Chapter 3: Theories & Therapies

Um, welcome back to the deep dive.

Yeah, thanks for having me back.

So today we are, we're clearing the decks.

We have a massive stack of notes in front of us.

A very specific textbook, actually.

Right, and a very clear mission.

We are basically buckling down for what I'm calling a survival study session.

I love that.

Yeah, we are looking specifically at essentials of psychiatric mental health nursing.

The fourth edition, to be exact.

Fourth edition, yes.

And we are doing a deep comprehensive dive into chapter three, theories and therapies.

That's right.

And I actually want to speak directly to the nursing students who are listening right now.

Because they're the ones cramming for an exam or a clinical rotation.

Exactly.

I know the temptation.

You see chapter three, history and theory, and your brain just goes, skip.

You just want to skip it.

You do.

You want to get straight to the pharmacology.

You want the diagnosis criteria.

You want to know what to do when a patient is actively in crisis on the floor.

Because that feels like the real work, you know.

History just feels like, well, it feels like trivia.

It does.

But, and I really can't stress this enough, this chapter is not trivia.

It is the operating system for everything else.

You can't effectively treat a psychiatric patient without understanding the architecture of these theories.

You really can't.

When you're on the floor and you're trying to figure out why a patient is projecting their anger onto you or why talk therapy is prescribed alongside medication, the answers are right here in chapter three.

These theories provide the lens through which you actually assess behavior and plan care.

Precisely.

We're going to decode the whole dense history of psychiatric care today.

Moving from the early days of Freud and the talking cure.

All the way to the modern biological revolution and the recovery model.

Right.

We're going to break down exactly why we treat patients the way we do today.

And just to set the ground rules for you listening, we are sticking strictly to the text of chapter three.

No outside opinions.

No Googling.

No bringing in outside clinical practices.

We are giving you exactly what is in this source material, so you can walk into your exam with absolute confidence.

So let's get into it.

We got to start at the beginning.

The Victorian era.

The couch.

The cigar.

Sigmund Freud.

The grandfather of it all.

You just can't avoid him.

No, he really is considered the father of psychiatry.

You have to remember before him, mental illness was often dismissed or it was treated as a spiritual failing.

Like a moral weakness.

Freud was an Austrian neurologist who completely revolutionized how we think about the mind by introducing psychoanalytic theory.

And the biggest contribution he made, the thing that changed literally everything was the concept of the unconscious.

Exactly.

He proposed that the vast majority of our mental disturbances aren't coming from what we're thinking about right now.

They were the result of early trauma?

Early trauma or incidents that we often don't even remember.

And to explain this, he used that famous iceberg analogy.

Everyone knows the image.

But let's drill down into the specifics for the exam because the text is very specific about the layers.

It is.

So picture that iceberg floating in the ocean.

First, you have the conscious mind.

That's the tip of the iceberg.

The tip of the iceberg.

The part sticking right out of the water.

It contains all the material a person is aware of at any one time.

So your perceptions, your current thoughts.

The feeling of the chair you're sitting in right now.

Okay, that's easy.

That's the no.

Then just below the surface of the water, you have the pre -conscious.

This contains material that can be retrieved rather easily through conscious effort.

It's kind of like a filing cabinet in your brain.

So you aren't thinking about your childhood phone number right now.

But if I ask you for it, you can go into the pre -conscious and pull it right out.

It's accessible, just not active.

Exactly.

But then you have the unconscious.

This is the massive bulk of the iceberg deep underwater.

It's huge compared to the tip.

Right.

It includes all the repressed memories, passions, unacceptable urges, just lying deep below the surface.

And the critical point Freud made is that memories and feelings associated with trauma are placed here because they are too painful to face.

They're too heavy.

But just because they're underwater doesn't mean they're gone.

No.

And that's the crux of the theory, isn't it?

The unconscious exerts a powerful effect on conscious behavior.

A massive effect.

Yeah.

You might be acting out or feeling incredibly anxious and have absolutely no idea why.

Because the driver is deep underwater.

Exactly.

Now within this mind, Freud described a battle.

The internal battle.

The Eid, the ego, and the superego.

I always picture this like those old cartoons with the angel and the devil sitting on your shoulders.

It's a useful simplification.

But let's unpack the actual clinical definitions for the students.

First, you have the Eid.

The Eid.

The Eid is there right at birth.

It is totally unconscious and completely impulsive.

It's the source of all drives, instincts, reflexes, and needs.

And it operates on what Freud called the pleasure principle.

Right.

Which basically means - We'll call it what I want and I want it right now.

Yes.

It doesn't care about social norms.

It doesn't care about reality.

It's a screaming, hungry infant.

It seeks to experience pleasure and avoid pain instantly.

So that's the devil on the shoulder.

Eat the cake.

Punch the guy.

Sleep in.

Exactly.

Then on the other side, you have the superego.

This develops later, usually between ages three and five.

This is the moral component.

It represents the ideal rather than the real.

It seeks perfection.

It is the conscience instilled by your parents and by society.

So the superego is that nagging voice saying, you shouldn't eat that cake.

It's gluttonous.

You should be working.

Right.

So you have the eyed screaming I want and the superego screaming you mustn't.

And caught right in the middle is the ego.

The ego.

It resides in the conscious, pre -conscious and unconscious levels and it operates on the reality principle.

It's the negotiator.

It's the adult in the room.

Yes.

The ego attempts to negotiate a solution that satisfies the EADS needs in a way that is actually socially acceptable to the superego.

So in a healthy person, the ego is the leader.

Yes.

If the EADS takes over, you get impulsive dangerous behavior.

And if the superego takes over?

You get crippling guilt and inferiority complexes.

Now the text mentions that the ego develops defense mechanisms to handle this constant war.

Yes.

The ego develops these defenses to ward off anxiety by preventing conscious awareness of threatening feelings.

The text lists several, but I really want to highlight the distinction between repression and suppression because students often mix these up on exams.

They do all the time.

Okay, hit me.

What is the difference?

Repression is unconscious.

It is the involuntary exclusion of unpleasant or unwanted experiences, emotions or ideas from conscious awareness.

So you don't choose to do it?

No.

For example, a person who was abused as a child might have absolutely no memory of the events.

That is repression.

Their brain hid it to protect them.

Suppression, on the other hand, is the conscious counterpart.

Yes.

It's when you deliberately shove something down, like a nursing student saying, I can't worry about my breakup right now.

I have to study for this psych exam.

You are actively choosing to put it away.

That's the crucial distinction.

One is automatic.

One is a choice.

What about reaction formation?

That's one of those terms that just sounds complicated.

It's actually fascinating.

Reaction formation is when unacceptable feelings or behaviors are kept out of awareness by developing the exact opposite behavior or emotion.

So doing the reverse of what you feel.

Right.

The text gives a great example.

A person who harbors hostility toward children becomes a Boy Scout leader.

Wow.

Or a recovering alcoholic who constantly preaches about the eavers of drinking.

They're fighting their own internal urge by aggressively acting out the opposite.

That makes total sense.

It's overcompensating to hide the truth.

Then there is projection.

This one is incredibly common in clinical settings.

This involves placing your own unacceptable feelings onto someone else, right?

Exactly.

So if a patient is feeling incredibly angry and hostile, but their superego says anger is bad, they might project it and say to the nurse, why are you being so angry with me?

They see their own anger in your face.

Precisely.

And if you as the nurse don't understand that, you'll get defensive.

You'll say, I'm not angry.

And an argument starts.

But if you understand projection, you realize, ah, this isn't about me.

Right.

Speaking of things not being about you, we need to talk about transference and countertransference.

The text highlights these as vital concepts for nursing.

If you take nothing else from Freud,

take these.

Transference refers to the feelings that the patient has toward the health care worker that were originally held toward significant others in his or her life.

So let's say you're a nurse and you're simply setting a boundary,

telling a patient it's time for group therapy.

And suddenly the patient becomes hostile or maybe oddly submissive and fearful.

They aren't seeing you.

They are seeing a controlling mother or a strict father.

They are transferring the template of that past relationship right onto you.

Exactly.

And this is actually available for exploration.

You can help the patient see this.

You could say, I notice you seem very angry right now.

I wonder if this situation reminds you of something.

And the flip side of that is countertransference.

This is the danger zone.

This is the unconscious feelings that the health care worker has toward the patient.

So it goes the other way.

Yes.

Imagine a patient who is struggling with alcohol addiction and is maybe a bit manipulative.

If you grew up with an alcoholic parent, you might find yourself feeling irrationally angry or disgusted or maybe overly eager to save them.

You aren't reacting to the patient.

You're reacting to your own history.

And the text is very clear on this.

This underscores the importance of maintaining self -awareness.

If you don't recognize countertransference, you will lose your professional objectivity and you can seriously damage the therapeutic relationship.

Before we leave Freud entirely, we have to touch on his psychosexual developmental stages.

The text acknowledges these are pretty controversial.

They are.

Freud believed personality was essentially set in stone by age five.

He outlined the oral stage from zero to one year, the anal stage one to three years, and the phallic stage three to six years, followed by latency and genital stages.

The controversy comes from his focus on sexuality and biology, right?

Yes.

The text explicitly mentions the criticism of his theory as misogynistic, specifically the concept of penis envy.

Which is the idea that women feel inferior because they lack male anatomy.

Which, as the text notes, lacks scientific rigor.

To put it mildly.

To put it very mildly.

But we study him because he laid the groundwork.

He was the first to say, childhood trauma shapes the adult mind.

That concept is the bedrock of everything that follows.

It really is.

Okay, let's move forward in history.

We're stepping away from the intra -psychic, the stuff inside the head, and moving to the interpersonal.

Enter Harry Stack Sullivan.

The Sullivan has a huge shift.

He believed that the purpose of all behavior is to get needs met through interpersonal interactions, and to decrease or avoid anxiety.

He defined anxiety as any painful feeling or emotion that arises from social insecurity.

Right.

And he had a very poignant view on loneliness.

He viewed loneliness as the most painful human condition.

But here is the part that is really relevant for nurses.

The transmission of anxiety.

Sullivan believed anxiety is transmitted from the primary caregiver to the infant.

If the mother is anxious, the baby actually feels it via empathy.

It's like a contagion.

It is.

And the child learns to behave in ways to avoid that anxiety, which leads to his concept of the self -system.

The text breaks this down into three parts.

The good me, the bad me, and the not me.

Let's decode these.

Sure.

This is how we organize our personality to manage anxiety.

First, the good me.

These are the behaviors and feelings that get positive feedback from caregivers.

Like, you are such a good boy for sharing.

We feel good about these parts of ourselves.

Second, the bad me.

These are behaviors that get negative feedback.

Don't touch that.

This creates anxiety.

We accept these are parts of us, but we hide them or feel guilty about them.

And the third one, the not me.

This is the most complex one.

The not me consists of feelings or behaviors that create such intense, overwhelming anxiety that the person dissociates from them entirely.

They deny these things are part of them at all.

Right.

The text uses the example of a person suffering from schizophrenia.

The terrifying experiences of a psychotic episode might be pushed into the not me.

They are just too scary to acknowledge as part of the self.

So this theory led to interpersonal therapy, or IPT.

How is that different from Freud's psychoanalysis?

Well, Freud digs into the distant past.

IPT deals with the here and now.

So it's much more immediate.

Exactly.

If you're doing IPT, the therapist is an active participant observer.

They are helping you look at your current relationships.

Are you grieving?

Do you have conflicts with your spouse?

Do you lack social skills?

The goal is to improve your social functioning now to reduce your depression now.

Precisely.

Focus on the present.

Okay, let's pivot.

We've done the unconscious mind.

We've done social relationships.

Now let's talk about the scientists, the behaviorists.

Pavlov, Watson, Skinner.

These researchers had absolutely no patience for hidden drives or repressed memories.

They basically said, if I can't see it and measure it, it's not science.

For them, personality is simply learned behavior.

That's it.

Let's start with the dogs.

Ivan Pavlov.

Classical conditioning.

Pavlov noticed that dogs salivated when they saw food.

That's a natural reflex.

He started ringing a bell at the exact same time he brought the food.

Bell, food, salivate.

Bell, food, salivate.

Just pairing them together over and over.

Eventually, he rang the bell, no food, and the dogs salivated anyway.

They learned to react to the neutral sound.

Right.

And for humans, this is huge.

Think about a baby crying when they see a white coat because the last time they saw a white coat, they got a shot.

Or a combat veteran diving for cover when a car backfires.

Exactly.

That is a conditioned, involuntary response.

Then John B.

Watson took this and, well, he went to a pretty dark place with it.

The little Albert experiment.

This is a classic example of unethical science.

Watson wanted to prove fear was learned.

He took a nine -month -old baby, Albert, who loved playing with a white rat.

Okay.

Then, every time Albert reached for the rat, Watson made a terrifyingly loud noise with a hammer behind the baby's head.

Oh, man.

After just a few times, Albert would scream and cry just at the sight of the rat.

He conditioned a phobia into a baby.

He did.

He proved that you could program a human being.

Yeah.

He actually boasted, give me a dozen healthy infants and I'll guarantee to take anyone at random and train him to become any type of specialist are.

I might select doctor, lawyer, merchant chief,

and he has even beggar man and thief.

It's chilling, but it paved the way for B .F.

Skinner.

Yes.

Skinner introduced operant conditioning.

While Pavlov was about involuntary reflexes, Skinner was about voluntary behavior.

It's all about consequences.

Exactly.

Positive reinforcement.

You study, you get an A.

You are likely to study again.

You are adding a good thing.

And negative reinforcement.

You have a headache, you take an aspirin, the headache goes away.

You are likely to take aspirin again.

You are removing a bad thing.

And then punishment?

You drive fast, you get a ticket, you stop driving fast.

Yeah.

Adding a bad consequence to decrease the behavior.

So how do we actually use this in nursing?

We aren't training rats or traumatizing babies with hammers.

We use behavioral therapy.

It's incredibly practical.

One major tool is systematic desensitization.

This is the gold standard for phobias.

Let's walk through an example.

Say you are terrified of elevators.

We don't just shove you in an elevator.

That would be flooding.

Instead, first we teach you relaxation techniques.

Deep breathing, muscle relaxation.

Okay.

Then we have you just imagine an elevator while you're relaxing.

Then maybe look at a picture of one.

Taking it step by step.

Right.

Then stand in the lobby near the elevator.

Then stand in the elevator with the door open.

We gradually break the link between the stimulus and the fear response.

What about aversion therapy?

That's the opposite.

That's pairing a bad habit with a punishment.

The text mentions disulfiram, also known as antabuse.

This is a medication for alcoholism.

Yes.

If you take this pill and then you drink alcohol, you get violently ill.

Frobbing, headache, vomiting, difficulty breathing.

The goal is to teach the brain alcohol equals sickness.

Exactly.

And finally, there's biofeedback.

Which uses technology.

Right.

You hook a patient up to sensors that show their heart rate or muscle tension on a screen in front of them.

By watching the screen, the patient actually learns to consciously control their body's response.

Slowing their heart rate, relaxing their muscles.

Yes.

It gives them agency over their physiology.

Okay.

Moving on.

We've been very mechanical with the behaviorists.

The humanistic theories swung the pendulum back to the human side.

This was the third force in psychology.

The humanists, like Abraham Maslow and Carl Rogers, felt the other theories were just too pessimistic.

They wanted to focus on human potential and strengths.

Maslow's Hierarchy of Needs.

If you are in nursing school, this pyramid is burned into your retina.

Figure 3 .2 in the text.

It is fundamental to nursing practice.

Maslow argued that humans have layers of needs.

And you have to start at the bottom.

Yes.

At the base, you have physiological needs.

Food, water, oxygen, sleep, sex, body temperature.

Next up, safety needs.

Security, protection, freedom from fear, law and order.

Then, belonging and love needs.

Intimacy, friendship, family.

Then, esteem needs.

Status, self -respect, confidence.

And finally, at the top, self -actualization.

Becoming everything one is capable of becoming.

The text mentions he added a level later on, right?

Yes.

Self -transcendence.

This is focusing on something higher than the self -like spirituality or helping others.

Why is this critical for a nurse?

I mean, it seems like common sense.

Because of prioritization.

The text is very clear.

Basic needs take precedence.

So if you have a patient who is manic and hasn't slept or eaten in three days.

You cannot effectively start therapy about their self -esteem or their childhood trauma.

You have to address the physiological collapse first.

You need to stabilize the base of the pyramid before you can climb.

That's a very clear clinical directive.

What about Carl Rogers?

Rogers developed person -centered therapy.

He emphasized that people are basically healthy and have an innate drive toward growth.

He changed the language, didn't he?

He did.

He didn't call them patients, which implies sickness.

He called them clients.

He believed the therapist shouldn't tell the client what to do.

The therapist should just create an atmosphere where the client can find their own answers?

Yes.

And he had three essential ingredients for that atmosphere.

First,

congruence or genuineness.

The therapist is real, not putting on a professional mask.

Second is empathy.

Truly understanding the client's world.

And third, respect or unconditional positive regard.

Accepting the client absolutely without judgment.

Okay, let's talk about the therapy that you see everywhere today.

Cognitive theory and Aaron Beck.

This is huge.

Beck was originally a psychoanalyst, but he noticed that his depressed patients all seemed to have the same types of negative thoughts.

His breakthrough was realizing it's not the event that causes the emotion.

It's your evaluation of the event.

Can we break that down using the ABC model?

Let's do it.

A is the activating event.

Let's say a friend walks past you in the hall without saying hello.

Happens all the time.

B is the belief.

If your belief is, she hates me, I'm unlovable,

then… And then C is the consequence.

You feel sad and rejected.

Right.

But if you change B, the belief, to she must be distracted or just didn't see me, then the consequence is neutral.

You don't feel sad.

So the entire goal of cognitive behavioral therapy, CBT, is to change the B.

Exactly.

To challenge those automatic thoughts.

Beck identified schematocore.

These are hidden assumptions we have about ourselves.

I am a failure.

Or the world is dangerous.

And these schemata trigger automatic thoughts, which are often irrational.

We call them cognitive distortions.

Cable 3 .3 in the text lists these.

Let's define a few because students absolutely need to spot them in patient dialogue.

First one, all or nothing thinking.

Thinking in black and white.

If I don't get an A on this exam, I am a total failure.

There is no middle ground.

Next, catastrophizing.

Taking a small event and blowing it up into a disaster.

I made a typo in this email.

My boss will see it.

I'll get fired.

I'll lose my house.

I'll live under a bridge.

Spiraling completely out of control.

What about personalization?

Assuming responsibility for external events.

The party ended early.

It must be because I was boring.

CBT teaches patients to catch these thoughts, check the evidence, and replace them with reality.

Now we're entering the modern era.

The biological model.

This is the dominant model in psychiatry today.

It views abnormal behavior as a disease with a physical cause.

Neurochemical imbalances, genetic susceptibility, or brain damage.

Therefore, we treat it with physical interventions.

Exactly.

There was a specific turning point for this.

The psychotropic revolution in the 1950s.

Specifically, the discovery of chlorpromazine, brand name thorazine.

Before 1950, we had very few tools.

Patients with severe psychosis were often restrained, secluded, or given treatments like insulin shock.

It was pretty bleak.

It was.

Then they found thorazine.

It was a strong tranquilizer.

It calmed patients down and reduced hallucinations without just knocking them unconscious.

It proved that a chemical could fix a mental symptom.

It changed everything.

It emptied out the state hospitals and it birthed the entire field of psychopharmacology.

We need to get technical for a second.

The text talks about the synapse.

This is crucial for understanding how these meds work.

You have neurons, which are nerve cells,

but they don't touch.

There is a tiny gap between them called the synapse.

To send a message,

one neuron shoots chemicals neurotransmitters across that gap to hit receptors on the other side.

And mental illness is often a problem right in that gap.

Yes.

Too much dopamine, you might get hallucinations like in schizophrenia, too little serotonin or norepinephrine, you might get depression.

So how do antidepressants actually work?

Many of them, like SSRIs, Prozac, Zoloft work, by blocking reuptake.

After the neurotransmitters released into the gap, the first neuron usually sucks it back up to recycle it.

That's reuptake.

Like a vacuum.

The medication blocks that vacuum.

It keeps the serotonin in the gap longer, hitting the receptors more often, which boosts the signal.

But the biological model isn't just pills.

The text details brain stimulation therapies.

Right.

Like ECT, electroconvulsive therapy.

People get so scared of this because of movies like One Flew Over the Cuckoo's Nest.

But modern ECT is very safe and controlled.

The patient is under anesthesia, right?

Yes, under anesthesia with muscle relaxants.

We use a small electric current to induce a brief seizure.

We don't know exactly why it works, but it resets the neurotransmitters.

It is highly effective for severe suicidal depression that hasn't responded to medications.

And there are newer ones, too.

RTMS,

repetitive transcranial magnetic stimulation, uses magnetic coils on the scalp to pulse the brain.

No seizure, no anesthesia.

And VNS, vagus nerve stimulation, which is like a pacemaker for the brain.

Here's the most important takeaway from this section for me.

The text emphasizes that it's not meds or R therapy.

No, absolutely not.

This is the concept of neuroplasticity.

The text notes that psychotherapy actually changes the brain structurally.

That's amazing.

It is.

Research shows that CBT can cause physical changes in brain function and structure, very similar to medication.

So the most effective treatment is often the combination of both.

The meds stabilize the chemistry so the patient can engage in the therapy.

And the therapy rewires the pathways for long -term health.

Let's shift gears to developmental theories.

How do we grow up?

The text covers four big names.

Let's start with Jean Piaget.

Piaget focused on cognitive development, how we learn to think.

He outlined distinct stages.

First, sensorimotor, from zero to two years, learning through movement and senses.

This is where object permanence develops.

Knowing a toy still exists when it's hidden under a blanket.

Exactly.

Then, preoperational, two to seven years.

Ego -centric thinking.

They literally can't see another person's viewpoint.

Then concrete operational, seven to eleven.

Logical thinking, but very concrete.

Then finally, formal operational, eleven and up.

Abstract thinking.

The nursing implication here is communication.

Right, exactly.

If you're explaining a surgery to a five -year -old in the preoperational stage, you can't use abstract metaphors.

They will take you literally.

You have to tailor your education to their specific cognitive level.

Then we have Eric Erickson, the eight stages of man.

Erickson believed we develop through a series of social crises.

For example, infancy, zero to one and a half years.

Trust versus mistrust.

If the caregiver is consistent, we learn to trust.

If not, we learn fear.

Adolescence, twelve to twenty.

Identity versus role confusion.

Who am I?

Where do I fit in?

And old age, sixty -five plus.

Integrity versus despair.

Looking back, did I live a meaningful life?

Nurses use this to assess where a patient might be stuck.

Yes.

If a forty -year -old patient is acting rebellious and struggling to find who they are, you might realize they never successfully resolve that adolescent identity crisis.

What about Margaret Mahler?

Object relations theory.

She focused on the psychological separation from the mother.

She described the reproach -mall phase around one and a half to two years.

The toddler moves away to explore, gets scared, runs back to mom for emotional refueling, and then goes out again.

Her big concept is good enough parenting.

Parents don't need to be perfect.

They just need to provide enough consistency and security for the child to feel safe exploring the world.

Finally, moral development.

Kohlberg and Gilligan.

Laurence Kohlberg outlined stages of moral reasoning, moving from, I don't want to get punished, all the way to, I follow universal ethical principles.

But Carol Gilligan criticized his work.

She did.

She noted his studies were mostly based on boys.

She argued that boys focus on justice and rules.

Girls, she argued, focus on care and relationships.

So, if asked, is stealing a drug wrong if it saves a life?

Kohlberg might say yes, stealing is against the law.

Gilligan might say no, saving the relationship in the human life is more important than the abstract rule.

Okay, stop the presses.

We have arrived at the most critical section for this audience, nursing theories.

Because nursing isn't just applied psychology, it has its own framework.

And the most important name here is Hildegard Peplau.

She is considered the mother of psychiatric nursing.

She polished interpersonal relations in nursing in 1952.

Why was that such a big deal?

Because before her, nurses were basically custodians.

We cleaned, we fed the patients, we followed the doctor's orders.

Peplau said no, nursing is therapy.

She shifted the focus from doing things to the patient to doing things with the patient.

The relationship itself is the tool for healing.

And she gave us the four levels of anxiety.

If you are listening to this for an exam, pause, rewind, and memorize this part.

This is incredibly high yield.

You absolutely need to know the symptoms and the nursing interventions for each level.

Let's start with level one, mild anxiety.

Okay, what does that look like?

Symptoms.

You are alert.

You actually see, hear, and grasp more information.

You might have slight restlessness.

It's like the feeling you get right before a test.

What about learning?

This is actually the best time for learning.

Problem solving is highly effective.

So what's the nursing intervention?

Help the patient identify the anxiety, discuss the cause, use that energy for problem solving.

Level two, moderate anxiety.

Symptoms.

The perceptual field narrows.

You have what's called selective inattention.

You might need things pointed out to you.

Physical signs start appearing.

Tension, pounding heart, increased pulse, voice tremors.

Can they still learn?

You can still learn and problem solve, but not at an optimal level.

You need direction.

So the intervention is what?

Speak in short, simple sentences.

Encourage the patient to talk about their experience.

Don't try to teach complex new material right now.

Level three, severe anxiety.

Symptoms.

The perceptual field is greatly reduced.

You might focus on one specific detail, like a stain on the wall or many scattered details.

You cannot see the connections between events.

Physical symptoms.

Headache, nausea, dizziness, trembling, hyperventilation, a strong sense of impending doom.

Learning.

Learning and problem solving are not possible at this level.

So what do you do as the nurse?

Your only goal is to lower the anxiety.

Remain with the patient.

Be firm, short, and directive.

Say, sit down, take a deep breath with me.

Do not ask them to make decisions.

Level four, panic.

Symptoms.

Absolute terror.

The person is unable to process what is happening in the environment.

They may lose touch with reality, experience hallucinations, behaviors, erratic screaming, running, or completely mutant withdrawn, physical, severe immobility, or extreme hyperactivity.

Learning is definitely impossible.

Impossible.

Intervention.

Safety is the only priority.

Minimize environmental stimuli.

Turn down the lights.

Reduce noise.

Stay with the patient.

Tell them, you are safe.

I am here.

Just maintain safety.

Use physical restraints only if absolutely necessary for safety.

No teaching.

No therapy.

Just safety.

That breakdown is essential.

The text closes this section with the recovery model.

This feels like the modern philosophy of nursing overall.

It is.

The old medical model was very paternalistic.

You are sick.

I am the expert.

I will cure you.

The recovery model acknowledges that some mental illnesses, like schizophrenia or bipolar disorder, are chronic.

We might not cure them.

So the focus shifts to empowerment.

Yes.

The patient is a partner.

The goal is living a meaningful life, as defined by the patient.

It moves the question from what is wrong with you to what happened to you and what do you need to thrive.

Let's briefly touch on group therapy.

A group is a gathering of two or more people, ideally six to ten, with a common purpose.

And the setting matters.

You want a circle of chairs, no tables.

Tables act as physical and psychological barriers.

You want open communication.

The text distinguishes between content and process in a group.

This can be tricky.

Content is what is actually said.

The literal transcript of the meeting.

Process is the underlying dynamic.

Who is talking?

Who is interrupting?

Who is rolling their eyes?

So if a patient says, I am so happy to be here, but they are looking at the floor and their arms are tightly crossed.

The content is happy.

The process is resistant or uncomfortable.

The nurse's job is to track that process.

And groups go through stages.

Tuck man stages.

Yes.

Forming the polite stage.

Who are you?

What are we doing?

Storming the conflict stage.

Testing the leader.

Saying, I don't want to do this.

This is totally normal.

And norming.

The team stage.

Okay, we are a group.

Cohesion builds.

Performing the productive work stage where real issues are addressed.

And adjourning the ending.

Mourning the loss of the group.

Irvin Yellam identified why groups work the curative factors.

The big ones are universality.

The realization that I'm not the only one.

That relief is massive.

Altruism.

Patients get to help others, which boosts their own self -esteem.

And catharsis.

Safely expressing strong emotions.

Finally, let's look at the therapeutic milieu and family therapy.

Milieu refers to the environment.

In an inpatient psych unit, the entire environment is the treatment.

The structure, the rules, the safety, the casual interactions in the hallway.

It's all designed to be a safe testing ground for healthy behavior.

And family therapy treats the family as a system.

The identified patient, the one with the symptoms, is often just expressing the dysfunction of the whole family unit.

The text defines some key dysfunctional patterns you need to know.

First, triangulation.

When two people, like mom and dad, have conflict and they drag in a third person, the child, to stabilize the relationship, tell your father dinner is ready.

Exactly.

Then there's scapegoating.

Blaming the least powerful member of the family to avoid looking at the real issues.

And the double bind.

A no -win situation.

The text gives the example of a parent who says I love you but stiffens up when the child hugs them.

The words say love, the body says rejection.

Right.

And the child is confused.

If they address it, they're wrong.

If they ignore it, they're confused.

It creates immense anxiety because they are damned if they do, damned if they don't.

We have covered a massive amount of ground today.

From Ford's iceberg to the modern recovery model.

It is a lot to take in.

But here is the ultimate synthesis for you.

Nursing is eclectic.

You don't just pick one theory and stick to it exclusively.

Never.

You use behavioral techniques like rewards for a child with ADHD.

You use CDT for a depressed adult.

You use PEP law to assess anxiety in literally every patient you meet.

And you use the recovery model to empower them all.

These aren't just abstract ideas.

These are your actual tools for evidence -based care.

Exactly.

I want to leave you, the listener, with one final provocative thought.

Consider that shift we talked about from the medical model where the doctor fixes you to the recovery model where we walk together as partners.

It's a profound shift.

How does that change the power dynamic in every single conversation you have with a patient?

If you aren't the boss but the partner, how does that change the way you listen?

That really is the question that defines modern psychiatric nursing.

Thank you for sticking with us through this deep dive.

Good luck with your studies and good luck on the floor.

You've got this.

This has been the Last Minute Lecture Team, signing off.