality Structure:
○​ Id: Impulsive, pleasure-seeking desires.
○​ Ego: Mediator enabling mature, adaptive behaviors.
○​ Superego: Moral and ethical principles opposing the id.
13.​Levels of Awareness:
○​ Conscious: Thoughts and emotions in awareness.
○​ Preconscious: Retrievable with effort.
○​ Unconscious: Hidden, motivating thoughts and emotions, including repressed traumatic
memories.
14.​Techniques in Psychoanalysis:
○​ Dream Analysis: Interpreting symbolic meanings in dreams.
○​ Free Association: Quickly responding to words to uncover subconscious thoughts.
 15.​Ego Defense Mechanisms:
○​ Psychological methods to protect oneself from distress.
○​ Often unconscious; examples include denial and reaction formation.

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Study Guide: Introduction to Psychosocial Theories

Eclectic Approach in Mental Health Treatment

●​ Incorporates concepts from multiple theories to provide a well-rounded approach to care.

●​ Includes both psychosocial models and neurobiologic theories to address mental health
holistically.

Key Psychosocial Theories

1.​ Psychoanalytic (Freud)

2.​ Developmental (e.g., Erikson's stages)
3.​ Interpersonal (e.g., Peplau’s nurse-client relationship)
4.​ Humanistic (e.g., Maslow’s hierarchy of needs)
5.​ Behavioral (e.g., Pavlov's conditioning)
6.​ Existential (e.g., exploring meaning in life).

Freud’s Psychoanalytic Theory

1. Core Concepts:

●​ Human behavior is caused and explainable.

●​ Unresolved childhood trauma and repressed feelings influence behavior.
●​ Example: Hysterical symptoms like speech or limb paralysis stem from unconscious conflicts.

2. Personality Structure:

●​ Id: Primitive desires (e.g., aggression, pleasure-seeking).

 ●​ Superego: Moral compass (values, societal rules).
●​ Ego: Mediates between the id and superego, ensuring realistic and adaptive responses.
●​ Conflict between these components can cause anxiety.

3. Levels of Awareness:

●​ Conscious: Thoughts/emotions actively in awareness.

●​ Preconscious: Can be recalled with effort (e.g., childhood memories).
●​ Unconscious: Hidden motivations, repressed memories, and defense mechanisms.

Freud’s Techniques for Uncovering the Unconscious

1.​ Dream Analysis:

○​ Dreams reflect hidden desires or fears.
○​ Example: Snake in dreams = phallic symbol, fear of intimacy.
2.​ Free Association:
○​ Responding quickly to words to bypass conscious filters.
○​ Uncovers subconscious feelings.

Ego Defense Mechanisms

●​ Tools the ego uses to protect against distress and anxiety.

●​ Operate mostly at the unconscious level.
●​ Examples:
○​ Denial: Refusing to accept reality (e.g., ignoring a terminal diagnosis).
○​ Reaction Formation: Acting the opposite of true feelings (e.g., overly cheerful when
scared).

Reflection & Application

●​ These theories provide tools for therapeutic interventions like building trust, exploring
subconscious influences, and resolving inner conflicts.
●​ Freud’s framework underpins many modern therapy models, emphasizing the importance of early
development and subconscious drives.

. Compensation

●​ Overachievement in one area to offset perceived deficiencies in another.

●​ Example: A nurse with low self-esteem works extra shifts to gain approval from her supervisor.
2. Conversion

●​ Emotional conflict is expressed through a physical symptom, often sensorimotor.

●​ Example: A teenager who develops blindness after being forbidden to see explicit movies.

3. Denial

●​ Refusal to acknowledge an unpleasant reality or condition.

●​ Example: A diabetic person eating candy despite knowing the risks.

4. Displacement

●​ Venting emotions on a less threatening target than the one causing the stress.
●​ Example: A person angry with their boss yells at their spouse.

5. Dissociation

●​ A temporary change in consciousness or identity to avoid emotional conflict.

●​ Example: Amnesia preventing someone from recalling a traumatic event like an accident.

6. Fixation

●​ Stopping or becoming stuck at a developmental stage due to unresolved tasks.

●​ Example: An adult unable to delay gratification or develop a stable sense of identity.

7. Identification

●​ Adopting the traits of others, usually as a means of finding identity or achieving goals.
●​ Example: A nursing student aspiring to be a critical care nurse after admiring an instructor in that
specialty.

8. Intellectualization

●​ A person separates emotions from the facts of a situation to avoid emotional distress.
●​ Example: Someone discussing a traumatic event like a car accident without showing emotion.

9. Introjection

●​ Adopting another person’s beliefs, attitudes, or values as one's own.

●​ Example: A person who dislikes guns becomes an avid hunter to align with a close friend.

10. Projection

●​ Unconsciously attributing one’s own unacceptable thoughts or feelings onto others.

●​ Example: A person with prejudices calling others bigoted.

11. Rationalization
 ●​ Creating logical explanations to justify behaviors, avoiding guilt or responsibility.
●​ Example: A student blaming their failure on a teacher's unfairness instead of their own lack of
preparation.

12. Reaction Formation

●​ Acting in the opposite way of what one truly feels to protect themselves.
●​ Example: A woman who never wanted children becomes overly nurturing.

13. Regression

●​ Reverting to an earlier developmental stage to feel safe or cope with stress.

●​ Example: A child asks for a bottle when a new sibling arrives.

14. Repression

●​ Excluding painful or anxiety-provoking thoughts and feelings from consciousness.

●​ Example: A woman having no memory of a traumatic event like being mugged.

15. Resistance

●​ Opposition to confronting or processing distressing information.

●​ Example: A nurse avoids talking to a terminally ill patient due to discomfort.

16. Sublimation

●​ Redirecting an unacceptable impulse into a socially acceptable activity.

●​ Example: A person quits smoking and chews hard candy to manage the urge.

17. Substitution

●​ Replacing a desired goal with something more easily attainable.

●​ Example: A woman opens a daycare center after being unable to have children.

18. Suppression

●​ Consciously avoiding thoughts or feelings that are too distressing.

●​ Example: A student ignores thoughts about a parent's illness while focusing on exams.

19. Undoing

●​ Performing an acceptable behavior to negate or counteract previous unacceptable actions.

●​ Example: A person who cheated on their spouse buys flowers to make amends.

Reflection & Application

These defense mechanisms provide ways individuals cope with anxiety, unresolved conflict, or stress.
Understanding these can enhance therapeutic strategies by identifying when and why clients use these
mechanisms.

Freud's Psychosexual Stages

Freud proposed that childhood development is driven by libido, or sexual energy. He believed children
progress through five stages, with each stage focused on a specific area of pleasure and conflict. Failure to
successfully transition between stages may result in fixation or regression, leading to psychopathology.

Stage Age Range Focus/Developmental Task

Oral Birth to 18 months Mouth is the primary source of pleasure; includes sucking,
biting, and chewing.

Anal 18–36 months Anus and sphincter control; toilet training occurs.

Phallic/Oedipal 3–5 years Genital area is of interest; includes penis envy and oedipal
complex.

Latency 5–11 or 13 years Sexual drive is channeled into social and intellectual
activities (e.g., school).

Genital 11–13 years and Begins at puberty, involving sexual maturity and the ability
beyond for intimacy.

Transference and Countertransference

●​ Transference: When the client projects feelings and attitudes from past relationships onto the
therapist.
○​ Example: An adolescent might react to the nurse as they would their parent, expressing
rebellious feelings.
●​ Countertransference: When the therapist projects their own emotions or experiences onto the
client.
○​ Example: A nurse may become frustrated with a client and react with a parental tone
based on their own experiences with their children.

Current Psychoanalytic Practice

●​ Goal: Uncover unconscious conflicts and repressed thoughts that may cause anxiety or distress.
●​ Techniques include free association, dream analysis, and behavior interpretation.
●​ Limitation: Psychoanalysis is intensive, lengthy, and expensive, making it more accessible to a
wealthier demographic.
Erikson's Psychosocial Stages of Development

Erik Erikson extended Freud’s work by emphasizing social and psychological growth through the
lifespan. He proposed eight psychosocial stages, each with a central life task and virtue to be developed.

Stage Age Range Virtue Task

Trust vs. Mistrust Infancy (birth to 18 Hope Developing trust in caregivers and
months) the world as safe and reliable.

Autonomy vs. Shame Toddler (18 months to Will Gaining a sense of independence
and Doubt 3 years) and control over actions.

Initiative vs. Guilt Preschool (3–5 years) Purpose Developing a conscience and
managing conflict.

Industry vs. School Age (5–11 Competence Developing confidence and

Inferiority years) competence through achievements.

Identity vs. Role Adolescence (11–18 Fidelity Forming a strong sense of personal
Confusion years) identity.

Intimacy vs. Isolation Young Adulthood Love Forming meaningful, intimate

(18–40 years) relationships.

Generativity vs. Middle Adulthood Care Contributing to society and guiding

Stagnation (40–65 years) the next generation.

Ego Integrity vs. Maturity (65+ years) Wisdom Reflecting on life and accepting it
Despair with a sense of fulfillment.

Erikson’s theory highlights the importance of successfully resolving conflicts at each stage to ensure
healthy psychological development. The ability to move forward is influenced by successful resolution of
the preceding stages.

Key Concepts to Remember

●​ Psychosexual Stages: Freud’s theory focuses on sexual energy (libido) and how conflicts at each
stage of childhood lead to personality development or pathology.
●​ Psychosocial Stages: Erikson's stages extend beyond childhood, focusing on the psychosocial
challenges and virtues needed throughout the lifespan to maintain mental and social well-being.
 ●​ Transference/Countertransference: These concepts are crucial in understanding the dynamics
in therapeutic relationships, where past experiences influence present interactions.

Jean Piaget's Cognitive Stages of Development

Piaget focused on how children’s intelligence and cognitive functions evolve, suggesting that biological
maturation drives cognitive development through distinct stages. He emphasized that children develop
higher levels of cognitive abilities as they progress through each stage.

Stage Age Range Key Characteristics

Sensorimotor Birth to 2 Development of object permanence; child learns self as

years separate from environment.

Preoperational 2 to 6 years Use of language and symbolic gestures; ability to classify

objects.

Concrete 6 to 12 years Logical thinking develops; understands spatiality and

Operations reversibility but still concrete.

Formal Operations 12 to 15 Abstract thinking, logical reasoning, and cognitive maturity

years+ achieved.

Key Points:

●​ Piaget's theory highlights the age-dependent development of cognitive skills.

●​ Cognitive maturity is typically achieved by adolescence.
●​ Critics suggest that development might be more individualized than Piaget’s staged approach
suggests.

Harry Stack Sullivan's Interpersonal Theory

Sullivan extended personality development to the significance of interpersonal relationships, asserting

that anxiety from poor or unsatisfying relationships is the root of emotional problems. He identified stages
of development, each with a specific focus on interpersonal interactions, and proposed three cognitive
modes of experience.

Stage Age Range Focus

Infancy Birth to language Need for bodily contact and tenderness; Prototaxic mode (no
onset connection between experiences).

Childhood Language to 5 Focus on parents as sources of praise and acceptance;

years Parataxic mode (sequences of experiences).
 Juvenile 5 to 8 years Shift to Syntaxic mode (analyzing experiences across
situations); developing interpersonal needs.

Preadolescence 8 to 12 years Formation of genuine intimacy with same-sex friends; shift to

Syntaxic mode; attachment and love capacity.

Adolescence Puberty to Shift to opposite-sex relationships; self-esteem consolidation or

adulthood self-ridicule.

Key Points:

●​ Sullivan’s model emphasizes how interpersonal experiences shape personality.

●​ Prototaxic mode (infancy) involves unconnected experiences, while Syntaxic mode
(preadolescence and beyond) allows more complex interpersonal understanding.
●​ Emotional disorders arise when earlier modes (e.g., prototaxic) persist into adulthood.

Key Concepts to Remember:

●​ Piaget: Focused on cognitive growth, emphasizing the development of logical thinking and
reasoning as children mature through distinct stages.
●​ Sullivan: Highlighted the role of interpersonal relationships in emotional development and
suggested that anxiety from poor relationships leads to emotional distress.

Therapeutic Community or Milieu (Harry Stack Sullivan)

●​ Therapeutic Community: Sullivan's concept of a therapeutic community focuses on

interpersonal relationships between clients. The interaction among clients in a safe, therapeutic
setting provides significant benefits. This approach emphasizes client-to-client interactions rather
than just client-therapist interactions.
●​ Milieu Therapy: Developed by Sullivan, this approach encourages clients to practice
interpersonal skills, offer feedback to one another, and work cooperatively to solve problems in
daily life.
●​ Role of the Nurse: In milieu therapy, the nurse manages the environment to ensure safety and
encourage social interaction among clients. While inpatient hospital stays may be too short for
deep interpersonal development, the nurse still plays a key role in creating a safe, supportive
environment.

Key Points:

●​ Sullivan developed the therapeutic community to show that interactions among clients were
crucial to their treatment, not just the therapist-client relationship.
●​ Today, the concept of milieu therapy is less emphasized due to shorter inpatient stays, but the
nurse still manages the environment to foster safety and interaction.
Hildegard Peplau’s Therapeutic Nurse-Patient Relationship

Peplau expanded on Sullivan’s theories, focusing on the nurse-patient relationship and its phases. Her
model includes four stages: Orientation, Identification, Exploitation, and Resolution.

Stage Key Tasks

Orientation Nurse engages the patient, clarifies needs, explains routines, and fosters
participation in treatment.

Identification Patient starts feeling stronger, works with nurse interdependently, and expresses
emotions.

Exploitation Patient fully utilizes available services, sets personal goals (e.g., returning home,
work), and fluctuates between dependence and independence.

Resolution Patient becomes independent, no longer requires services, and sets new goals for
themselves.

Key Points:

●​ Peplau’s model outlines a dynamic nurse-patient relationship that evolves in stages.

●​ Each phase has distinct tasks, with the nurse guiding the process to foster patient independence
and empowerment.
●​ The model is foundational to modern nursing practice and emphasizes therapeutic communication
and mutual goals between the nurse and patient.

Key Concepts to Remember:

●​ Therapeutic Community/Milieu: Focuses on client-to-client interactions in a supportive, safe

environment, with the nurse playing a key role in managing the milieu.
●​ Peplau’s Nurse-Patient Relationship: Involves four stages where the nurse helps the patient
progress from initial dependency to independence, with clear tasks and goals at each stage.

Peplau’s Roles of the Nurse in the Therapeutic Relationship

Peplau identified several roles that the nurse assumes to meet the needs of the client. These roles help
foster a supportive, healing relationship and can evolve based on the patient's needs:

1.​ Stranger: The nurse offers the same courtesy and acceptance to the client as they would to any
stranger.
 2.​ Resource Person: The nurse provides specific answers to questions within a larger context,
helping the client understand their situation better.
3.​ Teacher: The nurse helps the client learn, either formally or informally, about health, treatment,
and coping strategies.
4.​ Leader: The nurse provides direction to the client or group, guiding them toward health and
recovery goals.
5.​ Surrogate: The nurse serves as a substitute for someone important to the client (e.g., a parent or
sibling) to meet emotional needs.
6.​ Counselor: The nurse promotes experiences that lead to health, such as encouraging the client to
express feelings and address emotional challenges.

Additional Roles:

●​ Peplau also mentioned that the nurse can take on roles such as consultant, tutor, safety agent,
mediator, administrator, observer, and researcher, depending on the situation.

Key Points:

●​ Nurses play dynamic and versatile roles that shift according to the client's needs and the
therapeutic process.
●​ The roles help foster healing, learning, and self-empowerment in the client.

Peplau’s Four Levels of Anxiety

Peplau defined anxiety as the initial response to a perceived threat. She identified four levels of anxiety,
each with distinct characteristics and implications for treatment:

Level Characteristics

Mild - Heightened awareness, sharpened senses, and increased motivation.

- Able to solve problems and learn effectively.

- Perceptual field is wide and can take in all available stimuli.

Moderate - Decreased perceptual field, focusing on immediate tasks.

- Can learn new behavior or solve problems, but with assistance.

- Needs redirection.

Severe - Dread, terror, and limited focus on scattered details.

- Physiology symptoms (tachycardia, diaphoresis, chest pain).

 - Cannot be redirected and may seek emergency care, believing they are having a heart
attack.

Panic - Loss of rational thought, possibly experiencing delusions or hallucinations.

- Complete physical immobility or aimless running (may lead to self-injury).

- Unable to process stimuli, with distorted perceptions and disorganized personality.

- May become mute or unresponsive.

Key Points:

●​ Mild anxiety is beneficial and allows for learning and problem-solving.

●​ Moderate anxiety can be managed with guidance, but requires assistance to remain focused.
●​ Severe anxiety overwhelms the individual, affecting rational thought and behavior.
●​ Panic anxiety leads to a total loss of control, requiring immediate intervention.

Humanistic Theories

Humanism emphasizes the positive qualities of individuals, focusing on their potential for growth and
self-actualization. Unlike psychoanalysis, which focuses on past experiences and repressed issues,
humanism looks more toward the present and future, helping individuals achieve higher self-esteem and
personal growth.

Key Points:

●​ Humanism is centered around promoting personal growth, self-esteem, and the ability to change.
●​ It is a shift away from seeing people as driven by neurotic impulses and instead focuses on their
capacity for growth and positive change.

Abraham Maslow: Hierarchy of Needs

Maslow’s theory focuses on understanding human motivation through a hierarchy of needs, where basic
physiological needs must be met before higher needs become a priority. The hierarchy is often
represented as a pyramid, with five levels:

1.​ Physiological Needs: The most basic needs for survival, including food, water, sleep, shelter, and
freedom from pain.
2.​ Safety and Security Needs: The need for protection from harm, security, and safety from threats
or deprivation.
3.​ Love and Belonging Needs: The need for social connections, intimacy, friendship, and
acceptance.
 4.​ Esteem Needs: The need for self-respect, confidence, and esteem from others.
5.​ Self-Actualization: The highest level, representing the need to achieve one's fullest potential,
including a pursuit of beauty, truth, and justice.

Key Points:

●​ Self-Actualization: The realization of personal potential and creativity. Few people achieve
complete self-actualization.
●​ Motivation: A person’s behavior is dominated by the most pressing unmet need. For instance, a
person with unmet physiological needs will focus on food and shelter over love or esteem.
●​ Regression: People can regress to lower levels in times of crisis, such as health issues or
traumatic events, which may cause them to focus on more immediate survival needs.

Carl Rogers: Client-Centered Therapy

Rogers introduced client-centered therapy, focusing on the client’s active role in the therapeutic process.
Key principles of this therapy include:

1.​ Unconditional Positive Regard: Nonjudgmental care that supports the client regardless of
behavior.
2.​ Genuineness: The therapist’s realness, ensuring that their feelings align with their words and
actions.
3.​ Empathetic Understanding: The therapist deeply understands and communicates the client's
feelings and personal meaning.

Key Points:

●​ Self-Actualization: Rogers, like Maslow, believed that humans naturally strive for
self-actualization, improving their lives and becoming their best selves.
●​ Self-Esteem and Growth: Positive relationships promote self-esteem, which is essential for the
process of self-actualization. Negative or unsupportive relationships hinder growth and can lead
to defensive behavior.
●​ Role of the Therapist: In client-centered therapy, the therapist does not act as an expert but
provides a supportive environment that encourages the client’s self-awareness and growth.

Behavioral Theories

Behaviorism focuses on observable behaviors and how these can be shaped through rewards and
punishments. It rejects the idea of exploring internal mental states and instead emphasizes the external
factors that drive behavior.

Key Concepts:
 ●​ Behavioral Conditioning: Behavior is learned and modified through reinforcement and
punishment. Positive reinforcement encourages desired behavior, while negative reinforcement
discourages undesired behavior.
○​ Positive Reinforcement: A reward that encourages repetition of a behavior (e.g.,
receiving a paycheck for work).
○​ Negative Reinforcement: The removal of an unpleasant stimulus to encourage behavior
(e.g., stopping speeding when a driver receives a ticket).
●​ Impact of Rewards and Punishments: Behaviorism shows how external factors influence
actions. For example, if a person receives a regular paycheck, they are motivated to continue
working. However, if they stop receiving it, they may stop working.

Key Points:

●​ Behavior Change: External consequences (rewards/punishments) influence whether a behavior

will be repeated.
●​ Observable Behavior: Behaviorism does not focus on internal psychological processes but rather
on actions and responses that can be measured and modified.

Ivan Pavlov: Classical Conditioning

Classical Conditioning involves learning through association. Pavlov's experiments with dogs led to his
discovery of how behavior can be conditioned using external stimuli.

●​ Key Experiment: Pavlov rang a bell before presenting food to dogs. Initially, the dogs salivated
only when they saw or smelled food (unconditioned stimulus). After repeated pairings of the bell
(neutral stimulus) with food, the dogs salivated when hearing the bell alone, even without food
(conditioned response).
●​ Key Concepts:
○​ Unconditioned Stimulus (US): Naturally triggers a response (e.g., food).
○​ Conditioned Stimulus (CS): A neutral stimulus that, after repeated pairing with a US,
triggers a conditioned response (e.g., bell).
○​ Conditioned Response (CR): A learned response to the CS (e.g., salivation in response
to the bell).

This concept is important in understanding how certain behaviors (like fears or phobias) can be learned
through association.

B.F. Skinner: Operant Conditioning

Skinner expanded on behaviorism with Operant Conditioning, which explains how behaviors are shaped
by consequences (reinforcements or punishments). Unlike Pavlov, who focused on involuntary responses,
Skinner emphasized voluntary behaviors.

●​ Principles of Operant Conditioning:

 ○​ All behavior is learned: Behavior is influenced by past experiences.
○​ Consequences: Rewards and punishments follow behavior and affect its recurrence.
○​ Reinforcement: Positive or negative reinforcement increases the likelihood that behavior
will occur again.
○​ Continuous Reinforcement: A reward is given every time the behavior occurs,
reinforcing the behavior quickly but with a short-lasting effect.
○​ Intermittent Reinforcement: Random rewards increase behavior longevity, as behavior
continues even after rewards stop.
●​ Applications:
○​ Behavior Modification: Positive reinforcement (e.g., praise for assertiveness) or
negative reinforcement (e.g., removing anxiety by speaking first) encourages desired
behaviors.
○​ Token Economy: Used in group settings (e.g., group homes) to reinforce good behaviors
(e.g., completing tasks) with tokens that can be exchanged for rewards.
○​ Phobia Treatment: Systematic Desensitization gradually exposes clients to
anxiety-provoking situations while they practice relaxation techniques, helping them
manage their fears.

Existential Theories

Existential therapists focus on a person’s struggle with identity, self-awareness, and responsibility. They
argue that individuals can experience psychological problems when they are disconnected from their true
selves or avoid personal responsibility.

●​ Core Ideas:
○​ Self-Alienation: People feel lost, lonely, and disconnected from their own desires or the
world around them.
○​ Responsibility: People need to take responsibility for their thoughts, behaviors, and
choices to live fulfilling lives.
○​ Living Fully in the Present: Emphasis on personal growth by acknowledging current
feelings and focusing on future possibilities.
●​ Existential Therapies:
○​ Rational Emotive Therapy (Albert Ellis): Focuses on confronting irrational beliefs that
prevent self-acceptance.
○​ Logotherapy (Viktor Frankl): Encourages finding meaning in life through personal
responsibility.
○​ Gestalt Therapy (Frederick Perls): Emphasizes identifying feelings in the present to
foster self-acceptance.
○​ Reality Therapy (William Glasser): Focuses on responsible behavior to achieve life
goals.
Cognitive Therapy

Cognitive Therapy, pioneered by Aaron Beck, emphasizes how a person’s thought patterns influence
emotions and behavior. By changing maladaptive thoughts, people can improve their emotional and
behavioral responses.

●​ Core Ideas:
○​ Thought-Emotion Link: People’s emotions and behaviors are influenced by how they
interpret situations.
○​ Cognitive Distortions: Unhelpful thought patterns, such as catastrophizing or
overgeneralizing, contribute to mental health issues like depression.
○​ Treatment Goal: To identify and change distorted thinking patterns to improve
emotional regulation and behavior.

Rational Emotive Therapy (RET) – Albert Ellis

RET focuses on identifying and challenging irrational beliefs that cause emotional distress.

●​ Irrational Beliefs: Ellis identified 11 common irrational beliefs (e.g., “If I love someone, they
must love me back equally”). These beliefs lead to unhappiness and blaming others.
●​ ABC Technique:
○​ A: Activating Event (e.g., conflict in a relationship).
○​ B: Belief (e.g., the irrational thought).
○​ C: Consequence (e.g., emotional distress).
●​ Goal: Change irrational beliefs and automatic negative thoughts that lead to emotional
difficulties.

Logotherapy – Viktor Frankl

Frankl developed logotherapy, focusing on finding meaning in life, especially in extreme situations like
his experience in Nazi concentration camps.

●​ Key Concept: The search for meaning (logos) is central to mental well-being.
●​ Application: In therapy, Frankl helps individuals find meaning in their suffering, guiding them to
see their life's purpose even in dire circumstances.
●​ Relevance: Often used in spirituality, grief counseling, and existential crises.

Gestalt Therapy – Fritz Perls

Gestalt therapy encourages awareness of present feelings and thoughts to foster self-acceptance and
responsibility.
 ●​ Focus: The "here and now," meaning living in the present rather than dwelling on the past.
●​ Methods: Therapists may use activities such as writing letters, journaling, or role-playing to
increase awareness and self-acceptance.
●​ Goal: Help individuals resolve past issues and increase self-awareness in the present moment.

Reality Therapy – William Glasser

Reality therapy focuses on personal responsibility and the behaviors that hinder achieving life goals.

●​ Core Idea: Individuals are responsible for their own actions and need to examine how their
behavior affects their ability to reach goals.
●​ Focus: Examines how behavior prevents goal achievement and encourages responsible
decision-making.
●​ Application: Used for individuals with delinquent behaviors, emotional issues, or poor school
performance.

Crisis Intervention

Crisis intervention aims to help individuals cope with overwhelming emotional responses to life stressors.

●​ Crisis Definition: A crisis is a turning point that disrupts a person’s normal coping mechanisms,
leading to emotional distress.
●​ Types of Crises:
○​ Maturational Crises: Predictable events (e.g., marriage, childbirth).
○​ Situational Crises: Sudden, unexpected events (e.g., death, job loss).
○​ Adventitious Crises: Social crises such as natural disasters or violence.
●​ Resolution: Crisis is usually temporary (4–6 weeks) and can result in:
○​ Returning to pre-crisis functioning.
○​ Functioning at a higher level.
○​ Stabilizing at a lower level, a negative outcome.
●​ Intervention Techniques:
○​ Directive Interventions: Promote problem-solving, raise self-awareness, and offer
guidance.
○​ Supportive Interventions: Provide empathy, encourage emotional expression, and affirm
self-worth.
●​ Outcome: Early intervention and clear definition of the crisis lead to better recovery outcomes.
Effective crisis intervention often involves a balance of both directive and supportive strategies.

Cultural Considerations in Psychosocial Theories

●​ Psychosocial Theorists: Many major theorists (e.g., Erikson) were white and from Western
cultures, which may not apply to people from diverse racial, ethnic, or cultural backgrounds.
 ●​ Erikson's Stages: For example, Erikson's emphasis on autonomy for toddlers may not be suitable
for cultures where independence is not a primary developmental milestone.
●​ Nurse’s Role: Nurses must be cautious not to make faulty assumptions when working with
individuals from different cultural backgrounds. Understanding cultural factors is essential for
providing effective care.

Treatment Modalities

Benefits of Community Mental Health Treatment:

●​ Shift to Outpatient Care: Recent changes emphasize outpatient care due to its effectiveness and
cost-efficiency. This allows individuals to remain in the community and maintain relationships
while receiving treatment.
●​ Inpatient Care: Advised for severe cases (e.g., suicidal depression, psychosis) where close
supervision is necessary.

Individual Psychotherapy:

●​ Purpose: A one-on-one relationship between therapist and client aimed at helping individuals
explore their feelings, behaviors, and relationships to foster personal growth and emotional relief.
●​ Phases: Similar to nurse-client relationships: introduction, working phase, and termination.
●​ Choosing a Therapist: The therapist’s theoretical approach should align with the client’s needs,
and the client may need to try several therapists before finding a good fit. It is crucial to verify
therapists’ credentials.

Group Therapy and Group Development

Group Definition: A group involves individuals working together to accomplish a task or therapeutic
goal. The dynamics of how members interact (group process) are crucial to group success.

●​ Group Content: What is said within the group (e.g., educational material, emotions).
●​ Group Process: How members interact with each other (e.g., seating arrangements, tone of
voice).

Stages of Group Development:

1.​ Pregroup Stage: The group is formed, the purpose is identified, and structure is established.
2.​ Initial Stage: Members introduce themselves and set group expectations.
3.​ Working Stage: The group focuses on its task or purpose. Trust is built, and members begin
sharing more openly. Group cohesiveness, where members work cooperatively, leads to positive
outcomes.
 4.​ Termination Stage: The group reviews accomplishments and closes. The group may disband
after achieving its goals.

Group Leadership:

●​ Formal Leaders: Appointed based on qualifications, particularly in therapy and educational

groups.
●​ Informal Leaders: May emerge based on respect from group members.
●​ Leader’s Role: A good leader encourages participation, clarifies thoughts, and helps manage
group dynamics.

Group Roles:

●​ Growth-Producing Roles: Help facilitate the group's success, such as information seekers or
encouragers.
●​ Growth-Inhibiting Roles: Can hinder group progress, such as monopolizers or critics.

Group Therapy:

●​ Purpose: Involves individuals with a common goal (e.g., coping with mental health issues).
Group rules are established, and members are expected to contribute and receive feedback.
●​ Learning Outcomes: Clients develop interpersonal skills and gain insights into how others
perceive them. This is crucial for individuals with mental health disorders who struggle with
social interactions.

Cultural Considerations

Psychosocial theories, such as those proposed by Erikson, may not be universally applicable across
different racial, ethnic, or cultural groups. For instance, Erikson's focus on autonomy and independence
for toddlers may not align with cultures that emphasize communal living and interdependence in early
childhood. Nurses should be mindful of these cultural differences and avoid assumptions when working
with clients from diverse backgrounds.

Treatment Modalities

Benefits of Community Mental Health Treatment

The trend toward community-based mental health care is driven by cost-effectiveness and the
understanding that individuals benefit from remaining integrated in their communities. Outpatient
treatment allows individuals to maintain relationships, continue working, and build upon lifelong coping
skills, communication, and self-esteem. Inpatient care is reserved for clients in more acute distress, such
as those who are severely suicidal or psychotic.

Individual Psychotherapy
Individual psychotherapy helps clients explore their feelings, attitudes, and behaviors to foster personal
change. A strong therapist-client relationship is essential for success, and clients should carefully select
therapists whose approach aligns with their needs. There are various types of therapists, and it is crucial to
verify their credentials before starting therapy.

Group Therapy

In group therapy, individuals with similar issues work together, supporting each other and providing
feedback. Group therapy can help individuals gain insight, develop interpersonal skills, and understand
how their behaviors affect others. Groups can vary in structure (open or closed) and purpose (e.g.,
psychotherapy, education, support).

Key stages of group development include:

1.​ Pregroup: Selection of members, purpose, and structure.

2.​ Initial stage: Members introduce themselves, discuss the group's purpose, and establish
expectations.
3.​ Working stage: The group focuses on its purpose, develops cohesiveness, and members begin to
share and solve problems.
4.​ Termination stage: The group reviews its progress and prepares to disband.

Types of Groups

●​ Psychotherapy groups: These are often structured with a therapist leading and may be open or
closed.
●​ Family therapy: Involves the family in the treatment process to address dynamics contributing to
the client’s issues.
●​ Family education: Programs like NAMI’s Family-to-Family course help family members
understand and cope with mental illness.
●​ Education groups: These focus on imparting specific information, such as stress management or
medication management.
●​ Support groups: These allow individuals with shared problems to support one another in a safe,
non-judgmental environment.
●​ Self-help groups: These are informal groups where members with common experiences help
each other, such as Alcoholics Anonymous.

Complementary and Alternative Therapies (CAM)

The NCCIH investigates CAM therapies to determine their safety and effectiveness. These therapies can
be used alongside conventional treatment (complementary) or in place of it (alternative). Examples
include mindfulness-based stress reduction (MBSR), acupuncture, and herbal therapies. Nurses should
inquire about CAM use in a non-judgmental way to ensure comprehensive care.

Psychiatric Rehabilitation
Psychiatric rehabilitation helps individuals with severe and persistent mental illness live in the community
by focusing on their strengths rather than just the illness. These programs, often called community support
services, involve the client in planning their rehabilitation and aim to help them manage symptoms, access
services, and lead independent lives. Key components of psychiatric rehabilitation include assistance with
activities of daily living, social support, vocational training, and education about the illness and treatment.
Programs also provide safe spaces for socialization and help clients engage in community life.

Clients are encouraged to actively participate in setting goals for their rehabilitation. This helps ensure
that services meet their most important needs, which can improve their quality of life and recovery
outcomes. Peer mentoring, counseling, and advocacy are increasingly common in these programs, with
consumer-run programs on the rise. Mental health rehabilitation is a key element in the recovery process,
as discussed in later chapters.

The Nurse and Psychosocial Interventions

Psychosocial interventions are key nursing activities aimed at improving social and psychological
functioning. These interventions are not limited to mental health settings but apply across all areas of
nursing practice. For example, a nurse on a medical–surgical unit might use behavioral strategies like
limit setting to manage manipulative behavior or provide positive reinforcement for patient efforts, such
as when a client with diabetes requests a piece of cake.

Understanding various psychosocial theories and treatment modalities helps nurses select the most
appropriate interventions for clients. Specific interventions for different mental disorders will be detailed
in later chapters.

Telehealth Care Delivery

Telehealth is becoming an increasingly popular method of delivering therapy, particularly to younger

adults, due to its convenience, cost-effectiveness, and flexibility. Research is ongoing to compare the
effectiveness of telehealth versus traditional methods of care, focusing on privacy, communication,
empathy, rapport-building, and therapy outcomes.

Self-Awareness Issues for Nurses

Nurses must reflect on their own beliefs about psychosocial theories and treatment approaches,
understanding that different approaches may work for different clients. The nurse’s personal opinions
should not interfere with the therapeutic process. For example, if a nurse believes that weight loss is
necessary for an overweight client but the client is working on self-acceptance instead, the nurse’s role is
to support the client's goals, even if they differ from the nurse’s personal beliefs.

Nurses must be open to a variety of treatment approaches, as no single theory can address all human
behavior. The client’s feelings, perceptions, and goals are the most important factors in determining the
effectiveness of interventions.

CHAPTER 7
Introduction to Nursing Philosophies

●​ Biopsychosocial Model: Individuals are unique beings influenced by biological, psychological,

and social factors. Nurses assess these factors to plan personalized care.
●​ Cultural Influence: Culture affects health, illness, and treatment responses. Cultural diversity
refers to the vast differences among populations, which can shape responses to illness.
●​ Individual Responses to Illness: The way people cope with illness involves complex interactions
between personal, interpersonal, and cultural factors.

2. Key Individual Factors in Health and Illness

●​ Age and Development:

○​ Age affects illness response (e.g., schizophrenia prognosis varies with age of onset).
○​ Younger people may have less coping experience and a less developed sense of identity.
○​ Developmental stage influences illness expression, e.g., children with ADHD may have
difficulty articulating symptoms.
●​ Erikson’s Psychosocial Development:
○​ Stages: Each stage involves specific tasks necessary for emotional and psychological
well-being. Unresolved issues from earlier stages affect future coping mechanisms.
○​ Critical Tasks in Early Life: For example, infants must develop trust in caregivers to
form healthy relationships later in life.

3. Erikson’s Stages of Psychosocial Development

●​ Trust vs. Mistrust (Infancy): Developing trust in caregivers and the world.
●​ Autonomy vs. Shame/Doubt (Toddler): Gaining a sense of independence and control.
●​ Initiative vs. Guilt (Preschool): Developing a conscience and managing emotions.
●​ Industry vs. Inferiority (School-age): Building confidence and skills.
●​ Identity vs. Role Diffusion (Adolescence): Establishing a clear sense of self and belonging.
●​ Intimacy vs. Isolation (Young Adult): Forming meaningful relationships and connections.
●​ Generativity vs. Stagnation (Middle Adult): Contributing to society and guiding the next
generation.
●​ Ego Integrity vs. Despair (Maturity): Reflecting on life with acceptance or regret.

4. Adult Growth and Development Tasks

●​ Young Adult (25–45 years): Tasks include achieving independence, forming intimate
relationships, and establishing a career.
●​ Middle Adult (45–65 years): Tasks include maintaining relationships, coping with life
transitions, and contributing to society.
 ●​ Older Adult (65+ years): Tasks include preparing for retirement, managing health changes, and
finding meaning in life after retirement.

5. Implications for Nursing

●​ Assess Developmental Stages: Nurses should assess if clients are facing unresolved
developmental tasks. This could influence their response to illness.
●​ Tailored Care: Understanding a client’s psychosocial development helps nurses tailor
interventions that are sensitive to the client’s life stage and psychological needs.
●​ Support Emotional Health: Nurses must support clients through developmental tasks (e.g.,
identity formation in adolescence or maintaining meaningful relationships in adulthood) to
promote recovery and well-being.

. Genetics and Biologic Factors

●​ Genetic Influence: Heredity plays a key role in determining predispositions to various disorders,
including Alzheimer’s and mental health disorders like bipolar disorder, depression, and
alcoholism. While genetic links to some conditions are known, research is ongoing.
●​ Family History: A family history of certain disorders can provide essential information during
nursing assessments, as genetic makeup affects how individuals respond to illness and treatment.

2. Physical Health and Health Practices

●​ Impact on Coping: Physical health influences the ability to cope with illness. For example, poor
nutrition, sleep deprivation, or chronic illness can impair coping mechanisms. Nurses should
assess the client’s physical health, even when treating mental health conditions.
●​ Health Practices: Personal health practices, such as exercise, have positive effects on mental
health by reducing depression and anxiety. Social engagement in physical activities also enhances
social support and well-being.

3. Response to Drugs

●​ Biologic Differences and Drug Metabolism: Biologic differences, including ethnicity, affect
how individuals metabolize psychotropic drugs. Some ethnic groups metabolize drugs more
slowly, which can increase side effects and the need for adjusted dosages. Nurses must monitor
drug efficacy, side effects, and serum drug levels.

4. Self-Efficacy
 ●​ Definition: Self-efficacy refers to the belief that one’s actions can influence life outcomes. High
self-efficacy leads to greater motivation, stress management, and goal-setting, while low
self-efficacy is associated with anxiety, depression, and self-doubt.
●​ Improving Self-Efficacy:
○​ Success Experience: Mastery in overcoming obstacles enhances confidence.
○​ Social Modeling: Observing others succeed can inspire belief in personal success.
○​ Social Persuasion: Encouragement boosts confidence.
○​ Stress Management: Learning to manage stress and interpret physical sensations
positively (e.g., viewing fatigue as accomplishment).
●​ Impact on Recovery: Clients with higher self-efficacy are more confident and have better social,
coping, and functional skills, enhancing recovery outcomes.

5. Hardiness

●​ Definition: Hardiness is the ability to cope with stress and illness. It consists of three
components:
○​ Commitment: Involvement in life activities.
○​ Control: Decision-making ability in life situations.
○​ Challenge: Viewing change as an opportunity for growth.
●​ Moderating Stress: High hardiness is associated with better coping with stress. People with high
hardiness may handle stressful life events better than those with low hardiness.
●​ Limitations: Hardiness may be more beneficial for individuals who value individual achievement
and independence. In cultures that prioritize relationships, hardiness may not be as useful.

6. Resilience and Resourcefulness

●​ Resilience: The ability to respond healthily to stress. Resilience explains why some individuals
cope well with stress while others may be overwhelmed.
○​ Family Resilience: Involves positive outlooks, communication, flexibility, support, and
shared activities within the family unit.
○​ Mental Health Benefits: Resilience promotes mental health and helps individuals
flourish, even in stressful situations.
●​ Resourcefulness: The ability to solve problems and believe in one’s capacity to cope with new or
adverse situations.
○​ Development: Resourcefulness develops through life experiences and social interactions.
○​ Examples: Engaging in self-care, monitoring emotions, and taking proactive actions to
address stressful situations.

Implications for Nursing Practice

 ●​ Nurses should assess not only the client’s medical condition but also their genetic background,
physical health, and psychosocial factors like self-efficacy, resilience, and resourcefulness. This
holistic approach ensures more personalized and effective care.

Spirituality

●​ Definition: Spirituality encompasses a person's essence, beliefs about life's meaning, and
purpose. It may involve belief in a higher power, religious practices, cultural beliefs, and a
connection with the environment.
●​ Role in Mental Health:
○​ Spirituality can provide comfort, especially for those with mental disorders, helping them
cope with stress and illness.
○​ Religious practices like prayer or attending religious services, along with social support,
are linked to better health outcomes and mental well-being.
○​ Hope and Faith: Hope has been identified as a key factor in reducing symptoms and
aiding in recovery from psychiatric and physical conditions. People with more hope
experience fewer symptoms, while hopelessness correlates with worsening symptoms.
○​ Nursing Implication: Nurses should respect and incorporate clients' spiritual and
religious practices into care plans, as these practices often provide comfort and support.

2. Interpersonal Factors

●​ Sense of Belonging:
○​ Definition: A sense of belonging refers to feeling valued and accepted within a social
system or environment.
○​ Maslow's Hierarchy: Belonging is a basic psychosocial need and is crucial for
psychological and social well-being. It involves:
■​ Value: Feeling needed and accepted.
■​ Fit: Feeling that one meshes well with the group.
○​ Impact on Health: A strong sense of belonging promotes health, decreases anxiety, and
fosters a sense of purpose and productivity. Lack of belonging can impair mental and
physical health.
○​ Nursing Implication: Nurses should foster environments that enhance clients' sense of
belonging, promoting feelings of value and inclusion.

3. Social Networks and Social Support

●​ Social Networks: These are groups of people with whom an individual feels connected. Strong
networks are associated with better stress coping abilities and overall health.
●​ Social Support:
 ○​ Definition: Emotional and practical assistance provided by friends, family, and
healthcare providers. It is more than just social contact; it involves genuine emotional
sustenance.
○​ Impact on Health: Emotional and functional social support improves health and
well-being outcomes, especially when the support system responds to requests for help.
○​ Effective Support: For support to be effective, the client must feel that it boosts their
confidence and meets their needs. The support system must be responsive and align with
the client’s expectations and desires.
○​ Nursing Implication: Nurses should help clients identify reliable sources of support and
encourage them to seek assistance when needed.

4. Family Support

●​ Role of Family: Family can be a vital source of social support in the recovery process for
individuals with mental illness. While family dynamics may not always be positive, they often
play an essential role in recovery.
●​ Nursing Implication: Nurses should encourage continued family involvement, even when clients
are hospitalized, and recognize family strengths as key resources for recovery. Support from
family members can significantly impact the client's well-being and progress.

Key Takeaways for Nursing Practice

●​ Spirituality and Religion: Respecting and integrating clients’ spiritual or religious beliefs into
care plans can enhance coping and provide emotional support.
●​ Belonging and Social Networks: Enhancing clients' sense of belonging and encouraging strong
social networks and support systems are critical for mental and physical health.
●​ Family Involvement: Nurses should support and facilitate family involvement, as family support
is often integral to the recovery process.

Culturally Competent Care

●​ Definition: Culturally competent care involves being sensitive to and knowledgeable about
factors such as culture, race, gender, sexual orientation, social class, and economic status. It
means providing care that respects the cultural differences and beliefs of clients.
●​ Importance: The U.S. population is diverse, and health care providers need to understand
different cultural practices and beliefs to offer holistic and meaningful care.
●​ Nursing Implication: Nurses must continuously learn about other cultures and apply that
knowledge to patient care, ensuring the client’s cultural needs and preferences are met.

2. Beliefs About Causes of Illness

 ●​ Cultural Influence on Health: Culture shapes beliefs about what causes illness. Common
cultural views:
○​ Unnatural/Personal Causes: Illness is seen as the result of an external agent, spirit, or
supernatural force.
○​ Natural Causes: Illness is attributed to natural conditions, such as environmental factors
(cold, heat, dampness).
●​ Impact on Treatment: Clients with these beliefs may prefer traditional remedies over Western
medicine.
●​ Stigma: Mental illness may carry shame, and seeking help might be seen as a weakness or
failure, especially for issues like suicidal ideation.

3. Factors in Cultural Assessment (Giger's Model)

●​ Giger’s model identifies six factors to consider when conducting cultural assessments:
1.​ Communication
2.​ Physical Distance or Space
3.​ Social Organization
4.​ Time Orientation
5.​ Environmental Control
6.​ Biologic Variations

4. Communication

●​ Verbal and Nonverbal Differences:

○​ Language barriers may complicate verbal communication.
○​ Nonverbal cues, such as eye contact and touch, vary across cultures. For instance, while
some cultures value direct eye contact, others may perceive it as rude.
●​ Nursing Implication: Nurses must understand the meaning of nonverbal cues in different
cultures and adjust communication styles accordingly.

5. Physical Distance or Space

●​ Cultural Variation: Comfort with personal space varies. Some cultures prefer close proximity
during interactions, while others may require more space.
●​ Nursing Implication: Nurses should be aware of clients' comfort zones and adjust their physical
distance during interactions.

6. Social Organization
 ●​ Family and Social Structures: Cultural values influence decision-making, with some cultures
prioritizing family input over individual autonomy.
●​ Nursing Implication: Nurses should involve family when appropriate, respecting the client's
cultural preferences in decision-making.

7. Time Orientation

●​ Cultural Differences: Cultures may view time differently, with some emphasizing punctuality
and others taking a more flexible approach.
●​ Nursing Implication: Nurses should not label clients as noncompliant for missing appointments
or not adhering to strict timelines if their cultural orientation to time is different.

8. Environmental Control

●​ Control Over Health: Some clients may believe that they have control over their health, while
others may attribute illness to natural causes or supernatural forces.
●​ Nursing Implication: Nurses should assess clients’ beliefs about control over health and tailor
their approach to treatment and care accordingly.

9. Biologic Variations

●​ Cultural and Ethnic Variations: There are biological differences among people from different
cultural backgrounds that affect health, such as varying responses to medications.
○​ Examples: Sickle cell anemia in African Americans, Tay-Sachs disease in the Jewish
community.
●​ Nursing Implication: Nurses should be aware of potential biological variations and their impact
on health care, particularly in terms of drug responses and genetic conditions.

10. Socioeconomic Status and Social Class

●​ Socioeconomic Factors: Income, education, and occupation influence a person’s health, access to
care, and ability to follow treatment plans.
●​ Impact of Social Class: While social mobility is common in the U.S., in other cultures (e.g.,
India), social class can rigidly define health care access and social interactions.
●​ Nursing Implication: Nurses should assess the impact of socioeconomic status and social class
on a client’s ability to access health care and adhere to treatment recommendations.
Key Takeaways for Nursing Practice

●​ Cultural Competency: Nurses must be culturally aware and capable of providing care that
respects clients’ cultural values, traditions, and health beliefs.
●​ Assessment Tools: Using models like Giger’s cultural assessment factors ensures nurses consider
all aspects of a client's cultural background.
●​ Holistic Care: Incorporating cultural beliefs into care plans promotes trust, improves patient
satisfaction, and enhances outcomes.

Cultural Patterns and Differences

●​ Cultural Awareness: Knowledge of cultural patterns helps nurses understand clients from
diverse backgrounds, but it’s important to remember that there is significant variation within any
culture.
●​ Client-Centered Care: Nurses should avoid assuming that all clients from a particular culture
follow the same practices or beliefs. The nurse must ask the client directly about their preferences
and health practices.
●​ Importance of Individual Assessment: Each person and family may have different beliefs and
practices, so individualized assessments are necessary to ensure culturally competent care.

2. Nurse's Role in Working with Clients of Various Cultures

●​ Gathering Cultural Information: The nurse must ask the client about their cultural values,
beliefs, and health practices. Questions like, “What do you expect me to do for you?” or “How
would you like to be cared for?” help the nurse understand client preferences.
●​ Communication: Nurses should pay attention to the client’s preferences regarding greetings, eye
contact, and physical distance. The nurse should adjust their approach based on the client's
behavior—for example, returning a handshake if the client offers one, or refraining if not.
●​ Health Practices and Religious Beliefs: Nurses must inquire about dietary preferences, religious
or spiritual practices, and health and illness beliefs (e.g., “What kinds of remedies have you
tried?”).
●​ Avoid Assumptions: Nurses must avoid assuming that all clients from the same culture share the
same values or health practices. It is essential to ask each client individually about their specific
needs and preferences.

3. Cultural Awareness and Sensitivity

●​ Avoiding Assumptions: It’s critical not to assume a client’s preferences based on cultural
generalizations or the nurse’s own cultural experiences. Asking the client directly fosters respect
and better care.
 ●​ Open and Objective Approach: Clients are more likely to share their personal and cultural
information if the nurse is genuinely interested and non-judgmental. This approach encourages
trust and open communication.
●​ Variability Within Cultures: Even within the same culture, individuals may have different
beliefs and practices, so the nurse should not assume that clients from the same background think
or act the same way.

4. Best Practices for Cultural Competence

●​ Organizational Tools for Cultural Competence: Tools like the Cultural Competence
Organizational Review can help healthcare organizations assess their cultural competence,
identify gaps, and ensure that cultural initiatives are effectively integrated into practice.
●​ Commitment to Cultural Competence: Organizations and healthcare providers must commit to
using these tools to improve cultural competence and enhance the quality of care provided to
diverse populations.

5. Self-Awareness Issues

●​ Influencing Factors: The nurse must be aware of various factors influencing a client's response
to illness, including biological, interpersonal, and cultural factors.
●​ Emotional Responses and Biases: Nurses may feel anxious or worried about offending clients
from different cultures. It’s important to recognize and address these feelings, as well as any
stereotypes or misconceptions, to provide effective care.
●​ Building Cultural Competence: Nurses with limited experience working with diverse groups
should seek opportunities for education, reflection, and discussion with colleagues to improve
cultural awareness and sensitivity.

6. Points to Consider When Working with Individual Responses to Illness

●​ Genuine Caring Attitude: Approach each client with compassion and respect for their unique
cultural and personal perspectives on health and illness.
●​ Addressing Preferences Early: At the beginning of the interaction, ask the client how they
prefer to be addressed and how you can support their spiritual, religious, and health practices.
●​ Identifying Negative Feelings: If negative stereotypes or biases arise, nurses should discuss
these feelings with colleagues to challenge and dispel misconceptions, ensuring that their practice
remains respectful and culturally competent.

Key Takeaways for Nursing Practice

 ●​ Cultural Sensitivity: Always ask the client about their specific cultural needs and preferences
rather than making assumptions based on cultural norms.
●​ Non-Judgmental Approach: Maintain an open, objective, and non-judgmental attitude to foster
trust and encourage clients to share their cultural practices and health beliefs.
●​ Cultural Competence is Ongoing: Nurses must continuously reflect on and improve their
cultural competence through education, self-awareness, and collaboration with colleagues.

CHAPTER 8

1. Introduction to Psychosocial Assessment

●​ Purpose: The psychosocial assessment in psychiatric nursing helps to evaluate the client's
emotional state, mental capacity, and behavioral function. It serves as a clinical baseline and
guides the development of a care plan.
●​ Mental Status Examination: This is a key part of the psychosocial assessment, providing
insights into the client’s current mental health condition and serving as a foundation for treatment
evaluation.

2. Factors Influencing the Assessment

●​ Client Participation: Active participation is necessary for a thorough assessment. Mental

conditions like depression, psychosis, or cognitive impairments may limit the client’s ability to
engage fully in the process.
●​ Health Status: Physical conditions like pain, anxiety, or fatigue can hinder a client’s ability to
provide complete or accurate information. The nurse must address these issues to ensure a valid
assessment.
●​ Previous Experiences: Past negative experiences with healthcare may affect a client’s
willingness to participate. These perceptions can lead to underreporting or exaggerating
symptoms.
●​ Client’s Ability to Understand: Communication barriers such as language differences or hearing
impairments must be considered, as they can lead to misunderstandings or inaccurate information
being provided.
●​ Nurse’s Attitude: A nurse’s tone and approach can greatly influence the assessment. If the nurse
is perceived as rushed, judgmental, or nonaccepting, the client may withhold important
information. A supportive, nonjudgmental approach is key to gathering accurate data.

3. Conducting the Interview

●​ Environment: The setting should be quiet, private, and comfortable to minimize distractions and
foster trust. Safety should also be a priority, especially if the client has a history of threatening
behavior.
 ●​ Family and Friends’ Input: If available, input from family or friends can be valuable. However,
the nurse should ensure privacy, particularly in cases of suspected abuse. If the client does not
consent to speaking with family separately, the nurse must respect their wishes and work within
these constraints.
●​ Open-Ended Questions: Starting with broad, open-ended questions allows the client to share
their experience in their own words. Examples include:
○​ "What brings you here today?"
○​ "Tell me what has been happening to you."
○​ "How can we help you?"
●​ Focused Questions: If the client struggles to answer broad questions, more direct and specific
questions should be used. These should focus on one issue at a time to prevent confusion.
Examples:
○​ "How many hours did you sleep last night?"
○​ "Have you been thinking about suicide?"
○​ "What over-the-counter medications are you taking?"
●​ Nonjudgmental Approach: The nurse must ask sensitive questions in a neutral, nonjudgmental
tone to avoid causing the client to become defensive. For example:
○​ Instead of asking, “How often do you physically punish your child?” ask, “What types of
discipline do you use?”

4. Best Practices for Conducting the Psychosocial Assessment

●​ Client Comfort and Privacy: Ensure the environment is private and free of distractions,
especially in sensitive cases.
●​ Respecting Client Autonomy: Allow the client to lead the conversation where possible, and use
their responses to guide further questions.
●​ Clear and Focused Questions: Use simple, clear questions to help clients express themselves.
Avoid overwhelming them with multiple questions at once.
●​ Maintain a Nonjudgmental Attitude: Approach all sensitive topics, such as abuse or substance
use, in a factual, non-accusatory manner to promote honest disclosure.

Key Takeaways for Nursing Practice

●​ Effective Communication: Tailor questions to the client’s needs, adjusting from open-ended to
closed-ended questions as necessary.
●​ Client-Centered Care: A successful psychosocial assessment depends on active client
participation, a supportive environment, and the nurse’s ability to manage factors such as anxiety,
pain, or cognitive impairments.
●​ Privacy and Safety: Ensure that the environment is safe and conducive to open communication,
especially in situations involving potential abuse or intimidation.
1. Importance of Communication

●​ Building Trust: Before beginning the assessment, it is essential to address the client’s feelings
and perceptions to create a trusting relationship. This helps establish a safe environment where
the client feels comfortable sharing personal information.

2. Components of the Psychosocial Assessment

●​ The psychosocial assessment involves several key areas, each of which provides valuable insights
into the client’s mental health and functioning. The components are organized systematically to
ensure thorough assessment:
1.​ History
2.​ General appearance and motor behavior
3.​ Mood and affect
4.​ Thought process and content
5.​ Sensorium and intellectual processes
6.​ Judgment and insight
7.​ Self-concept
8.​ Roles and relationships
9.​ Physiologic and self-care concerns

3. History

●​ Age & Developmental Stage: The nurse assesses the client’s age and developmental level. For
example, struggles with personal identity in a 17-year-old may be normal, but if a 35-year-old
client is facing similar challenges, further exploration is needed.
●​ Cultural & Spiritual Beliefs: The nurse must consider cultural and spiritual factors to avoid
stereotypes and ensure culturally sensitive care.
●​ Health Beliefs: The client’s beliefs about health and illness, such as views on mental health
treatment or medication, influence the assessment and care planning.

4. General Appearance and Motor Behavior

●​ Appearance: The nurse evaluates the client’s hygiene, grooming, dress, posture, eye contact, and
overall appearance.
○​ Automatisms: Repeated behaviors like tapping fingers or twisting hair, often due to
anxiety.
○​ Psychomotor Retardation: Slow movements indicating possible depression or other
issues.
 ○​ Waxy Flexibility: A condition where the client maintains an awkward or uncomfortable
position for extended periods.
●​ Speech: The nurse assesses the client’s speech for:
○​ Quantity (e.g., talkative or minimal responses)
○​ Quality (e.g., fluent or hesitant)
○​ Abnormalities (e.g., neologisms, stuttering, or perseveration)

5. Mood and Affect

●​ Mood: Describes the client’s prevailing emotional state, such as sadness, anxiety, or euphoria.
●​ Affect: Refers to the outward expression of mood, which may not always align with the client’s
verbal expressions.
○​ Blunted Affect: Little emotional expression.
○​ Broad Affect: Full range of emotional expressions.
○​ Flat Affect: No facial expression.
○​ Inappropriate Affect: Emotional expression does not match the situation.
○​ Restricted Affect: Limited emotional expression, often serious or somber.
●​ Labile Mood: Rapid mood swings with no apparent stimuli.
●​ Mood Rating: To assess mood intensity, nurses can ask clients to rate their mood on a scale from
1 to 10.

6. Thought Process and Content

●​ Content: What the client is thinking about.

●​ Process: How the client is thinking, including:
○​ Clarity of ideas (e.g., organized vs. disorganized thinking)
○​ Self-harm or suicide urges
●​ Cognitive Functioning: The nurse also assesses whether thoughts are coherent, logical, and
connected to the present situation.

7. Sensorium and Intellectual Processes

●​ Orientation: Assess whether the client is aware of time, place, and person.
●​ Memory: Evaluates short-term and long-term memory.
●​ Sensory Disturbances: The nurse asks about any abnormal sensory experiences or
misperceptions, such as hallucinations.
●​ Concentration & Abstract Thinking: The ability to focus and understand complex ideas are
assessed.
8. Judgment and Insight

●​ Judgment: The ability to interpret and respond appropriately to situations.

●​ Insight: The client’s understanding of their own condition and behaviors.

9. Self-Concept

●​ Personal View of Self: How the client views their identity and physical appearance.
●​ Qualities: Attributes or personal characteristics that the client identifies with.

10. Roles and Relationships

●​ Roles: The client’s current social roles (e.g., parent, employee, spouse) and their satisfaction with
these roles.
●​ Significant Relationships: Quality of relationships with family, friends, and others.
●​ Support Systems: The presence of supportive people or groups in the client’s life.

11. Physiologic and Self-Care Concerns

●​ Eating and Sleep Patterns: Any disturbances in eating or sleep habits.

●​ Health Problems: Existing medical conditions and how they impact the client’s mental health.
●​ Medication Compliance: Whether the client is following prescribed treatments.
●​ Activities of Daily Living: The client’s ability to perform daily tasks like bathing, dressing, and
eating independently.

Key Takeaways for Nursing Practice

●​ Holistic Approach: The psychosocial assessment is comprehensive, addressing both mental and
physical health.
●​ Cultural Sensitivity: Understanding cultural, spiritual, and health beliefs is crucial for providing
effective care.
●​ Observations and Documentation: The nurse must be objective and specific when documenting
behavior, using clear descriptions to avoid misinterpretation or bias.

Thought Process and Content

●​ Thought Process: Refers to the manner in which the client thinks, inferred from their speech and
speech patterns.
 ●​ Thought Content: Refers to what the client says. It assesses the logical flow of their thoughts,
whether ideas are related and coherent.
●​ Common terms for thought process and content:
○​ Circumstantial Thinking: The client eventually answers the question after providing
unnecessary details.
○​ Delusion: A false, fixed belief that isn’t grounded in reality.
○​ Flight of Ideas: Rapid, fragmented speech with unrelated ideas.
○​ Ideas of Reference: Misinterpreting general events as personally directed.
○​ Loose Associations: Thoughts that jump from one to another with little relation.
○​ Tangential Thinking: The client goes off-topic without answering the original question.
○​ Thought Blocking: A sudden stop in the middle of a sentence or thought.
○​ Thought Broadcasting: Belief that others can hear or know the client’s thoughts.
○​ Thought Insertion: Belief that others are implanting thoughts in the client’s mind.
○​ Thought Withdrawal: Belief that others are stealing the client’s thoughts.
○​ Word Salad: A jumble of words with no meaningful connection.

Suicide or Harm Assessment

●​ Nurses assess suicide risk by directly asking questions such as:

○​ Ideation: “Are you thinking about killing yourself?”
○​ Plan: “Do you have a plan to kill yourself?”
○​ Method: “How do you plan to do this?”
○​ Access: “Do you have the means to carry out your plan?”
○​ Where: “Where would you do this?”
○​ When: “When do you plan to do this?”
○​ Timing: “What day or time do you plan to kill yourself?”
●​ When clients express anger or threats toward others, nurses assess whether the client has thoughts
or plans to harm them by asking similar questions about that person.​
If a threat is specific, healthcare providers are legally obligated to warn the target of the threat
(duty to warn), even if it means breaching confidentiality.

Sensorium and Intellectual Processes

●​ Orientation: The client’s awareness of person, place, and time is documented as “oriented × 3.”
Loss of orientation begins with time, followed by place, and finally, person. It is not synonymous
with confusion, which reflects difficulty understanding one’s surroundings.
●​ Memory: Assessed through verifiable questions like asking about current or past presidents, the
client’s address, or social security number.
●​ Ability to Concentrate: Assessed through tasks such as spelling words backward, serial sevens
(subtracting 7 from 100), or repeating days of the week in reverse.
●​ Abstract Thinking and Intellectual Abilities: Nurses assess abstract thinking by asking the
client to interpret proverbs or explain similarities between objects (e.g., comparing an apple and
an orange).

Sensory-Perceptual Alterations
 ●​ Hallucinations: False sensory perceptions, like hearing voices (auditory) or seeing things that
don’t exist (visual), are assessed. Initially, clients may perceive these as real but later recognize
them as hallucinations.

Judgment and Insight

●​ Judgment: Refers to the ability to interpret and adapt behavior based on one’s environment and
situation. For instance, engaging in risky behaviors (e.g., spending beyond means or unsafe
sexual practices) indicates poor judgment. Nurses can assess judgment through hypothetical
questions (e.g., "What would you do if you found a stamped envelope on the ground?").
●​ Insight: Refers to the client’s understanding of their situation and acceptance of responsibility.
Lack of insight might be shown when a client blames others for their behavior or expects
problems to be solved without personal effort.

Self-Concept

●​ Self-Concept: Includes how the client views their worth, body image, and emotional state.
Nurses assess this by asking the client to describe themselves and how they cope with problems
or emotions.
●​ Coping Strategies: Nurses inquire about how the client manages issues like anger or
disappointment, assessing the effectiveness of these strategies.

Roles and Relationships

●​ Roles: Nurses assess the various roles the client occupies (e.g., family roles like parent or spouse,
occupation roles like employee or student). Satisfaction with these roles and their fulfillment can
impact the client’s mental health.
●​ Relationships: Nurses evaluate the client’s social relationships, satisfaction with them, and any
losses. Poor relationships may indicate mental health problems or contribute to them.
○​ Questions might include:
■​ “Do you feel close to your family?”
■​ “Do you have or want a relationship with a significant other?”
■​ “Are your relationships meeting your needs?”
■​ “Have you been involved in any abusive relationships?”
●​ Family Assessment: If the client’s family plays a significant role in their stress or well-being, the
nurse may perform a more detailed family assessment, looking at:
○​ Parenting practices
○​ Social interactions within the family
○​ Problem-solving patterns
○​ Issues like housing, finances, and health behaviors.
●​ Social Media: Nurses also consider the impact of social media on the client’s relationships, as
online connections may influence real-life interactions and mental health.
In psychosocial assessments, it's essential to consider the client's physiological functioning. Emotional
distress can significantly affect basic physiological processes like eating, sleeping, and medication
adherence. For example:

●​ Eating and Sleeping Patterns: Emotional problems can lead to changes in these
habits—excessive eating or poor appetite, and disrupted sleep patterns. For instance, clients with
bipolar disorder might go days without eating or sleeping, while those with major depression
may struggle to even get out of bed.
●​ Chronic or Major Health Issues: Nurses assess whether the client has any ongoing health
problems or follows prescribed treatment and dietary recommendations.
●​ Substance Use: The use of alcohol, over-the-counter drugs, or illicit substances should also be
explored. Nurses should use nonjudgmental language and stress the importance of truthful
answers for an accurate care plan.
●​ Noncompliance with Medications: Noncompliance may occur for reasons such as undesirable
side effects, lack of desired results, difficulty obtaining medication, or cost. The nurse needs to
explore these barriers and offer support to ensure adherence to prescribed treatment.

Data Analysis

After gathering data, the nurse analyzes the overall information, looking for patterns or themes to form
conclusions about the client’s strengths and needs. This analysis helps in formulating nursing diagnoses
and creating a plan of care. A comprehensive assessment may involve input from the client, family, and
caregivers. This ongoing process of reassessment aids in adjusting the care plan as needed based on
changes in the client's condition or needs.

Psychological Tests

Psychological testing can provide additional insights into the client’s mental state, aiding in care planning.
There are two types of tests:

●​ Intelligence Tests: Evaluate cognitive and intellectual abilities.

●​ Personality Tests: Reflect aspects like self-concept, impulse control, and reality testing. These
may be objective (e.g., true-or-false or multiple-choice questions) or projective (e.g., Rorschach
inkblots). Objective tests include:
○​ MMPI-2: Assesses personality across 20 primary scales.
○​ Beck Depression Inventory (BDI): Measures levels of depression.
○​ Tennessee Self-Concept Scale (TSCS): Evaluates self-concept.

Projective Tests:

●​ Rorschach Test: Analyzes responses to inkblot images to explore coping styles and ideation.
●​ Thematic Apperception Test (TAT): Client interprets pictures, revealing themes about mood
and interpersonal relationships.
●​ Sentence Completion Test: The client finishes incomplete sentences, providing insights into
their thoughts and emotions.
Psychiatric Diagnoses

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) provides criteria for diagnosing
mental disorders. This tool helps professionals classify disorders and distinguish between them based on
symptoms and behaviors.

Mental Status Examination (MSE)

The MSE evaluates a client's cognitive abilities and is often used to screen for conditions like dementia.
It includes assessments of orientation (person, place, time), memory, ability to perform tasks (e.g., math
calculations), and other cognitive functions. The fewer tasks a client can perform accurately, the more
likely there is a cognitive deficit. An abbreviated version of the exam is often used in practice.

Together, these components—physiologic and self-care assessments, data analysis, psychological testing,
and mental status exams—help form a comprehensive understanding of the client’s health and guide
appropriate care planning.

The Zero Suicide Model, developed by the National Action Alliance for Suicide Prevention, is an
evidence-based framework aimed at reducing suicide risk in clinical settings. This model involves 10 key
steps that enhance suicide prevention efforts:

1.​ Suicide Risk Assessment: Comprehensive evaluation of suicide risk.

2.​ Brief Interventions: Strategies to enhance client safety and provide immediate support.
3.​ Coping Strategies: Teaching skills that help the client manage distress and maintain ongoing
contact.
4.​ Ongoing Monitoring: Continuous support and monitoring during high-risk periods and
transitions in care.

Implementing and evaluating this model across different settings helps improve outcomes, as clinicians
compare its success with traditional methods. Outcome evaluation plays a crucial role in refining best
practices for managing suicide risk.

Self-Awareness Issues for Nurses

Self-awareness is essential for nurses during the psychosocial assessment process, ensuring that personal
feelings, biases, and values do not affect their ability to gather accurate and comprehensive information.
Nurses must recognize and manage these personal biases to maintain a nonjudgmental stance, especially
when dealing with clients whose beliefs and behaviors differ from their own.

Two challenging areas of assessment for nurses include:

1.​ Sexuality: Questions about intimate relationships and behaviors can be uncomfortable for both
the nurse and the client.
2.​ Self-Harm and Suicide: Discussing thoughts of suicide may be difficult for some nurses, but it is
a critical part of the assessment. Research shows that asking directly about suicidal thoughts does
not increase the risk of suicide and is essential for ensuring the client's safety.
Nurse's Approach to Self-Awareness:

●​ Nurses should avoid letting personal values, such as beliefs about abortion or infidelity, influence
the assessment process.
●​ Nonjudgmental Listening: It’s important to listen to clients without judgment and provide
support in discussing sensitive topics.
●​ Professional Growth: Gaining experience and seeking advice from colleagues can help nurses
manage discomfort in these areas.
●​ Clear Communication: To ease the client's discomfort with personal questions, nurses can say,
"I need to ask you some personal questions. This will help the staff provide better care for you."

Key Points in Psychosocial Assessment

●​ Non-Judgmental Approach: Nurses should gather all necessary information without making
judgments.
●​ Openness and Directness: Clear, direct communication about uncomfortable topics can help
reduce client anxiety and encourage openness.
●​ Self-Awareness: Examining personal beliefs and biases is a growth opportunity for nurses,
helping them manage discomfort and enhance the quality of care.
●​ Addressing Discomfort: If a nurse’s personal beliefs differ from the client’s, it’s important to
discuss those differences with colleagues to prevent them from interfering with the nurse-client
relationship.

CHAPTER 9

1. Introduction to Mental Health Care and Legal Reform

●​ Historical Context:
○​ Clients with mental illness historically subjected to inhumane treatment and
institutionalization.
○​ Legal reforms in the 1970s focused on improving patient rights and treatment conditions.
○​ Key legal concepts: civil rights, involuntary commitment, and patient rights.

2. Client Rights in Mental Health

●​ Retention of Civil Rights:

○​ Clients retain most civil rights except the right to leave the hospital if involuntarily
committed.
○​ Rights include:
■​ Right to refuse treatment.
■​ Right to send and receive mail.
■​ Right to visitors (with certain restrictions).
○​ Examples of Restrictions:
■​ Suicidal clients may not keep certain objects (e.g., belts, shoelaces).
■​ Visitors may be restricted if they contribute to aggressive behavior.
 ■​ Supervised phone calls may be mandated for clients making threatening calls.
●​ Patient's Bill of Rights (Highlights):
○​ Right to informed consent about treatment options, benefits, and providers.
○​ Right to least restrictive environment that meets treatment needs.
○​ Right to confidentiality and non-discrimination.
○​ Right to choose providers and receive treatment decisions based on professional
recommendations, not third-party payers.

3. Involuntary Hospitalization

●​ Definition:
○​ Occurs when a client is detained against their will because they pose a danger to
themselves or others (suicidal ideation, aggression).
●​ Process of Commitment:
○​ Emergency Detention: A client can be detained for 48-72 hours pending a hearing to
determine commitment.
○​ Civil commitment laws vary by state but follow similar guidelines.
○​ Client's Rights during Commitment:
■​ Right to treatment, but restricted from leaving the hospital during the
commitment process.

4. Release from the Hospital

●​ Voluntary Clients:
○​ Can leave the hospital unless they are deemed a danger to themselves or others.
○​ May request discharge, but if they are still dangerous, involuntary commitment may be
pursued.
●​ Involuntary Clients:
○​ Release occurs once they no longer pose a risk.
○​ Clients may stop taking medication after discharge and risk becoming a threat again.

5. Mandatory Outpatient Treatment

●​ Definition:
○​ Involuntary treatment post-discharge, requiring clients to continue therapy, take
prescribed medication, and attend follow-up appointments.
○​ Court-ordered treatment: Common for clients with persistent mental illness who
repeatedly fail to adhere to voluntary treatment.
●​ Benefits of Mandated Outpatient Treatment:
○​ Shorter inpatient stays.
○​ Reduced risk of dangerous behavior.
○​ More cost-effective than repeated hospitalizations.
●​ States without Mandated Outpatient Treatment:
○​ Connecticut, Maryland, Massachusetts, and Tennessee.
6. Conservatorship and Guardianship

●​ Definition:
○​ Appointed for clients who are unable to care for themselves due to mental incompetence
or severe disability.
○​ Legal Guardianship: A court-appointed individual assumes responsibility for the
client’s care and legal decisions (e.g., signing contracts).
○​ Conservatorship: A guardian for financial matters, such as managing the client's money
and paying bills.
●​ Differences between Conservatorship and Guardianship:
○​ Conservator of Person: Responsible for the client’s overall well-being (health care,
living arrangements).
○​ Conservator of Financial Affairs: Manages financial assets (often referred to as Power
of Attorney).

7. Key Ethical and Legal Issues in Mental Health

●​ Balancing Rights with Protection:

○​ Legal protections are designed to ensure the client’s rights are respected while protecting
the client and others from harm.
○​ The role of mental health professionals in upholding the legal rights of clients while
ensuring their safety.

1. Least Restrictive Environment

●​ Definition:​
Clients are entitled to receive treatment in the least restrictive environment that is appropriate to
meet their needs. This includes:
○​ Outpatient care or group home settings when possible.
○​ Avoiding restraints or seclusion unless necessary for safety.
●​ Relevance to Deinstitutionalization:​
The concept was central to the deinstitutionalization movement, aiming to reduce the number of
individuals institutionalized in psychiatric hospitals.
●​ Regulatory Oversight:
○​ The Joint Commission develops and updates standards for restraint and seclusion,
reviewing them every 2 years as part of their accreditation process.

2. Restraint and Seclusion

●​ Restraint:
○​ Definition: The physical restriction of a person's freedom of movement, either by human
force or mechanical devices (e.g., wrist or ankle restraints).
○​ Purpose: Used to manage clients who are physically aggressive or dangerous (e.g.,
hitting, kicking, hair pulling).
●​ Seclusion:
 ○​ Definition: Involuntary confinement in a specially designed, locked room for safety and
monitoring.
○​ Room Setup: Often includes a bolted-down bed and removal of sharp or dangerous
objects.
●​ Regulations for Use:
○​ Short-Term Use: Permitted only when a client poses an imminent danger to themselves or
others, and all other means of de-escalation have failed.
○​ Monitoring:
■​ Adults: Face-to-face evaluation within 1 hour, ongoing monitoring every 1-2
hours.
■​ Children: Face-to-face evaluation every 4 hours, monitoring more frequent.
●​ Debriefing and Family Involvement:
○​ A debriefing session is required within 24 hours of release from restraint or seclusion.
○​ Families must be informed about the use of restraint/seclusion (signed release of
information required for adults).

3. Client's Experience of Seclusion

●​ Client Feedback:
○​ Many clients report feeling angry, frightened, or helpless while in seclusion, viewing it as
a form of punishment.
○​ Clients suggest that other interventions, such as staff interaction or family presence, could
reduce the need for seclusion.
●​ Goal of Seclusion:​
The primary aim is to allow the client to regain physical and emotional self-control, but clients
may perceive it as ineffective or overly punitive.

4. Confidentiality and HIPAA

●​ HIPAA Overview:
○​ The Health Insurance Portability and Accountability Act (HIPAA) of 1996 mandates the
privacy and protection of health information, including mental health and substance
abuse records.
○​ Violations of HIPAA can result in civil penalties (fines) and criminal penalties (prison
sentences).
●​ Special Considerations in Mental Health:
○​ Mental health records have additional protections under HIPAA.
○​ There is concern that these privacy laws may limit communication among providers and
hinder collaboration with family members.
●​ Education and Communication:​
It is important to educate clients and families about their rights under HIPAA to ensure clear
communication and prevent misunderstandings.

5. Duty to Warn Third Parties

●​ Tarasoff v. Regents of the University of California (1976):
○​ Case Summary:​
A mental health client, Prosenjit Poddar, threatened to kill his ex-girlfriend. Despite
warning campus police, he was not detained. Later, he followed through on the threat,
leading to the death of Tatiana Tarasoff. The court ruled that mental health professionals
have a duty to warn identifiable third parties of threats made by clients, even if discussed
confidentially during therapy sessions.
●​ Implications:
○​ This case set a legal precedent for the duty to warn that has been adopted in many states,
though the specifics vary by state (mandatory vs. discretionary warning laws).
●​ Impact:​
Mental health professionals are often required to break confidentiality when a client makes
specific threats to an identifiable individual or group.

Duty to Warn Third Parties: Clearly outlines the factors that determine when a clinician must
intervene to warn others of a potential threat from a client.

Insanity Defense: Discusses the criteria for the insanity defense and its limited application in the
legal system.

Nursing Liability: Provides an explanation of how nursing professionals can be held liable for
negligence or malpractice and the key elements involved in legal cases. It also covers intentional
torts and the specific responsibility of nurses.

Prevention of Liability: Offers actionable steps to reduce the risk of legal trouble by emphasizing
safe practices, teamwork, and thorough documentation.

Ethical Principles: Explains core ethical principles such as autonomy, beneficence,

nonmaleficence, justice, veracity, and fidelity, and how they guide nurses in ethical
decision-making.

1. Ethical Dilemmas:

●​ Definition: Ethical dilemmas occur when ethical principles conflict, such as autonomy vs.
nonmaleficence (doing no harm). For instance, when a client refuses treatment but poses a danger
to themselves or others, the decision to override autonomy for the sake of safety creates a
dilemma.
●​ Examples of Dilemmas: Includes complex situations like forced medication, the right to refuse
care, confidentiality in reporting reckless behavior, and maintaining professional boundaries in
rural areas.
●​ Legal vs. Ethical Decisions: Distinguishes between the legality of an action (clear cut) and the
ethical concerns (often subjective, with multiple possible actions).

2. Ethical Theories:
●​ Utilitarianism: The “greatest good for the greatest number,” often used in mental health settings
to justify involuntary actions for the public good.
●​ Autonomy vs. Public Good: Balancing individual rights against societal safety and the moral
challenges of empowering individuals with mental illness while ensuring their safety and that of
others.

3. Ethical Decision-Making:

●​ Steps for Decision-Making: Includes gathering information, clarifying values, identifying options,
reviewing legal considerations, and building consensus.
●​ ANA Code of Ethics: Emphasizes compassion, respect for human dignity, patient rights, and
professional integrity.

4. Shared Decision-Making:

●​ Health Literacy: A focus on improving health literacy for better patient participation in
decision-making, especially for those with severe mental illness.
●​ Integrative Model for Shared Decision-Making: Proposes a model to improve health literacy and
decision-making in mental health care.

5. Self-Awareness Issues:

●​ Nurse’s Personal Beliefs: Nurses must recognize and manage personal values that might conflict
with patient care, ensuring professional responsibilities are met, even when personal beliefs differ.
●​ Examples: The nurse supporting a client grieving over an abortion despite personal opposition,
illustrating the importance of separating personal beliefs from professional duties.

6. Points to Consider When Confronting Ethical Dilemmas:

●​ Collaborate and Seek Guidance: Encourage nurses to consult with colleagues and supervisors
rather than making decisions in isolation.
●​ Reflect on Personal Values: Nurses should reflect on their values before encountering ethical
issues to avoid confusion between personal and professional roles.