Chapter 2: Theories & Therapies in Mental Health Nursing

Sigmund Freud's psychoanalytic theory introduced concepts such as the three levels of psychological awareness—conscious, preconscious, and unconscious—and the structural model of personality comprised of the impulsive id, the rational ego, and the moral superego. Classical psychoanalysis relies on techniques like free association and dream analysis to uncover unconscious conflicts, and it established the crucial concepts of transference and countertransference. Building on Freudian ideas, Harry Stack Sullivan’s interpersonal theory emphasized that human behavior is motivated by the drive to meet needs and avoid anxiety, which he defined as arising from social insecurity. This focus on interpersonal relationships became the core of Hildegard Peplau’s groundbreaking theoretical framework for psychiatric nursing, which highlights the nurse-patient relationship as foundational and stresses the nurse's self-awareness and ability to intervene based on different levels of patient anxiety. Behavioral theories reject internal conflict, arguing that personality is simply learned behaviors influenced by conditioning. Key behavioral models include Ivan Pavlov's classical conditioning of involuntary responses and B. F. Skinner's operant conditioning, which uses reinforcement (positive and negative) to modify voluntary behavior. Behavioral treatments discussed include modeling, token economies, aversion therapy, biofeedback, and various forms of exposure therapy, such as systematic desensitization and flooding. In contrast, cognitive theorists assert that thoughts precede feelings and actions, meaning that distorted thinking can lead to psychological distress. This led to the development of Albert Ellis’s rational-emotive therapy, which targets irrational "shoulds" and "musts," and Aaron Beck’s cognitive behavioral therapy (CBT), which focuses on identifying and correcting automatic thoughts and cognitive distortions through techniques like reality testing. More specialized forms include Trauma-Focused CBT (TF-CBT) and Marsha Linehan’s Dialectical Behavioral Therapy (DBT), which teaches skills like mindfulness and emotional regulation to individuals with severe behavioral disorders. Humanistic theories, notably Abraham Maslow's Hierarchy of Needs, stress self-actualization and are vital for nursing practice by prioritizing physiological needs before higher-level needs can be addressed. The chapter also covers the dominant Biological Model, which views mental illness as a physical problem treated via pharmacotherapy and brain stimulation therapies like ECT, rTMS, VNS, and DBS. Finally, important developmental frameworks include Jean Piaget's stages of cognitive development, Erik Erikson's eight psychosocial crises spanning the lifespan, Margaret Mahler's object relations theory of separation-individuation, and the moral development theories of Lawrence Kohlberg and Carol Gilligan.