- Answer Key -
+- Chapter 1 -
++ Chapter + 2 + + Fundamentals of Theories and Therapies +
+- Unfolding Case Study -
-- Review Questions -
-Chapter Outline
+ + + + + + +- Competency-Based Assessments -
-+ Introduction +
+Clinical professions are evidence-based and founded in theory. The professional specialty of psychiatric-mental health (PMH) nursing addresses brain-based behaviors. Therefore, it seeks theoretical foundations in biological and psychosocial theories. Psychiatric-mental health nursing follows established guidelines based upon the client’s state of health. Multiple theories have been developed to account for how the client comes to be in that state. Nurses must understand the different theoretical concepts and interventions to apply in care of the client experiencing mental health alterations. Comprehension of classic and established theories and therapies relevant to psychiatric-mental health nursing provide a foundation for professional nursing practice. Further, this understanding develops the nurse’s ability to plan client care that is person-centered. Nurses also benefit from self-awareness, which can come with understanding the impact of psychosocial factors on health, illness, and recovery.
- Index -
- -+ 2.1 + + Psychoanalytic Theories and Therapies +
+Learning Objectives
+By the end of this section, you will be able to:
+-
+
- Define psychoanalytic theories and therapies +
- Identify nursing applications of psychoanalytic theories and therapies +
Dr. Sigmund Freud (1856–1939) was the founder of psychoanalysis and noted for his theory that provides explanation of mental health, associated influences, and treatments (Mcleod, 2024b). Freud’s work on the ego defense mechanisms contributed significantly to the nurse’s work in therapeutic communication with clients.
+Definitions
+Freud’s psychoanalytic theory reaches into several areas of mental health and illness. Each area influences the client’s experience and leads the practitioner to investigate or assess the areas where distress originates, such as components of the personality and levels of consciousness. The nurse’s understanding of personality development can bring insight to nursing approaches and provide the basis for person-centered care.
+Personality Development and Levels of Consciousness
+Freud theorized that personality develops between the first and fifth years of life and believed that the person’s manner of being was set by this age. Freud thought the personality was controlled by the mind and that the mind had a structure that included three elements: the id, the ego, and the superego. Each element has a specific function.
+Freud often used the description of an iceberg to visualize the mind; only a tenth of the mind is conscious, while the other 90 percent of the mind is unconscious. The awareness of one’s own existence, sensations, thoughts, and surroundings is consciousness. It is the part of the mind comprising psychic material of which the individual is aware. Whereas, unconsciousness is all the repressed memories, thoughts, and unacceptable feelings a person may have. The unconscious cannot be recalled without a trained therapist. Between these areas, Freud conceptualized the preconscious mind where thoughts and feelings are available to the conscious mind though not currently being applied (Mcleod, 2024b).
+Id
+The id is the part of the personality that is the most primitive and exists in infants. The id drives the instincts, reflexes, and needs. It lacks logic and cannot solve problems. It is often manifested by instinctive behaviors that all humans have to communicate and relieve stress and discomfort. Examples are crying, gagging, laughing, and coughing. The id strives to have all needs in check or to reach a sense of pleasure. Once the needs are met, the id-driven behaviors cease. There are other tensions or stresses that cannot be satisfied by these instinctive measures, such as anxiety. At the point of personality development, around the age of two, the ego takes over (Erwin, 2002).
+Ego
+The ego is both physiological and psychological and maturity often emerges around the fourth or fifth year of development. The ego is the part of the personality that experiences, reacts to, and negotiates with the outside world and thus mediates between the primitive drives of the id and the demands of the social and physical environment. Freud labeled this process that the ego goes through reality testing, meaning that it satisfies the id through manners that are appropriate and it weighs the positives and negatives of an id demand before reacting.
+When the id surfaces that a person is hungry, for example, and wants to be fed to satisfaction, their ego enters and staves off the id with delayed gratification. The ego then synchronizes the id, reality, and the superego to manifest behaviors that are expressive. The ego therefore negotiates with the id to please the superego and is a learned component of the personality that contributes social expectations to meeting demands of reality.
+Superego
+The superego is the moral compass for the personality, the conscience of the person. The superego is the part of the personality representing the conscience, formed in early life by internalization of the standards of parents and other models of behavior. It echoes the good and bad learned from the primary caregiver from birth on. The problem with the superego is that it projects the ideal, not the realistic, striving for perfection in modeling learned responses. If a person has a strong superego, they may exhibit this through perfectionistic tendencies by being critical of themselves and others, and suffering from feelings of inferiority. Figure 2.2 and Figure 2.3 show how the id, ego, and superego relate to each other.
+Another area of Freud’s theory is the psychosexual stages of development, which proposes that childhood experiences shape the adult personality and can underlie mental health problems. Freud created these stages and believed every human developed through these stages. It is important to understand these stages as nurses care for children and adults to assess development. The stages of psychosexual development are summarized in Table 2.1.
+| Stage | +Age (Years) | +Erogenous Zone | +Major Conflict | +Adult Fixation Example | +
|---|---|---|---|---|
| Oral | +0–1 | +Mouth | +Weaning off breast or bottle | +Smoking, overeating | +
| Anal | +1–3 | +Anus | +Toilet training | +Neatness, messiness | +
| Phallic | +3–6 | +Genitals | +Oedipus/Electra complex; identify with gender role | +Vanity, overambition Difficulty with relationships |
+
| Latency | +6–12 | +None | +Social interaction | +None | +
| Genital | +12+ | +Genitals | +Intimate relationships | +None | +
Psychoanalytic Theories Related to Stress Response
+In Freudian theory, defense mechanisms—thoughts, words, and behaviors prompted by the unconscious mind—surface when demands of reality cannot be met by the person. Defense mechanisms are essentially stress responses. In the short-term, defense mechanisms reduce anxiety and provide a buffer to stressful situations. If relied upon longer term, however, defense mechanisms can result in ineffective coping and contribute to mental illness (Ito & Matsushima, 2017).
+Freud believed that all defense mechanisms were rooted in anxiety. The environments in which all humans live have stressors that threaten, create pain, or create tension. The defense mechanism seeks to decrease the threat, stress, pain, or tension. Defense mechanisms like denial or distortion of reality keep reality less threatening. While some defense mechanisms are necessary to live in a healthy emotional manner, too many can cause problems with healthy adjustments and personal growth. Table 2.2 summarizes common ego defense mechanisms.
+| Mechanism | +Rationale | +Example | +
|---|---|---|
| Displacement | +Transferring unacceptable feelings to another situation or person | +A client criticizes the nurse after becoming angry with the physician. | +
| Reaction formation | +Exhibiting opposite behavior to disguise underlying feelings | +A person who worries about their own alcohol use offers to speak against drinking at a school. | +
| Undoing | +Acting in a way that cancels or makes up for another behavior | +A person brings their partner a gift after having an argument. | +
| Projection | +Assigning blame or responsibility to others for thoughts/behaviors unacceptable to self | +A teenager states he would not have used tobacco if his brother did not bring it into the home. | +
| Denial | +Rejecting the truth to delay acceptance of reality | +Someone receives news of a loved one involved in a traffic accident and exclaims, “Oh no! That can’t be true!” | +
| Regression | +Exhibiting behaviors usually seen at an earlier stage of development when the current problem did not exist | +A preschool-aged child begs for a bottle when the parents are absent. | +
Two other areas of Freud’s psychoanalytic theory that are helpful to nursing are the concepts of transference and countertransference. An unconscious feeling the client has toward another (such as a health-care worker) that is originally based on a childhood experience with an important person in their life is transference. For example, the nurse’s mannerisms may prompt unconscious recall for the client of positive or negative experiences from a past relationship, which influences the client’s response to the nurse. In nursing practice, the nurse should consider the concept of transference when recognizing and analyzing cues during client interaction. Whereas countertransference is the unconscious feeling the health-care worker has toward the client. If the client reminds the health-care worker negatively of someone they know, this can cause a problem with therapeutic communication and relationship. The nurse may also feel protective or affectionate toward the client, based on unconscious feelings from a past relationship. Feedback from nursing peers and mentors is very important, as is the nurse’s need for self-reflection and supervisory assistance so that the therapeutic relationship remains strong and client care is optimal. In all nurse-client interactions, nurses should strive to avoid personalizing clients’ behaviors and remarks.
+Nursing Application of Psychoanalytic Theories
+Because Freud’s theory discusses the complex human personality and how it is influenced by past events, it is helpful in nursing practice. It can provide a more in-depth comprehension of client behavior, emotions, development throughout stages of life, and motivations, which will improve the therapeutic relationship and enhance provision of care. By delving into unconscious processes, nurses are able to be more at one with clients, better understand their nonverbal behaviors, and clue into foundational mental health challenges. The theory reinforces the notion that humans and their environments are intermingled and that nurses should look at their clients in that broader context. The theory also emphasizes the need for focused listening, which can help nurses recognize the use of defense mechanisms as cues to the client’s feelings. The nurse can then reflect on what the client is saying to help them process their thoughts and emotions. Nurses also benefit from awareness of transference and countertransference in their interactions with clients, which improves nursing practice.
++ 2.2 + + Interpersonal Theories and Therapies +
+Learning Objectives
+By the end of this section, you will be able to:
+-
+
- Define interpersonal theories and therapies +
- Identify nursing application of interpersonal theories and therapies +
Interpersonal theory, first described by Harry Stack Sullivan (1892–1949), holds that human behaviors can be explained through relationships with others. Influences from these relationships shape personality, ability to cope with stressors, and, ultimately, survival. Interpersonal theory is substantiated by data obtained through observation and investigation.
+These theories enable the nurse to develop person-centered care, become aware of reasons behind client responses, interpret behaviors, avoid judgment, and, ultimately, teach clients self-awareness. This section will explore interpersonal theories of Harry Stack Sullivan, Hildegard Peplau, and Erik Erikson.
+Definitions
+Interpersonal theories posit that personality development and mental health depend upon relationships between people. With the therapeutic relationship between nurse and client being so foundational to nursing practice, these theories resonate when nurses interact with clients. In fact, many interventions have been created based on interpersonal theory. More specifically, interpersonal theories focus on how to assess, interact, and intervene with clients who may be struggling to communicate when dealing with mental health issues.
+Interpersonal theory was originally created by Harry Stack Sullivan. He developed a theory founded on the belief that interpersonal interaction is the basis for the person’s behaviors and sense of self. The main mental health problem identified by Sullivan was anxiety. He believed that human anxiety was fueled by the need for human interaction. He coined the term significant other, as the main person, or a parent, from which humans have their first interpersonal interaction. He believed that this relationship was crucial for healthy emotional development.
+Hildegard Peplau (1909–1999) was influenced by Sullivan’s interpersonal theory and extended it to nursing practice, thereby developing the first systematic theoretical framework for psychiatric nursing in her book, Interpersonal Relations in Nursing (1952). Peplau was the first to create and define the nurse’s interpersonal relationship with the client as the foundation for nursing practice. She changed the mindset of nursing practice from what nurses do to clients to what they do with clients. Her theory speaks to helping clients make positive changes in their health care and wellness through education. She believed that illness presents an opportunity for learning, growth, and coping, and that self-awareness/reflection and the environment are keys. The nurse-client relationship is broken down in stages in her theory: pre-orientation, orientation, working, and mutual termination. The nurse and client move through these phases in an interwoven manner over time during which the nurse encourages the client’s process of thoughts and feelings. The client’s self-awareness is increased during these interactions (Hagerty et al., 2017).
+Erik Erikson (1902–1994) was an American psychoanalyst and follower of Freud’s theories. Erikson believed that a human’s personality is developed throughout their life span and created a developmental model to reflect this. Erikson’s theory described eight stages of human development, conflicts through which people negotiate individual needs against needs and demands of society in order to grow. Many of the stages involve interpersonal relations. Erikson’s work is referenced by other studies of human development in mental health, aging, and child development (Orenstein, 2022). For example, according to Orenstein (2022), the recovery stage of mental illness involves trusting the possibility of regaining health; therefore, this represents a resolution of Erikson’s stage of trust versus mistrust.
+Nursing Application of Interpersonal Theories
+Peplau’s most lauded contribution to nursing is the application of interpersonal theory to anxiety. She described levels of anxiety as mild, moderate, severe, and panic on perception of learning (Table 2.3). She promoted and taught different strategies to lower anxiety to a level where the client could learn and cope with life’s stresses.
+| Level | +Perception | +Signs/Symptoms | +Helpful or a Hindrance | +Nursing Interventions | +
|---|---|---|---|---|
| Mild | +Normal experiences of everyday life, with perceived reality in sharp focus. | +Slight discomfort, restlessness, irritability, mild tensions, relieving behaviors such as nail biting, foot/finger tapping, or fidgeting. | +Can be constructive for the person, as this may be a signal that something needs attention or is dangerous for them. The person can ask for help. | +Emotional support; encouraging communication; family /significant other support. | +
| Moderate | +Perceptual field narrows, details are missing. The ability to think clearly is hampered; however, learning and problem-solving can still occur, but not at the optimal level. | +Tension, pounding heart, increased pulse and respiratory rate, perspiration, gastric discomfort, headache, and urinary urgency. Voice tremors and visible; shaky hands are possible. | +Can be constructive for the person, as this may be a signal that something needs attention or is dangerous for them. Can also be a hindrance to a person because they are unable to focus as sharply on details outside of the anxious thoughts. |
+ Sitting with the client, speaking slowly and calmly, using short simple sentences. Assure client that the nurse is available, and they can ask for help if needed. Provide a quiet environment with decreased stimuli. Encourage the client to talk about their feelings and what happened prior to the symptoms/signs occurring. Ask the client, “What evidence do you have?” “Think a minute, are you basing this conclusion on fact or feeling?” Offer antianxiety medication as ordered. Help the client to problem-solve. | +
| Severe | +Perceptual field is greatly reduced. The person may focus only on one detail or many scattered details, but have trouble discerning what is happening in the environment, even when another person shows them. Possible confusion and may be dazed by the reality. Behavior is automatic and its purpose is to relieve anxiety. | +Headache, nausea, dizziness, insomnia may increase. Trembling and experiencing a pounding heart are common. Hyperventilation and a sense of impending doom may occur. | +The person needs to have intervention with this level of anxiety. They are unable to make safe or logical decisions. | +Remove the client from the stimuli if possible. Stay with the client. Ask the client to discuss their feelings and what happened for the anxiety to accelerate, if possible. Same interventions as moderate anxiety. Offer antianxiety medication as ordered. |
+
| Panic | +Unable to process what is happening and may lose touch with reality. Dysregulated behavior results. Pacing, running, shouting, screaming, or withdrawal may result. The person may experience hallucinations, or false sensory perceptions, such as seeing people or objects not seen by others. | +Immobility, or severe hyperactivity, garbled speech, or inability to speak, numbness, tingling, shortness of breath, dizziness, chest pain, nausea, trembling, chills, flushing skin, palpitations. | +This person needs immediate attention. They may need to be removed from the situation or stimuli. They may need to be placed in an environment where they cannot hurt themselves or others. | +Help the client to move to safe space. Allow client to pace, or withdraw; however, keep the client within eyesight. Stay with the client. Help and keep client safe from injury. All interventions with severe anxiety and offer medication as needed and ordered. Once the incident is over, debrief with the client about what happened and assist the client in reframing the issues. Provide honest praise for the client’s ability to recover. |
+
Peplau also defined the nurse-client relationship as the connection between the professional nurse and those seeking health services (Hagerty et al., 2017). This connection is accomplished through application of the therapeutic relationship, which contains specific phases. The phases of this relationship are denoted in Figure 2.4.
+These phases are interwoven and overlap as the client and nurse develop rapport, which is the process during which the nurse creates an atmosphere of safety, trust, and understanding. During this process, the nurse should use the attributes of empathy, transparency, and positive regard. The nurse assists the client with problem-solving in a practical, emotional, and situational manner. When used in a nursing context, empathy involves the nurse placing themselves in the client’s shoes, through compassion, understanding, and identification. The interpersonal process is a process where the nurse and client communicate to develop an understanding of their roles and responsibilities in the therapeutic relationship. This is often during the orientation phase of the nurse-client relationship.
+Erik Erikson’s developmental theory has implications for nursing practice and development of the therapeutic relationship as well. Nurses use this theory, for instance, during the assessment of the client. Review of the client’s behavioral patterns can help identify age-appropriate, or delayed, development of interpersonal skills. Delays can hinder normal development and result in a diminished sense of self. Understanding the stages of emotional development of the client allows the nurse to interact with and assess the client in the most age-appropriate manner. Table 2.4 lists Erikson’s stages of development.
+| Stage | +Age (Years) | +Developmental Task | +Description | +
|---|---|---|---|
| 1 | +0–1 | +Trust vs. mistrust | +Trust (or mistrust) that basic needs, such as nourishment and affection, will be met | +
| 2 | +1–3 | +Autonomy vs. shame/doubt | +Sense of independence in many tasks develops | +
| 3 | +3–6 | +Initiative vs. guilt | +Take initiative on some activities, may develop guilt when success not met or boundaries overstepped | +
| 4 | +7–11 | +Industry vs. inferiority | +Develop self-confidence in abilities when competent or sense of inferiority when not | +
| 5 | +12–18 | +Identity vs. confusion | +Experiment with and develop identity and roles | +
| 6 | +19–29 | +Intimacy vs. isolation | +Establish intimacy and relationships with others | +
| 7 | +30–64 | +Generativity vs. stagnation | +Contribute to society and be part of a family | +
| 8 | +65– | +Integrity vs. despair | +Assess and make sense of life and meaning of contributions | +
+ 2.3 + + Cognitive Theories and Therapies +
+Learning Objectives
+By the end of this section, you will be able to:
+-
+
- Define behavioral and cognitive behavioral theories and therapies +
- Identify nursing application of behavioral and cognitive behavioral theories and therapies +
Behavioral theory states that human responses can be retrained. Behavior therapies, in general, provide techniques for people to learn how to control or modify negative behaviors. Primary behavior therapy seeks to change the person’s responses to the environment, usually with reward systems.
+Cognitive behavioral theory, one major type of behavioral therapy commonly practiced today, is based on the belief that human thinking drives human behaviors. Cognitive therapy brings behavioral change through identification of negative emotions and reframing the personal script. Examples of this technique include modeling, cognitive, exposure, and acceptance or commitment therapy. The goal for behavioral techniques is to modify or change negative emotions or anger-based behavior associated with identified situations. Cognitive behavioral techniques can assist the person to be more effective at managing or coping with negative emotions (Horiuchi et al., 2018).
+Definitions
+The form of psychotherapy that is used to change the way a person feels about or perceives an experience is called cognitive behavioral therapy (CBT). It is effective for a range of problems, including depression, anxiety disorders, alcohol and drug use problems, marital conflict, eating disorders, and severe mental illness. CBT helps a person to recognize distorted/negative thinking with the goal of changing thoughts and behaviors to respond to changes in a more positive manner. Numerous research studies suggest that CBT leads to significant improvement in functioning and quality of life. Studies show that CBT has been demonstrated to be as effective as, or more effective than, other forms of psychological therapy or psychiatric medications (American Psychological Association, 2017).
+CBT treatment usually involves efforts to change behavioral patterns. Strategies to achieve these goals might include facing one’s fears instead of avoiding them, using role-play to prepare for potentially problematic interactions with others, and learning to calm one’s mind and relax one’s body. CBT aims to help develop skills to manage feelings in healthy ways. Through in-session exercises and “homework” between sessions, people develop coping skills, whereby they learn ways to change their own thinking and behavior, ultimately changing how they feel. For example, through journaling and reflection on feelings versus behaviors, a client will be developing coping strategies to employ the next time they are exposed to the same situation. CBT clinicians focus on current situations, thought patterns, and behaviors rather than past events. A certain amount of information about one’s history is needed, but the focus is primarily on developing more effective ways of coping with life moving forward.
++ Link to Learning +
+This fact sheet describes the core principles of CBT and outlines treatment strategies.
+Essential Elements of Cognitive Behavioral Therapy
+CBT is based on the principle that how a person perceives life experiences or interprets events determines how they will feel, behave, or respond. The essential function of CBT is to assist in changing the way a person thinks or perceives an experience to improve the emotion or behavior associated with the event.
+CBT has three main core principles, shown in Table 2.5. One principle is that emotional upsets become thoughts that obstruct ways of analyzing situations. A second principle is that emotional upsets are learned behaviors or patterns of thinking. A third principle is that one’s quality of life can be enhanced through better ways of coping with emotions. Treatment with CBT utilizes the influential relationships between these three principles and assists the person to understand their own way of thinking.
+| Principle | +Strategy | +Rationale | +
|---|---|---|
| Thoughts | +Learning how to recognize thought-process distortions that are causing emotional upsets, then reevaluating and applying to reality | +What we think affects how we feel and act. | +
| Behavior | +Understanding the behaviors and motivations of others in similar situations | +How we behave affects how we think and feel. | +
| Emotion | +Learning new coping techniques to apply in difficult situations; application of problem-solving skills to determine which coping technique to use | +What we feel affects how we think and act. | +
Specific techniques taught to manage one’s thoughts and emotions include mindfulness-based cognitive therapy (MBCT), where behavioral therapy is combined with meditation, and dialectical behavior therapy (DBT), which focuses on problem-solving skills and the ability to find and seek acceptance of negative emotions while tolerating stressors. MBCT has been effective in helping clients cope with anxiety, depression, and bipolar disorders, while DBT has proven effective in helping clients cope with personality disorders, substance abuse, and eating disorders (Good Therapy, 2018).
+ +Another CBT-based technique is called acceptance and commitment therapy (ACT), which relies on positive reinforcement (providing a reward for desired behavior, i.e., praise or material incentive) and counterconditioning. Counterconditioning means becoming deconditioned to the negative stimulus. This can be accomplished through brief exposures while being supported until tolerance is built, or by learning a relaxation technique to mitigate the stress of the exposure. ACT has been shown to help people cope with anxiety, stress, psychosis, OCD, substance use, eating disorders, and depression (Glasofer, 2024).
++ Clinical Safety and Procedures (QSEN) +
++ QSEN Competency: Teamwork and Collaboration +
+The role of the nurse in caring for clients experiencing emotional stressors is related to primary nursing care, but in collaboration with interprofessional team members. As an interprofessional team member, the nurse may consult with psychiatrists, psychologists, licensed social workers, and other health-care providers. The scope and practice of each team member is clearly defined within their professional licensure.
+Nurses play a vital role in behavioral therapy as interprofessional team members modeling and teaching desired behaviors. The nurse, as the coordinator of care, spends the most time observing and interacting with the client. The nurse’s assessment plays a crucial role in understanding and treating the client’s behavior, which allows for a more successful treatment plan.
+Behavioral Therapy in Groups
+The treatment of several clients together by one or more group facilitators addressing traumatic or stress disorders, depression, learning differences, or other conditions likely to benefit from the interaction is group therapy (Malhotra & Baker, 2022). Group therapy provides opportunities for supportive exchange within the group of individuals who have similar challenges. The professionals who facilitate group therapy may explore emotional, cognitive, and spiritual struggles. Before group therapy begins, the organizer determines group goals, size, duration of meetings, facilitator, and member characteristics. Group therapy can have a fixed life or be ongoing with members leaving and being replaced over time. The group usually has a set of agreed rules, such as the role of members in the group, contribution expected from members, the role of the leader in the group, dealing with inappropriate behavior, etiquette regarding starting and finishing the group as well as when members can leave the room. Group therapy can be in treatment settings or in the community and can take place face-to-face or in virtual sessions.
+Group behavioral (and interpersonal) therapy has been proven to be effective in managing substance use disorders, such as addictions, and promoting supportive relationships. Group therapy can be a powerful motivator for change when members are stimulated with new thought processes, develop bonds with other members, and experience adjustments to negative behavior. In group CBT, for instance, the group leader helps group members become aware of negative thought patterns that influence their actions and emotions. CBT groups enable members together to discover ways to refashion their behaviors and interpretations of situations by determining the foundations of their thoughts.
+A form of group therapy wherein all the participants of the group are related, as defined by the family members is family behavioral therapy (FBT). FBT can address substance abuse and other addictions, and also assists with managing secondary co-occurring problems within the family unit. Addictions can negatively affect the whole family and can cause secondary problems, such as abuse or conflict, mistreatment of children, and unemployment. In family therapy, the family members try to resolve negative behavior and interactions through learning new coping skills. Then, participants apply these strategies to improve the situation at home.
++ Cultural Context +
++ Adapted Cultural Formulation Interview for Children and Adolescents +
+The Cultural Formulation Interview (CFI) is a structured tool in the DSM-5, adaptable to the setting, and used to assess the influence of culture on a client’s experience of distress (Jarvis et al., 2020). The following is an adapted version of the CFI tool for children and adolescents that may be used in family therapy.
+-
+
- Suggested introduction to the child or adolescent: We have talked about the concerns of your family. Now I would like to know how you are feeling about being [age] years old. +
- Feelings of age appropriateness in different settings: Do you feel you are like other people your age? In what way? Do you sometimes feel different from other people your age? In what way?
+
- If they acknowledge sometimes feeling different: Does this feeling of being different happen more at home, at school, at work, and/or at some other place? Do you feel your family is different from other families? Does your name have special meaning for you? Is there something special about you that you like or are proud of?
+ - Age-related stressors and supports: What do you like about being at home? At school? With friends? What don’t you like at home? At school? With friends? Who is there to support you when you feel you need it? At home? At school? Among your friends? +
- Age-related expectations: What do your parents or grandparents expect from a person your age in terms of chores, schoolwork, play, or religion? What do your teachers expect from a person your age? What do other people your age expect from a person your age? (If they have siblings, what do your siblings expect from a person your age?) +
- Transition to adulthood (for adolescents): Are there any important celebrations or events in your community that recognize reaching a certain age or growing up? When is a youth considered ready to become an adult in your family or community? What is good about becoming an adult in your family? In school? In your community? How do you feel about “growing up”? In what ways are your life and responsibilities different from your parents’ life and responsibilities? +
(American Psychiatric Association, 2013)
+Nursing Applications of Behavioral Therapies
+Nurses use behavioral therapy treatments and techniques to help clients alter their maladaptive responses to certain scenarios. Altering these responses can often ameliorate psychological distress and mental health challenges. Nurses can use CBT practices, for instance, to assist clients in lessening psychological distress and in building up coping tools to enhance their mental health. Nurses assess and evaluate, on an ongoing basis, clients with mental health challenges to recognize behavioral changes and developments. As educators, nurses teach clients about the effects of thoughts and feelings on behavior. Nurses are support persons and coaches when clients are in counterconditioning, for example, and can provide honest praise for the client’s accomplishments. Further, nurses facilitate collaborative care when working with therapists and other providers.
+In group therapy, nurses can play a vital role in leading or facilitating the group to achieve desired outcomes and providing feedback to group members. In family therapy, nurses can teach the family unit new coping strategies that reduce negative behavior and reinforce adaptation to common stressors. Interventions, such as education related to healthy lifestyle, can be effective for stress reduction and for family unity.
++ Link to Learning +
+The Patient Health Questionnaire-9 is a quick screening tool with nine criteria for assessing a client’s risk of depression. It can be used during CBT to assess the client’s risk of depression related to inability to cope with life stressors.
++ 2.4 + + Humanistic Theories and Therapies +
+Learning Objectives
+By the end of this section, you will be able to:
+-
+
- Define humanistic theories and therapies +
- Identify nursing application of humanistic theories and therapies +
Humanistic theory emerged after the concepts of psychoanalytic and behavioral theories. Humanistic theory states that persons must be viewed as holistic beings with free will and choice, as continually moving toward self-actualization, which is the realization of full potential or inner fulfillment considered as a drive or need present in everyone.
+Humanistic theory places the person at the center of mental health care where they are supported to identify personal strengths and discover their own perspectives. Humanistic theory has a wellness focus and acknowledges environmental effects on health (Sussex Publishers, 2022). Two humanistic theorists are discussed here: Abraham Maslow and Carl Rogers.
+Definitions
+The humanistic theory is based on identification of holistic human needs. When these needs are met, persons can grow and achieve their goals in life. When needs go unmet, persons may struggle to move to next levels in life. In therapy utilizing these guidelines, the therapist and client work together to determine the client’s life accomplishments and where assistance is needed for growth.
+Abraham Maslow
+Abraham Maslow (1908–1970) believed humans were motivated by unmet needs. Maslow created a model that started with the most basic needs of all human beings and worked into the most esoteric and abstract human needs (Figure 2.5). These needs were incremental and necessary for a client to become a fully functioning whole person. He initially had five levels of needs: physiological, safety/security, belonging and love/social, esteem, and self-actualization. Later, he added cognitive and aesthetic needs (placed between esteem and actualization). These additions represented the need to obtain and understand knowledge and the need for beauty and symmetry (McLeod, 2018).
+Carl Rogers
+Psychologist Carl Rogers (1902–1987) is known for his humanistic theory and person-centered approach to therapy. He said that an individual’s actions are motivated by the potential of self-actualization, by the possibility of achieving their best self, their highest potential. He based his theory on the idea of self-concept, which is a person’s awareness of who they are. Self-concept has three components, according to Rogers: self-image, self-esteem, and the ideal self. He believed that humans have the ability to be self-aware, to evolve, and to recover with the person-centered therapist offering unconditional positive regard, empathy, and congruence. This supportive process allows the person to work toward their chosen goals in their own way (Millacci, 2022).
+Humanistic Therapies Applications in Mental Health Nursing
+Maslow’s theory has had a profound effect on nursing. Understanding the humanistic model demonstrates to the nurse what the priority client needs are. The nurse must be able to understand that physiological needs must be met before higher-level needs, such as safety or love and belonging. It is important for the nurse to know this in the assessment phase of the interaction with the client, when recognizing and analyzing cues. It is important that the nurse prioritize and personalize the care of every client.
+Maslow’s hierarchy of needs theory is a major foundation of nursing practice as is Carl Rogers’s theory. His belief was that client care should be done with empathy and should encourage clients to voice their emotions and form trusting relationships with the nurse that provide a foundation for client self-awareness and self-care. Nurses should respect clients, their autonomy, and treat them with genuine empathy and understanding in order for clients to reach their potential.
+Because humanistic therapy is a holistic approach, aspects of care focus on the client’s personal development and recovery. Strength identification is part of this process, and feedback from the nurse is meaningful. Also significant to nursing practice are the concepts of person-centered care and therapeutic communication wherein nurses establish rapport with clients by focusing on them as individuals. As the person reacts to others and to different situations, the nurse can assist the client to find relevance and plan their own success. This nursing focus on the client as an individual encourages trust and transparency in the process.
++ Clinical Judgment Measurement Model +
++ Humanistic Approach to Client Care Scenario +
+Layer 4 of the CJMM provides contextual elements of clinical decision-making in the form of realistic client-care environmental factors. Consider the following example:
+-
+
- Environmental cues: secure psychiatric hospital unit +
- Client observation cues: young adult, panic anxiety +
- Medical record cues: history of bipolar mood disorder +
- Time pressure cues: client rapidly losing personal control +
To analyze these cues, nurses must interpret the information. This client has a safety need. The nurse assures the client as to safety and the availability of nursing staff to assist the client. The nurse says, “You can tell us how you are feeling.” The nurse reminds the client of their prior success in self-management and assures the client of the staff’s interest in returning the client to self-care, thereby establishing trust and person-centered care.
++ 2.5 + + Biological Theories and Therapies +
+Learning Objectives
+By the end of this section, you will be able to:
+-
+
- Define biological theories and therapies +
- Identify nursing application of biological theories and therapies +
From a biological perspective, psychiatric-mental health conditions are considered physiological disorders with a focus on the neurological and immune systems of the body, as well as genetic components of health. Trauma and injury are also considered with diagnoses and treatment of mental illness (Schwartz & Corcoran, 2017). Magnetic and computerized imaging are used to study the brain and detect areas of damage or change. The premise is to find where the problem is in the brain and target that area with medications, diet, surgery, or other therapies, such as brain stimulation.
+Definitions
+Biological theory centers on an actual physical reason for psychiatric problems and, in effect, has decreased the stigma long associated with mental illness. For instance, when a person is diagnosed with schizophrenia, under this theory it has a physical root cause, which displaces blame.
+Medication Therapy
+Biological therapy provides remedies for mental health disorders by physically treating the brain. Medical understanding of the action of neurotransmitters in the brain provides the rationale for pharmacological approaches. Intended to restore balance in this chemical process, medication therapy is a commonly utilized method to treat mental health disorders.
+Using chemicals to adjust the brain chemistry to assist the client with a mental health disorder is psychopharmacology. With the inception of chlorpromazine, also known as Thorazine, a strong antipsychotic medication, many psychiatric clients were able to move from a state of psychosis to a manageable lifestyle (Lindamood, 2005). Medications that target neurotransmitters help restore brain function by regulating these neurotransmitters. Clients report having less emotional distress and greater satisfaction with their lives, due to taking these medications. Clinicians began to understand the vital role these chemicals provided as a new way to treat psychiatric disorders, other than psychoanalysis and behavioral therapy. Many medications have proven effective to treat and/or control psychosis, mania, depression, and anxiety. These medications have decreased lengths of hospitalization and helped clients have more productive lives.
+Diet
+Healthy lifestyles include healthy diets. Research has found evidence of dietary influence on mental health. Grajek et al. (2022) reviewed possible connections between nutrition and mental health. Nutrition may be able to reduce inflammatory processes in the body and promote optimal circulatory and cellular health. Studies reviewed by Grajek et al. (2022) found that complex carbohydrates, antioxidants, vitamins B9, D, E, C, carotenoids, tryptophan, alpha-lipoic acid, and soluble fiber could have these therapeutic effects. Recent research describes new disciplines of psychodietetics and nutritional psychiatry (Grajek et al., 2022).
+Psychosurgery
+Neurosurgery intended to alter psychological responses is called psychosurgery (De Jesus et al., 2023). It can be used for a select group of clients who have not experienced successful treatment for anxiety disorders and obsessive-compulsive disorders. Psychosurgery alters small portions of brain tissue in specific areas that control certain behaviors. Changes are made by thermal, radiation, or surgical methods without damage to the person’s general function. Drastic surgeries such as frontal lobotomy are no longer performed due to disabling effects.
+Brain Stimulation
+Brain stimulation therapies are those that stimulate the brain through neurochemicals, electricity, and nerve action (National Alliance on Mental Illness [NAMI], 2023). There is traditional electroconvulsive therapy (ECT), which uses electricity to stimulate targeted areas of the brain by creating a controlled seizure, most commonly used to treat major depression. Now other brain stimulation therapies, such as transcranial magnetic stimulation (TMS), aim to target specific brain areas to treat the problem. These therapies also treat other disorders, such as epilepsy, Parkinson disease, and several chronic pain disorders.
+Nursing Application of Biological Theory
+The major concepts of the biological theory related to nursing are basic care of the client, through monitoring and supporting their physical needs. Nurses are responsible for overseeing sleep, activity, nutrition, hydration, elimination, and other functions for the client. The nurse is responsible for administering medications and preparing the client for procedures. The nurse also monitors drug-level laboratory reports and ensures the client’s therapeutic level is met. This physical care of the psychiatric client is part of the holistic approach nursing is known for.
+For clients in treatment with biological therapies, teaching is a nursing intervention that promotes health, prevents harm, and empowers the client through partnership with the health-care team. Specific to medication teaching, clients must be made aware of the indications and effects of all medications prescribed, including drug-food interactions. Nurses also conduct preoperative or pre-procedure teaching and witness the surgical or procedural written consent. This education contributes to the effectiveness of the plan of care.
+In dietary education, nurses can teach how stress can result in food choices detrimental to overall health and educate clients on the aspects of emotional eating, where food becomes a substitute for addressing feelings. Nurses can counsel on grocery shopping and meal preparation.
++ Link to Learning +
+This article from Sutter Health discusses how proper nutrition can enhance mental health, and poor nutrition can negatively affect thinking and energy level.
+Nurses also play a supportive role as advocates for the expressed preferences of the client in treatment with biological therapies. The client’s beliefs and values must be considered and explored. Open exchange of this information contributes to best outcomes of care. Clients and families must be informed of aspects of all biological therapies.
++ Link to Learning +
+The Use of Theories in Psychiatric Nursing-II discusses all the major theories reviewed in this chapter and how nurses can use them in practice.
++ 2.6 + + Developmental Theories and Therapies +
+Learning Objectives
+By the end of this section, you will be able to:
+-
+
- Define developmental theories and therapies +
- Identify nursing application of developmental theories and therapies +
Psychiatric-mental health nurses can utilize concepts from developmental theories to enhance their awareness of the client’s experience. This knowledge informs client education as well. Nurses may apply cognitive development theory when observing the client’s interactions with the environment, whether in treatment or in the community. The theory of object relations empowers nurses to recognize and analyze cues in the client’s presentation and expressed needs, which leads to focused care planning. Moral development theory informs nurses when ethical questions arise. All theory application contributes to the nurse’s self-awareness and effectiveness in client care. This section covers theories of Jean Piaget, Margaret Mahler, and Lawrence Kohlberg.
+Definitions
+Developmental theories seek to explain the process of a child’s understanding. This process is investigated as occurring in steps or stages, or in a continual way through the life span.
+Jean Piaget
+Jean Piaget (1896–1980) was a Swiss psychologist and researcher. Piaget worked in a boys’ school and scored the intelligence exams given to the boys, noting that younger children would consistently give incorrect answers to the same questions the older children would answer correctly. This brought him to conclude that cognitive development was a dynamic process with primitive awareness and recognition to a more complex manner of thinking. He found that the mental representation of the world or process of information depended on the cognitive stage humans reached and mastered (Scott & Cogburn, 2023). The theory had four stages of development: sensorimotor, preoperational, concrete operational, and formal operational. Table 2.6 describes these stages.
+| Stage | +Ages | +Description | +
|---|---|---|
| Sensorimotor | +Birth to 2 years | +Basic reflexes through purposeful movement, spatial abilities, and hand-eye coordination. The physical interaction provides the child with understanding of the environment. Around nine months, the concept of object permanence is mastered. This means the child is able to believe an object exists after the first encounter. | +
| Preoperational | +2–7 years | +Egocentric thinking where the child thinks in concrete terms, not in the abstract. They expect others to see the world as they do. They cannot conceptualize qualities without specific objects to show this. They are unable to comprehend, for instance, that the same amount of (mass, volume, or number) liquid can be stored in a tall, thin glass as a short, wide glass. | +
| Concrete Operational | +7–11 years | +Logical thinking starts and abstract thinking is possible. Diversity of thought is possible, and the child can see multiple ways to solve problems. The ability to understand classification, sorting with distinct differences, creating patterns, and the concept of reversibility. | +
| Formal Operational | +11 years to adulthood | +Conceptual reasoning starts at the same time as puberty. Problem-solving and abstract thinking are the same abilities as an adult. | +
Piaget’s concepts are utilized in therapies in educational settings, especially with children.
+Margaret Mahler
+The theory of object relations, according to theorist Margaret Mahler (1897–1985), is how a person relates to the world according to their past relationships. Specifically for the infant, the mother or significant other becomes one with the child. The infant cannot conceptualize the mother’s permanence when the two are apart, which is known as the concept of object constancy. Therefore, in the infant’s understanding, the mother does not exist when not physically present. A variation of other theories, Mahler places less emphasis on primitive human drives and more importance on consistent relationship patterns.
+Mahler believed that psychological problems were related to the disruption in separation from the object (Blom, 2018). She studied the process of how infants move from total self-interest to struggle with separation from the mother, to becoming a physically and psychologically differentiated toddler (Table 2.7). This natural healthy process is developed by the object, that is, the parent/significant person, allowing the child to wander off in a safe environment while staying close by so the child is assured the parent is still present. Over time and over exposure to this type of experience, the child begins to trust the process and become an individual. Another important piece of exposure is to reward the child when they return to the mother. This reward is a verbal or other sensory affirmation that reinforces the action was good. Mahler also believed that “perfect parenting” was not necessary for this transitional trust to develop.
+Mahler’s concepts are utilized in therapies by recognizing that individuation is a complex process (Blom, 2018). Treatment approaches factor into therapy with families who experience periods of transition such as a new baby, a child beginning school, or a young adult leaving home. Mahler’s framework guides assessment of individual growth. Couples therapy explores separation-individuation, recognizing that personality development occurs throughout the life span.
+| Stages of Development | +Infant’s Behaviors | +
|---|---|
| Autistic stage: (0–1 month) | +Infant’s focus is self Mother/caregiver is one with the infant, not existing separately |
+
| Symbiotic stage: (1–5 months) | +Infant begins to realize mother/caregiver’s separate existence and main source of support | +
| Separation-individuation stage: (5–24 months) |
+ Infant’s focus shifts to difference between self and mother/caregiver Motor skills develop, allowing physical separation Infant explores environment, though remains dependent on mother/caregiver Infant begins to fear loss of mother/caregiver and must learn to balance dependence with independence, i.e., “terrible two’s” as infant tests new behaviors, resulting in development of self-concept |
+
+ Link to Learning +
+In the article “An Object Relations Approach to Cult Membership”, the authors apply the theories of object relations to interactions throughout life that are guided by the earliest relationships.
+Lawrence Kohlberg
+Psychologist Lawrence Kohlberg (1927–1987) expanded upon Piaget’s cognitive stages by establishing moral stages. His theory of moral development provides a framework of three levels and six stages for understanding the progression a child develops when learning right from wrong (Smith, 2023).
+The first level, preconventional, has two stages. This level is distinguished by rules and listening to authority. During the first stage, punishment and obedience, the child learns obedience is the way to avoid punishment. The second stage is instrumental purpose orientation. In this stage, the child sees that others look at rules differently and if they choose to not follow the rules, they risk punishment.
+The second level, conventional, has stages three and four. The third stage is good interpersonal relationships. In this stage, the child begins to start using motivation and personality as reason for following or not following the rules. The child thinks in terms of “good and bad” as a person who gets along with others. Stage four is maintaining the social order. The person becomes aware of the fact “rules are rules.” People all must fall in line with these, not only to avoid punishment, but because of the broader view of society. The person begins to see that following authority maintains social order. The person sees this in large systems, such as government and corporations.
+The postconventional level houses stages five and six. Stage five is social contract and individual rights. In stage five, the person believes that social order is good and correct. Stage six is universal ethical principles. The overarching sentiment here is that actions should create justice for all who are involved, and, as a society, people are obliged to break unjust laws/rules.
+Kohlberg’s concepts are utilized in therapies to help explain that people can have different reactions to similar ethical concerns. Kohlberg’s theory can guide parents and caregivers as children develop their own moral framework and, ultimately, learn about social expectations.
+Nursing Application of Developmental Theories
+Developmental theories help the nurse know how to assess, intervene, and evaluate the client. These theories help the nurse develop approaches to client care based on clients’ developmental levels, regardless of chronological age. These levels are multilayered and unique with each client.
+Nursing Application of Cognitive Development Theory
+Nurses’ understanding of basic principles of human growth and development allows focused care planning, especially for teaching. In addition, nursing expectations for client responses can be realistic and provide situations wherein clients can receive positive feedback for accomplishments. Because interaction with the environment is important to human development, the nurse acts as milieu manager in hospital settings and promotes healthy public communities through advocacy and consulting.
+Nursing Application of Object Relations Theory
+When nurses learn the client’s history, an understanding of childhood experiences may provide cues to client behaviors, emotions, and coping ability so the nurse gains the knowledge to plan appropriate care. For nurses themselves, object relations theory gives opportunities for self-awareness. Nurses may experience reactions to client care scenarios that are unexpected or confusing. These situations can prompt the nurse to seek mentoring or feedback from colleagues.
+Nursing Application of Moral Development Theory
+Moral development theory can assist nurses to understand clients’ reasoning and decision-making. By understanding where clients fall in the stages of moral development, the nurse can customize their care to what the client requires. Understanding these theories allows the nurse to appreciate the importance of their own moral compass. Nurses often come across ethical dilemmas when interfacing with clients. Kohlberg’s theory can contribute to a more educated approach to these dilemmas because it illuminates the level of moral reasoning of all parties involved in the situation, including clients, loved ones, and other health-care providers.
++ 2.7 + + Holistic Health and Interventions +
+Learning Objectives
+By the end of this section, you will be able to:
+-
+
- Define holistic health-care theories and therapies, including social determinants of holistic health care +
- Describe mindfulness as a type of holistic health care +
- Identify nursing application of holistic theories +
Holistic health care is a wellness modality used to treat and prevent physical and mental health problems. Holistic health care can greatly enhance the success of treatment and outcomes and can be combined with pharmacological interventions. Clients in treatment for mental health care may spend a lot of time in a hospital setting trying new therapies or medication regimens. A holistic approach to transitioning back into a community setting can prevent hospital readmissions (State of New South Wales [NSW] Government, 2020). Incorporation of community-based programs after hospital discharge, such as social services, community treatment facilities, and group housing are often used as reintegration techniques. The ultimate goal of holistic health care is increased treatment effectiveness.
+Definitions
+The multifaceted approach that reflects the client’s physical and emotional well-being and considers the whole person and how they interact with their environment is called holistic health. It is a focus on one’s quality of life versus a physical ailment, illness, or disease. The nurse understands there are numerous factors that affect a client’s actual health goals and potential outcomes. These factors include physical, emotional, cultural, family, spiritual, psychological, and environmental influences. Accurate assessment helps the nurse interpret the complex interactions between all the different factors. To assess the impact of each influence, the nurse should perform a functional assessment. Functional assessments include the client’s developmental patterns as well as behavior and response to stressors. Analyzing collected data from the functional assessment and applying interventions creates a solid foundation for providing holistic health care.
++ Link to Learning +
+The Functional Analysis Screening Tool (FAST) is designed to identify a number of factors that may influence the occurrence of problem behaviors.
+Social Determinants and Associated Interventions: Healthy People 2030
+The conditions of the environments where people live, work, play, worship, and go to school are social determinants of health (SDOH). Ideally, all components of the environment would support health and a good quality of life for the inhabitants. Environmental conditions may contribute to health and well-being or may be detrimental or harmful. Even moderate support can be beneficial in a less-than-optimal environment. For example, someone with no home or income of their own may be part of a faith-based community that comforts and assists them.
+As described by Healthy People 2030, the five areas that comprise SDOH are economic, education, health care, neighborhood, and community (Figure 2.6). Therefore, unemployment or debt, education that is disrupted or unavailable, low access to health care, a neighborhood with violence or crime, or a larger community without resources can have damaging effects on health of the people.
+Drafted by the Office of Disease Prevention and Health Promotion, Healthy People 2030 sets data-driven national objectives to improve health and well-being associated with social determinants. Through research, common themes of social determinants emerged among various populations that appeared to be preventing people from achieving health-care goals, as defined by the person. The Healthy People Committee developed interventions for health-care workers to help individuals overcome the effects of these conditions. The goal or mission envisions a society in which all people can achieve their full potential for health and well-being across the life span.
++ Link to Learning +
+Healthy People 2030 is a set of objectives based on public health priorities that are intended to improve the health and well-being of Americans.
+The Patient-Centered Medical Home Model
+The patient-centered medical home (PCMH) model, developed by the Veterans Health Administration, is an example of a proactive, primary care-based, interdisciplinary team model using person-centered, holistic care, and active communication and coordination among providers. This model is considered effective for clients with complex health-care needs. Figure 2.7 illustrates the medical home model. As homeless veterans stabilize clinically and socially, as evidenced by their moving into permanent housing and demonstrating appropriate self-care and health-seeking behaviors, they are transitioned to traditional care settings to continue their care. Research indicates that the medical home model reduced emergency department visits and hospitalizations of the homeless population by integrating supports that addressed social determinants of health into a clinical care model (Centers for Disease Control and Prevention [CDC], 2021).
+Mindfulness
+An individual’s state of awareness, achieved through personal focus, being in the present, and/or meditation is called mindfulness. Attention to being fully cognizant of a situation without extreme reaction can provide calming and centering. The practice of mindfulness dates back to ancient times and was originally grounded in Buddhist and Hindu traditions (Figure 2.8).
+Research has shown that mindfulness can have positive health outcomes related to managing stress, anxiety, and many types of depression (Crosswell et al., 2017). Mindfulness has been described as, “non-elaborative, nonjudgmental, present-centered awareness in which each thought, feeling, or sensation that arises is acknowledged and accepted as it is” (Delegran & Haley, 2016, para 3). Mindfulness is a holistic technique, involving all the person’s senses and contributing to overall well-being.
+Mindfulness practice utilizes techniques for one to be present and in the moment. One exercise might be the following:
+++Compare your default state to mindfulness when studying for an exam in a difficult course or preparing for a clinical experience. What do you do? Do you tell yourself, “I am not good at this” or “I am going to look stupid”? Does this distract you from paying attention to studying or preparing? How might it be different if you had an open attitude with no concern or judgment about your performance? What if you directly experienced the process as it unfolded, including the challenges, anxieties, insights, and accomplishments, while acknowledging each thought or feeling and accepting it without needing to figure it out or explore it further?
+
If practiced regularly, mindfulness helps a person start to see the habitual patterns that lead to automatic negative reactions that create stress. By observing these thoughts and emotions instead of reacting to them, a person can develop a broader perspective and can choose a more effective response.
+Mindfulness-Based Stress Reduction
+Mental training used to alter how pain or stress is processed within the central nervous system, thereby diminishing or reducing one’s perception of pain or stress, is called mindfulness-based stress reduction (MBSR). MBSR has shown positive outcomes in a variety of health-care settings for both physical and emotional disruptions (Lamothe et al., 2016). MBSR was originally developed for clients with chronic illness who were not responding to existing medical treatments. MBSR was first researched and funded by the National Center for Complementary and Integrative Health (NCCIH) at the University of Massachusetts in 1979. The NCCIH created a Stress Reduction Clinic and treated a variety of clients with health conditions, such as cancer, chronic pain, and autoimmune disorders. Clients completed modules and workshops on techniques like meditation to lower stress levels and increase well-being.
+ +Because MBSR showed such encouraging results in physical conditions, mental health providers started combining it with cognitive therapy and incorporating it into the treatment plans of clients suffering from depression. In recent years, MBSR has shown positive outcomes as a coping technique for caregiver burden as well (Nathan et al., 2017). Due to the pandemic and social distancing mandates, mental health-care practitioners have recently started offering MBSR modules and workshops in a virtual platform.
++ Link to Learning +
+The Mindfulness Project is a tool with numerous mindfulness activities.
+Guided Imagery
+Another form of mindfulness is guided imagery, which provides an alternate narration the mind can focus on during an unpleasant experience. According to the pain gate theory, the brain can only experience one pathway at a time, either pleasure or pain, but not both (Krau, 2020). Guided imagery allows for the pleasure pathway to take over, decreasing the body’s perception of pain. Guided imagery is often used during labor as a coping technique for contraction pain. The nurse helps the laboring mom picture something that brings a pleasant thought or feeling, like her newborn’s outfit or ultrasound picture. The mental image accompanied with slow, controlled breathing and relaxation of tension in the shoulders, hands, and feet can provide a nonpharmacological approach to pain management.
+Guided imagery has also been proven effective as an intervention in mental health scenarios. For example, during a client’s anxiety, the nurse can offer to assist the client with an exercise. Allow the client to sit comfortably in a quiet area. Begin by describing a beach with waves coming in on the sand and going back out to sea. Using the mental image of ocean waves, the nurse can instruct the client to breathe in as the waves approach the beach and breathe out as the waves go back. Nurses also teach guided imagery to promote relaxation and sleep.
+Teaching Mindfulness Requires Self-Awareness
+To teach mindfulness to clients, the nurse must first examine their own self-awareness and beliefs. Different treatments and interventions work for different clients. There is no one single treatment that is effective in every situation. The nurse must not impose their own beliefs or personal opinions onto the client, nor provide less than quality care just because the client’s beliefs differ from their own.
+The therapeutic relationship between a nurse and client must be founded on trust and a judgment-free space in order to be effective in producing positive outcomes. For instance, a client who is obese may want to be more accepting of their weight and may need assistance with interventions related to achieving a positive body image. The nurse may believe instead of self-acceptance, the client should be focusing on health promotion and ways to reduce their weight. The nurse has a responsibility, however, to support the client and help them achieve their goals. Using applications of mindfulness, the nurse should be aware of their surroundings and display the empathy needed by the client to achieve their goal. Nurses who practice self-awareness are better equipped to provide quality client-centered care, resulting in more positive outcomes.
+Key elements for the nurse to consider when incorporating self-awareness include:
+-
+
- A client’s perception is the most influential factor in determining their response to intervention, rather than how the nurse feels they should respond. +
- Behavior and emotions will differ between clients in the same situation, with the same variables. +
- No one intervention will work with every client. +
- Becoming familiar with a variety of cognitive and holistic interventions will increase effectiveness in promoting a positive well-being. +
+ Clinical Safety and Procedures (QSEN) +
++ QSEN Competency: Client-Centered Care +
+Nurses practice client-centered care when building trust and avoiding judgment in the therapeutic relationship. Building trust means “do what you say you will do.” For example, if the nurse states a group exercise will start at 9:00, the group should start on time. If the nurse states they will return to meet with the client after lunch, the nurse should do so. Avoid judgment in nurse-client interactions, by saying, for example, “I can see your point,” “This seems important to you,” or “Is it fair to say you were angry about that?” instead of responding with comments such as, “You’re not making sense,” “That’s not relevant,” or “You shouldn’t have felt that way.”
+Nursing Application of Holistic Health Care
+Holism in health care is a psychosocial approach that does not set illness apart, but treats the whole person. Nightingale, by using the environment as therapy, was incorporating a holistic approach. Nurses should consider the physical and social environment when treating clients.
+ +During interviewing and data collection, nursing awareness of the physical environment and the nurse’s attitudes are essential components. If the interaction takes place in a busy or noisy area or the nurse expresses impatience or fatigue, the client will not feel supported.
+Nurses should also take into account the client’s outside environment. In the community, for example, nurses can practice advocacy by volunteering and promoting efforts to address food insecurities, housing initiatives, or transportation systems. In public health settings, nurses can make inquiries with empathy, such as, “Do you sometimes run out of necessities?” or “What would be the best way to help you with child care?” They can then make referrals or arrange consults as indicated by clients’ preferences.
++ Clinical Safety and Procedures (QSEN) +
++ QSEN Competency: Quality Improvement (QI) +
+Nurses use quality improvement projects or task forces to track client responses and positive outcomes. For instance, surveys can be implemented after the initiation of techniques, such as mindfulness or self-awareness behaviors among staff members, then results analyzed to show correlation of positive care outcomes.
++ Summary +
+ ++ 2.1 + + Psychoanalytic Theories and Therapies +
+ +The psychoanalytic theory from Sigmund Freud provides a foundation to understand psychiatric problems. This theory is the basis for the nurse to view the client through the lens of personality development and unconscious influences on behavior, and to incorporate this into the care of the client.
+The id, ego, and superego keep the person in balance between satisfying every primal want and bowing to societal pressures. The use of defense mechanisms is necessary for all humans to emotionally adjust to their environment. At the same time, defense mechanisms utilized over the long-term can become patterns of ineffective coping, causing problems with social adjustment and emotional growth.
+Freud also created stages of sexual development that he believed affected a person’s emotional growth and/or adaptation. And the two concepts of transference and countertransference reveal that all clients have a past and are attempting to frame their reality in ways that are safe and familiar. These ideas enhance therapeutic communication and active listening to assist the client as needed.
++ 2.2 + + Interpersonal Theories and Therapies +
+ +Interpersonal theories identify interpersonal relationships as drivers for human development. Erikson believed the personality develops throughout the life span and presented an age-based order to reflect this. Nursing observation of client behavior can provide cues to the client’s developmental stage, which allows nurses to address psychological needs and develop a therapeutic relationship. Peplau applied interpersonal theory to nursing. She defined the nurse-client relationship, which includes the phases of pre-orientation, orientation, working, and mutual termination. Peplau also presented nurses with focused approaches for the described four levels of anxiety: mild, moderate, severe, and panic.
++ 2.3 + + Cognitive Theories and Therapies +
+ +Behavioral therapeutic interventions for emotional problems can include one or more of the following: milieu therapy, group therapy, family therapy, and forms of cognitive behavioral therapy. Goals of these therapies include awareness of emotions and modification of associated negative behaviors. Learned techniques assist the person to be more effective at coping with stressors in identified situations. Nurses are teachers, advocates, and support persons. Comprehensive knowledge of the different types of behavioral and cognitive behavioral therapy helps the nurse select appropriate and effective interventions and treatment approaches.
++ 2.4 + + Humanistic Theories and Therapies +
+ +Humanistic theory views persons as holistic beings utilizing free will to reach self-actualization, as defined by the person. Maslow’s hierarchy of needs model guides nursing assessment and Rogers’s concepts of the person’s sense of self assists the nurse with individualized care planning. Both theorists cite self-actualization as the ultimate goal of human achievement. In a therapeutic approach based on humanistic theory, clients are empowered and supported toward their own recovery.
++ 2.5 + + Biological Theories and Therapies +
+ +Biological theories have helped with the stigma of mental health by identifying organic bases for many disorders. Biological therapies include medications, diet, surgery, or other therapies such as brain stimulation. Nurses function as educators and advocates through direct care, medication administration, surgical and procedural care, monitoring, and teaching for clients and families. In addition, nurses should remain aware of the latest in developments of biological therapies so that recipients of care receive current information and optimal support.
++ 2.6 + + Developmental Theories and Therapies +
+ +Developmental theories investigate human development through the life span. Theorists Jean Piaget, Margaret Mahler, and Lawrence Kohlberg all contributed developmental theories to explain how children develop throughout stages to reach a more complex way of thinking. Moral development also takes on more complex forms as individuals age and develop the ability to distinguish right from wrong. Nurses can apply these theories to practice to understand exactly where their clients stand in their ability to understand concepts and make decisions. These theories also come into play when ethical dilemmas arise.
++ 2.7 + + Holistic Health and Interventions +
+ +To provide quality holistic care, the nurse must recognize multiple determinants—the physical, emotional, cultural, family, spiritual, psychological, and environmental influences to which the client is exposed. To achieve this, the nurse must find out as much as possible about a client’s personal values, beliefs, and health practices. Healthy People 2030 describes identified obstacles affecting a client’s ability to achieve health-care goals. Nurses who become knowledgeable in these obstacles can develop client-specific interventions to overcome negative effects of social determinants. Nurses should remember the client is the best source of information.
+Mindfulness has a long history and has been proven as an effective intervention in both physiological and psychological disorders. Techniques such as guided imagery, mindfulness-based stress reduction, yoga, and physical exercise are techniques the nurse can incorporate into the client’s plan of care. Nurses must practice self-awareness to build trusting therapeutic relationships and provide judgment-free quality care.
++ Key Terms +
+ +-
+
- acceptance and commitment therapy (ACT) +
- relies on positive reinforcement and counterconditioning +
-
+
- behavior therapy +
- a method to change the person’s responses to the environment, usually with reward systems +
-
+
- chlorpromazine +
- also known as Thorazine, a strong antipsychotic medication, first generation +
-
+
- cognitive behavioral therapy (CBT) +
- used to change the way a person feels or perceives an experience and therefore behaves +
-
+
- cognitive development +
- dynamic process with primitive awareness and recognition to a more complex manner of thinking +
-
+
- consciousness +
- aware of one’s own existence, sensations, thoughts, surroundings, the part of the mind comprising psychic material of which the individual is aware +
-
+
- countertransference +
- unconscious feeling the health-care worker has toward the client +
-
+
- defense mechanisms +
- thoughts, words, and behaviors prompted by the unconscious mind; can reduce anxiety in the short-term; may result in ineffective coping if used longer term +
-
+
- dialectical behavior therapy (DBT) +
- focuses on problem-solving skills and the ability to find and seek acceptance by regulating negative emotions and tolerating stressors +
-
+
- ego +
- part of the psychic apparatus that experiences and reacts to the outside world and thus mediates between the primitive drives of the id and the demands of the social and physical environment +
-
+
- electroconvulsive therapy (ECT) +
- uses electricity to stimulate targeted areas of the brain +
-
+
- empathy +
- helps nurses to place themselves in the client’s shoes, through compassion, understanding, and identification +
-
+
- family behavioral therapy (FBT) +
- type of group therapy where all the participants of the group are related +
-
+
- group therapy +
- addresses interaction pattern problems while also providing disorder-specific support within a group of strangers who have similar challenges +
-
+
- guided imagery +
- alternate narration the mind can focus on during an unpleasant experience +
-
+
- holistic health +
- clinical approach that considers the client’s physical and emotional well-being, the whole person, and how they interact with their environment +
-
+
- humanistic theory +
- places the person at the center of mental health care where they are supported to identify personal strengths and discover their own perspectives +
-
+
- id +
- part of the mind that is the most primitive, it drives the instincts, reflexes, and needs +
-
+
- interpersonal process +
- where the nurse and client communicate to develop an understanding of their roles and responsibilities in the therapeutic relationship +
-
+
- milieu +
- therapeutic, controlled, and supportive environment that provides safety and structure while one seeks treatment and works on changing negative behavior +
-
+
- mindfulness +
- a state of awareness, achieved through personal focus, being present and through meditation +
-
+
- mindfulness-based cognitive therapy (MBCT) +
- behavioral therapy that is combined with meditation +
-
+
- mindfulness-based stress reduction (MBSR) +
- mental training used to alter how pain is processed within the central nervous system, thereby diminishing or reducing one’s perception of pain +
-
+
- moral development +
- provides a framework for understanding the progression through which a child develops in terms of learning right and wrong +
-
+
- nurse-client relationship +
- pre-orientation, orientation, working, and mutual termination phases where the nurse and client move through these phases in an interwoven manner over time +
-
+
- preconscious +
- part of the mind where thoughts and feelings are available to the conscious mind though not currently being applied +
-
+
- psychopharmacology +
- using chemicals to regulate brain chemistry to assist the client with mental health disorders +
-
+
- psychosexual stages of development +
- proposes that childhood experiences shape the adult personality and can underlie mental health problems +
-
+
- psychosurgery +
- neurosurgery intended to alter psychological responses +
-
+
- rapport +
- process where the nurse creates an atmosphere of safety, trust, and understanding +
-
+
- reality testing +
- when thoughts and emotions can be objectively evaluated by the person +
-
+
- self-actualization +
- realization of full potential or inner fulfillment considered as a drive or need present in everyone +
-
+
- significant other +
- the main person, or a parent, from which humans have their first interpersonal interaction +
-
+
- social determinants of health (SDOH) +
- conditions of the environments where people live or work +
-
+
- superego +
- part of the personality representing the conscience, formed in early life by internalization of the standards of parents and other models of behavior +
-
+
- theory of object relations +
- how a person relates to the world is dependent upon their past relationships, specifically with the significant person +
-
+
- transcranial magnetic stimulation (TMS) +
- brain stimulation therapy targeting specific brain areas +
-
+
- transference +
- an unconscious feeling the client has toward another or the health-care worker that is originally based on a past experience with an important person in their life +
-
+
- unconsciousness +
- the repressed memories, thoughts, and unacceptable feelings a person may have +
+ Assessments +
+ ++ Review Questions +
+ ++ Check Your Understanding Questions +
+ ++ Reflection Questions +
+ ++ What Should the Nurse Do? +
+ ++ Competency-Based Assessments +
+ ++ References +
+ +Acha, K. (2017, May 26). Cognitive behavior therapy (CBT): The way we think affects the way we act and feel. https://kennethmd.com/cognitive-behavior-therapy-the-way-we-think-affects-the-way-we-act-and-feel/
+American Psychological Association. (2013). Cultural formulation interview (CFI). https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview.pdf
+American Psychological Association. (2017). What is cognitive behavioral therapy? APA Div. 12 (Society of Clinical Psychology). https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral
+Belsiyal, C. X., Rentala, S., & Das, A. (2022, July 29). Use of therapeutic milieu interventions in a psychiatric setting: A systematic review. J Educ Health Promot,11(234).https://doi.org/10.4103/jehp.jehp_1501_21.
+Berry, M. (2023). What to expect during your first 12-Step meeting. American Addiction Centers. Recovery.org. https://recovery.org/what-to-expect-during-your-first-12-step-meeting/
+Blom, I. (2018). Observing development from infancy to parenthood: Separation-individuation, attachment, and intersubjectivity in the clinical encounter. In M. H. Etezady, I. Blom, & M. Davis (Eds.), Psychoanalytic trends in theory and practice: The second century of the talking cure (pp. 43–70). Lexington Books/Rowman & Littlefield.
+Burke, N. J., Joseph, G., Pasick, R. J., & Barker, J. C. (2009, October). Theorizing social context: Rethinking behavioral theory. Health Education & Behavior, 36(5 Suppl):55S–70S. https://doi.org/10.1177/1090198109335338
+Centers for Disease Control and Prevention (CDC). (2021, May 12). Patient-centered medical home (PCMH) model. https://www.cdc.gov/dhdsp/policy_resources/pcmh.htm
+Cherry, K. (2023). Freud’s stages of human development the 5 psychosexual stages of development by age. Verywellmind. https://www.verywellmind.com/freuds-stages-of-psychosexual-development-2795962
+Creswell, J. D., Pacilio, L. E., Lindsay, E. K., & Brown, K. W. (2014). Brief mindfulness meditation training alters psychological and neuroendocrine responses to social evaluative stress. Psychoneuroendocrinology, 44, 1–12. https://doi.org/10.1016/j.psyneuen.2014.02.007
+Crosswell, A. D., Moreno, P. I., Raposa, E. B., Motivala, S. J., Stanton, A. L., Ganz, P. A., & Bower, J. E. (2017). Effects of mindfulness training on emotional and physiologic recovery from induced negative affect. Psychoneuroendocrinology, 86, 78–86. https://doi.org/10.1016/j.psyneuen.2017.08.003
+Darmedru, C., Demily, C., & Franck, N. (2018). Prévenir la violence associée à la schizophrénie avec la remédiation cognitive [Preventing violence in schizophrenia with cognitive remediation]. L'Encephale, 44(2), 158–167. https://doi.org/10.1016/j.encep.2017.05.001
+De Jesus, O., Fogwe, D. T., Mesfin, F. .B., & Das, J. M. (2023, February 12). Neuromodulation Surgery for Psychiatric Disorders. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 29493988. https://pubmed.ncbi.nlm.nih.gov/29493988/
+Delegran, L. (2016). What is spirituality? University of Minnesota. https://www.takingcharge.csh.umn.edu/what-spirituality
+Delegran, L., & Haley, A. (2016). What is mindfulness? University of Minnesota’s Earl E. Bakken Center for Spirituality & Healing. https://www.takingcharge.csh.umn.edu/what-mindfulness
+Donovan, N. J., Wu, Q., Rentz, D. M., Sperling, R. A., Marshall, G. A., & Glymour, M. M. (2017). Loneliness, depression and cognitive function in older U.S. adults. International Journal of Geriatric Psychiatry, 32(5), 564–573. https://doi.org/10.1002/gps.4495
+Erwin, E. (2002). The Freud encyclopedia: Theory, therapy, and culture. Taylor & Francis.
+Glasofer, D. R. (2024, January 16). What is acceptance and commitment therapy (ACT). Verywell Mind. https://www.verywellmind.com/acceptance-commitment-therapy-gad-1393175
+Good Therapy. (2018). Mindfulness-based cognitive therapy (MBCT). https://www.goodtherapy.org/learn-about-therapy/types/mindfulness-based-cognitive-therapy
+Gorman, L. M., & Sultan, D. F. (2008). Psychosocial nursing for general patient care (3rd ed.). FA Davis Co.
+Grace, E. (2019). Mahler’s theory of development. kids’ development. https://www.kidsdevelopment.co.uk/mahlersdevelopmenttheory.html
+Grajek, M., Krupa-Kotara, K., Białek-Dratwa, A., Sobczyk, K., Grot, M., Kowalski, O., & Staśkiewicz, W. (2022, August 22). Nutrition and mental health: A review of current knowledge about the impact of diet on mental health. Front Nutr, 9:943998. https://doi.org/10.3389/fnut.2022.943998
+Haber, J. (2000). Hildegard E. Peplau: The psychiatric nursing legacy of a legend. Journal of the American Psychiatric Nurses Association, 6(2), 56–62.
+Hagerty, T. A., Samuels, W., Norcini-Pala, A., & Gigliotti, E. (2017, April). Peplau’s theory of interpersonal relations: An alternate factor structure for patient experience data? Nurs Sci Q, 30(2),160–167. https://doi.org/10.1177/0894318417693286
+Hodge, K. (2023, June 12). The role of humanistic and existential therapy in mental health. https://www.mentalhealthcenter.org/role-of-humanistic-and-existential-therapy/
+Horiuchi, S., Tsuda, A., Aoki, S., Yoneda, K., & Sawaguchi, Y. (2018). Coping as a mediator of the relationship between stress mindset and psychological stress response: A pilot study. Psychology Research Behavior Management, 11, 47–54. https://doi.org/10.2147/PRBM.S150400
+Ito, M., & Matsushima, E. (2017, April). Presentation of coping strategies associated with physical and mental health during health check-ups. Community Ment Health J, 53(3), 297–305. https://doi.org/10.1007/s10597-016-0048-9
+Jarvis, G. E., Kirmayer, L. J., Gómez-Carrillo, A., Aggarwal, N. K., & Lewis-Fernández, R. (2020, January). Update on the cultural formulation interview. Focus The Journal of Lifelong Learning in Psychiatry, 18(1), 40–46. https://doi.org/10.1176/appi.focus.20190037
+Joseph, B. (1988). Object relations in clinical practice. The Psychoanalytic Quarterly, 57(4), 626–642, https://doi.org/10.1080/21674086.1988.11927224
+Kourkouta, L., & Papathanasiou, I. V. (2014). Communication in nursing practice. Materia socio-medica, 26(1), 65–67. https://doi.org/10.5455/msm.2014.26.65-67
+Krau, S. D. (2020). The multiple uses of guided imagery. The Nursing Clinics of North America, 55(4), 467–474. https://doi.org/10.1016/j.cnur.2020.06.013
+Lamothe, M., Rondeau, É., Malboeuf-Hurtubise, C., Duval, M., & Sultan, S. (2016). Outcomes of MBSR or MBSR-based interventions in health care providers: A systematic review with a focus on empathy and emotional competencies. Complementary Therapies in Medicine, 24, 19–28. https://doi.org/10.1016/j.ctim.2015.11.001
+Lindamood, W. (2005). Thorazine - purpose antipsychotic. Chemical and Engineering News, 83(25). https://cen.acs.org/articles/83/i25/Thorazine
+Lindsay, E. K., & Creswell, J. D. (2017). Mechanisms of mindfulness training: Monitor and acceptance theory (MAT). Clinical Psychology Review, 51, 48–59. https://doi.org/10.1016/j.cpr.2016.10.011
+Lindsay, E. K., Young, S., Smyth, J. M., Brown, K. W., & Creswell, J. D. (2018). Acceptance lowers stress reactivity: Dismantling mindfulness training in a randomized controlled trial. Psychoneuroendocrinology, 87, 63–73. https://doi.org/10.1016/j.psyneuen.2017.09.015
+Malhotra, A., & Baker, J. (2022, December 13). Group Therapy. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549812/
+McLeod, S. A. (2018). Maslow’s hierarchy of needs. Simply Psychology. https://www.simplypsychology.org/maslow.html
+Mcleod, S. A. (2024a). Defense mechanisms in psychology explained (+ examples). Simply Psychology. https://www.simplypsychology.org/defense-mechanisms.html
+Mcleod, S. A. (2024b). Sigmund Freud’s theories & contribution to psychology. Simply Psychology. https://www.simplypsychology.org/sigmund-freud.html
+Meyer, L. F., Telles, L. E. B., Mecler, K., Soares, A. L. A. G., Alves, R. S., & Valença, A. M. (2018). Schizophrenia and violence: Study in a general psychiatric hospital with HCR-20 and MOAS. Trends in Psychiatry and Psychotherapy, 40(4), 310–317. https://doi.org/10.1590/2237-6089-2017-0039
+Millacci, T. S. (2022). Humanistic psychology’s approach to wellbeing: 3 theories. PositivePsychology.com. https://positivepsychology.com/humanistic-psychology/
+Nash, J. (2019, May 27). The history meditation: Its origins and timeline. Positive Psychology. https://positivepsychology.com/history-of-meditation/
+Nathan, H. J., Poulin, P., Wozny, D., Taljaard, M., Smyth, C., Gilron, I., Sorisky, A., Lochnan, H., & Shergill, Y. (2017, December 1). Randomized trial of the effect of mindfulness-based stress reduction on pain-related disability, pain intensity, health-related quality of life, and A1C in patients with painful diabetic peripheral neuropathy. Clin Diabetes, 35(5), 294–304. https://doi.org/10.2337/cd17-0077
+National Alliance on Mental Illness (NAMI). (2023). ECT, TMS and Other Brain Stimulation Therapies. https://www.nami.org/About-Mental-Illness/Treatments/ECT-TMS-and-Other-Brain-Stimulation-Therapies
+National Center for Complementary and Integrative Health (NCCIH). (2024). Serving as an efficient and effective steward of public resources. https://www.nccih.nih.gov/about/nccih-strategic-plan-2021-2025/serving-as-an-efficient-and-effective-steward-of-public-resources
+Orenstein, G. A., & Lewis, L. Eriksons stages of psychosocial development. (2022, November 7). In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556096/
+Pehlivan, T., & Güner, P. (2016). The use of theories in psychiatric nursing-II. J Psy Nurs, 7(2), 100–104.
+Schneider, K. J., Pierson, J. F., & Bugental, J. F. T. (Eds.). (2015). The handbook of humanistic psychology: Theory, research, and practice (2nd ed.). Sage Publications, Inc.
+Schwartz, S., & Corcoran, C. (2017). Biological approaches to psychiatric disorders: A sociological approach. In T. Scheid & E. Wright (Eds.), A handbook for the study of mental health: Social contexts, theories, and systems (pp. 98–125). Cambridge University Press. https://doi.org/10.1017/9781316471289.009
+Scott, H. K., & Cogburn, M. (2023, January 9). Piaget. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448206/
+Shao, K., Pekrun, R., Marsh, H. W., & Loderer, K. (2020). Control-value appraisals, achievement emotions, and foreign language performance: A latent interaction analysis. Learning and Instruction, 69, Article 101356. https://doi.org/10.1016/j.learninstruc.2020.101356
+Smith, J. (2023). Lawrence Kohlberg’s stages of moral development. https://seattleanxiety.com/lawrence-kohlbergs-stages-of-moral-development
+State of New South Wales (NSW) Government. (2020). What is a holistic approach? Mental Health Updates. https://www.health.nsw.gov.au/mentalhealth/psychosocial/principles/Pages/holistic.aspx
+Sussex Publishers. (2022). Humanistic therapy. Psychology Today. https://www.psychologytoday.com/us/therapy-types/humanistic-therapy
+Sutter Health. (2023). Eating well for mental health. https://www.sutterhealth.org/health/nutrition/eating-well-for-mental-health
+Tang, Y. Y., Tang, R., & Posner, M. I. (2016). Mindfulness meditation improves emotion regulation and reduces drug abuse. Drug and Alcohol Dependence, 163 Suppl 1, S13–S18. https://doi.org/10.1016/j.drugalcdep.2015.11.041
+Thornton, M. & Persaud, S. (2018). Preparing today’s nurses: Social determinants of health and nursing education. Online Journal of Issues in Nursing, 23(3), 1–9. https://doi.org/10.3912/OJIN.Vol23No03Man05
+Zhu, X., Li, W., & Wang, X. (2016). Characteristics of aggressive behavior among male Inpatients with schizophrenia. Shanghai Archives of Psychiatry, 28(5), 280–288. https://doi.org/10.11919/j.issn.1002-0829.216052
+