Conceptual Models in Nursing ...........

conceptual models

1. CONCEPTUAL MODELS IN PSYCHIATRIC Nursing

2. INTRODUCTION Mental health professionals practice within the framework of a conceptual model. ‘Model is an organised complex body of knowledge such as concepts related to human behaviour’.

3. DEFINITION OF CONCEPTS Mental formulations of an object or event which will come from individual perceptual experience, e.g. ideas, mental images, etc which describes phenomena. Conceptual model provides philosophical, pragmatic orientations to the service and scientific knowledge of rendering better service, responsibilities and accountability.

4. Types of Models Models help health professionals by suggesting : Reasons for observed behaviour Therapeutic treatment strategies Appropriate roles for patient and therapist

5. Conceptual Models In Mental Health Nursing

6. 1. PSYCHO-ANALYTICAL MODEL Psycho-analytical theory was developed by Sigmund Freud in the late 19 th and early twentieth centuries. It focused on the nature of deviant behaviour and proposed a new perspective on human development. It is based on the concept of intra-psychic conflict within the individual.

7. VIEWS OF BEHAVIORAL DEVIATIONS Psychoanalytic theory supports the notion that all human behaviour can be explained. Freud believed that repressed (driven from conscious awareness) sexual impulses and desires motivate human behaviour. Disrupted behaviour in the adult is traced to the earlier developmental stages. Symptoms are symbols of the original conflict.

8. VIEWS OF BEHAVIORAL DEVIATIONS Neurotic symptoms arise when so much energy goes into controlling anxiety that it interferes with the person’s ability to function. Psychotic symptoms arise when ego must invest most of libido in defending against primitive id impulses leaving only little energy to deal with external reality.

9. THEORIES OF MIND In 1900, Sigmund Freud developed this theory in the ‘interpretation of dreams’. According to this theory the mind structure of the human psyche was divided into three layers: CONSCIOUS MIND: It is the upper portion of the mind, occupies only one-tenth of our total psyche or mental life. All mental activities are meaningful and purposeful. The conscious mental process of thinking is based on reality principle.

10. THEORIES OF MIND SUBCONCIOUS MIND or PRE - CONSCIOUS MIND: Just beneath the conscious layer lies the subconscious mind. It stores all types of information just beneath the surface of awareness. It can be easily brought to the level of conscious at a moment’s notice whenever required .

11. THEORIES OF MIND UNCONSCIOUS MIND: It is the largest and most important region of the mind. U nconscious mind contains ideas and the repressed material that can only reach the conscious through preconscious, when the censor is relaxed e.g. dreams or abreaction or overpowered, e.g. slips of tongue and free association.

12. THEORY OF PSYCHOSEXUAL DEVELOPMENT In 1905 Sigmund Freud has described psychosexual development of the individual from birth to adulthood. These stages are gradual, sequential, emergence of sexual instincts starts from infancy to adulthood. Oral phase( Birth to 1 & half years) Anal phase( 1 to 3 years) Phallic phase/Oedipal phase( 3 to 5 years) Latency phase( 5 to 12 years) Genital Phase( 12 to 18 years)

13. THE STRUCTURAL THEORY OF MIND In 1923, Sigmund Freud divided the mental apparatus into three dynamic components: ID: It is the original state of mental apparatus with which a newborn is born. It is totally unconscious, containing the basic drives and instincts concerned with survival, sexual drive and aggression. It has qualities like, ‘it must get, what it wants and when it wants’, in this way Id is quite selfish and unethical. It is based on pleasure principle.

14. THE STRUCTURAL THEORY OF MIND EGO: It is primarily determined and guided by the reality principle. It is intermediary between three sets of forces i.e. the instinctive, irrational demands of the Id, realities of the external world and the ethical, moral demands of the super ego. SUPER EGO: It is the direct antithesis of Id and represents the ethical and moral aspect of the psyche. It contains punitive conscience and non-punitive conscience.

15. PSYCHOANALYTICAL THERAPEUTIC PROCESS 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. The analytic therapist uses the techniques of free association, dream analysis, and interpretation of behaviour.

16. PSYCHOANALYTICAL THERAPEUTIC PROCESS Free association: The client may talk about anything at all. The theory is that, with relaxation, the unconscious conflicts will inevitably drift to the fore. The therapist, who is trained to recognize certain clues to problems and their solutions that the client would overlook. Catharsis: It is the sudden and dramatic outpouring of emotion that occurs when the trauma is resurrected.

17. PSYCHOANALYTICAL THERAPEUTIC PROCESS Dream analysis: In sleep, people are less resistant to unconscious and will allow a few things in symbolic form to come to awareness. These wishes from the id provide the therapist and client with more clues. Parapraxes : A Parapraxes is a slip of the tongue, often called a Freudian slip. Freud felt that they were also clues to unconscious conflicts. Patient is seen 5 times a week for several years and is hence time consuming and expensive.

18. ROLES OF PATIENT AND THERAPIST Patient has to be an active participant freely revealing all thoughts as they occurred and describing all dreams. Patient often lies down to induce relaxation. Analyst keeps his or her verbal responses brief and noncommittal. Interpretations are presented for patient to accept or reject but rejection suggests resistance.

19. ROLES OF PATIENT AND THERAPIST Psychoanalyst is a shadow person. Analyst is usually out of sight during therapy session to ensure non verbal response do not influence the patient. Frustration expressed towards analyst is interpreted as transference. By the end of therapy, patient should be able to view analyst realistically having worked through conflicts and dependency needs.

20. 2. BEHAVIORAL MODEL It is derived from ‘Learning Theories’ focused on client’s actions, not on thoughts and feelings. Behavioural approach is used frequently to control the undesirable behaviour. VIEWS OF BEHAVIORAL DEVIATION: Behavioural deviation is a result of learned phenomenon which is deviant from the acceptable norms. People learn their behaviour from their history or past experiences, particularly those experiences that were repeatedly reinforced.

21. BASIC ASSUMPTIONS All behaviour is learned. Behaviour is a response to stimuli from the environment. Behaviour that is rewarded with reinforces tends to recur. Deviations from the norm are habitual responses that can be modified through application of learning theory. Positive response is reinforced.

22. BASIC ASSUMPTIONS Human beings are passive organisms that can be shaped or conditioned to do anything, if correct responses are rewarded or reinforced. Maladaptive behaviour can be unlearnt and replaced with adaptive behaviour.

23. TECHNIQUES OF BEHAVIOURAL THEORY Systemic Desensitization Operant conditioning Procedures for increasing adaptive behaviour: Positive Reinforcement Token Economy 3. Operant conditioning procedures to teach new behaviour; Modelling Shaping Chaining Prompting

24. TECHNIQUES OF BEHAVIOURAL THEORY 4. Operant conditioning procedures for decreasing maladaptive behaviour: Time out Response cost Punishment Ignoring/Extinction Restitution Assertiveness Training Aversion Therapy Flooding Reciprocal Inhibition

25. ROLE OF PATIENT AND THERAPIST The therapist maintains a consistent and firm attitude to bring about change in learned behaviour. Patient has to play an active role in practicing new behaviours, generalizing concepts and practicing desired behaviours.

26. 3. INTERPERSONAL MODEL Harry Stack Sullivan (1892–1949) was an American psychiatrist who extended the theory of personality development to include the significance of interpersonal relationships. Hildegard Peplau (1909–1999) was a nursing theorist and clinician who built on Sullivan’s interpersonal theories and also saw the role of the nurse as a participant observer. Peplau developed the phases of the nurse–client therapeutic relationship, which has made great contributions to the foundation of nursing practice.

27. VIEWS OF BEHAVIORAL DEVIATIONS Sullivan believed that one’s personality involved more than individual characteristics, particularly how one interacted with others. He thought that inadequate or non-satisfying relationships produced anxiety, which he saw as the basis for all emotional problems. Person behaviour bases on two drives: Satisfaction includes basic human drives like hunger etc. Security relates to culturally defined needs like social norms etc.

28. INTERPERSONAL THERAPEUTIC PROCESS Therapist: Uses exploratory and behaviour change techniques and encourages expression of affect. Actively encourages development of trust by relating to patient and sharing feelings and reactions to the patient. Helps patient identify interpersonal problems and encourages attempts at successful styles of relating. Closeness in therapeutic relation builds trust, facilitates empathy, enhances self esteem and fosters growth towards healthy behaviour.

29. INTERPERSONAL THERAPEUTIC PROCESS Peplau described this process as “psychological mothering” which includes the following steps: Patient is accepted unconditionally. Recognitions to patient’s responses is given. Power in relationship shifts to patient as the patient is able to delay gratification for goal achievement. Milieu therapy: It involves clients’ interactions with one another; i.e., practicing interpersonal relationship skills, giving one another feedback about behaviour, and working cooperatively as a group to solve day-to-day problems.

30. ROLE OF PATIENT AND THERAPIST Therapist functions as a “participant observer” whose role is to engage patient, establish trust and empathize. An atmosphere of uncritical acceptance is encouraged. Relation itself serves as a model of adaptive interpersonal relationship. While patient matures in ability to relate therapeutic situations are enhanced.

31. 4. EXISTENTIAL MODEL This model focuses on the person’s experience in the present and now with much less attention focused on the person’s past. VIEWS OF BEHAVIORAL DEVIATIONS: Behavioural deviations result when one is out of touch with oneself or environment. Alienation is caused by self imposed restrictions. The person who is self alienated is lonely and sad and feels helpless. Lack of self-awareness, coupled with harsh self-criticism, prevents the person from participating in satisfying relationships.

32. The person is not free to choose from all possible alternatives because of self-imposed restrictions. Existential theorists believe that the person is avoiding personal responsibility and giving in to the wishes or demands of others instead of being real. EXISTENTIAL THERAPEUTIC PROCESS: Importance is given to present and the belief that humans find meaning through their experiences. These therapies encourage the person to live fully in the present and to look forward to the future. 4. EXISTENTIAL MODEL

33. Rational E motive T herapy : It believes that people have “automatic thoughts” that cause them unhappiness in certain situations. It used the ABC technique to help people identify these automatic thoughts: A is the activating stimulus or event, C is the excessive inappropriate response, and B is the blank in the person’s mind that he or she must fill in by identifying the automatic thought. EXISTENTIAL THERAPEUTIC PROCESS

34. Reality therapy: Therapeutic focus is need for identity through responsible behaviour. Individuals are challenged to examine ways in which their behaviour thwarts their attempts to achieve life goals. Gestalt therapy: A therapy focusing on the identification of feelings in the here and now (present), rather than what they may perceive to be happening based on past experience which leads to self-acceptance. EXISTENTIAL THERAPEUTIC PROCESS

35. “Encounter” is not merely meeting of two or more people; it also involves their appreciation of total existence of each other. Logo therapy: A therapy designed to help individuals assume personal responsibility. The search for meaning ( logos ) in life is a central theme . It is based on the premise that the primary motivational force of an individual is to find a meaning in life. EXISTENTIAL THERAPEUTIC PROCESS

36. ROLE OF PATIENT AND THERAPIST Therapist and patient are equal in their common humanity. Therapist acts as a guide to the patient. Therapist is direct in specifying areas needing change. Therapist and patient have to be open and honest. Patient is expected to assume and accept responsibility for behaviour. Patient is always active in therapy working to meet the challenges presented by the therapist.

37. OTHER MODELS

38. SUMMARY Today’s mental health treatment has an eclectic approach, meaning one that incorporates concepts and strategies from a variety of sources. Today we discussed an overview of major theories, highlight the ideas and concepts in current practice and explain the various treatment modalities. As nurses knowledge of theoretical models provides a framework for patient care and communication.

39. REFERENCES Stuart W. Galia ; Laraia T. Michele, “Principles and Practice of Psychiatric Nursing”, Elsevier Publications, 8 th Edition, Page no- 50 to 58 Kaplan I. Harold, Sadock J. Benjamin, “Synopsis of Psychiatry”, William and William Publications, 8 th Edition Mary C. Townsend, “Psychiatric Mental Health Nursing- Concepts of care in evidence based Practice”, Jaypee Publication; 5 th Edition, Page no- 22 to 43 Neeraja KP, “Essentials of Mental health and psychiatric nursing”vol one,jaypee publishers,1 st edn,Pp-155-179

40. Thank you