In the Philippines, 3.

3% of the population or
DAY 1 (01/15/24) 3,298,652 Filipinos live with depression. Suicide
Mortality Rate is 3.2 (per 100,000 population)
PRELIMS OUTLINE
In Northern Mindanao, in 2022 the suicide rate is
Concepts of Mental Health and Mental Illness .16% (per 100,000 population, while it increased in
 State of Mental Health and Mental Illness 2023 which is .66% (per 100,000 population)
on the Country and the World
 Mental Health Care Delivery System in the MENTAL HEALTH CARE DELIVERY SYSTEM IN THE
Philippines PHILIPPINES AND ITS IMPORTANCE AND IMPACT
 National Mental Health Program IN THE COMMUNITY
 Introduction to mhGAP
RA NO. 11036 - The Department of Health (DOH) has
Concepts and Patterns of Human Behavior been at the forefront in creating a national mental
 Mental Health and Mental Illness health policy, through the Republic Act 11036, “The
 Mental Disorder Causes Mental Health Act”. The passing of the law
 Psychiatric Nursing supported and highlighted the value of working
together.
Psychiatric-Mental Health Nursing (9th Edition)
 Chapter I: Foundation of Psychiatric- Section 40 of the Mental Health Act reads as follows:
Mental Health Nursing
“MANDATE” – The Philippine Council for
Mental Health, herein referred to as the
Council.
I. CONCEPTS OF MENTAL HEALTH AND MENTAL
ILLNESS PHILIPPINE COUNCIL FOR MENTAL HEALTH
STRATEGY FRAMEWORK 2024 – 2028
STATE OF MENTAL HEALTH AND MENTAL
ILLNESS ON THE COUNTRY AND THE WORLD The Department of Health (DOH), in partnership with
the World Health Organization (WHO) – Philippines,
- Globally, mental health has become a
is facilitating the formulation of the Philippine
development priority.
Council for Mental Health Strategic Plan with
- The World Health Report (2001) estimates
Monitoring and Evaluation Framework for 2024-
that 1 in 4 people in the world will be affected
2028 as part of the key activities under the WHO
by mental or neurological disorders at some
Special Initiative for Mental Health.
point in their lives.
VISION - Mental Health and Wellbeing for all
MORBIDITY IN MENTAL HEALTH
Filipinos.
Depression affects an estimated 4.4% of people in the
MISSION - Value, promote, and protect the basic
world.
rights of all Filipinos to Mental Health and Well-
Anxiety disorders affect 3.6% of thepopulation. being, and provide comprehensive, integrated,
accessible and quality mental health program and
 A fifth of global cases come from the Western services.
Pacific, where 3.6% are affected by depressive
disorders and 2.9% by anxiety GUIDING PRINCIPLES - Biopsychosocial and
 In Northern Mindanao the highest case is Spiritual / Equitable Comprehensive / Integrated and
Psychosis or Schizophrenia 4.2% per 100,000 Balances Care Protecting Rights / Life Stage
population in 2023 while .88 % in 2022. Approach.

MORTALITY IN MENTAL HEALTH IMPACT:

Suicide is the act of killing yourself, most often as a  Promotion of Mental Health & Wellbeing and
result of depression or other mental illness. Reduce Premature Mortality
 Prevention and treatment of substance abuse
 Men commit suicide three times the rate of  Reduce vulnerability of individual and
women. communities
 Women are four times more likely than men to
attempt suicide.
  Provision of MHPSS during
emergencies and disaster
(disaster response)
 Trained all the doctors and
nurses of the primary care
facilities of Northern
Mindanao with mhGAP
 MH medications provision
to all LGUs who submitted
Mental their MH registry
Neurological and  Mentoring and coaching
Substance Use of mhGAP trained doctors
Disorder (MHS) and nurses of the primary
care facilities
 Trained doctors of the
primary care facilities for
Full Accreditation to be a
DOH Accredited Physician
to conduct DDE
 MOA signing of the
creation of the Regional
MH Council

SUPPORT PROCESS
INTRODUCTION TO mhGAP
1. Responsive MNS policy & MOPs aligned with
Mental, neurological and substance use disorders
UHC
respond poorly to treatment? FALSE
2. Effective lgu engagement
3. Quality MNS research & development &  Most common mental, neurological and
dissemination substance use disorders respond well to
4. Adequate competent & resilient MNS service treatment.
providers  Up to 70% of persons with chronic psychosis can
5. Expanded MAP – MH be stable and live symptom free with adequate
6. Improved leadership & governance of PCMH treatment.
secretariat, technical working groups, and
regional MH councils
7. Integrated MHS information
8. Integrated CBMH, CBDR, MHPSS, mhGAP
quality rights & others
9. Increased budget allocation for MNS and
Social protection

NATIONAL MENTAL HEALTH PROGRAM

REGIONAL MENTAL HEALTH PROGRAM

IMPLEMENTATION

 Mental Health Awareness

in the workplace, schools
and community
 Suicide prevention
activities
 Advocacy activities on the
Wellness of Daily 12 “S” ng DOH –stress
Living management
 Mental Health Playbook for
peer support group
 Healthy Lifestyle advocacy
activities – Healthy
Pilipinas campaign
 Mental Health Fair
 All primary care facilities
have an MHPSS trained
staff
 Provision of MHPSS thru
Extreme Life the DOH NorMin Kumusta
Experience ka Hotline
 Psychological First Aid
(PFA) Training for LGUs
 TRUE OR FALSE  What can you do to fight stigma and
discrimination?
1. People with mental, neurological and substance
use disorders are not capable of making decisions As HEALTH PROVIDERS we can:
about their medical, financial, personal and social
lives? 1. Change our own perception and attitude
towards people with mental, neurological and
 FALSE - Many scientists, business people, artists, substance use disorders
politicians, and people from different 2. Respect and advocate for the implementation
backgrounds have mental, neurological and of relevant international conventions, such as
substance use conditions and that do not stop the United Nations Convention on the Rights
them from making decisions that lead to great of Persons with Disabilities
success! 3. Reaffirm that all persons with all types of
disabilities must enjoy all human rights and
2. People with mental, neurological and substance fundamental freedoms.
use disorders cannot understand information 4. Play a large part in fulfilling these rights
about their medical treatment?
MENTAL HEALTH GAP ACTION PROGRAM
(mhGAP)
 FALSE - People with mental, neurological and
substance use disorders can understand mhGAP is the WHO programme to scale up care for
information about their disorders if it is given in mental, neurological and substance use disorders
an appropriate manner and time
 mhGAP was launched by the WHO
- People with mental, neurological and DirectorGeneral in 2008.
substance use disorders have the right to  The initial focus is on increasing non-specialist
explanations of treatment plans with risks care, including primary healthcare, to address the
and benefits explained. unmet needs of people all over the world.

STIGMA & DISCRIMINATION mhGAP-IG Conditions

Many individuals with mental, neurological or 1. Depression

substance use disorders are perceived by the 2. Psychosis
community as weak, inhuman, dangerous or inferior 3. Bipolar disorder
because of their symptoms. 4. Epilepsy
5. Developmental disorders
As a result of stigma, these people are excluded or 6. Behavioral disorders
they exclude themselves: 7. Dementia
8. Alcohol use and alcohol use disorders
 A father about his intellectually challenged
9. Drug use and drug use disorders
daughter. “Girls like her are only for house work,
10. Self-harm/suicide
bringing her to your clinic is a waste of my time”
11. Other significant emotional or medically
 “I can’t come to see a doctor. If someone sees me
12. unexplained complaints
I’ll never get married”
MENTAL HEALTH AND NON-SPECIALIZED
What are the effects of stigma & discrimination?
HEALTHCARE
Emotional  Affects sense of self-worth. Mental and physical health are interwoven
State?
Prognosis?  Contributes to shortened life Primary care for mental health
expectancy
 Slows recovery  Enhances access
Access and  Limits access and quality of  Promotes respect of human rights
Quality of health care.
Treatment?  Is affordable and cost- effective
Human Rights?  Can lead to abuse.  Generates good health outcomes
Family?  Disrupts Relationships.
WHO WORLD MENTAL HEALTH PLAN 2013 –
2020
Stigma and Discrimination in the Health Care
System Mental Health is valued, promoted, protected;
mental disorders are prevented; and persons afflicted
People with mental, neurological and substance use by mental disorders are able to exercise the full range
disorders can experience stigma and discrimination of human rights
from the health system
 Access high quality, culturally- appropriatehealth
 Can you think of any examples from your and social care in a timely way topromote
experience? recovery.
 Highest possible level of health and participate II. CONCEPTS AND PATERNS OF HUMAN
fully in society at work, free from stigmatization BEHAVIOR
and discrimination.
MENTAL HEALTH AND MENTAL ILLNESS

Everyone has mental health…

MENTAL HEALTH

A state of well-being in which every individual

realizes his or her own potential, can cope with the
normal stresses of life, can work productively, and is
able to make a contribution to the community.
(WHO)

Is the simultaneous success at working, loving &

creating with the capacity for mature & flexible
resolution of conflicts between instincts, conscience,
other people & reality. (American Psychiatric
Association)
What is the mhGAP Intervention Guide (mhGAP-
Is the successful adaptation to stressors from the
IG)?
internal or external environment, evidenced by
For mental health and substance use disorders in thoughts, feelings, & behaviors that are age-
non – specialized health setting appropriate & congruent with local & cultural norms.
(Townsend)
Who is the target audience for mhGAP-IG?
Is the successful performance of mental function,
1. Staff not specialized in mental health or resulting in productive activities, fulfilling
neurology relationships, & the ability to adapt to change & cope
2. General physicians, family physicians, nurses with adversity. It provides people with the capacity
3. First point of contact and outpatient care for rational thinking, communication skills, learning,
4. First level referral centers emotional growth, resilience & self-esteem (US DoH
& Human Services, 1999)

Implies mastery in the areas of life involving love,

work & play

MENTAL DISORDER

“collectively all diagnosable mental disorders” or

“health conditions that are characterized by
alterations in thinking, mood, or behavior (or some
combination thereof) associated with distress and/or
impaired functioning.”

MENTAL ILLNESS

A state of imbalance characterized by a disturbance

in person’s thoughts, feelings & behavior.
KEY MESSAGES
- Is the inability of the person to effectively
 The burden of mental, neurological and adjust to life as demonstrated by the use of
substance abuse disorders is large and growing multiple coping mechanisms, which do not
 Stigma and discrimination are common buffer the individual from profound psychic
 You can effectively manage these conditions in insults.
non-specialized health care and reduce stigma
and discrimination MENTAL HEALTH PROBLEM
 The base course provides the basic skills to Also affects a person’s thinking, feeling, or social
identify and manage these conditions (in relationships but not to the extent that significantly
consultation with specialists if needed. hampers functioning like that of a mental disorder.
 MENTAL DISORDER CAUSES 6. Social or cultural expectations
7. Substance abuse
It is multifactorial…
MENTAL HYGIENE

Is the science that deals with measures to promote

mental health, prevent mental illness & suffering &
facilitate rehabilitation dealing with preservation of
mental & emotional health.

The science of maintaining mental health &

preventing the development of psychosis and
neurosis.

PSYCHIATRIC NURSING

Interpersonal process whereby the professional

nurse practitioner through the therapeutic use of
CAUSES self, assist an individual family, group or community
to:
BIOLOGICAL
a) Promote Mental Health
 Ang sakit sa isip ay mas b) Prevent Mental Illness & Suffering
karaniwan sa mga taong may c) Participate in the Treatment &
mga kaanak na meron ding
Rehabilitation of the Mentally Ill
Namamanang kondisyon sa isip.
Katangian  May mga genes na Is a process whereby the nurse assists the person as
nagpapataas sa peligro ng
individuals or in groups, to develop a more positive
pagkakaroon ng sakit sa isip
na maaring ma-trigger ng self-concept, a more satisfying pattern of
nakababahalang sitwasyon. interpersonal relationships, & a more satisfying role
 Ang exposure sa mga virus, in society. (Taylor)
Environmental toxin, alak o droga habang
Exposures nasa sinapupunan ay maaring Is the provision of nursing care to patients where the
Before Birth magdulot ng sakit sa isip major therapeutic goal is the prevention, detection,
balang araw treatment & rehabilitation of psychiatric disorders.
 Pabago-bagong lebel ng (Matheney & Topalis)
Brain natural na kemikal sa utak
Chemistry (neurotransmitters). Psychiatric Mental Health Nursing is a specialized
 Sa ilang kaso, hindi balanseng area of nursing practice employing theories of human
lebel ng hormones. behavior as its science & purposeful use of self as its
art. It is directed toward both preventive & corrective
PSYCHOLOGICAL impacts upon mental disorders & their sequelae, & is
concerned with the promotion of optimal mental
Severe  Na nararanasan kalimitan health for society, the community & those individuals
Psychological habang lulamaki , katulad ng who live within it. (American Nurses’ Association)
Trauma emosyonal, pisikal, o sekswal
na abuso It is both a Science & and Art
 Maaring direkta, tulad ng
An Important pagkawala ng magulang, o Core: Interpersonal Process
Early Loss simbolikong kawalan tulad ng
kawalan ng pakialam PSYCHIATRIC NURSING

Poor Ability to ANCIENT TIMES Demonic or Divine

Relate to ARISTOTLE Four Humors
Others RENAISSANCE Criminals
PRE-CHRISTIAN TIME Priest : Exorcism

SOCIAL / ENVIRONMENTAL
ABC MANAGEMENT OF MENTAL ILLNESS
Certain stressors can trigger an illness in a person
who is susceptible to mental illness, which include: a. Assistance
b. Banishment
1. Death or separation of parents c. Confinement (St. Mary’s of Bethlehem:
2. Dysfunctional family life Bedlam)
3. Feelings of inadequacy, low self-esteem,
anxiety, anger, or
4. loneliness
5. Changing jobs or schools
 ENLIGHTENMENT (1790’s) Disadvantages: Homelessness is linked to
deinstitutionalization, and many people “slip through
The insane were no longer treated as less than the cracks” of the system.
human. Human dignity was upheld.
EVOLUTIONARY TIMELINE IN PSYCHIATRIC
PHILIPPE PINEL (1745 - 1825) NURSING
- Unchained the mentally ill (1793)

WILLIAM TUKE (1723 - 1822)

- Established the York Retreat

The asylum movement developed.

SCIENTIFIC STUDY (1870’s)

Humans could be studied, and that study held

promise for treating and curing mental health
problems.

SIGMUND FREUD (1856 - )

- Emphasized the importance of early life

experiences in shaping mental health.

EMIL KRAEPLIN (1856 - 1926)

- Developed classification of mental illness.

EUGENE BLEULER (1857 - 1920)

- Was optimistic about treatment.

The study of human mind and treatment approaches

to psychiatric conditions flourished.

The “Decade of the Brain” can be traced back to

Kraepelin’s.

PSYCHOTROPIC DRUGS (1950’s)

1949 Lithium
1950 Chlorpromazine
1952 Monoamine Oxidase Inhibitors
1957 Haloperidol
1958 Tricyclic Antidepressants (TCA’s)
1960 Benzodiazepine

PSYCHOTROPIC DRUGS

Some mental disorders are caused by chemical

imbalances. If the chemical problem could be found
through research, then a chemical cure could be
found as well. Also, people would no longer need to
be confined.

A destigmatizing of mental illness occurred. Parents

and others were not blame. The term least restrictive
environment evolve from this discovery.

COMMUNITY MENTAL HEALTH

Community mental health center acts (1963)

Individuals do not need to be hospitalized away from

family and community.

Advantage: Intervention in familiar surroundings

has helped many people and less expensive.
1O FACTS ON MENTAL HEALTH
 -Spasms may cause unnatural
DAY 2 (01/16/24)
positioning of the neck.
- Abnormal eye movement, excessive
PRELIMS OUTLINE CONTINUATION
salivation.
 Torticollis – twisted head and
Psychiatric-Mental Health Nursing (9th Edition)
neck.
 Chapter II: Neurobiologic Theories and  Opisthotonus - tightness in
Psychopharmacology the entire body with the head
 Chapter III: Psychosocial Theories and back and an arched neck.
Therapy  Oculogyric Crisis - eyes
rolled back in a locked
position.
3. Akathisia – continuous restlessness
III. CHAPTER II: NEUROBIOLOGIC THEORIES AND
- inability to sit still
PSYCHOPHARMACOLOGY
- Constant moving
INTRODUCTION - Foot tapping
- Hand movements may be seen
Psychopharmacology – the use of medications to 4. Tardive Dyskinesia
treat mental illness. - Abnormal muscle movements
- Such as lip smacking
PRINCIPLES: GUIDE THE USE OF MEDICATIONS
- Tongue darting
 Effect on target symptom - Chewing movements
 Adequate dosage for sufficient time - Slow and aimless arm and leg
 Lowest dose needed for maintenance 5. Neuroleptic Malignant Syndrome
 Lower doses for the elderly - Fatal, idiosyncratic reaction to
 Tapering rather than abrupt cessation to antipsychotic medication
avoid rebound or withdrawal - Rigidity, high fever,
 Follow-up care - Autonomic instability: unstable BP,
 Simplify the regimen for increased diaphoresis, pallor, delirium, elevated
compliance enzymes (creatine phosphokinase)

ANTIPSYCHOTIC DRUGS ANTICHOLINERGIC SIDE EFFECTS

Conventional; atypical; new generation. o Orthostatic hypotension

o Dry mouth
Schizophrenia, acute o Constipation
mania, psychotic o Urinary hesitance or retention
USES depression, drug-induced
o Blurred vision
psychosis, other
psychotic symptoms o Dry eyes
Treat psychotic o Photophobia
symptoms, such as o Nasal congestion
ACTION delusions and o Decreased memory
hallucinations, by
blocking dopamine CONVENTIONAL ANTIPSYCHOTIC DRUGS
receptors.
Phenothiazines (Thorazine, Prolixin, Mellaril,
Stelazine); Navane, Haldol, Loxitane, Moban.
COMMON NEUROLOGICAL EFFECTS OF
ANTIPSYCHOTIC DRUGS SIDE EFFECTS:

1. Pseudoparkinsonism  Extrapyramidal Side Effects (EPS)

- muscle tremors, cogwheel rigidity,  Pseudoparkinsonism
drooling, shuffling gait, slow  Dystonia
movements.  Akathisia
2. Dystonia  Anticholinergic Side Effects
- spasms of the tongue, neck, back and  Tardive dyskinesia (TD)
legs.  Neuroleptic Malignant Syndrome (NMS)
PATIENT TEACHING: PATIENT TEACHING:

Adhering to medication regimen.  Take in the morning

 Agitation
Managing side effects:  Take with food
 Thirst  Akathisia
 Constipation  Nausea
 Sedation  Propranolol given for akathisia
 Insomnia
ATYPICAL ANTIPSYCHOTIC DRUGS  Sexual dysfunction (anorgasmia/impotence)

Clozaril, Risperdal, Zyprexa, Seroquel, Geodon TCA ANTIDEPRESSANT DRUGS

SIDE EFFECTS: Imipramine (Tefranil), Desipramine (Nerpramin),

Amitriptyline (Elavil), Dexepin (Sinequan),
 Fewer EPS’s Clomipramine (Anafranil)
 Weight Gain
 Agranulocytes (Clorazil) SIDE EFFECTS:

PATIENT TEACHING:  Anticholinergic (blurred vision, urinary

retention, dry mouth, constipation)
 Adhering to medication regimen  Orthostatic hypotension
 Reducing sugar and caloric intake  Sedation
 Clozaril  Weight gain
 Weekly WBC monitoring
 Tachycardia
 Discontinue medication and seek care at first
 Sexual dysfunction
sign of infection
PATIENT TEACHING:
NEW GENERATION ANTIPSYCHOTIC DRUGS
 Taking in the evening
Aripiprazole (Abilify)  Using caution when driving
SIDE EFFECTS: MAOI ANTIDEPRESSANT DRUGS
 Headache Phenelzine (Nardil), Tranylcypronsane (Parnate),
 Anxiety Isocarboxazid (Marplan)
 Nausea
SIDE EFFECTS:
PATIENT TEACHING:
 Sedation
 Adhering to medication regimen.
 Insomnia
ANTIDEPRESSANT DRUGS  Weight gain
 Dry mouth
SSRI, TCA, & MAOI  Orthostatic hypotension
 Sexual dysfunction
Major depression, panic
disorder  Hypertensive crisis with excessive tyramine
USES and other anxiety or sympathomimetic drugs.
disorders, bipolar
depression, psychotic PATIENT TEACHING:
depression.
Interact with the  Following tyramine-free diet (avoid aged
monoamine cheeses, aged meats, beer and wine,
neurotransmitter sauerkraut, soy)
ACTION systems in the brain,  Avoiding sympathomimetic drugs
particularly the  Using caution when driving
neurotransmitters
norepinephrine and
serotonin.

SSRI ANTIDEPRESSANT DRUGS

Fluoxetine (Prozac), Paroxetine (Fexil), Sertraline

(Zoloft), Citalopram (Celexa), Escitalopram (Lexapro)

SIDE EFFECTS:

 Anxiety
 MOOD STABILIZING DRUGS USES ADHD, residual ADD in
adults, and narcolepsy.
Lithium; Anticonvulsant Medications ACTION Cause release of
(Carbamazepine (Tegretol)), Valproic Acid neurotransmitters.
(Depakote), Lamotrigine (Lamictal), Gabapentin
(Neurontin)
SIDE EFFECTS:
USES Bipolar Disorder
Act on the  Anorexia
ACTION neurotransmitters of the  Weight loss
brain.  Nausea
 Irritability

SIDE EFFECTS: LITHIUM PATIENT TEACHING:

 Nausea  Avoiding caffeine, sugar, and chocolate

 Diarrhea  Taking after meals
 Anorexia  Long-term use can cause dependency
 Fine hand tremor
 Polydipsia DISULFIRAM ANTABUSE
 Polyuria USES Aversion therapy for
 Fatigue treatment of alcoholism.
 Weight gain ACTION Causes an adverse
 Acne reaction when alcohol is
ingested.
PATIENT TEACHING: LITHIUM

 Taking with food SIDE EFFECTS:

 Having monthly blood levels drawn 12 hours
after last dose (maintain therapeutic levels  Fatigue
between 0.5-1.5 mEq/L)  Drowsiness
 Halitosis
ANTIANXIETY DRUGS  Tremor
 Impotence
Benzodiazepines; Buspirone (BuSpas)
PATIENT TEACHING:
Anxiety disorders,
USES insomnia, OCD,  Avoiding alcohol (including products such as
depression, PTSD, shaving cream, aftershave, cologne, many
alcohol withdrawal.
OTC medications)
ACTION Moderate the actions of
GABA.  Family should never administer without the
person's knowledge

SIDE EFFECTS: IV. CHAPTER III: THEORETICAL FOUNDATIONS

OF PSYCHIATRIC NURSING CARE
 Tolerance and dependence
 Drowsiness BIOLOGICAL THEORY / MODEL
 Sedation
 Poor concentration  Genetic Vulnerability
 Impaired memory  Biochemical Factors
 Clouded sensorium CEREBRUM
PATIENT TEACHING: The cerebrum is divided into two hemispheres; all
 Using caution during driving due to slower lobes and structures are found in both halves except
reflexes and response time for the pineal body, or gland, which is located
 Never discontinuing abruptly withdrawal can between the hemispheres.
be fatal PINEAL BODY
 Avoiding alcohol
- An endocrine gland that influences the
STIMULANT DRUGS activities of the pituitary gland, islets of
Methylphenidate (Ritalin), Pemolire (Cylert), Langerhans, parathyroids, adrenals, and
Dextroamphetamine gonads.

CORPUS CALLOSUM
 - A pathway connecting the two hemispheres TYPE MECHANISM OF
and coordinating their functions. ACTION
Dopamine Excitatory
LEFT HEMISPHERE
PHYSIOLOGIC EFFECTS: Controls complex
- Controls the right side of the body and is the movements, motivation, cognition; regulates
center for logical reasoning and analytic emotional response.
functions such as reading, writing, and
mathematical tasks. Norepinephrine Excitatory
(noradrenaline)
RIGHT HEMISPHERE
PHYSIOLOGIC EFFECTS: Causes changes in
- Controls the left side of the body and is the attention, learning and memory, sleep and
center for creative thinking, intuition, and wakefulness, mood.
artistic abilities.
Epinephrine Excitatory
BRAIN STEM (adrenaline)

The brain stem includes the midbrain, pons, and PHYSIOLOGIC EFFECTS: Controls fight or flight
medulla oblongata and the nuclei for cranial nerves response.
III through XII.
Serotonin Inhibitory
PONS - Above the medulla and in front of the
PHYSIOLOGIC EFFECTS: Controls food intake, sleep
cerebrum, the pons bridges the gap both structurally
and wakefulness, temperature regulation, pain
and functionally, serving as a primary motor control, sexual behaviors, regulation of emotions.
pathway.
Histamine Neuromodulators
MIDBRAIN - The midbrain connects the pons and
cerebellum with the cerebrum. PHYSIOLOGIC EFFECTS: Controls alertness, gastric
secretions, cardiac stimulation, peripheral allergic
- It measures only 0.8 in (2 cm) length and responses.
includes most of the reticular activating
system and the extrapyramidal system. Acetylcholine Excitatory or Inhibitory

RETICULAR ACTIVATING SYSTEM - Influences PHYSIOLOGIC EFFECTS: Controls sleep and

motor activity, sleep, consciousness, and awareness. wakefulness cycle; signals muscles to become alert.

EXTRAPYRAMIDAL SYSTEM - Relays information Neuropeptides Neuromodulators

about movement and coordination from the brain to
the spinal nerves. PHYSIOLOGIC EFFECTS: Enhance, prolong, inhibit,
or limit the effects of principal neurotransmitters
LOCUS COERULEUS - A small group of
norepinephrineproducing neurons in the brain stem, Glutamate Excitatory
is associated with stress, anxiety, and impulsive
behavior. PHYSIOLOGIC EFFECTS: Results in neurotoxicity if
levels are too high.
LIMBIC SYSTEM
y-Aminobutyric Acid Inhibitory
The limbic system is an area of the brain located
above the brain stem that includes the thalamus, PHYSIOLOGIC EFFECTS: Modulates other
neurotransmitters.
hypothalamus, hippocampus, and amygdala.

THALAMUS - Regulates activity, sensation, and PSYCHOANALYTIC THEORIES

emotion. Sigmund Freud (1856 - 1939)
HYPOTHALAMUS - Involved in temperature “The Father of Psychoanalysis”
regulation, appetite control, endocrine function,
sexual drive, and impulsive behavior associated with Freud believed that repressed (driven from
feelings of anger, rage, or excitement. conscious awareness) sexual impulses and desires
motivate much human behavior.
HIPPOCAMPUS & AMYGDALA - Involved in
emotional arousal and memory. PERSONALITY COMPONENTS: ID, EGO, &
SUPEREGO
MAJOR NEUROTRANSMITTERS
Id - The part of one’s nature that reflects basic or
Major Neurotransmitters have been found to play a innate desires such as pleasure-seeking behavior,
role in psychiatric illnesses as well as in the actions aggression, and sexual impulses.
and side effects of psychotropic drugs.
 - The id seeks instant gratification, causes EGO DEFENSE MECHANISMS
impulsive unthinking behavior, and has no
regard for rules or social convention. Freud believed that the self, or ego, uses ego defense
mechanisms, which are methods of attempting to
Ego – The balancing or mediating force between protect the self.
the id and the superego.
1. COMPENSATION - Overachievement in one area
- The ego represents mature and adaptive to offset real or perceived deficiencies in another
behavior that allows a person to function area.
successfully in the world.  Napoleon complex: diminutive man
becoming emperor.
Superego - The part of a person’s nature that reflects
 Nurse with low self-esteem working
moral and ethical concepts, values, and parental
double shifts so that her supervisor will
and social expectations.
like her
- Therefore, it is in direct opposition to the id.
2. CONVERSION - Expression of an emotional
conflict through the development of a physical
symptom, usually sensorimotor in nature.
 Teenager forbidden to see X-rated movies
is tempted to do so by friends and
develops blindness, and the teenager is
unconcerned about the loss of sight.

3. DENIAL - Failure to acknowledge an unbearable

condition; failure to admit the reality of a
situation or how one enables the problem to
continue.
 Diabetic person eating chocolate candy
 Spending money freely when broke
 Waiting 3 days to seek help for severe
BEHAVIOR MOTIVATED BY SUBCONSCIOUS abdominal pain
THOUGHTS AND FEELINGS
4. DISPLACEMENT - Ventilation of intense feelings
Freud believed that the human personality functions
toward persons less threatening than the one
at three levels of awareness: conscious,
who aroused those feelings.
preconscious, and unconscious.
 Person who is mad at the boss yells at his
Conscious - refers to the perceptions, thoughts, and or her spouse.
emotions that exist in the person’s awareness.  Child who is harassed by a bully at school
mistreats a younger sibling.
Preconscious - thoughts and emotions are not
currently in the person’s awareness, but he or she
5. DISASSOCIATION - Dealing with emotional
can recall them with some effort.
conflict by a temporary alteration in
Unconscious - the realm of thoughts and feelings consciousness or identity.
that motivates a person even though he or she is  Amnesia that prevents recall of
totally unaware of them. yesterday’s auto accident
 Adult remembers nothing of childhood
Freud believed that much of what we do and say is sexual abuse.
motivated by our subconscious thoughts or feelings
6. FIXATION - Immobilization of a portion of the
Freudian Slip - a term we commonly use to describe
slips of the tongue. personality resulting from unsuccessful
completion of tasks in a developmental stage.
FREUD’S DREAM ANALYSIS  Never learning to delay gratification
 Lack of a clear sense of identity as an
Freud believed that a person’s dreams reflect his or
adult.
her subconscious and have significant meaning.

Dream Analysis - a primary technique used in 7. IDENTIFICATION - Modeling actions and

psychoanalysis, involves discussing a client’s dreams opinions of influential others while searching for
to discover their true meaning and significance. identity, or aspiring to reach a personal, social, or
occupational goal.
Free Association - in which the therapist tries to  Nursing student becoming a critical care
uncover the client’s true thoughts and feelings by nurse because this is the specialty of an
saying a word and asking the client to respond instructor she admires.
quickly with the first thing that comes to mind.
8. INTELLECTUALIZATION - Separation of the 16. SUBLIMATION – Substituting a socially
emotions of a painful event or situation from the acceptable activity for an impulse that is
facts involved; acknowledging the facts but not unacceptable
the emotions.  Person who has quit smoking sucks on
 Person shows no emotional expression hard candy when the urge to smoke arises
when discussing serious car accident  Person goes for a 15-minute walk when
tempted to eat junk food
9. INTROJECTION - Accepting another person’s
attitudes, beliefs, and values as one’s own 17. SUBSTITUTION - Replacing the desired
 Person who dislikes guns becomes an gratification with one that is more readily
avid hunter, just like a best friend available
 Woman who would like to have her own
10. PROJECTION – Unconscious blaming of children opens a day care center
unacceptable inclinations or thoughts on an
external object. 18. SUPPRESSION – Conscious exclusion of
 Man who has thought about same-gender unacceptable thoughts and feelings from
sexual relationship but never had one conscious awareness
beats a man who is gay.  Student decides not to think about a
 Person with many prejudices loudly parent’s illness to study for a test
identifies others as bigots.  Woman tells a friend she cannot think
about her son’s death right now
11. RATIONALIZATION - Excusing own behavior to
avoid guilt, responsibility, conflict, anxiety, or loss 19. UNDOING - Exhibiting acceptable behavior to
of self-respect make up for or negate unacceptable behavior
 Student blames failure on teacher being  Person who cheats on a spouse brings the
mean spouse a bouquet of roses
 Man says he beats his wife because she  Man who is ruthless in business donates
does not listen to him large amounts of money to charity

12. REACTION FORMATION - Acting the opposite of FIVE STAGES OF PSYCHOSEXUAL DEVELOPMENT
what one thinks or feels Freud based his theory of childhood development on
 Woman who never wanted to have the belief that sexual energy, termed libido, was the
children becomes a supermom driving force of human behavior.
 Person who despises the boss tells
everyone what a great boss she is Oral (Birth – 18 Mths.) - Major site of tension and
gratification is the mouth, lips, and tongue; includes
13. REGRESSION – Moving back to a previous biting and sucking activities.
developmental stage to feel safe or have needs
- Id is present at birth.
met
- Ego develops gradually from rudimentary
 A 5-year-old asks for a bottle when new
structure present at birth.
baby brother is being fed
 Man pouts like a 4-year-old if he is not the Anal (18 – 36 Mths.) - Anus and surrounding area
center of his girlfriend’s attention are major source of interest. Voluntary sphincter
control (toilet training) is acquired.
14. REPRESSION – Excluding emotionally painful or
anxiety-provoking thoughts and feelings from Phallic/Oedipal (3 – 5 Yrs.) - Genital is the focus of
conscious awareness. interest, stimulation, and excitement.
 Woman has no memory of the mugging - Penis is organ of interest for both sexes.
she suffered yesterday - Masturbation is common.
 Woman has no memory before age 7, - Penis envy (wish to possess penis) is seen in
when she was removed from abusive girls; oedipal complex (wish to marry
parents opposite-sex parent and be rid of same-sex
parent) is seen in boys and girls.
15. RESISTANCE – Overt or covert antagonism
toward remembering or processing anxiety- Latency (5 – 11 Yrs.) - Resolution of oedipal
producing information. complex.
 Nurse is too busy with tasks to spend time - Sexual drive channeled into socially
talking to a dying patient. appropriate activities such as school work
 Person attends court-ordered treatment and sports.
for alcoholism but refuses to participate - Formation of the superego.
 - Final stage of psychosexual development. BEHAVIORAL THEORIES

Genital (11 – 13 Yrs.) - Begins with puberty and the Ivan Pavlov’s Theory
biologic capacity for orgasm; involves the capacity for
true intimacy. CLASSICAL CONDITIONING

TRANSFERENCE & COUNTERTRANSFERENCE  Before Conditioning: Neutral Stimulus; No

salivation
Transference - occurs when the client displaces onto  During Conditioning: Neutral Stimulus;
the therapist attitudes and feelings that the client Unconditioned Stimulus; Unconditioned
originally experienced in other relationships. Response
 After Stimulus: Conditioned Stimulus;
- Transference Patterns are automatic and Conditioned Response
unconscious in the therapeutic relationship.
Burrhus Frederic Skinner’s Theory
Countertransference - occurs when the therapist
displaces onto the client attitudes or feelings from his OPERANT CONDITIONING
or her past.
SOCIAL INTERPERSONAL MODEL
- Nurses can deal with countertransference by
examining their own feelings and responses, Harry Stack Sullivan’s Theory
using self-awareness, and talking with  One’s personality involves more than
colleagues. individual characteristics, particularly
CURRENT PSYCHOANALYTIC PRACTICE how one interacts with others
 Inadequate or satisfying relationships
Psychoanalysis - focuses on discovering the causes anxiety as the basis for all emotional
of the client’s unconscious and repressed thoughts. problems.

- Psychoanalysis is still practiced today but on DEVELOPMENTAL COGNITIVE MODES OF

a limited basis. Thus, it has become known as EXPERIENCE
“therapy for the wealthy.”
1. PROTAXIC - (Unconnected experiences that
DEVELOPMENTAL THEORIES have no relationship to one another)
2. PARATAXIC - (Begins to connect experiences
Erik Erikson (1902 - 1994) in sequence)
Psychosocial Stages of Development 3. SYNTAXIC – (Begins to perceive him or
herself and the world within the context of
A German-born psychoanalyst, who extended the environment)
Freud’s work on personality development across
the life span while focusing on social and FIVE STAGES OF DEVELOPMENT
psychological development in the life stages. Jean Piaget
The stages, life tasks, and virtues: - Human intelligence progress through a series
of stages based on age
STAGE VIRTUE
Trust vs Mistrust [infant] Hope - COGNITIVE DEVELOPMENT
Autonomy vs Shame & Will
Doubt [toddler] Develops sense of self as
SENSORIMOTOR: separate from the
Initiative vs Guilt Purpose
birth to 2 years environment and the
[preschool]
concept of object
Industry vs Inferiority Competence
permanence.
[school age]
PREOPERATIONAL: Develops the ability to
Identity vs Role Confusion Fidelity
2 to 6 years express self with
[adolescence]
language, understanding
Intimacy vs Isolation Love
the meaning of symbolic
[young adult]
gestures.
Generativity vs Stagnation Care
CONCRETE Begins to apply logic to
[middle adult]
OPERATIONAL: thinking, understands
Ego Integrity vs Despair Wisdom
6 to 12 spatiality and
[maturity]
years reversibility.
FORMAL Learns to think and
OPERATIONAL: reason in abstract terms.
12 TO 15 years
 HUMANISTIC THEORIES Martha Elizabeth Roger’s System-Oriented
Nursing Theory
Abraham Maslow’s Hierarchy of Needs
 Human organism has an energy field that
is in constant mutual interaction with the
energy fields of the environment and of
other human organisms.
 Psyche: Promote symphonic interaction
and harmony between humans and the
environment re-patterning human
environmental fields or providing
assistance in mobilizing inner resources
or energy fields.
 Nurses therapeutic touch, guided imagery,
Carl Rogers: Client – Centered humor, meditation to promote symphonic
interactions and harmony of well-being.
- Reinforced the importance of the self in the
formation of the personality Rosemarie Parse’s Theory of Human Being
- People are motivated by an innate tendency
 Posit quality of life from each persons'
to actualize, maintain, and enhance the self.
perspective as the goal of nursing
practice: nurse is a guide.
 Psycho-social-spiritual-biochemical
approach.

DEVELOPMENT OF NURSING THEORY

Hildegard Peplau’s Interpersonal Theory

 ONE-TO-ONE NURSE CLIENT

 THERAPEUTIC RELATIONSHIP
 LEVELS OF ANXIETY

Dorothea Elizabeth Orem’s Behavioral Nursing

Theory

 Self-care deficit/ proposes that the

recipient of nursing care are person's who
are incapable of continuous self care or
independent care.
 Person could not function biologically,
symbolically and socially educate or
consult with individual to improve the
deficit.
 Psyche is the neglect of self-care

Roy Callista’s Theory of Adaptation

 Human being use coping mechanism to

adapt to both internal and external
stimuli.
 Regulator: physiologic response
 Cognator: perceptual social information-
processing.
 Hall (1966) described four distance zones:
DAY 3 (01/17/24)
This amount of space is
PRELIMS OUTLINE CONTINUATION comfortable for parents
with young children,
people who mutually
Psychiatric-Mental Health Nursing (9th Edition) desire personal contact,
INTIMATE 0 – 18 or people whispering.
 Chapter V: Therapeutic Relationship ZONE inches
 Chapter VI: Therapeutic Communication Invasion of this intimate
zone by anyone else is
threatening and produces
anxiety.
This distance is
V. CHAPTER VI: THERAPEUTIC COMMUNICATION PERSONAL 18 – 36 comfortable between
ZONE inches family and friends who
INTRODUCTION are talking.
This distance is
Communication – is the process use to exchange
acceptable for
information: SOCIAL 4 – 12 ft. communication in social,
ZONE work, and business
 Verbal – what is said, or content settings.
 Nonverbal – behavior such as facial expression, This is an acceptable
tone of voice, hesitancy, distance from speaker distance between a
 Context – environment or situation, including PUBLIC 12 – 25 ft. speaker and an audience,
culture. ZONE small groups, and other
informal functions (Hall,
 Congruency – when content and process agree
1963)
 Incongruency – when content and process do
not agree.
TOUCHING
WHAT IS THERAPEUTIC COMMUNICATION?
 A client may be comforting and supportive if it is
Therapeutic Communication involves permitted and welcome;
interpersonal interactions between the nurse and the
 Nurse must evaluate whether the client perceives
client. It focuses on the client’s specific needs and is
touch as positive or threatening and unwanted
used to:
and should never assume that touching a client is
 Establish the therapeutic relationship acceptable.
 Identify the client’s most important concerns As intimacy increases, the need for distance
 Assess the client’s perceptions decreases. Knapp (1980) identified five types of
 Recognize the client’s needs touch:
 Guide the client toward satisfactory and
acceptable solutions a) Functional-Professional Touch - is used in
examinations or procedures such as when the
Is the foundation for establishing a therapeutic NPR nurse touches a client to assess skin turgor or
a massage therapist performs a massage.
ESSENTIAL COMPONENTS OF THERAPEUTIC
COMMUNICATION
b) Social-Polite Touch - is used in greeting, such
PRIVACY AND RESPECTING BOUNDARIES as a handshake and the “air kisses” some
people use to greet acquaintances, or when a
Therapeutic communication is most comfortable at 3 gentle hand guides someone in the correct
to 6 feet; should not be less than 18 inchers. direction.

Proxemics is the study of distance zones between

c) Friendship-Warmth Touch - involves a hug
people during communication.
in greeting, an arm thrown around the
shoulder of a good friend, or the backslapping
some people use to greet friends and relatives.
 d) Love-Intimacy Touch - involves tight hugs “We do want to show people what we do, and we
and kisses between lovers or close relatives. also want to show what the issues and implications
are of what we do… However we also don’t
e) Sexual-Arousal Touch – is used by lovers. particularly want to wash all our dirty laundry in
public.”
ACTIVE LISTENING
VERBAL COMMUNICATION SKILLS
Means refraining from other internal mental
activities and concentrating exclusively on what the USE CONCRETE MESSAGES
client says.
 Are specific and clear
Concentrating exclusively on what client is saying  Elicit more accurate responses
and can be prompted by:  Avoid the need to go back and rephrase
unclear questions, which interrupts the flow
 Facing the client
of a therapeutic interaction
 Using moderate eye contact
 Removing physical barriers ABSTRACT MESSAGES
 Maintaining open body posture
 Leaning forward  Unclear, vague and require interpretation.

ACTIVE OBSERVATION

Means watching the speaker’s non-verbal actions as

he or she communicates

 Confidentiality
 Self-disclosure
 Self-awareness
 Therapeutic Use of Self

JOHARI WINDOW

Named after the first names of its inventors, Joseph

Luft and Harry Ingham, is one of the most useful
THERAPEUTIC COMMUNICATION TECHNIQUES
models describing the process of human interaction.
Facilitate interaction and enhance communication
A widely used, model for understanding the benefits
between client and nurse.
of feedback and opening up the hidden aspects of
relationships and communication patterns. Techniques that encourage the client to discuss his or
her feelings or concerns in more depth include:

Delving further
Exploring into a subject or
an idea.
Questions or “I think that we
statements that should talk more
help the patient about your
Focusing expand on a relationship with
topic of your mother.”
importance.
Repeating the “You say that your
main thought mother left you
Restating the patient when you were 5
A four paned ‘window’ divides awareness into four expressed. years old.”
different types, as represented by the quadrants:
open, hidden, blind, and unknown. Directing back “You’re feeling
the patient’stense and anxious,
The lines dividing the four panes are like window actions, and it’s related to a
blinds, which can open or close as the interaction Reflection thoughts, ideas, conversation you
progresses. feelings, had with your
questions, or husband last
Blind Quadrant – represents knowledge that is overt content. night?”
to outsiders but hidden from internal people in the Informing “I think you need
same way one remains oblivious to a smut on one’s to know more
about how your
cheek whilst it is plainly obvious to an observer.
medication works.”
Open Quadrant – represents knowledge that is Sharing Asking the “Your smiling, but I
Perception patient to verify sense that you are
known to all. This can be purely factual but can also
the nurse’s really very angry
include elements of Mission/Vision.
 understanding with me.”  Closed Body Positions – Such as crossed legs
of what the or arms folded across the chest, indicate that
patient is the interaction might threaten the listener
thinking or
who is defensive or not accepting.
feeling.
An active  Accepting Body Position - This open posture
process of demonstrates unconditional positive regard,
receiving trust, care, and acceptance.
Listening information and
examining Vocal Cues - Are nonverbal sound signals
reaction to the transmitted along with the content: voice volume,
message tone, pitch, intensity, emphasis, speed, and pauses
received. augment the sender’s message.

The use of extraneous words with long, tedious

Maintaining eye descriptions is called circumstantiality.
contact and
receptive Eye Contact - The eyes have been called the mirror of
nonverbal
the soul because they often reflect our emotions.
communication.
Looking into the other person’s eyes during
Encourage the “What are you
communication, is used to assess the other person
patient to select thinking about?”
Broad topics for “Can you tell me and the environment and to indicate whose turn it is
Opening discussion. more about that?” to speak; it increases during listening but decreases
while speaking (Wasajja, 2018).
Attempting to “I’m not sure what
put into words you mean. Could Silence - The client may be depressed and struggling
vague ideas or you tell me about to find the energy to talk.
Clarification unclear that again?”
thoughts of the Sometimes, pauses indicate the client is thoughtfully
patient to considering the question before responding.
enhance the
nurse PRINCIPLES OF THERAPEUTIC COMMUNICATION
understanding.
- The nurse is an open,
honest, sincere person
INTERPRETING SIGNALS OR CUES who is actively involved in
the relationship.
Cues are verbal or nonverbal messages that signal - The nurse’s response is
key words or issues for the client. Finding cues is a Genuiness sincere: the nurse is not
function of active listening. thinking and feeling one
thing and saying
 Covert Cues – Vague or hidden messages that something different.
need interpretation and follow-up - Whatever the nurse shows
must be real and not
 Metaphors – “My son’s bedroom looks like a
merely a “professional
bomb went off.” response” that has been
 Proverbs – Old accepted sayings learned and repeated.
 Clichés – Trite phrase such as, “she has more - Nurse should not be
guts than brains.” judgemental; without
ridicule, criticism, or
NONVERBAL COMMUNICATION SKILLS Respect reservation.
- Caring, liking, and valuing
Facial Expression - The human face produces the are other terms for
most visible, complex, and sometimes confusing respect.
nonverbal messages. - Patient is regarded as a
person worth and is
Facial expressions can be categorized into expressive, respected.
impassive, and confusing: - Empathy: is the ability to
enter into the life of
 Expressive - portrays the person’s moment- another person to
Empathetic accurately perceive his or
by-moment thoughts, feelings, and needs.
Understanding her current feelings and
 Impassive - frozen into an emotionless their meanings.
deadpan expression similar to a mask. - Rogers, “to sense the
 Confusing - is one that is the opposite of what patient’s private world as
the person wants to convey. if it were your own, but
without losing the ‘as if’
Body Language (e.g., gestures, postures, movements, quality.
and body positions) Concreteness - Using specific terminology
rather than abstractions
 when discussing the Nurse’s responsibility to establish a therapeutic
patient’s feelings. environment that fosters trust and understanding.
- Avoid vagueness and
ambiguity. Appropriate information about the nurse should be
Honesty - shared at this time.

EXAMPLE: “Hello, Delia! My name is Mr. Manuel, I

will be your nurse for the next two weeks. I am a
junior nursing student of Liceo de Cagayan
BLOCKS TO THERAPEUTIC COMMUNICATION
University.”
- Giving advise
Nurse – Patient Contract
- Providing false reassurance
- Asking too many “why” questions - Outline the nurse and patient responsibilities
- Using emotionally charged language - These responsibilities should be agreed on
- Straying from patient’s agenda an informal or verbal contract.
- Using clichés - Contract should state:
- Delivering double messages o Time, place and length of sessions
- Lecturing o When the sessions will terminate
o And;

Who will be involved in  Family Members

the Treatment Plan  Health Team
Members
Patient Responsibilities  Arrives on Time
 Ends on Time
 Arrives on Time
 Ends on Time
 Maintains
Nurse’s confidentiality at all
Responsibilities times
 Evaluates progress
with the patient
VI. THERAPEUTIC NURSE PATIENT  Documents sessions
RELATIONSHIP  A specified length of
time
NURSE – PATIENT RELATIONSHIP Conditions of  Attainment of mutual
Termination goals
 A therapeutic, not social relationship  The discharge of the
 Is always client centered and goal directed patient if hospitalized
 Is objective rather than subjective
 Is a limited relationship with the goal of
Confidentiality
helping the client find a more satisfying
behavior patterns and coping strategies and - Does not imply secrecy or the exclusive
increasing self-worth possession if information.
 Is not a mutual satisfaction, although the - Involves the disclosure of certain
nurse may benefit from the client’s positive information to another specifically
outcome authorized person.
- Important in providing for the continuity and
ASES OF THE NURSE-CLIENT RELATIONSHIP
comprehensiveness of patient care and
(PEPLAU’S MODEL)
should be clearly explained to the patient.
ORIENTATION PHASE
WORKING PHASE
Begins when the nurse and client meet and ends
Usually divided into two sub-phases.
when the client begins to identify problems to
examine.  Problem Identification
o the client identifies the issues or concerns
During the orientation phase, the nurse establishes
causing problems.
 roles,  Exploitation
 purpose of meeting, o the nurse guides the patient to
 parameters of subsequent meetings; o examine feelings and responses
 identifies the client’s problems; and o encourages behavior change
o develop better coping skills and a more
 clarifies expectations.
positive self-image; and
Nurse begins to build trust with the patient. o develops independence.
 TERMINATION PHASE

The termination or resolution phase is the final stage

in the nurse–client relationship.

- This stage had been initiated during the

orientation phase
- Formal termination is determined when the
problems are resolved
- Ends when the relationship is ended.

Patient often have feelings about the ending of the

relationship

 May often try to avoid termination by acting

angry
o As if the problem has not been resolved

Nurse have feelings about the ending of the

relationship

 Nurse can acknowledge the patient’s feelings

of anger
o Appropriate to tell the patient that the
nurse enjoyed the time spent outside the
therapeutic relationship.
o Inappropriate for the nurse to agree to
see the patient outside the therapeutic
relationship.

Nurse Responsibilities

 Nurse’s tasks during this phase revolve

around establishing the reality of the
separation.
 The nurse and the patient review the
progress made in therapy and the attainment
of specified goals
 Feelings of rejection, loss, sadness, and anger
are expressed and explored.
 Patient’s dependence on the nurse should
decrease, and his interdependence with his
environment and significant others should
increase.

Obstructions of the Therapeutic Relationship

1. Resistance
2. Transference
3. Countertransference