Chapter 7: Models for Working With Psychiatric Patients

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Welcome back to the Deep Dive.

Today we are wading into some waters that I think a lot of nursing students and honestly even seasoned pros find a little murky.

Oh for sure.

We are talking about the frameworks, the actual mental scaffolding that you really need to survive and you know thrive in a psychiatric clinical rotation.

It's definitely a different beast than medsurg.

I mean you walk onto a cardiac floor, you know the plumbing,

you know the pump, the pipes, the pressure.

Right, it's tangible.

Exactly.

You walk onto a psych unit and you're dealing with the invisible.

You see

shouting, withdrawal, crying, intense suspicion, but the why isn't showing up on an x -ray.

That is the perfect way to frame it.

You're navigating a territory where the landmarks are, well they're emotional and cognitive, not anatomical.

So our mission today is to build a map for that territory.

We are digging into the core models for working with psychiatric patients.

And this isn't just you know academic history.

I know students often gloss over the theory chapters to get to the meds or the diseases.

Yeah, they want the what to do, not the why we do it.

Right, but if you don't understand these models, recovery, psychoanalytical, developmental, interpersonal, and cognitive behavioral,

you are flying blind.

You're just reacting to symptoms rather than you know treating the person.

Right, we want to move from patient is shouting, give sedative, to patient is shouting because of this specific dynamic, so I will intervene this way.

That's the goal.

We are going to break these down sequentially, unpack the heavy concepts, and really spend some quality time on those crucial tables, the ones about defense mechanisms and developmental stages, because that is where the rubber meets the road, isn't it?

Absolutely, and for each one we'll really emphasize the nurse's role because, spoiler alert, your job changes depending on which lens you're looking through.

So let's start with the big one, the modern context.

The text calls it the recovery model, and I think to really get this we have to understand what it's replacing, or at least what it's challenging.

It's challenging the traditional medical model.

Now we aren't, you know, bashing the medical model here.

If I have appendicitis, please use the medical model.

Please.

Diagnose me, cut it out, cure me.

Right, the medical model is very linear.

It's problem, diagnosis, fix, cure.

Exactly, it focuses on curing the disease, alleviating the symptoms, and it's incredibly effective for acute pathology.

But the dynamic, it's often paternalistic.

The doctor is the general, the nurse is the lieutenant.

And the patient is the private who follows orders.

Right, and we call that compliance.

And that works when you're unconscious on an operating table.

But in mental health, it's a different story.

In mental health, a cure, in that traditional sense, like wiping out an infection, it isn't always the reality.

Schizophrenia, bipolar disorder, these are often chronic lifelong conditions.

So if cure is the only goal, you're setting everyone up for failure.

You are.

We leave the patient feeling broken because they aren't fixed.

So the recovery model just flips the script entirely.

It stops asking, how do we fix you?

And starts asking, how do we help you live a meaningful life?

I love that.

Precisely.

The text defines recovery as a process of change,

where individuals improve their health and wellness and self -directed life.

And that term self -directed, that's the North Star here.

It's about their goals, not just our clinical goals.

Yes.

It's about striving to reach full potential.

Even if the symptoms, the voices, the anxiety, are still hanging around in the background.

It sounds like a shift from just symptom management to life management.

It is.

The text lists 10 guiding principles for this.

And they're, well, they're beautiful, but they're also rigorous.

Principles like person -driven, holistic, based on respect.

There's one that really stood out to me.

Emerging from hope.

That feels like such a soft skill.

But in psych, hope is basically a vital sign, isn't it?

It is the catalyst for recovery.

I mean, think about it.

If you're told you have a chronic brain disorder that will never go away, and the best you can hope for is just staying out of the hospital.

That's devastating.

It's crushing.

It induces despair.

The recovery model says, no, you can have a job.

You can have relationships.

You can have a life.

That hope is what motivates the person to do the hard work of therapy.

Now, this shift brings up some vocabulary that might trip up students.

We see the term consumer used a lot in this model instead of patient.

And that is controversial in some circles, but here is the logic.

Patient implies passivity.

Right.

Like you're waiting.

Exactly.

It implies suffering.

You are waiting for the doctor to fix you.

Consumer, on the other hand, implies choice.

It implies a transaction between equals.

You're consuming a service health care and you have a say in what you're buying.

It levels the playing field.

It does.

It underscores that the mental health professionals are partners, not dictators.

And that leads directly to that powerful slogan mentioned in the notes.

Nothing about us without us.

I love that.

It sounds like a protest chant.

It is.

It comes from the disability rights movement.

And it means you don't make policies, you don't design treatment plans, and you don't build hospitals without the direct input of the people who are actually going to be using them.

This brings us to a really tricky practical point for nurses on the floor.

Resistance.

In the medical model, if I tell a patient,

take this pill and they say, no, I document non -compliant.

Non -compliant.

It's such a dirty word in the recovery model.

Right.

Because in the recovery model, that refusal means something totally different.

Exactly.

If we view the consumer as a partner,

then resistance isn't just stubbornness.

It's a sign that the person has their own plan or their own perspective that we are missing.

So it's data, not disobedience.

It's data.

Maybe they aren't taking the medication because it makes them sleep 16 hours a day and they can't hold down a job.

Their goal is keep job.

Our goal is stop the voices.

The resistance is just the friction between those two plans.

So the nurse's job isn't to force compliance, but to actually investigate the resistance.

Yes.

You listen.

You negotiate.

You collaborate.

You say, okay, you don't want to take this.

Help me understand why.

And let's figure out a way to meet your goals.

Which is, by the way, so much harder.

It takes more time than just handing over a cup of water and a pill.

Much harder.

But it's also much more effective in the long run.

And speaking of effectiveness,

there's a clinical element here that is pretty unique to this model.

Peer support.

Ah, the peer counselors.

These aren't nurses.

They aren't social workers.

So who are they?

They are the experts by experience.

These are individuals who have lived through mental illness themselves.

They have been psychotic or suicidal or addicted, and they have recovered.

They undergo training to become certified specialists.

So they're actually on the treatment team.

Yes.

And their value is immense.

I mean, imagine you are a young man experiencing your first psychotic break.

You are terrified.

A doctor in a white coat tells you it will be okay.

You don't believe him.

He has no idea what it feels like.

He's just reading from a book.

Right.

But then a peer counselor sits down and says, hey,

I heard voices too when I was your age.

It was terrifying.

Here's how I got through it.

That credibility is just untouchable.

It bridges a gap that we as clinicians often can't cross.

They also educate the staff.

They remind us that recovery is real, that it actually happens.

So to wrap a bow on the recovery model for the student listening, your role is partnership.

Your assessment focuses on their perception of health, not just yours.

You are an advocate and a collaborator.

Perfectly said.

Now let's get into the time machine.

We're going from the most modern approach all the way back to the foundation.

Siebenfreude and the psychoanalytical model.

The classic, the couch, the cigar.

I feel like pop culture has caricatured Freud so much that we sometimes forget what he actually contributed.

We do.

We get hung up on the sexual stuff and some of the weirder specific theories, but the architecture he built,

the whole topography of the mind is still the bedrock of how we understand human behavior.

It all starts with the unconscious, doesn't it?

Right.

Before Freud, the assumption was that we generally knew why we did things.

Freud came along and said,

actually, you're a stranger to yourself.

He mapped the mind into three levels, the conscious, the pre -conscious, and the unconscious.

The iceberg analogy is usually the go -to here.

And it holds up really well.

The conscious mind is the tip of the iceberg, the part that's above the water.

It's what you are aware of right now.

My voice, the temperature of the room, maybe that you're hungry.

It is a tiny, tiny fraction of who you are.

OK, then the pre -conscious, what's that?

That's just below the surface of the water.

These are memories or bits of knowledge you aren't thinking about right now, but you can pull them up easily with a little effort.

If I ask, what did you have for breakfast?

You access the pre -conscious and bring it to the conscious.

And then the monster, the unconscious, the biggest part of the iceberg.

The vast, vast mountain of ice under water.

This is the repository for everything unacceptable.

Repressed memories, traumatic experiences, forbidden desires, brutal conflicts.

We shove them down there because they are just too painful to look at.

And this is the key to the whole model, right?

Just because they are out of sight doesn't mean they are inactive.

Not at all.

They are the engine in the basement running the whole house.

They drive our anxieties, our patterns, our self -sabotage.

The goal of psychoanalytical therapy is what he called insight.

It's diving into that dark water, grabbing a chunk of that unconscious material and dragging it up to the surface so we can finally deal with it.

Okay, but when that material tries to bubble up on its own or when reality gets too stressful, the mind has a kind of security system.

And that's the defense mechanisms.

This is table 7 -2 in your text.

And frankly, if you memorize nothing else from this chapter, memorize this table.

You will see these behaviors in every single patient and likely in your friends, family and yourself.

Let's walk through the heavy hitters.

We need to go beyond just the definition and look at what this actually looks like in a hospital room.

Let's start with the big one.

Denial.

Denial is the unconscious refusal to admit that an unacceptable truth exists.

And the key word there is unconscious.

It's not lying.

Lying is conscious.

Denial is when the brain literally blocks the reality to protect the ego from collapsing.

So the text gives the example of who is alcohol dependent.

Right.

Mr.

Davis says, I can quit whenever I want.

I just like the taste.

He isn't trying to trick you.

In his reality, he doesn't have a problem.

If he had to admit he was an addict, the shame would be too great.

So his mind just deletes the diagnosis.

So as a nurse arguing with him, showing him his lab results, that doesn't work.

It never works.

It's like trying to argue the brick wall.

You can't logic someone out of a defense mechanism.

You have to address the underlying anxiety first.

Okay.

Next up, repression versus suppression.

This is a classic exam question trap.

They sound so similar.

They do.

But the difference is voluntary versus

involuntary.

Suppression is conscious.

It's the Scarlett O 'Hara approach.

I'll think about that tomorrow.

I love that.

The example in the text is Ms.

Ames.

She is going through a really painful divorce, but she tells the nurse, I'm not ready to talk about that right now.

She knows it's happening.

She just shelves it so she can function.

That is actually a healthy adaptive defense mechanism in moderation.

And repression.

Repression is involuntary.

It is the unconscious exclusion of painful impulses or memories.

Example is Mrs.

Young, a victim of incest.

She genuinely cannot remember the abuse.

It's not that she doesn't want to talk about it.

For her, the file is corrupted.

Her brain hid it away to allow her to survive childhood.

That's powerful.

Projection.

This is one I feel like I see all the time in everyday life.

It is ubiquitous.

Projection is taking your own unacceptable feelings or faults and attributing them to someone else.

It is the I'm rubber, you're glue defense.

The text mentions Mr.

Jones, a patient with schizophrenia.

How does that play out?

So Mr.

Jones is struggling.

He can't handle his job because of his illness.

That makes him feel inadequate and weak.

Those feelings are too to own.

So he projects that badness outward.

He tells the nurse, I can't go to work because my coworkers are mean.

They are sabotaging me.

So he turns an internal failure into an external persecution.

Precisely.

It preserves his self -esteem, but it ruins his reality testing.

Okay.

What about displacement?

The text calls it discharging pent up feelings on a less threatening object.

Yeah.

This is the classic kick the dog mechanism.

It's like the physics of you.

You can't scream back or you'll get fired.

So you swallow that anger, but it's still there simmering.

You go home, your wife asks, how was your day?

And you just explode.

Why is dinner not ready?

You are displacing the aggression from a threatening objects, the boss to a safe object, your wife.

It's so tragic really, because you end up hurting the people who are safest for you, which is why spotting it is so important.

If a patient screams at you over a cold cup of coffee, they probably aren't mad about the coffee.

No, they are mad about the diagnosis.

They just got from the doctor, but the doctor is scary and you, the nurse are safe.

That reframing helps the nurse not take it personally.

Exactly.

It's not about you.

It's displacement.

Let's talk about a more complex one reaction formation.

This is a tricky one.

This is when you act the exact opposite of how you truly feel because the true feeling is completely unacceptable to you.

The text introduces us to Mrs.

Wren.

Mrs.

Wren unconsciously hates her mother.

Maybe her mother was abusive or neglectful, but society tells us you must love your mother.

So Mrs.

Wren is terrified of her own hatred to keep it buried.

She goes completely overboard in the other direction.

She over compensates massively.

She tells the staff, my mother is a saint.

She's the most wonderful person alive.

She's overly solicitous, buys her gifts.

It's like that line from Shakespeare.

The lady protests too much.

That's the perfect example.

The very intensity of the expressed love is what betrays the underlying hate.

And finally, let's touch on regression.

Regression is going backward.

It's returning to an earlier developmental stage where you felt safe and cared for.

We see this in adults in the hospital constantly.

Oh yeah.

You'll have a CEO who runs a massive company.

He's admitted for surgery and suddenly he is whining.

He's demanding.

He wants his pillow left every five minutes.

He is pouting.

He has regressed to a childlike state because he feels helpless and vulnerable.

And the text example is a child, right?

A six -year -old.

Yes.

A six -year -old who starts wetting the bed again when a new sibling is born.

The baby gets all the attention and care.

So the six -year -old unconsciously adopts baby -like behaviors to compete for that safety and love.

Now, Freud focused a lot on drives, but the text mentions that modern psychoanalysis has shifted toward relationships.

This is where we get into object relations and self -psychology.

Right.

We move from I want sex and aggression to I want connection and validation.

And this brings up two concepts that are absolutely vital for the nurse -patient relationship.

Transference and counter -transference.

Okay.

So transference is the patient's baggage they bring to you.

Exactly.

Transference is when the patient unconsciously displaces feelings from a significant figure in their past onto the nurse.

Let's say you are a male nurse.

You are an authority figure.

The patient had a distant, critical father.

Even though you were being kind and professional, the patient might act defensive with you or rebellious or maybe seek your approval desperately.

So they aren't seeing me.

They aren't seeing you.

They are seeing a father figure ghost.

And the nurse needs to be able to spot that.

You have to.

Otherwise you get sucked right into the drama.

You think, why does this guy hate me?

I've been nothing but nice.

He doesn't hate you.

He hates dad.

And then there is the flip side.

Counter -transference.

This is the nurse's baggage.

It's when the patient triggers something in you.

Maybe a patient reminds you of your sweet, frail grandmother.

You find yourself giving her extra snacks, spending too much time in her room, protecting her from the doctor's bad news.

You lose your objectivity.

You do.

That's counter -transference.

It blurs your professional boundaries and it's not actually helpful to the

We also have to touch on a very sophisticated concept mentioned in the text.

Projective identification.

This sounds like a level deeper than just simple projection.

This is the black bolt of defense mechanisms.

It's really complex.

So in simple projection,

I think you are angry, even though I'm the angry one.

In projective identification, I actually unconsciously manipulate you into becoming angry.

So it's interactional.

You make it happen.

The text gives a stunning, tragic example.

A mother who was a teen mom.

She has unresolved trauma and fear about sexuality.

She has a teenage daughter.

The mother projects this idea of promiscuity onto the daughter.

She accuses her.

She restricts her.

She checks her phone.

She treats her like a criminal.

She basically suffocates her.

Right.

And the daughter, she gets so frustrated and alienated that she rebels.

She goes out and The mother actually created the environment that fulfilled her own projection.

That is heavy.

So for the nurse on the floor, we aren't doing five years of analysis.

What is our role in this psychoanalytical model?

We are not analysts.

Let's be clear about that.

We don't interpret dreams.

Our role is to use this knowledge to understand the meaning behind the behavior.

So it's about observation.

Observation and awareness.

If a patient is using denial, we don't try to shatter it, but we also don't reinforce it.

We listen.

If we see displacement, we don't retaliate.

We help the patient gain just a little bit of insight.

We might say something like, I notice you seem really upset after your phone call with your wife.

Can we talk about that?

It's about raising awareness, not providing a cure.

Exactly.

Making the unconscious just a little bit more conscious so it has less power over them.

Okay, let's move on.

Section three, the developmental model.

And this means Eric Erickson.

Erickson.

He took Freud's ideas but zoomed way out.

Freud basically stopped at adolescence.

Erickson said, no, we grow and change until the day we die.

He proposed eight stages of psychosocial development.

And the core idea here is mastery, right?

Yes.

Each stage presents a crisis, a conflict.

If you solve it successfully, you gain a virtue mastery.

If you fail, you get stuck.

You develop a deficit that you carry with you.

And it haunts you in the later stages.

Again, we have a massive table, table 7 -3.

But as you mentioned earlier, we need to look at this through the lens of treating adults.

Because nursing students will see a 40 -year -old patient and think, why do I need to know about toddler development?

And the answer is because that 40 -year -old might be emotionally stuck at the toddler stage.

You have to learn to treat the stage, not the age.

Okay.

That's a great mantra.

Let's run through them with that adult lens.

First stage, trust versus mistrust infancy.

Zero to 18 months.

The fundamental question the baby asks is, is the world safe?

Can I trust people to meet my needs?

If the answer is yes, you get the virtue of trust and optimism.

If the answer is no,

you get mistrust.

And in an adult psychiatric patient, what does that look like?

It looks like paranoia.

It looks like the patient with schizophrenia who refuses to eat the hospital food because he's convinced it's poisoned.

Yeah.

He never mastered that fundamental belief that people are generally good.

Okay.

Stage two, autonomy versus shame and doubt.

This is the no phase of the toddler.

It is.

18 months to three years.

This is all about gaining control over one's body and impulses.

Potty training is the classic example.

Mastery looks like self -control and willpower.

The failure looks like deep self -doubt or a compulsion to control everything and everyone because they feel so out of control inside.

I can see that in some obsessive compulsive traits.

Exactly.

Next, initiative versus guilt.

The preschool years, three to five.

This is where the child starts to plan and initiate projects.

I'm going to build a fort.

Mastery is having a sense of purpose, being able to take the lead.

The problem is a patient who is passive, apathetic, terrified of making a mistake.

They feel guilty just for taking up space or having a desire.

Then we have industry versus inferiority.

The school years, six to 12.

This is the look what I made stage.

It's all about competence.

Can I do things well?

An adult with mastery here has a good work ethic.

They enjoy completing tasks.

An adult stuck in inferiority feels incompetent like a failure.

So they might have a spotty work history.

Very spotty work history.

Or they give up immediately when things get hard.

You'll hear them say, I can't do it.

I'm stupid.

Then comes the big one.

Identity versus role diffusion.

Adolescence, 12 to 20.

Big identity crisis.

Who am I?

What do I believe in?

Mastery is a solid sense of self.

You know your values, your style, your place in the world.

The problem role diffusion is just chaos.

We see this so clearly in borderline personality disorder.

They mirror whoever they are with.

They feel empty inside.

They'll join a cult.

Then they'll leave it.

They constantly change their look, their name, their career path.

They're desperately trying to find a stable self.

Next up, intimacy versus isolation.

Young adulthood, 18 to 30.

Once you know who you are, can you share that person vulnerably with someone else?

Mastery is love, commitment, mutuality.

The failure is isolation,

being alone.

Or, and this is important, it can look like promiscuity.

Sleeping with everyone but connecting with no one.

So they're avoiding the vulnerability of true intimacy.

Yes.

They're keeping everyone in a distance emotionally.

Generativity versus stagnation.

Adulthood, 30 to 65.

This is a giving back stage.

It's about creating something that outlasts you.

Parenting, mentoring, creative work, community involvement, stagnation is total self -absorption.

This is the classic midlife crisis.

Being obsessed with your own comfort and needs, unable to care for the next generation.

And the final act, integrity versus despair, 65 and up.

You're looking back on your life.

Was it a good one?

Did it have meaning?

Mastery is wisdom accepting your life with all its triumphs and flaws.

Despair is bitterness, regret, and a deep fear of death.

The feeling that it was all a waste.

So practically speaking, you mentioned partial mastery.

It's not all or nothing.

Right.

It's rarely black and white.

Most of us have some trust, but maybe a little mistrust.

Some industry, some inferiority.

But in severe mental illness, the deficits are often profound and they really dictate the patient's behavior.

And the nurse's role is to identify that deficit and then help bridge it.

Exactly.

If you have a patient who is profoundly stuck in trust versus mistrust, you can't jump straight to asking them to set life goals, which is a generativity task.

Completely.

You have to go back to basics.

You keep your promises.

You show up on time for your meetings with them.

You are consistent.

You are reliable.

You are trying to repair that foundational crack in the trust stage so they can even begin to move forward.

That's a really helpful roadmap.

It gives you patience with what might seem like difficult behaviors.

You can realize, oh, he's not just being a jerk.

He's stuck in stage two.

Precisely.

It builds empathy, which is our most important tool.

Moving on to section four, the interpersonal model.

This brings us to Harry Steck Sullivan and, of course, the legend Hildegard Peplau.

If Freud is the father of psychiatry, Hildegard Peplau is the mother of psychiatric nursing.

This model is our home turf.

Sullivan's big idea was that you can't understand a person in a vacuum, right?

Right.

He said humans are fundamentally social animals.

Personality is just the pattern of how we relate to other people.

Therefore, mental illness is usually a failure of interpersonal skills.

It's not just a chemical imbalance in the brain.

It's a relationship imbalance.

He focused a lot on anxiety as the driver of all this.

He did.

He saw anxiety as the central problem.

He believed anxiety arises from social insecurity, the fear of disapproval.

And what do we do when we are anxious?

We develop what he called security operations, behaviors to lower the anxiety.

Some are healthy.

Some are really not.

And then enter Hildegard Peplau.

She took these theories and wrote the book Interpersonal Relations in Nursing, which changed everything.

She revolutionized the field.

Before Peplau, nurses were basically custodians.

She said, no, the nurse is a therapist.

She defined the nurse -patient relationship as the core tool of healing.

She viewed the relationship as a microcosm.

I think this is such a cool and powerful concept.

It is.

It means that the way the patient relates to you, the nurse, is a small -scale version of how they relate to the rest of the world.

A microcosm.

Yes.

If a patient is manipulative with you, they are manipulative with their spouse.

If they are shy and avoidant with you, they are shy and avoidant with their boss.

The patterns repeat.

So the hospital unit becomes a kind of social laboratory.

Exactly.

It is a safe space to observe these patterns and to practice new ones.

The text uses the example of a man with intense social anxiety around women.

He feels insecure.

His anxiety spikes.

So his security operation is to avoid them entirely.

So how does the nurse intervene in the interpersonal model?

It's not just about medication.

No, it's not.

She doesn't just give him a valium for his anxiety.

She uses the relationship itself.

She engages him in conversation.

She might even role play with him.

They practice.

Okay, let's pretend I'm a co -worker in the break room.

Just try saying hello.

It's basically social skills training.

It is re -education in a safe environment.

By having a successful, non -threatening interaction with the female nurse, his anxiety drops a little.

He learns, hey, I can talk to a woman and not die.

He gains a real skill he can take with him outside the hospital.

That puts a lot of responsibility on the nurse to be self -aware, though.

A huge responsibility.

Peplos said you have to be a participant observer.

You are in the relationship, but you are also watching the relationship from a clinical perspective.

You have to constantly ask yourself, what is going on between us right now, and what does it tell me about this person's illness and their patterns?

Let's pivot to our last major model, Section 5, the cognitive behavioral models.

We are entering the realm of thoughts.

We are.

We're leaving the unconscious of Freud and the relationship of Sullivan and Peplow, and we are focusing squarely on the mind.

The central premise of CBT, or cognitive behavioral therapy, is simple, but it's radical.

It is not events that upset us.

It is our view of the events that upsets us.

This is the work of two giants, Albert Ellis and Aaron Beck.

The founding fathers of CBT.

Let's look at Ellis first.

He gave us rational motive therapy in the famous ABC framework.

This is another one you absolutely want to write down.

ABC.

Okay, break it down for us.

A is the activating event.

Something happens.

Let's say you fail a nursing school exam.

C is the consequence,

the feeling.

You feel depressed and workless.

Most people think A causes C.

I failed the test, so I feel worthless.

That sounds pretty logical on the surface.

But Ellis comes along and says,

wrong.

A does not cause C.

B causes CB.

CB is the belief.

It's the thought you have about the event.

Ah, it's the middle man.

It's the filter.

If your belief is, I must be perfect to be a lovable person, then failing the test, A, leads you to feel worthless, C.

But if your belief is, this was a really hard test, I'm disappointed, but I'll study more for the next one, then the consequence is just mild disappointment, not a full -blown depression.

So the intervention, the therapy, happens at B.

Exactly.

The therapy is D, disputing the irrational belief.

You challenge the logic.

Who says you have to be perfect?

Where is that rule written?

Is it actually true that one failure makes you a worthless human being?

It's like being a lawyer for the defense against the patient's own inner critic.

That is a great analogy.

You are cross -examining their automatic thoughts.

Which brings us to Aaron Beck.

He focused on those automatic thoughts and cognitive distortions.

These are those rapid -fire negative thoughts that pop into our heads before we even notice them.

I'm stupid.

They hate me.

It's never going to work.

Beck identified common patterns of this distorted thinking.

Like all -or -nothing thinking, right?

Black and white.

Exactly.

If I don't get an A on this paper, I'm a total failure.

Or another one is catastrophizing, taking a small problem and assuming you will end an absolute disaster.

She didn't text me back immediately.

She's going to break up with me.

I'll die alone.

The text lists some common irrational beliefs that fuel these distortions.

Things like, I must be loved and approved of by everyone.

Yeah.

And the past determines the present, meaning I can't change.

L is called these the musts and the shoulds.

He famously said, we musterbate.

We make ourselves miserable with these rigid absolute demands on ourselves and the world.

I must do well.

You must treat me kindly.

The world must be fair.

And when reality doesn't match the must,

we crash emotionally.

Now, there are two variations of CBT mentioned here that are super relevant for specialized nursing.

First, motivational enhancement therapy.

Motivational enhancement is huge for addiction treatment.

It's based on the stages of change.

It acknowledges that you can't force someone to change if they are in pre -contemplation, which is basically denial.

It's a very non -confrontational way to help them find their own motivation to change.

And the other is DBT dialectical behavior therapy.

This is the gold standard for borderline personality disorder.

Developed by Marshall Linehan.

It was specifically designed for patients who were chronically suicidal and engaging in self -harm cutting, burning.

She found that traditional CBT didn't work well for them because they felt invalidated when the therapist challenged their thoughts.

So how is DBT different?

What's the dialectic?

It's dialectical because it balances two opposites, acceptance and change.

The therapist says, in essence, I accept you exactly as you are.

Your emotional pain is real and understandable.

And D, you need to change your behaviors to get the life you want.

It focuses heavily on teaching practical skills.

Distress, tolerance, mindfulness, emotion regulation.

So it's teaching them how to survive a crisis without cutting themselves.

So to sum it up, the nurse's role in the cognitive model is a bit like a coach.

You are a cognitive coach.

You listen for the shoulds, the oughts and the musts.

You ask Socratic questions.

What is the evidence for that thought?

You give homework assignments.

For the next three days, write down three things that went right.

You are actively helping them rewire their thinking patterns.

We have covered a lot of ground.

Five very distinct models.

But the chapter ends with section six, the integrative approach.

Because in the real world, patients don't fit into these neat little boxes.

This is the art of nursing.

You have the science, which are the models.

But the art is knowing which tool to pick up at which time.

We don't subscribe to just one.

We are eclectic.

We use what works for the patient in front of us at that moment.

The text gives a great example of a divorced patient who is crying and sleeping all day.

Let's look at her through the kaleidoscope of these different models.

Okay, let's play around, Robin.

You start.

What do you see through the psychoanalytical lens?

Okay, psychoanalytical.

I see regression.

She's sleeping to escape a painful reality, almost returning to a womb -like state.

And maybe some anger turned inward, which Freud would say is depression.

Good.

Now, developmental lens.

I see a clear failure in the stage of intimacy versus isolation.

The loss of the marriage has thrown her deep into isolation and despair.

Okay, my turn.

Cognitive lens.

I'm listening for the automatic thought.

It's probably something like, I am a failure because my marriage failed.

That irrational belief is driving the depression.

Perfect.

And finally, the interpersonal lens.

I see the crying as a communication.

It's a non -verbal wish for contact, for help.

And the sleeping is what Sullivan might call somnolent detachment.

It's a security operation to avoid the anxiety of being awake and alone.

It's incredible.

Same patient, same behaviors, but four completely different ways to understand it.

And four different avenues for intervention.

You might use interpersonal techniques to just sit with her while she cries, validating her need for contact.

Then you might use cognitive techniques to gently challenge her belief that she is a failure.

You use the tool that fits the moment.

Let's bring this all home with the case study from the end of the chapter.

Miss Levy.

This is a tough one.

Miss Levy is a classic complex case.

She's admitted after a suicide attempt.

She has a history of childhood abuse.

She has nightmares.

She has stormy relationships.

She doesn't trust men and she constantly fights with women.

She is full of anger, but she has this core belief that women shouldn't show anger.

And she says she's afraid of growing up.

Wow, that is a lot.

Where do we even start with her?

We start by mapping it out using our models.

Let's start with developmental.

Okay, developmental.

She was abused as a child.

She is profoundly stuck in trust versus mistrust.

She never learned the world was a safe place.

Right.

She's also clearly struggling with identity.

She doesn't know who she is.

And she explicitly says she fears growing up, which suggests a terror of the adult stages of intimacy and generativity.

Okay, interpersonal.

Her anxiety is sky high.

It's ruining her ability to work or have friends.

Her relationships are chaotic.

She likely uses a defense mechanism common in trauma survivors called splitting.

Seeing people is all good or all bad with no middle ground.

And cognitive.

That belief about anger seems key.

It's the core conflict.

She has a toxic core belief.

Women shouldn't show anger.

But she is angry and for very good reasons because of the abuse.

So every time she feels that legitimate anger, she also feels intense guilt and shame.

That internal war is likely what drove her to the suicide attempt.

She's trying to kill the bad angry part of herself.

So putting it all together for an integrated nursing plan.

First, safety.

That's the medical model and recovery model.

Keep her alive.

Period.

Then you build a therapeutic alliance that's interpersonal and developmental.

You become a consistent, trustworthy figure.

You show her that not all people will hurt her.

That starts to repair the deep crack in her trust stage.

Then you can start the other work.

Then you can do the cognitive work.

You help her reframe the anger.

It is okay to be angry about what happened to you.

Anger is a normal, healthy response to trauma.

You help her find her voice.

That's the recovery model again.

What does she want for her life beyond just surviving?

It really shows that these models aren't just dry text in a book.

They are the keys to unlocking the patient's prison.

Exactly.

Without the models, Mrs.

Levy is just a difficult patient or a borderline who is suicidal.

With the models, she is a person with understandable struggles that we can actually help.

And I think that brings us to the final thought mentioned in the text.

Despite all these theories, all these techniques,

what really matters?

The research consistently shows that the single best predictor of success in therapy, regardless of the model used, is the quality of the therapeutic alliance.

The relationship.

It's the relationship.

It doesn't matter if you are a master of CBT or a brilliant Freudian scholar.

If the patient doesn't feel heard, respected, and safe with you, nothing works.

So learn the models, but don't ever forget to be a human.

Be a human first.

The models are just the tools in your backpack.

The relationship is what builds the bridge to let you use them.

I think that is the perfect place to land.

We have built the map.

Now it's up to you, the listener, to go out and explore the territory.

It's a fascinating journey.

You're going to learn as much about yourself as you do about your patients.

I promise you that.

A huge thank you from the entire Last Minute Lecture team for tuning in.

We really hope this deep dive helps you feel a little left lost when you walk onto that psych unit for the first time.

Study hard, take care of yourselves, and we'll catch you next time.

Goodbye, everyone.