Psycho Social Theories And Therapy

Psychosocial Theories and Therapy

Psychoanalytic Theories • Pioneered by Sigmund Freud (1856– 1939) in Vienna

• Father of Psychoanalysis - “Your behavior today is directly or indirectly affected by your childhood days or experiences. - STRUCTURE – Personality Structure

• All human behavior is caused and can be explained • Personality components conceptualized as id, ego, and superego • Behavior motivated by subconscious thoughts and feelings; treatment involving analysis of dreams and free association • Ego defense mechanisms • Psychosexual stages of development • Transference and countertransference

Psychoanalysis focuses on discovering the causes of the client’s unconscious and repressed thoughts, feelings, and conflicts believed to cause anxiety and helping the client to gain insight into and resolve these conflicts and anxieties. Psychoanalysis is lengthy, expensive, and practiced on a limited basis today; however, Freud’s defense mechanisms remain current.

Personality Structure

• ID (4-5MONTHS) – – – –

Impulsive / I want to… I want to… I want to…

Instinctual drive PLEASURE PRINCIPLE PHYSIOLOGIC NEEDS PRIMARY PROCESS

• EGO – – – – –

Executive REALITY PRINCIPLE Conscious Competencies Decision Maker; Problem-Solving; Critical and Creative thinking

• SUPEREGO – – – – –

Should not Small voice of GOD Set norms, standards and values MORAL PRINCIPLE Conscience

Imbalances between Personality Elements ID

SE

M – anic A – nti-social N –arcissistic

SE

ID

O – bsessive Compulsive A – norexia nervosa

EGO

Schizophrenia

• During the phallic stage, what significant development will Susan expect of her child? B.sexual gratification in urination and defecation C.sexual disinterest in the opposite sex D.sexual and body awareness E.sexual identification and maturity

• Answer: C • Rationale: the child during the phallic stage begins to explore the body and be aware of basic sexual differences of a girl and a boy, a reason for penis envy and castration fear to set in. A is what toddlers experience during the anal stage. D is achieved during adolescence. B. maybe a sexual dysfunction.

ORAL STAGE • 18 months • Cry, suck, mouth • EGO @ 6 months – Child cries – fed – successful – Child cries – ignored – unimportant - narcissistic

ANAL STAGE – 3 years old • 18 months • SUPEREGO develops • Toilet training – Good Mother – Normal – Bad Mother • Clean, organized, obedient – OC (anal retentive) • Dirty, disorganized – Anti-social (anal expulsive)

PHALLIC STAGE • Preschooler (3 – 6 years old) • Parent – Oedipus Complex • Castration Fear

– Electra Complex • Penis Envy

LATENCY STAGE • 6 to 12 years old • School • Reading, writing, arithmetic • Ability to care about and relate to others outside

GENITAL STAGE • 12 years old and above • Developing satisfying sexual and emotional relationships with members of the opposite sex • Planning life’s goals

• A 36-year-old client with paranoid schizophrenia believes the room is bugged by the Armed Forces of the Philippines and a roommate is a foreign spy. The client has never had a romantic relationship, has no contact with family, and has not been employed for the past 14 years. Based on Erikson’s theories, the nurse should recognize that this client is in which stage of psychosocial development? A. autonomy vs. shame and doubt B. generativity vs. stagnation C. integrity vs. despair D. trust vs. mistrust

• Answer: D • Rationale: This client’s paranoid ideation indicates difficulty in trusting others. The stage of autonomy vs. shame and doubt deals with separation, cooperation, and self-control. Generativity vs. stagnation is the normal stage for this client’s chronological age. Integrity vs. despair is the stage for accepting the positive and negative aspects of one’s life, which would be difficult or impossible for this client.

Erik Erickson Psychosocial Theory of Development

0-18 mos.

Trust vs. Mistrust

-attachment to mother which lays foundations for later trust in others -conflict: general difficulties relating to others. suspicion, fear of the future

• 18 m0s – 3 yrs

Autonomy vs.

Shame/Doubt

• Gaining some basic control of self and environment • Conflict: independence-fear conflict, severe feelings of self-doubt

3 yrs – 6 yrs

Initiative vs. Guilt

-becoming purposeful and directive -conflict: aggression-fear conflict; sense of inadequacy and guilt

6 yrs – 12 yrs Industry vs. Inferiority • Developing social, physical and school skills, competence • Conflict: sense of inferiority; difficulty learning and working

• 12 yrs – 20 yrs Identity vs. Role Diffusion • Making transition from childhood to adulthood; developing a sense of identity • Conflict: confusion of who one is, identity submerged in relationships or group memberships

21 yrs – 35 yrs Intimacy vs. Isolation -establishing intimate bonds of love and friendship -conflict: emotional isolation

35 yrs – 55 yrs Stagnation

Generativity vs.

-fulfilling life’s goals that involve family, career and society, developing concerns that embrace future generations -conflict: self-absorption. Inability to grow as a person

• 55 yrs – above Integrity vs. Despair • Looking back into one’s life and accepting its meaning • Conflict: dissatisfaction with life, denial of or despair over prospect of death

Jean Piaget Cognitive Theory of Development

Jean Piaget (1896–1980) Described cognitive and intellectual development in children in four stages: sensorimotor, preoperational, concrete operations, formal operations

• SENSORIMOTOR STAGE-development

proceeds from reflex activity to representation and sensorimotor solutions to problems

– 0 to 18 months

• PRE-OPERATIONAL STAGE-development proceeds from sensorimotor representation to prelogical thought and solutions to problems • can use these representational skills only to view the world from their own perspective. • Understand the meaning of symbolic gestures

– 2 to 7 years

• CONCRETE OPERATIONAL-development

proceeds from prelogical thought to logical solutions to concrete problems • understand concrete problems • cannot yet contemplate or solve abstract problems

– 7 to 12 years

• FORMAL OPERATIONAL-development

proceeds from logical solutions to concrete problems to logical solutions to all classes of problems • cannot yet contemplate or solve abstract problems • can also reason theoretically

– 12 and above

Harry Stack Sullivan

(1892–1949)

• Established five life stages of personality development that included the significance of interpersonal relationships • Described three developmental cognitive modes: prototaxic, parataxic, syntaxic • Believed that unsatisfying relationships were the basis for all emotional problems • Described the concept of therapeutic milieu or community

Hildegard Peplau (1909–1999)

• Leading nursing theorist and clinician: developed the nurse– patient relationship with phases and tasks • Identified roles of the nurse: stranger, resource person, teacher, leader, surrogate, counselor • Described four levels of anxiety (mild, moderate, severe, panic) still widely used today

Humanistic Theories Abraham Maslow (1921 –1970) • Hierarchy of needs: basic physiologic needs, safety and security needs, love and belonging needs, esteem needs, selfactualization Carl Rogers (1902–1987) • Client-centered therapy • Concepts of unconditional positive regard, genuineness, and empathetic understanding

Theories IvanBehavioral Pavlov (1849–1936) B. F. Skinner (1904–1990) • Behaviorism focuses on behaviors and behavior changes rather than on explaining how the mind works • All behavior is learned • Behavior has consequences (reward or punishment) • Rewarded behavior tends to recur

• Positive reinforcement increases the frequency of behavior • Removal of negative reinforcers increases the frequency of behavior • Continuous reinforcement is the fastest way to increase behavior; random intermittent reinforcement increases behavior more slowly but with longer-lasting effect • Treatment modalities based on behaviorism include behavior modification, token economy, and systematic desensitization

Existential Theories therapy focuses on immediate • Cognitive thought processing and is used by most existential therapists Albert Ellis • Rational emotive therapy: people make themselves unhappy through “irrational beliefs and automatic thinking”—the basis for the technique of changing or stopping thoughts Viktor Frankl • Logotherapy: life must have meaning and therapy is the search for that meaning

Frederick “Fritz” Perls • Gestalt therapy emphasizes selfawareness and identifying thoughts and feelings in the here and now William Glasser • Reality therapy focuses on the person’s behavior and how that behavior keeps the person from achieving life goals Existential theorists believe that deviations occur when the person is out of touch with self or environment; thus, the goal of therapy is to return the person to an authentic sense of self.

Treatment Modalities

Community (outpatient) mental health treatment

• The client can often continue to work and can stay connected with family, friends, and other support systems while participating in therapy • Personality or behavior patterns gradually develop over the course of a lifetime and cannot be changed in a relatively short inpatient course of treatment

Hospital (inpatient) treatment

• Severely depressed and suicidal • Severely psychotic • Experiencing alcohol or drug withdrawal • Exhibiting behaviors that require close supervision in a safe, supportive environment

Individual Psychotherapy

• A method of bringing about change in a person by exploring his or her feelings, attitudes, thinking, and behavior • It involves a one-to-one relationship between the therapist and the client • The therapist’s theoretical beliefs strongly influence his or her style of therapy

SEVEN SUBTYPES

1.CLASSICAL PSYCHOANALYSIS • Based on Freud’s theory • To uncover unconscious feelings and thoughts that interfere with the client’s living a fuller life • Free association- client is encouraged to say anything that comes to mind, without censoring thoughts or feelings • Dream analysis • Working through (transference)-process of repeated interpretation to the person of his or her unconscious processes has the effect of bringing about change

2. PSYCHOANALYTICAL PSYCHOTHERAPY • Uses DREAM ANALYSIS, TRANSFERENCE and FREE ASSOCIATION AND COUNTERTRANSFERENCE • Therapist is much more involved and interacts with the client more freely • Done through intimate professional relationship between the nurse/therapist and the client over a period of time (introductory, working and termination phase)

3. SHORT TERM DYNAMIC PSYCHOTHERAPY • Indication-persons with specific symptom or interpersonal problem that he/she wants to work on • Therapist directs the content • Use of transference and dream analysis, NO FREE ASSOCIATION • Weekly sessions (total number-12 to 30) • Successful for highly motivated individuals who have insight and with positive relationship with the therapist

4. TRANSACTIONAL ANALYSIS • Eric Berne • Each person has three ego states and change from one to another frequently • Parent-concepts of standards of behavior and how things should be done e.g. “Go and take out the garbage.” • Adult-rational thinking and data analyzing part of the personality e.g. “Would you please take out the garbage” • Child- feelings associated with persons, things or incidents represent the need-gratifying aspects of the personality. E.g. “Is that why you married me?To be your garbage man?” • For group, family and individual • Client to identify ego states for each given situation • Rewarding of positive or negative behaviors with strokes • Client work through these behaviors

• A nurse teaches a client to control his panic by countering his negative thoughts of “I’m a failure, I can’t pass any examinations,” with “I have passed most examinations and I’ll try my best to pass the next test.” This is an example of: A. psychoeducation B. distraction C. positive self-talk D. panic control treatment

• Answer: C • Rationale: Positive self-talk is an intervention the client can learn to counter fearful or negative thoughts that occur when faced with increased anxiety and panic. These are preplanned, rehearsed statements that give the client an area to focus on when symptoms of panic begin.

5. COGNITIVE PSYCHOTHERAPY • Restructuring or changing ways in which people think about themselves 3 steps: 1.Thought stopping 2. Positive self-talk 3. Decatastrophizing • Therapists help patients identify these thoughts

6. BEHAVIORAL THERAPY • Changes in maladapted behavior can occur without insight into the underlying cause • Based on learning theory (B.F.Skinner, Pavlov) • Modeling • Operant conditioning • Self-control therapy- combination of cognitive & behavioral approaches “talking to self” • Systematic desensitization • Aversion therapy • Token economy

7. GESTALT THERAPY • Emphasis on the “here and now” • Only present behavior can be changed, not history • Uncover repressed feelings and needs • Techniques: have a person behave the opposite of the way he/she feels, presuming that a person can then come in contact with a submerged part of the self; in dreams, person is ask to play the roles of persons in the dream to get in touch with different repressed feelings

• During the meetings of a therapy group one member tends to monopolize the group discussion and no one is confronted this behavior. This nurse would best handle this situation by: A. saying to the client, “You use too much time in our sessions.” B. Ignoring the behavior because the client may become upset if confronted C. Encouraging the members of the group to do more talking by calling on various silent member D. Saying the group. “ I’m wondering why the group is so willing to let this client do so much of the talking.”

Group Therapy

• Group therapy involves a therapist or leader and a group of clients sharing a common purpose; members contribute to the group and expect to benefit from it. • Types of groups include: • Psychotherapy groups, family therapy, family education, support groups, self-help groups, education groups

• Stages of group development – Pregroup stage – Initial stage – Working stage – Termination stage

• Group leadership – Therapy groups and education groups: formal leader – Support groups and self-help groups: no formal leader Effective group leaders focus on group process as well as group content

• Group roles

– Growth-producing roles: information-seeker, opinionseeker, information-giver, energizer, coordinator, harmonizer, encourager, and elaborator – Growth-inhibiting roles: monopolizer, aggressor, dominator, critic, recognition-seeker, and passive follower

The therapeutic results of group therapy (Yalom, 1995) include the following: Gaining new information or learning Gaining inspiration or hope Interacting with others Feeling acceptance and belonging Universality -Becoming aware that one is not alone and that others share the same problems • Gaining insight into one’s problems and behaviors and how they affect others • Altruism - Giving of oneself for the benefit of others • • • • •

Psychosocial Interventions

Psychosocial interventions are nursing activities that enhance the client’s social and psychological functioning and promote social skills, interpersonal relationships, and communication. These interventions are used in mental health and other practice areas.

• The nurse recognizes that the focus of milieu therapy Is to: B.role-play life events to meet individual needs C.use natural remedies rather than drugs to control behavior D.manipulate the environment to bring about positive changes in behavior E.allow the clients freedom to determine whether or not they will be involved in activities

Milieu Therapy

Milieu Therapy

• Total environment has an effect on the individual’s behavior • Components – Physical Environment – Interpersonal relationships – Atmosphere of safety, caring, and mutual respect – For alcoholics

• The nurse plans to use family therapy as a means of assisting a family to cope with their child’s terminal illness. The nurse’s basis for this choice is that: A. it is more time-efficient to deal with the whole family together B. the entire family is involved, since what happens to one member impacts all C. the nurse can control manipulation and alliances better by using this mode of intervention D. it will prevent the parents from deceiving each other about the true nature of their child’s condition

• Answer: B • Rationale: Family therapy views the whole (Gestalt) within the context in which the emotional problems are occurring. Time efficiency is not an adequate rationale for choosing this therapeutic approach. Option C may or may not be true; an astute nurse can control manipulation and alliance within any group. Promotion of truthfulness is a secondary gain achieved through this mode of therapy

Assumption of Family Therapy

• Client: Whole family • Concepts: – The family is the most fundamental unit of the society. – Adaptive or maladaptive patterns of behavior are learned from the family – Dysfunction in the family = dysfunction in the individual

• Purpose – Improve relationships among family members – Promote family function – Resolve family problems

ATTITUDE THERAPY 1. Paranoid – Passive Friendliness 2. Withdrawn – Active Friendliness 3. Depressed / Anorexia – Kind Firmness 4. Manipulative – Matter of Fact 5. Assaultive – No Demand 6. Anti-social – Firm, consistent

PSYCHOSOMATIC THERAPY

One of the chief benefits of ECT is that it: A. shortens the hospitalization and followup periods B. often serves as an adjunct to psychotherapy and other treatment C. decreases the need for medication and psychotherapy D. enable the client to terminate psychiatric treatment

Electroconvulsive Therapy

• Effective in most affective disorders • The induction of a grandmal seizure in the brain. • Abnormal firing of neurons in the brain causes an increase in neurotransmitters • Number of Treatments: 6-12 ,3 times a week, about .5-2seconds • Unilateral or bitemporal

Indications: • Patients who require rapid response • Patients who cannot tolerate pharmacotherapy or cannot be exposed to pharmacotherapy • Patients who are depressed but have not responded to multiple and adequate trials of medication

Preparations for ECT: • Pretreatment evaluation and clearance • Consent • NPO from midnight until after the treatment • Atropine Sulfate- to decrease secretions, succinylcholine (Anectine)- to promote muscle relaxation, Methohexital Sodium(Brevital)- anesthethic • Empty bladder • Remove jewelry, hairpins, dentures and other accessories • Check vital signs • Attempt to decrease patient’s anxiety

Care after ECT: • O2 therapy of 100% until patient can breathe unassisted • Monitor for respiratory problems, gag reflex • Reorient patient • Observe until stable • Careful documentation. • Male erectile dysfunction

CRISIS • situation that occurs when an individual’s habitual coping ability becomes ineffective to merit demands of a situation

Crisis Intervention

• Four stages of crisis:

– Exposure to stressor – Increased anxiety when customary coping is ineffective – Increased efforts to cope – Disequilibrium and significant distress

• Types of crises: – Maturational – Situational – Adventitious

Steps in Crisis Intervention

• Identify the degree of disruption the client is experiencing • Assess the client’s perception of the event • Formulate nursing diagnoses • Involve the patient and family if applicable with planning • Implement interventions- new and old coping mechanisms • Evaluate-reassessment, reinforcement

Crisis state lasts 4–6 weeks. Outcome is either return to previous functioning level, improved coping, or decreased coping. Crisis intervention techniques are authoritative and facilitative. A balance of both types is most effective.

Anger, Hostility, and Aggression Anger is a normal human emotion. Hostility and aggression are inappropriate expressions of anger.

Anger Anger is a strong, uncomfortable, emotional response to a provocation, either real or perceived. It results when one is frustrated, hurt, or afraid and energizes the body for defense (fight or flight).

• Denying or suppressing angry feelings can lead to physical or emotional problems • Anger that is expressed inappropriately can lead to hostility and aggression • Appropriate expression of anger involves assertive communication skills that lead to problem solving or conflict resolution

• Venting angry feelings by engaging in safe but aggressive activities (punching bag, yelling) is called catharsis. However, research has shown that catharsis may increase rather than alleviate angry feelings • Clients with depression may have anger attacks when they feel emotionally trapped

• Which nursing intervention is most important when restraining a violent client? A. reviewing facility policy regarding how long the client can be restrained B. preparing an as needed dose of the client’s psychotropic medication C. checking that the restraints have been applied correctly D. asking if the client needs to use the bathroom or is thirsty

Hostility and Aggression

Hostile and aggressive behavior may occur suddenly without warning, but often stages or phases can be identified: • Triggering • Escalation • Crisis • Recovery • Postcrisis

Hostility is an emotion expressed by: • Verbal abuse • Lack of cooperation • Violation of rules or norms • Threatening behavior (verbal aggression)

Related Disorders Most psychiatric clients are not aggressive, but some exhibit angry, hostile, or aggressive behavior caused by: • Paranoid delusions • Auditory (command) hallucinations • Dementia, delirium • Head injury • Intoxication with alcohol or drugs • Antisocial and borderline personality

Intermittent Explosive Disorder: Rare psychiatric diagnosis involving discrete episodes of aggressive impulses resulting in serious injury or property damage Episodes are out of proportion to any provocation, and the person is remorseful and embarrassed afterward.

Acting Out An immature defense mechanism in which the person deals with emotional conflict or stress by actions rather than reflection or feelings; the person is trying to feel less powerless or helpless by acting out.

Etiology of Hostility and Aggression • Neurobiologic theories: decreased serotonin, increased dopamine and norepinephrine; damage to frontal or temporal lobes • Psychosocial theories: failure to develop impulse control and ability to delay gratification

Treatments and Medications Treatment often focuses on treating the underlying or comorbid psychiatric diagnosis such as schizophrenia or bipolar disorder.

Aggressive Clients

• Lithium for bipolar disorder, conduct disorder, or mental retardation • Carbamazepine (Tegretol) or valproate (Depakote) for dementia, psychosis, or personality disorders • Atypical antipsychotics such as clozapine (Clozaril), risperidone (Risperdal), and olanzapine (Zyprexa) for dementia, brain injury, mental retardation, and personality disorders • Benzodiazepines for older adults with dementia • Haloperidol (Haldol) and lorazepam (Ativan) for clients with psychoses

Assessment • Early assessment and intervention needed when clients are angry or hostile to avoid physically aggressive episodes • Nurse must assess both individual clients and the therapeutic milieu or environment • Assessment and intervention are based on five phases of aggression

Data Analysis Common nursing diagnoses: • Risk for Other-Directed Violence • Ineffective Coping

Intervention Interventions are most effective and least restrictive when implemented early in the cycle of aggression. • Managing the milieu includes: – Having planned activities; informal discussions – Scheduled one-to-one interactions; letting clients know what to expect – Helping clients with conflicts to solve their problems, including expression of angry feelings

• Managing aggressive behavior includes: – Triggering phase: • Approach in nonthreatening, calm manner • Convey empathy • Listen • Encourage verbal expression of feelings • Suggest going to a quieter area, or use of PRN medications • Physical activity such as walking

– Escalation phase:

• Take control • Provide directions in firm, calm voice • Direct client to room or quiet area for time out • Offer medication again • Let client know aggression is unacceptable and nurse or staff will help maintain/regain control if needed • If ineffective to that point, obtain assistance from other staff (show of force) to get client to take time out or take medication

– Crisis phase: • Staff must take control of situation as determined by facility or agency policy (trained in techniques for behavioral management) • Use restraint or seclusion only if necessary – Recovery phase as client regains control: • • • • •

Talk about the situation or trigger Help client relax or sleep Explore alternatives to aggressive behavior Provide documentation of any injuries Staff debriefing

– Postcrisis phase: • Client is removed from any restraint or seclusion and rejoins the milieu • Calm discussion of behavior; no lecturing or chastising; return to activities, groups, and so forth • Focus is on appropriate expression of feelings, resolution of problems or conflicts in nonaggressive manner

Community-Based Care

• Regular follow-up appointments, compliance with prescribed medication, and participation in community support programs help the client to achieve stability • Anger management groups are available to help clients express their feelings and learn problem-solving and conflict-resolution techniques

Self-Awareness Issues

• How nurse handles own angry feelings • Comfort with expression of anger from others • Ability to be calm, nonjudgmental • Nurse must have assertive communication skills, conflict resolution skills, ability to see that client’s behavior/anger is not personal or a sign of nurse’s failure, and ability to deal with own fear when clients are aggressive or threatening

Abuse and Violence

Clinical Picture of Abuse and Violence

• Abuse is the wrongful use and maltreatment of another person… …can be child, spouse, partner, or elder parent

Victims of abuse and trauma can have both physical and psychological injuries, including: • Agitation anxiety, silence • Suppressed anger or resentment • Shame and guilt • Feelings of being degraded or dehumanized; low self-esteem • Relationship problems; mistrust of authority figures

Characteristics of Violent Families

• Social isolation • Alcohol and other drug abuse • Power and control by abusive person • Intergenerational transmission process

Spouse or Partner Abuse

• Involves the mistreatment of one person by another in the context of an intimate relationship • 90% to 95% of domestic violence victims are women • Pregnancy escalates domestic violence • Abuse can occur in same-sex relationships

Battered Wife Syndrome

Psychodynamics • Often done by the husband to his wife • Abusive husband believes that he owns his wife (as one of his possessions) and starts to be violent and abusive when the wife shows signs of being independent (like having her own job)

Profile of the Abuser • • • • • • • •

Inadequate With low self-esteem Poor problem-solving and social skills Immature Needy Unreasonably jealous Possessive He longs for power and a sense of control, which he is able to have when he bullies and punishes the family physically

Profile of the Abused • Dependent • Low self-esteem • Perceives herself as unable to function away from her husband • Equates success with her blind loyalty to her husband • Fear of being killed by the abuser if they try to escape

Cycle of Abuse and Violence • Initial episode of violence • Honeymoon period: abuser promises it will never happen again, gives gifts and flowers, is affectionate • Tensions begins to build with arguments, silence, complaints • Violence occurs again • This cycle repeats over and over

Battered Wife Syndrome

When preparing to present a community program about women who are victims of physical abuse, which of the following would the nurse stress about the incidence of battering? a. Death from battering is rare. b. Battering is a major cause of injury to women. c. Lower socioeconomic groups are primarily affected. d. Battering rarely involves pregnant women.

Assessment • It is necessary to identify victims of abuse in all settings, since they often do not seek treatment directly • SAFE questions can be used to assess: – Stress/Safety-

What stress do you experience in your relationship? Do you feel safe in your relationship?

– Afraid/Abused- Have there been situations in your relationship where you have felt afraid

– Friends/Family-

Are your friends aware that you have been hurt? Do your family/siblings know about this abuse?

– Emergency plan –

Do you have a safe place to go and the resources you & your children need in an emergency?

Treatment and Intervention (cont’d) • Injuries -Assessment for physical after the episode of violence

injuries immediately

• Communication -The nurse must never indicate that

he or she thinks the woman should leave the relationship; need to keep the door open for further communication

• Information -Providing women with

information about shelters, services, and so forth is essential

Effect of Violence on the Children The violence the children experience has a great impact on their health and development. They tend to be more aggressive and have greater risk-taking behavior.

A 3-year-old client is bought to the emergency room with a fractured wrist and suspicious bruising on his arms. The step-father claims the boy fell out of bed. What is the most important criterion for the nurse to consider when deciding to report suspected child abuse? a. Inappropriate parental concern or the degree of injury. b. Absence of parents for questioning about the injury. c. Inappropriate between the history and injury. d. Incompatibility between the history and injury.

Child Abuse

Child abuse is intentional injury of a child, including: – Physical abuse or injuries – Sexual assault or intrusion – Neglect or failure to prevent harm (failure to provide adequate physical or emotional care or supervision; abandonment) – Psychological abuse

• Julia, 6 years old the youngest of 4 daughter of Mr. & Mrs. Gomez was brought to the emergency room with bruises all over the body and lacerations on her face. • During the initial interview with the parents, they gave a typical description of an abused child when they say that Julia: A. has always been different from her sisters B. does not show respect for others C. tends to lie frequently D. always displays temper tantrums

Parents who abuse children: (psychodynamics)

• Knowledge- Have minimal parenting knowledge and skills

• Unmet needs -Are incapable of meeting their own needs, much less those of a child

• Transmission- Often raise their children the way they were raised, including corporal punishment and abuse

• Unrealistic expectations -Expect the child to meet all their needs for love and affection

• Emotions -Are emotionally immature and needy

Assessment Suspect child abuse when there are:

• Delays in seeking treatment; old injuries that were not treated • Unusual injuries such as scalding and cigarette burns • Multiple, unexplained bruises • Inconsistent history, or illogical explanation for the injuries • Urinary tract infections; red, swollen, or bruised genitalia; tears of vagina or

Types of Child Abuse Physical Abuse • Involves the performance of a severe corporal punishment of hitting or beating child victims • These acts include biting, burning, cutting, poking, twisting limbs, or scalding with hot water • Signs and symptoms: – Untreated fractures – bruises of various ages – injuries not explained adequately by caregivers

Sexual Abuse • Involves sexual acts committed by an adult towards an individual below 18 years of age • This may involve incest, rape, sodomy, exposure, rubbing or fondling of the victim’s genitals • This also includes sexual exploitation of involving minors in acts of pornography or in doing obscene acts

Neglect Intentional or ignorant withholding of physical, emotional, or educational needs for the improvement of the child’s well-being May be in the form of: • refusal or delay in seeking medical treatment • abandonment • inadequate supervision • recklessness with the child’s safety • spouse abuse in the child’s presence, • failure to enroll the child in school

Psychological Abuse Abuse which adversely affects the child’s emotional make-up These may include:  verbal abuse  blaming  screaming  name-calling  constant family arguments resulting to fighting and yelling withholding of affection and experiences that promote love, security, and self-worth

This could also be in the form of parental

Changes in the Victims and Survivors of Abuse

Physical  Injuries in the form of fractures or burns  Sexuallty-transmitted diseases

Psychological  Oblivion- Appearing numb of oblivious to the surroundings  Shame/Silence -Often suffering in silence and continue to experience guilt and shame  Hapless -Children come to believe that they are to be blamed for everything  Agitation  Mistrust -They develop difficulty in trusting and relating with others  Emotions are intense -Emotionally, they are labile, intense, often unpredictable and may fear intimacy for

• B. C. D. E.

A nursing intervention which would help abusive parents is: Allow them to relate the history of child abuse in their family Instruct them on how they can encourage their children to obey them Teach them to handle angry behavior before it gets out of control Explain to them that as the child grows older, their needs differ.

Treatment and Intervention • Safe place - Getting the child to a safe place once abuse is identified • Individual therapy for the child, play therapy • Family therapy • Treatment for parents for any substance abuse or psychiatric issues • Social Services -Intensive involvement of social service agencies • Note:

Report all cases of child abuse to the AUTHORITY.

• A nurse is performing an admission assessment on a child and notes the presence of old and new bruises on the child’s back and legs. The nurse. suspects physical abuse and would: a. File charges against the mother and the father of the child b. Report the case to legal authorities c. Ask the mother to identify the individual who is physically abusing the child d. Tell the child that she will need to go to a foster home until the situation is straightened out.

Elder Abuse

Elder abuse is maltreatment of older adults by family members or caretakers, including:

– Physical, sexual, or psychological abuse or neglect – Self-neglect – Financial exploitation – Denial of adequate medical treatment

• 60% of perpetrators are spouses, 20% adult children, 20% others • People who abuse elders are almost always in a caretaker role • Elders are reluctant to report abuse because they fear the alternative (nursing home)

Assessment Possible indicators of physical abuse: • Malnourished, dehydrated • Rashes, sores, lice • Smell of urine, feces, dirt • Failure to keep needed medical appointments • Untreated medical condition

Possible indicators of emotional or psychological abuse: • Reluctance to talk openly • Helplessness • Withdrawal or depression • Anger or agitation

Possible indicators of selfneglect: • Inability to manage own finances • Inability to perform activities of daily living • Inadequate clothing • Signs of malnutrition or dehydration

Possible indicators of abuse by caregiver: • Caregiver speaks for the elderly person • Caregiver shows indifference or anger • Caregiver blames elderly person for physical problems • Caregiver shows defensiveness • Caregiver and client give conflicting accounts

Possible indicators of financial exploitation: • Recent changes in will that client could not make • Different signatures on checks • Unusual activity in bank accounts • Missing valuables • Inability to manage money

Treatment and Intervention Treatment and intervention may involve: • Providing adequate support and respite for the caregivers • Changing caregiving arrangements • Moving the elderly person to a safe environment

Rape Rape is a crime of violence and aggression expressed through sexual means. The act is against the victim’s will or against someone who cannot give consent.

•

b. b. c. d.

A female victim of a sexual assault is being seen in the crisis center for a third visit. She states that although the rape occurred nearly 2 months ago, she still feels “as though the rape just happened yesterday.” The nurse would respond by stating: “What can you do to alleviate some of your fears about being assaulted again.” “Tell me more about those aspects of the rape that cause you to feel like the rape just occurred.” “In time, our goal will be to help you move on from these strong feelings about your rape.” “In reality, the rape did not just occur. It has been over 2 months now.”

• The victim can be any age • Half of rapes are committed by someone known to the victim • Rape is underreported to the police • Same-sex rape can occur between partners but is most common in institutions

Male rapists have been categorized as: • Sadists- Sexual sadists aroused by pain of victim • Anger -Those who rape as a displaced expression of anger and rage • Predators- Exploitative predators • Inadequate men

Physical and psychological trauma to rape victims is severe: • Medical problems: victims are significantly less healthy; pregnancy, STDs, HIV are concerns • Psychological Trauma -Victims may feel frightened, helpless, guilty, humiliated, and embarrassed; may avoid previously pleasurable activities • Relational Problems -Relationship problems may occur, mistrust

Treatment and Intervention • Immediate support to ventilate fear and rage • Care by persons who believe that the rape happened • Coordination of all needed services in one location

• Giving the victim control over choices whenever possible • Prophylactic treatment for STDs • Referral to therapy services; counseling; and groups for longer-term help

Psychiatric Disorders Related to Abuse and Violence Two psychiatric disorders are associated with histories of violence and abuse: 2. Posttraumatic stress disorder (PTSD) 3. Dissociative disorders

PTSD Disturbing behavior resulting after a traumatic event at least 3 months after the trauma occurred Up to 60% of persons at risk (combat veterans, victims of violence and natural disasters) develop PTSD.

Dissociative Disorders

Dissociation is a subconscious defense mechanism that helps a person protect the emotional self from recognizing the full impact of some horrific or traumatic event by allowing the mind to forget or remove itself from the painful situation or memory. Dissociation can occur both during and after the event and becomes easier with repeated use.

Self-Awareness Issues • Becoming comfortable asking all women about abuse (SAFE questions) • Listening to accounts of abuse from clients and families • Recognizing client’s strengths, not just problems • Working with perpetrators of abuse; dealing with own feelings about abuse and violence

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Which of the following statements made by a client whose husband has just died would be the most important in determining whether her response is normal or delayed or extended?

C. D. E. F.

“My husband died 1 week ago.” “I feel sad and want to cry all the time.” “We were married for 40 years.” “We grew apart during the later years.”

Grief and Loss Grief refers to the subjective

emotions and affect that are a normal response to loss. Grieving, also known as bereavement, is the process of experiencing grief. Anticipatory grief is facing an imminent loss. Mourning is the outward sign of grief.

Experiences of grief and loss are essential and normal in the course of life; letting go, relinquishing, and moving on happen as we grow and develop.

Grief and loss are uncomfortable.

Types of Losses

Losses may be planned, expected, or sudden. Loss of a loved one is probably the most devastating type of loss, but there are many other types of losses: (Maslow’s) • Physiologic (loss of limb, ability to breathe) • Safety (domestic violence, posttraumatic stress disorder, breach of confidentiality)

• Security/sense of belonging (relationship loss [death, divorce]) • Self-esteem (ability to work, children leaving home) • Self-actualization (loss of personal goals, such as not going to college, never becoming an artist or dancer)

The Grieving Process

Nurses must recognize the signs of grieving to understand and support the client through the grieving process. The therapeutic relationship and therapeutic communication skills are paramount when assisting grieving clients.

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52 year old Renee Sandoval comes to the mental health clinic and related that since the death of her husband she feels really miserable. She says in a loud voice, “How could he leave me? I can’t deal with this!” Which of the following stages of the grief reaction is she most likely displaying at this time?

C. Denial C. Bargaining

B. anger D. resolution

Theories of the Grieving Process

Kubler-Ross’s stages of grieving:

• Denial (shock and disbelief) • Anger (toward God, relatives, health care providers) • Bargaining (trying to get more time, prolonging the inevitable loss) • Depression (awareness of the loss becomes acute) • Acceptance (person comes to terms with impending death or loss)

John Harvey’s phases of grieving: • Shock, outcry, and denial • Intrusion of thoughts, distractions, and obsessive reviewing of loss • Confiding in others to emote and cognitively restructure

Rodebaugh’s stages of grieving:

• Reeling • Feelings • Dealing • Healing There are many similarities among theorists about grief. Not all clients follow predictable steps or make steady progress.

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B. C. D. E.

What is the most therapeutic initial nursing intervention in helping a client deal with feelings after the loss of a spouse? Help the client see the positive aspects of the relationship with a spouse. Describe the stages of the grieving process Support the client’s expression of feelings Explain that in time the hurt feelings will lessen

Tasks of the Grieving Process • Undoing psychosocial bonds to loved one and eventually creating new ties • Adding new roles, skills, and behaviors • Pursuing a healthy lifestyle • Integrating the loss into life

Dimensions of Grieving

• Cognitive responses to grief

– Questioning and trying to make sense of the loss – Attempting to keep the lost one present

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Emotional responses to grief Spiritual responses to grief Behavioral responses to grief Physiologic responses to grief

Nurse’s Role

The nurse must encourage clients to discover and use effective and meaningful grieving behaviors: • Praying • Attending memorials and public services • Performing rituals • Staying with the body

Disenfranchised Grief or Complicated Grieving

Disenfranchised grief is grief over a loss that is not or cannot be openly acknowledged, mourned publicly, or supported socially: • A relationship has no legitimacy • The loss itself is not recognized • The griever is not recognized

Complicated grieving is a response that lies outside the norm of grieving in terms of: • extended periods of grieving • responses that seem out of proportion • responses that are void of emotion

Assessment (P-S-C)

• Does the client have adequate perception regarding the loss? – What does the client think and feel about the loss? – How is the loss going to affect the client’s life? – What information does the nurse need to clarify or share with the client?

• Does the client have adequate support? • Does the client have adequate coping behaviors?

Intervention (P-S-C) • Regarding perception of the loss – Explore perception and meaning of the loss

• Regarding adequate support – Help the client reach out and accept what others want to give

• Regarding adequate coping behaviors – Shift from an unconscious defense mechanism to conscious coping – Compare and contrast past coping – Encourage the client to care for self

Essential communication and interpersonal skills to assist grieving: (BUTTONS) • Beliefs- Respect the client’s personal beliefs • Uniqueness -Respect the client’s unique process of grieving • Touch -Appropriate use of touch indicates caring • Trust -Be honest, dependable, consistent, and worthy of the client’s trust • Offer Smile -Offer a welcoming smile and eye contact • Name- Refer to a loved one or object of loss by name (if acceptable in the client’s culture) • Simple - Use simple, nonjudgmental

Self-Awareness Issues • Examining one’s own experiences with grief and loss • Taking a self-awareness inventory and reflecting on the results may be helpful.