Hildegard Peplau: Therapeutic

Nurse-Patient Relationship
Four Phases of the NPR
1. Orientation Phase
- Directed by the nurse
- Involves engaging the client
in treatment

Pts behaviors fluctuate between

dependence and
interdependence

4. Resolution Phase
- Client no longer needs
professional services
- Gives up on dependent
behavior

Tasks:
Pts problems and needs are
clarified
Pt asks questions
Hospital routines and
expectations are explained
Pt harnesses energy toward
meeting problems
Pts full participation is elicited

Tasks:
Pt gives up on dependent
behavior
Services are no longer needed
Pt assumes power to meet own
needs, set new goal, etc.

2. Identification Phase
- Begins when the patient
works interdependently with
the nurse
- Expresses feelings
- Begins to feel stronger

1. Stranger
- Offering the client the same
acceptance and courtesy
that the nurse would to any
stranger

Tasks:
Pt responds to persons he
perceives as helpful
Feel stronger
Expresses feelings
Interdependent work with the
nurse occurs
Roles of both nurse and pt are
clarified
3. Exploitation Phase
- Client makes full use of the
services offered
Tasks:
Pt makes full uses of available
services
Goals such as going home and
returning to work emerge

Roles of the nurse in the Therapeutic

Relationship

2. Resource Person
- Providing specific answers to
questions within a larger
context
3. Teacher
- Helping client to learn
formally and informally
4. Leader
- Offering direction to the
client or group
5. Surrogate
- Serving as a substitute for
another such as a parent or
sibling
6. Counselor
- Promoting experiences
leading to health such as
expression of feelings

Four Levels of Anxiety

Humanistic Theories

Anxiety (by Peplau)

- Initial response to a psychic
threat

Humanism
- Focuses on persons positive
qualities, his or her capacity
to change (human
potential), and the
promotion of self-esteem
- Humanists direct more
attention to the present and
future

1. Mild Anxiety
- A positive state of
heightened awareness and
sharpened senses
- Can learn new behaviors and
solve problems
- Can take in all available
stimuli (perceptual field)
2. Moderate Anxiety
- Decreased perceptual field
(focus on immediate task
only)
- Can learn new behavior and
solve problems only with
assistance
- Another person can redirect
the person to a task
3. Severe Anxiety
- Involves feelings of dread
and terror
- Person cannot be redirected
to a task
- Has physiological symptoms
such as tachycardia,
diaphoresis, and chest pain
- May go to an emergency
department believing he is
having a heart attack
4. Panic Anxiety
- Loss of rational thought,
delusions, hallucinations
- Complete physical
immobility and muteness
- May bolt and run aimlessly
(often exposing himself to
injury)
(refer to page 51)

Abraham Maslow: Hierarchy of

Needs
Hierarchy of Needs
- Illustrates the basic drives or
needs that motivate people
arranged in a pyramid
First Level Physiologic Needs
- Dominates the persons
behavior
Second Level Safety and security
Third Level Love and belonging
- Enduring intimacy,
friendship, and acceptance
Fourth Level Esteem Need
- Like need for self-respect
and esteem from others
Highest Level self-actualization
- Need for beauty, truth, and
justice
Self-actualization
- A person who has achieved
all the needs of the
hierarchy and has developed
his or her fullest potential in
life
Carl Rogers: Client-centered
Therapy
Carl Rogers
- First to use client rather than
patient

Client-centered Therapy
- Focuses on the role of the
client as the key to the
healing process
- Each person experiences the
world differently and knows
his or her own experience
best
- Clients do the work of
healing, and within a
supportive and nurturing
client-therapist relationship,
they can cure themselves
- Therapist
o Takes a personcentered approach
o A supportive role
rather than a directive
or an expert role
- Client viewed as the expert
on his or her life
Three Central Concepts (to promote
clients self-esteem)
1. Unconditional positive regard
- A nonjudgmental caring for
the client that is not
dependent on the clients
behavior
2. Genuineness
- Realness or congruence
between what the therapist
feels and what he says to
the client
3. Empathetic understanding
- Therapist senses the feelings
an personal meaning from
the client and communicates
this understanding to the
client
Acc to Rogers
- Basic nature of humans is to
become self-actualized or
move toward self-

improvement and
constructive change
A person is born with a positive selfregard and a natural inclination to
become self-actualized
a. If relationships with others are
nurturing and supportive
- Person retains feelings of
self-worth and progresses
towards self-actualization
b. But if he encounters repeated
conflicts with others, nonsupportive
relationships
- He loses self-esteem,
becomes defensive, no
longer inclined towards selfactualization; not HEALTHY
Behavioral Theories
Behaviorism
- A school of psychology that
focuses on observable
behaviors and what one can
do externally to bring about
behavior changes
- Not explain how the mind
works
Behaviorists believe that behavior can
be changed through a system of
rewards and punishments
Ivan Pavlov: Classical Conditioning
- Laboratory experiment with
dogs
- Behavior can be changed
through conditioning with
external or environmental
conditions or stimuli

B. F. Skinner (Burrhus Frederic)

- Developed the theory of
operant conditioning
o People learn their
behavior from their
history or past
experiences,
particularly
experiences that were
repeatedly reinforced
- Believed that if behavior
could be changed, then so
too could the accompanying
thoughts or feelings
Principles of Operant Conditioning
1. All behavior is learned
2. Consequences result from
behavior reward and
punishment
3. Behavior that is rewarded with
reinforcers tends to recur
4. Positive reinforcers that follow
after a behavior increases
chance of reoccurrence
5. Negative reinforcers that are
removed after a behavior increases chance of
reoccurrence
6. Continuous reinforcement is the
fastest way to increase that
behavior but will not last long
after the reward ceases
7. Random intermittent
reinforcement is slower to
produce an increase in behavior
but the behavior continues after
the reward ceases
These principles are used in a therapy
called behavior modification
- A method of attempting to
strengthen a desired
behavior or response by
reinforcement, either
positive or negative

*Negative reinforcement removing a

stimulus immediately after a behavior
occurs so that the behavior is more
likely to occur again
Ex. If a client becomes anxious when
waiting to talk in a group, he or she
may volunteer to speak first to avoid
the anxiety
Systems Utilizing Operant
Conditioning
1. Token economy
- is a system for
providing positive
reinforcement to a child or
children by giving them
tokens for completing tasks
or behaving in desired ways
- used as a method of
strengthening a behavior, or
increasing its frequency
2. Systematic Desensitization
3. Behavioral Contract for anorexia
nervosa (increased unsupervised
time every weight gain)
4. For ADHD child gets a star or
sticker when tasks are completed
CLASSICAL
involves pairing a
previously neutral
stimulus (such as
the sound of a
bell) with an
unconditioned
stimulus (the
taste of food)
Focuses on
involuntary,
automatic
behavior
making an

OPERANT
Involves applying
reinforcement or
punishment after
a behavior

Focuses on
strengthening or
weakening
voluntary
behaviors
making an

association
between an
involuntary
response and a
stimulus
involves no such
enticements
passive on the
part of the learner

association
between a
voluntary
behavior and a
consequence
learner is also
rewarded with
incentives
requires the
learner to actively
participate and
perform some
type of action in
order to be
rewarded or
punished

Existential Theories
They believe that behavioral
deviations result when a person is out
of touch with himself or the
environment.
Goal: Helping the person discover an
authentic sense of self
- Encourage the person to live
fully in the present and to
look forward to the future
Cognitive Theory
- Used by many existential
theorists
- Focuses on immediate
thought processing how a
person perceives or
interprets his experience and
determines how he feels and
behaves
- Aaron Beck pioneers this
theory in pts with depression
Rational Emotive Theory
- Founded by Albert Ellis who
identified 11 irrational

beliefs that people use to

make themselves unhappy
Believes that people have
automatic thoughts that
cause individuals to be
unhappy
Utilized the ABC technique to
help people identify these
automatic thoughts:
A activating stimulus or
event
C excessive inappropriate
response
B blank in the persons
mind that he must fill in by
identifying the automatic
thought

Logotherapy
- Founded by Viktor Frankl
- Based his beliefs on his
observations on people in
Nazi concentration camps
during WWII why some
survived and others did not
- Concluded that survivors
were able to find meaning in
their lives even under
miserable conditions
- Searching for meaning
(logos) id the central theme
Gestalt Therapy
- Founded by Frederick Fritz
Perls
- Emphasizes identifying the
persons feelings and
thoughts in the here and
now
- Believed that self-awareness
leads to self-acceptance and
responsibility for ones own
thoughts and feelings
- Increases clients selfawareness by having them

write and read letters, keep

journals, and perform other
activities designed to put the

past to rest and focus on the

present