Intervention is a crucial component of the nursing process. Psychosocial interventions are nursing activities
that enhance the client’s social and psychological functioning and improve social skills, interpersonal relationships, and communication. Nurses often use psychosocial interventions to help meet clients’ needs and achieve outcomes in all practice settings, not just mental health. For example, a medical–surgical nurse might need to use interventions that incorporate behavioral principles such as setting limits with manipulative behavior or giving positive feedback.
For example, a client with diabetes tells the nurse,
“I promise to have just one bite of cake. Please! It’s my grandson’s birthday cake.” (manipulative behavior)
The nurse might use behavioral limit-setting by saying,
“I can’t give you permission to eat the cake. Your blood glucose level will go up if you do, and your insulin can’t be adjusted properly.”
When a client first attempts to change a colostomy bag but needs some assistance, the nurse might say,
“You gave it a good effort. You were able to complete the task with a little assistance.” (giving positive feedback)
Understanding the theories and treatment modalities presented in this chapter can help the nurse select appropriate and effective intervention strategies. In later chapters that present particular mental disorders or problems, specific psychosocial interventions that the nurse might use are described.
BEST PRACTICE:
INTERNET INTERVENTION FOR CAREGIVERS
The World Health Organization stresses the importance of accessible and cost-effective caregiver support.
Family care givers in the experimental group completed an Internet course “Mastery Over Dementia” while control group participants received minimal, more traditional education intervention. The control group members had significantly less depression and anxiety than control group members.
The next step is to offer Internet intervention for family caregivers for other disorders.
Blom, M. M., Zarit, S. H., Groot Zwaaftink, R. B., et al. (2015). Effectiveness of an internet intervention for family caregivers of people with dementia: Results of a randomized, controlled trial. Public Library of Science One, 10(2), e0116622.
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The nurse must examine his or her beliefs about the theories of psychosocial development and realize that many treatment approaches are available. Different treatments may work for different clients: No one approach works for everyone. Sometimes, the nurse’s personal opinions may not agree with those of the client, but the nurse must make sure that those beliefs do not affect the therapeutic process. For example, an overweight client may be working on accepting herself as being overweight rather than trying to lose weight, but the nurse believes the client really just needs to lose weight. The nurse’s responsibility is to support the client’s needs and goals, not to promote the nurse’s own ideas about what the client should do. Hence, the nurse must support the client’s decision to work on self-acceptance. For the nurse who believes that being overweight is simply a lack of will power, it might be difficult to support a client’s participation in a self-help weight-loss group, such as Overeaters Anonymous, that emphasizes overeating as a disease and accepting oneself.
Points to Consider When Working on Self-Awareness
Points to consider regarding psychosocial theories and treatment:
No one theory explains all human behavior. No one approach will work with all clients.
Becoming familiar with the variety of psychosocial approaches for working with clients will increase the nurse’s effectiveness in promoting the client’s health and well-being.
The client’s feelings and perceptions about his or her situation are the most influential factors in determining his or her response to therapeutic interventions, rather than what the nurse believes the client should do.
Can sound parenting and nurturing in a loving environment overcome a genetic or biologic predisposition to mental illness?
Which of the theories in this chapter fit with your beliefs about psychosocial development? Mental health and illness? Effective treatment? Explain why.
Psychosocial theories help to explain human behavior—both mental health and mental illness. There are several types of psychosocial theories, including psychoanalytic theories, interpersonal theories,
humanistic theories, behavioral theories, and existential theories.
Freud believed that human behavior is motivated by repressed sexual impulses and desires and that childhood development is based on sexual energy (libido) as the driving force.
Erik Erikson’s theories focused on both social and psychological developments across the life span. He proposed eight stages of psychosocial development; each stage includes a developmental task and a virtue to be achieved (hope, will, purpose, fidelity, love, caring, and wisdom). Erikson’s theories remain in wide use today.
Jean Piaget described four stages of cognitive development: sensorimotor, preoperational, concrete operations, and formal operations.
Harry Stack Sullivan’s theories focused on development in terms of interpersonal relationships. He viewed the therapist’s role (termed participant observer) as key to the client’s treatment.
Hildegard Peplau is a nursing theorist whose theories formed much of the foundation of modern nursing practice, including the therapeutic nurse–patient relationship, the role of the nurse in the relationship, and the four anxiety levels.
Abraham Maslow developed a hierarchy of needs stating that people are motivated by progressive levels of needs; each level must be satisfied before the person can progress to the next level. The levels begin with physiological needs and then proceed to safety and security needs, belonging needs, esteem needs, and finally self-actualization needs.
Carl Rogers developed client-centered therapy in which the therapist plays a supportive role, demonstrating unconditional positive regard, genuineness, and empathetic understanding to the client.
Behaviorism focuses on the client’s observable performance and behaviors and external influences that can bring about behavior changes rather than focusing on feelings and thoughts.
Systematic desensitization is an example of conditioning in which a person who has an excessive fear of something, such as frogs or snakes, learns to manage his or her anxiety response through being exposed to the feared object.
F. Skinner was a behaviorist who developed the theory of operant conditioning in which people are motivated to learn or change behavior with a system of rewards or reinforcement.
Existential theorists believe that problems result when the person is out of touch with the self or the environment. The person has self-imposed restrictions, criticizes himself or herself harshly, and does not participate in satisfying interpersonal relationships.
Founders of existentialism include Albert Ellis (rational emotive therapy), Viktor Frankl (logotherapy), Frederick Perls (gestalt therapy), and William Glasser (reality therapy).
All existential therapies have the goal of returning the person to an authentic sense of self through emphasizing personal responsibility for oneself and one’s feelings, behavior, and choices.
A crisis is a turning point in an individual’s life that produces an overwhelming response. Crises may be maturational, situational, or adventitious. Effective crisis intervention includes assessment of the person in crisis, promotion of problem-solving, and provision of empathetic understanding.
Cognitive therapy is based on the premise that how a person thinks about or interprets life experiences determines how he or she will feel or behave. It seeks to help the person change how he or she thinks about things to bring about an improvement in mood and behavior.
Treatment of mental disorders and emotional problems can include one or more of the following:
individual psychotherapy, group psychotherapy, family therapy, family education, psychiatric rehabilitation, self-help groups, support groups, education groups, and other psychosocial interventions such as setting limits or giving positive feedback.
An understanding of psychosocial theories and treatment modalities can help the nurse select appropriate and effective intervention strategies to use with clients.
REFERENCES
Aguilera, D. C. (1998). Crisis intervention: Theory and methodology (7th ed.). St. Louis, MO: Mosby.
Beck, A. T. (1976). Cognitive therapy and the emotional disorders. Madison, CT: International Universities Press.
Black, D. W., & Andreasen, N. C. (2014). Introductory textbook of psychiatry (6th ed.). Washington, DC: American Psychiatric Publishing.
Caplan, G. (1964). Principles of preventive psychiatry. New York, NY: Basic Books.
Erikson, E. H. (1963). Childhood and society (2nd ed.). New York, NY: Norton.
Freud, S. (1962). The ego and the id (The standard edition of the complete psychological works of Sigmund Freud) (J. Strachey, Trans.). New York, NY: W. W. Norton & Company. (Original work published 1923.)
Hou, R. J., Wong S. Y., Yip B. H., et al. (2014). The effects of mindfulness-based stress reduction program on the mental health of family caregivers: A randomized controlled trial. Psychotherapy and Psychosomatics, 83(1), 45–53.
Lewis, S. E., Hopper, K., & Healion, E. (2012). Partners in recovery: Social support and accountability in a consumer-run mental health center.
Psychiatric Services, 63(1), 61–65.
Maslow, A. H. (1954). Motivation and personality. New York, NY: Harper & Row.
National Alliance for the Mentally Ill. (2015). NAMI Provider Education Program. http//:www.nami.org/Find-Support/NAMI/Programs/NAMI-Provider/Educatiom
National Center for Complementary and Integrative Health. (2015). What is complementary, alternative, and interative health htpss://ncsih.nih.gov/health/whatiscam
Peplau, H. (1952). Interpersonal relations in nursing. New York, NY: G. P. Putnam’s Sons.
Rogers, C. R. (1961). On becoming a person: A therapist’s view of psychotherapy. Boston, MA: Houghton Mifflin.
Skinner, B. F. (1974). About behaviorism. New York, NY: Alfred A. Knopf, Inc.
Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York, NY: Norton.
Yalom, I. D., & Leszcz, M. (2015). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books.
ADDITIONAL READINGS
Berne, E. (1964). Games people play. New York, NY: Grove Press.
Caplan, G. (1964). Principles of preventive psychiatry. New York, NY: Basic Books.
Crain, W. C. (1980). Theories of development: Concepts and application. Englewood Cliffs, NJ: Prentice Hall, Inc.
Frankl, V. E. (1959). Man’s search for meaning: An introduction to logotherapy. New York, NY: Beacon Press.
Glasser, W. (1965). Reality therapy: A new approach to psychiatry. New York, NY: Harper & Row.
Miller, P. H. (1983). Theories of developmental psychology. San Francisco, CA: W. H. Freeman & Co.
Millon, T. (Ed.). (1967). Theories of psychopathology. Philadelphia, PA: W. B. Saunders.
Perls, F. S., Hefferline, R. F., & Goodman, P. (1951). Gestalt therapy: Excitement and growth in the human personality. New York, NY: Dell Publishing Co., Inc.
Sugarman, L. (1986). Life-span development: Concepts, theories and interventions. London, UK: Methuen & Co., Ltd.
Szasz, T. (1961). The myth of mental illness. New York, NY: Hoeber-Harper.
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MULTIPLE-CHOICE QUESTIONS
Select the best answer for each of the following questions.
Which of the following theorists believed that a corrective interpersonal relationship with the therapist was the primary mode of treatment?
Sigmund Freud William Glasser Hildegard Peplau Harry Stack Sullivan
Dream analysis and free association are techniques in which of the following?
Client-centered therapy Gestalt therapy
Logotherapy Psychoanalysis
Four levels of anxiety were described by Erik Erikson.
Sigmund Freud.
Hildegard Peplau.
Carl Rogers.
Correcting how one thinks about the world and oneself is the focus of behaviorism.
cognitive therapy.
psychoanalysis.
reality therapy.
The personality structures of id, ego, and superego were described by Sigmund Freud.
Hildegard Peplau.
Frederick Perls.
Harry Stack Sullivan.
The nursing role that involves being a substitute for another, such as a parent, is called counselor.
resource person.
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surrogate.
teacher.
Psychiatric rehabilitation focuses on client’s strengths.
medication compliance.
social skills deficits.
symptom reduction.
When a nurse develops feelings toward a client that are based on the nurse’s past experience, it is called
countertransference.
role reversal.
transference.
unconditional regard.
A group that was designed to meet weekly for 10 sessions to deal with feelings of depression would be a(n)
closed group.
educational group.
open group.
support group.
FILL-IN-THE-BLANK QUESTIONS
Write the name of the appropriate theorist beside the statement or theory. Names may be used more than once.
The client is the key to his or her own healing. _______________________________
Social and psychological factors influence development. _______________________________
Behavior change occurs through conditioning with environmental stimuli.
_______________________________
People make themselves unhappy by clinging to irrational beliefs.
_______________________________
Behavior is learned from past experience that is reinforcing. _______________________________
Client-centered therapy _______________________________
Gestalt therapy _______________________________
Hierarchy of needs _______________________________
Logotherapy _______________________________
Rational emotive therapy _______________________________
Reality therapy _______________________________
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SHORT-ANSWER QUESTIONS
Describe each of the following types of groups and give an example.
Group psychotherapy
Education group
Support group
Self-help group
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Key Terms
assertive community treatment (ACT) case management
clubhouse model
criminalization of mental illness day treatment
evolving consumer household
interdisciplinary (multidisciplinary) team partial hospitalization programs (PHPs) recovery
residential treatment settings stigma
Learning Objectives
After reading this chapter, you should be able to:
Discuss traditional treatment settings.
Describe different types of residential treatment settings and the services they provide.
Describe community treatment programs that provide services to people with mental illness.
Identify the factors that distinguish recovery programs from traditional treatment.
Identify barriers to effective treatment for homeless people with mental illness.
Discuss the issues related to people with mental illness in the criminal justice system.
Discuss the difficulties faced by military veterans both during and following service.
Describe the roles of different members of a multidisciplinary mental health-care team.
Identify the different roles of the nurse in varied treatment settings and programs.
MENTAL HEALTH CARE HAS UNDERGONE profound changes in the past 50 years. Before the 1950s, humane treatment in large state facilities was the best available strategy for people with chronic and persistent mental illness, many of whom stayed in such facilities for months or years. The introduction of psychotropic medications in the 1950s offered the first hope of successfully treating the symptoms of mental illness in a meaningful way. By the 1970s, focus on client rights and changes in commitment laws led to deinstitutionalization and a new era of treatment. Institutions could no longer hold clients with mental illness indefinitely, and treatment in the “least restrictive environment” became a guiding principle and right. Large state hospitals emptied. Treatment in the community was intended to replace much of state hospital inpatient care. Adequate funding, however, has not kept pace with the need for community programs and treatment (see Chapter 1).
Today, people with mental illness receive treatment in a variety of settings. This chapter describes the range of treatment settings available for those with mental illness and the psychiatric rehabilitation programs that have been developed to meet their needs. Both of these sections discuss the challenges of integrating people with mental illness into the community. The chapter also addresses two populations who are receiving inadequate treatment because they are not connected with needed services: homeless clients and clients who are in jail. In addition, the special challenges facing military veterans are presented. The chapter also describes the multidisciplinary team, including the role of the nurse as a member. Finally, it briefly discusses psychosocial nursing in public health and home care.