Interpersonal model & Behavior model

INTERPERSONAL & BEHAVIORAL MODEL IN PSYCHIATRY

1. CONCEPTUAL MODELS INTERPERSONALMODEL & BEHAVIORAL MODEL PREPARED BY Mrs. Divya Pancholi M.Sc. (Psychiatric Nursing) Assistant Professor SSRCN, Vapi

2. INTERPERSONAL MODEL Significant contributions in the interpersonal theory were made by Harry Stack Sullivan .

3. BASIC ASSUMPTIONS OF INTERPERSONAL THEORY Human being is a social being. His behavior grows out of his attempts to establish meaningful social relationship with others. Personality development is determined in the context of social interactions with others and is influenced by both biological and social factors.

4. Anxiety is a primary motivator of human personality formation and exhibition of human behavior. Anxiety is important in building self-esteem and enabling a person to learn from their life experiences. Interpersonal experiences determine the personality organization achieved by human beings. Security mechanisms are used to overcome or avoid or reduce the anxiety.

5. BASIC PRINCIPLES OF INTERPERSONAL THEORY Developmental proceeds through various stages, in each stage there is involvement of different patterns of relationship, e.g. in infancy- need for contact was fulfilled by the parents. In childhood- active participation in activities and interaction with adults will be observed. In early childhood- - detachment from parents and attachment with peer group increases. In preadolescent and adolescent - intimate relationship with heterosexual groups resulting into marriage and family formation. If any failure to make progress satisfactorily through various stages may result into maladaptive behavior.

6. CONTI… Anxiety has direct relationship in the personality formation, e.g. for fulfillment of basic needs an infant will depend on caretaker, lack of any of these needs will lead to develop mistrust or anxious or insecure and may prone for maladjustment.

7. CONTI… Early life experiences will influence individual’s development throughout his life. This lasting effect is produced by personifications, feelings, attitudes and ideas, forms as the result of experiences with anxiety and needs satisfaction with the mothering one.

8. CONTI… Socialization causes a lot of pressure on children, E.g. appreciation and praise by others, experiences of approval and tenderness is associated with good feelings about the self ‘good me.’

9. CONTI… Experiences associated with criticism, high anxiety situations results into ‘bad me’ and are associated with feelings of shame, guilt and low self-esteem 

10. CONTI… ‘Not I’ develops in reaction to overwhelming anxiety arising from situations that provoke feelings of ‘horror or dread’. Over a period an individual develops a ‘self-system’ and ‘self-esteem’ by using coping mechanisms to reduce anxiety of socialization pressures.

11. CONTI… Social exchange: social relationship is established to meet the mutual needs. Each person needs mutual help, recognition from others for self-identification. Social roles: every individual has to perform specific role set by the society, e.g. teacher, mother, priest, etc. Interpersonal accommodation: Two or more persons interact with each other and establish certain goals to build a satisfying relationship. It enables the nurse to understand clients’ background, relationship with significant people, etc.

12. MODES IN COGNITIVE PROCESSES 1. PROTOTAXIC MODE It is characterized by sensations, feelings and fleeting images occurring during infancy which are primitive and illogical. 2. PARATAXIC MODE It is also illogical in nature. Simultaneous events are considered as casually related. For example, a child who has experienced the amount of loss of several significant members in the family will conclude that all people entering in the hospital will die. It may be commonly observed in early childhood, if it continues into adulthood it may predispose into racial, sexual and ethnic stereotype and prejudices.

13. 3. SYNTAXIC MODE It is developed form, characterized by logical thinking emerges in the juvenile stage. i.e. the process by which people come to agreement about the meaning and significance of specific symbols. Human development proceeds through stages of development from infancy to old age.

14. STAGES OF DEVELOPMENT IN SULLIVAN’S INTERPERSONAL THEORY

15. STAGE AGE MAJOR DEVELOPMENTAL TASKS Infancy Birth to 18 months Relief from anxiety through oral gratification of needs Childhood 18 months to 6 years Learning to experience delay in personal gratification without undue anxiety Juvenile 6 to 9 years Learning to form satisfactory peer relationships Preadolescence 9 to 12 years Learning to form satisfactory relationships with persons of the same gender; initiating feelings of affection for another person Early adolescence 12 to 14 years Learning to form satisfactory relationships with persons of the opposite gender, developing a sense of identity Late adolescence 14 to 21 years Establishing self-identity; developing a sense of identity

16. INTERPERSONAL THERAPEUTIC PROCESS The therapist actively encourages trust by relating authentically to the client and shares the feelings and reactions with the client. The interpersonal therapist will explore the clients’ life history. It focuses on the person’s progress through the developmental stages of learning to relate productively to other people. The process of therapy is essentially a process of re-education , the therapist will help the client to identify interpersonal problems and then encourages him to try out more successful styles of relating closeness within the therapeutic relationship builds trust, facilitates empathy, enhances self-esteem and fosters growth towards healthy behavior.

17. CONTI… Power in relationship shifts to the client as he is able to delay gratification and to invest energy in goal achievement. Therapy is terminated when the client is able to establish satisfying relationship and meets his basic needs. The client learns that leaving a significant member or individual involves pain and an opportunity for growth. Termination will be experienced and shared by both therapist and the client.

18. ROLE OF THE PATIENT AND THE INTERPERSONAL THERAPIST Peplau has explained the interpersonal nursing roles: Stranger Resource person Teacher Leader Surrogate parent Counselor

19. APPLICATION TO NURSING C ornerstone in psychiatric nursing. Concepts like anxiety, trust, security, self-esteem and nurse-client relationship, etc. were included in nursing curriculums, which were derived from Sullivan’s work. The use of interpersonal process recordings in the clinical aspect of mental health nursing practice . It is deterministic in nature and more hopeful outlook for clients and practitioners in using this theory.

20. BEHAVIORAL MODEL

21. It is derived from ‘learning theories’ focused on client’s actions, not on thoughts and feelings. Behavioral approach is used frequently to control the undesirable behavior. Prominent therapists of behavioral theory/model/therapy include Joseph Wolpe , BF Skinner, Ivan Pavlov and John Watson INTRODUCTION

22. BASIC ASSUMPTIONS: Behavior is a response to stimuli from the environment. Either adaptive or maladaptive behavior is learnt . Change in behavior leads to a change in the cognitive and affective spheres . Therapist will emphasize on quantitative aspect of observable behavior. Deviations from the norm are habitual responses that can be modified through application of learning theory.

23. CONTI… Positive response is reinforced . The response is strengthened by repetition of the learning sequence. Reinforcement is essential to get the response. Positive reinforcement is a reward for selected behavior. Human beings are passive organisms that can be shaped or conditioned to do anything . If correct responses are rewarded or reinforced. Maladaptive behavior can be unlearnt and replaced with adaptive behavior, if the person receives appropriate stimuli to eliminate the maladaptive learning.

24. TECHNIQUES OF BEHAVIORAL THERAPY

25. 1. SYSTEMIC DESENSITIZATION Based on ‘Reciprocal Inhibition Behavioral Principle’ of counter conditioning. In this the clients will attain a state of complete relaxation and are then exposed to the stimulus that elicits the anxiety response.

26. CONTI… 1. Relaxation training 2.Hierarchy construction 3. Desensitization to stimulus

27. 1. Relaxation training will be given, e.g. mediation, hypnosis, mental imagery, bio-feedback, Jacobson progressive relaxation. 2. Ask the client to construct a hierarchy of anxiety provoking situation in descending order of anxiety provocation. 3. Desensitization of the stimuli: patient is asked to give a signal whenever anxiety is produced with each signal; he is asked to relax, after a few trials, client is able to control his anxiety gradually.

28. 2. FLOODING Prolonged contact with the anxiety will make the client to face the frustration and anxiety situation without much difficulty.

29. 3. AVERSION THERAPY Pairing of pleasant stimuli with an unpleasant response so that even in the absence of unpleasant response, the pleasant stimuli becomes unpleasant because of association.

30. 4. OPERANT CONDITIONING PROCEDURES FOR INCREASING ADAPTIVE BEHAVIOR   1. Positive reinforcement 2. Token economy

31. 1. POSITIVE REINFORCEMENT: To reinforce or improve the performance of the desirable behavior repeatedly a token. Reward material or symbolic appreciation will be given whenever the client performs an acceptable behavior , e.g. Modeling , Shaping.

32. 2. TOKEN ECONOMY: Indications- chronic hospitalized patients, children up to adolescent age. It is a positive reinforcement programme to encourage socially acceptable or desirable behavior among client; A small token will be given as an exchange for privileges.

33. 5. OPERANT CONDITIONING PROCEDURES TO TEACH NEW BEHAVIOR   1. Modeling 2. Shaping 3. Chaining

34. 1. Modeling : Acquiring new desirable behavior through imitation or by demonstration; the client will be given an opportunity to observe ‘Model behavior ’ either from therapist or psychiatric team members or through other patients. The team members will exhibit a specific desirable behavior which will be observed by the client and the he will be given an opportunity to perform target behavior in desirable manner, if he does so, reward or an appreciation will be given to encourage the client to perform those act repeatedly whenever is required.

35. 2. Shaping : Indication : Neurosis, Phobias, Physically handicapped, Autism, Obsession. Skills can be achieved through shaping technique; the therapist tries to shape the desired behavioral skill step by step. He positively reinforces the existing behavior and the responses which are closest for the desired behavior and ignores the other responses. Therapist will praise the client for his desired behavioral performance and if he fails no response will be given.

36. 3. Chaining : T raining will be given to learn complex tasks in break up manner, step by step: Forward chaining: The therapist will identify the difficulty of the client in performing complex tasks. He will give training to the client to learn first step, after client achieves it, the second step and the third until client achieves the task. Backward chaining: In backward direction, step by step the client will be assisted to learn desirable tasks from last step to next step likewise, e.g. for mentally disabled this training is adapted.

37. 6. OPERANT CONDITIONING PROCEDURES FOR DECREASING MALADAPTIVE BEHAVIOR Time out Response cost Punishment

38. Ignoring/extinction Restitution /over-correction

39. Time out: If the client performs undesirable acts or exhibits undesirable behavior . He will not be encouraged to perform the similar act and will be given negative reinforcement by some sort of punishment, e.g. if the child exhibits odd behavior , he is not allowed to play until he changes the behavior and adapts healthy, desirable behavior , punishment can be avoided if the caretaker is satisfied with the behavior .

40. Response cost : To teach adaptive behavior among the client token programs were activated. If those clients exhibit undesirable behavior , a fixed number of tokens or pints deducted from what the individual has got already.

41. Punishment: Whenever undesirable behavior exhibits, it has to be avoided by administering some sort of punishment with proper explanation; it will be used to decrease the undesirable behavior /maladaptive behavior .

42. Ignoring/extinction: Whenever the problematic behavior exists rewards or attention can be removed, e.g. not to have eye to eye contact or physical contact or moving away, not showing interest to talk or mingle with them.

43. Restitution : If the client exhibits undesired or problematic behavior , it will be corrected by wide range of punishment, e.g. if the child passes stools within the dress after toilet training, to avoid the repetition of the undesirable behavior , mother will ask the child to wash his clothes by himself.

44. 7. ASSERTIVENESS TRAINING

45. In 1949, Salter and in 1958, Wolpe have described assertiveness training. Aims: Alleviates interpersonally based anxiety. Improves interpersonal relationship, self-esteem, self-control Improves the ability to stand up for one’s own rights Clients are assisted to identify the usual mode of behavior Brings change in emotion and other behavior pattern .

46. Indications: Chronic depression Socially anxious person or socially awkward in nature Shy tendency    

47. Technique: The therapist will give assertive behavior training by role playing, coaching, modeling and role reversal technique and the by practicing it in real life situations. This training will help the client not to infringe on the rights of others and helps to ascertain the ability to stand for their rights, ignores passive behavior , inculcates the client for usual mode of behavior . Through assertiveness training, the client will learn social skills and improves interpersonal relationships, social behavior and social contacts. For example, eye-to-eye contact while speaking, appropriate behavior , etiquette behavior , interaction pattern, etc.

48. ROLE OF THE NURSE IN BEHAVIORAL THERAPY Nurses have to keep in mind, the principles of learning while administering behavioral therapy for the clients. Uses behavioral approaches like positive reinforcement, relaxation techniques. Involves the client and significant people in provision of care Positive responses will be reinforced.