Lecture A - History of Mental Illness and Psychiatry I.

Different Explanations for Mental Illness Over Time (Madness & Civilization) a. Early Medieval Ages (2nd Century - 16th Century) - Demonic Possession and/or Sin - MI associated with "sinful" behaviors: alcoholism, poor diet, and poor lifestyle--Early recognition of lifestyle factors in MI - Trephination practiced across the world, evidence it was practiced by Europeans, Incans -- Similar to Lobotomies b. 15th Century: "Ship of Fools": literary version of exclusion, mad people were sent away in ships c. 17th Century Europe - "The Great Confinement" d. 18th Century: Age of Reason/Enlightenment (1600-1800): spread from Europe to the United States to influence the Bill of Rights - Valuation of Reason - Emphasis on self-governance, natural rights, natural law, central emphasis on liberty, individual rights, reason, e. 19th Century, mental illness gradually came to be seen as an illness II. Mental Illness in 19th Century America -a. No standard, state/federal services - 1843: 13 mental hospitals in the entire country b. Mentally ill persons were kept in harsh conditions at home, poorhouses. Often chained to the floor or locked in a room without heat. No daylight, no furnishings, no fresh air. c. Lack of services mprisonment of Mentally Ill alongside criminals III. Dorothea Dix & Rights Movement- 19th Century a. Dix's Speech Delivered to Massachusetts State Legislature "I have come to present to you the strong claims of suffering humanity. I come as the advocate of the helpless, forgotten, insane men and women held in cages, closets, cellars, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience!" b. Dix's report caused a social uproar - denial over charges; arguments over cost of providing adequate health care for the mentally ill c. Dix went on to wage a national campaign for patient rights. Her assertion that mental illness was not a crime but a disease had huge implications for the way society and the state could and should treat patients with mental illness; inferred they were victims of disease, entitled to the same rights as persons with medical illness

- In 1843 there were 13 mental hospitals in the entire country - By 1880 there were 123 - Dorothea Dix played a direct role in founding 32 IV. Major Theories of Personality a. Sigmund Freud (1856 - 1939) i. Psychoanalytic Theory (early 1900s) Insisted upon psychological treatment of behavioral symptoms; talking about painful events as a cure for MI Sexual desire = primary motivation Cause of Mental Illness found unresolved childhood trauma Repression = subverted energy debilitation ii. Talk Therapy (Catharsis) "Talking Cure" = Psychological Treatment of Behavioral Problems, primarly Somatoform & Anxiety Disorders Free Associatoin, Dream Analysis, Full and Honest Disclosure of ALL Thoughts/Feelings, Redirection of Energy b. Freud's Theory of Awareness (Iceberg) CONSCIOUS = tip of the iceberg; contains all of the I nformation that a person is aware of at any one time PRECONSCIOUS = lies just below the surface of awareness; contains information that can be retrieved rather easily through conscious effort UNCONSCIOUS = bottom of the iceberg; all repressed memories, passions, unacceptable images. Freud believed that the unconscious exerted a powerful but unseen influence on the thoughts and feelings of the individual. Unconscious material can be brought to conscious awareness but only through the help of psychoanalysis (dream analysis, free association) c. Freud's Theory of Personality Structure ID = source of all drives, instincts, reflexes, needs, genetic inheritance and capacity to respond, as well as all the issues and wishes that motivate us; Lacks the ability to problemsolve; not rational Pleasure Principle Reflex Action is inherent and automatic; gag, cry, laugh,`scream; alleviate tension; short-acting Primary Process relieves psychic and emotional

energy EGO = Develops because the needs, wishes and demands of the ID cannot be satisfied by the primary process and reflex action REALITY PRINCIPLE: attempts to negotiate solution with the outside world, recognizes the limits to achieving its needs and tries to find ways around them - Secondary Processes and Reality Testing SUPEREGO = last portion of personality to develop; moral component to personality; consists of the "should nots" and "shoulds" internalized from our parents; represents the ideal rather than the real d. Freud's Theory of Defense Mechanisms & Anxiety Anxiety inevitable product of our environment Defense Mechanisms developed by the Ego in response to anxiety Two distinctive features; Operate on unconscious level (except supression) Falsify or distort reality to minimize perceived threat Examples e. Freud's Theory of Psychosexual Development Personality formed by time child enters school; future life experiences expand upon core personality 5 stages of psychosexual development prior to development of personality f. Psychoanalysis Rarely used; costly Freud's premise that personality forms in childhood rejected Implications for Nursing TRANSFERENCE - describes process wherin the client experiences feelings towards the Health Care provider that were originally inspired by significant others in his or her private life; When this occurs, it must be explored with the client - enables understanding of client's feelings and behaviors COUNTERTRANSFERENCE is the HC Worker's unconscious and personal response to the client and requires self-

awareness to avoid countertransference from influencing the nurse-client relationship Introduced importance of life events on mental illness and client's personality Created a role for the client to play and participate in their recovery h. Interpersonal Theory - Henry Stack Sullivan (1892-1949) met avoid Purpose of all human behavior is to get personal needs through interpersonal interactions and decrease or anxiety Defined anxietyas "any painful feeling or emotion arising from social insecurity or blocks to getting biological needs satisfied" Decrease our anxiety through Security Operations; Operations make up the Self System

Security

Implications for Nursing "Participant Observer" - argued HCWs must engage client on an authetnic level and participate in their world Argued for a psychotherapeutic environment characterized by an accepting atmosphere, promotion of opportunities to practice interpersonal skills, developing relationships Group therapy, family therapy, education and skill training programs i. Ego Theory - Erik Erikson (1902-1994) Argued for greater sphere of influence beyond mother-fatherchild triangle and that culture and society exert a significant influence on the individual Placed a greater emphasis on the role of the ego Argued for lifelong development: 8 stages Implications for Nursing Assists with patient assessment in the analysis of client behavior in reference to 8 stages of development (e.g. developmental delay) Allows development for stage-appropriate interventions Tailor nursing care to the individual j. Humanistic Theories - Focus on human potential and possibility of choosing life patterns supportive of personal growth Emphasize potential for SELF-ACTUALIZATION HC Professional must understand the client's perspective

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s/he subjectively experiences it k. Abraham Maslow's Theory of Self-Actualization (19081970) Characteristics of Self-Actualized Persons - Accurate perceptions of reality - Accept themselves and the world around them - Spontaneity, simplicity, and naturalness; don't live programmed lives **** Problem-centered rather than self-centered Implications for Nursing Advocated focus on clien'ts strengths and potential to build nurseclient relationship Pyramidal structure assists prioritization of client's needs l. Behavioral Theories (Watson) Personality consists of learned behaviors; so personality then becomes synonymous with behavior; changes over time Strong emphasis on the role of the environment in shaping behavior Conditioning/Ivan Pavlov - pairing a behavior with a condition that reinforces or diminishes the behavior's occurrence Skinner's Operant-Conditioning Theory - manipulation of selected reinforcers to elicit and strengthen desired behavioral responses - Reinforcer is the consequence of behavior and is defined as anything that increases the occurrence of behavior; its value lies in its particular meaning to the individual - Positive Reinforcement increases likelihood the behavior will be repeated; conversely for negative outcomes Implications for Nursing Provides a concrete model for modifying or replacing nontherapeutic behaviors (e.g. CBT) m. Biological Theories (1950s onward) chlorpromazine = powerful antipsychotic medication; led to a revolution in psychiatry Led to acceptance of the brain as playing a critical role in psychiatric illness focuses on neurological, chemical, and genetic issues and seeks to understand how the body and brain interact to create emotions, memories, perceptual experiences

Acceptance of Mental Illness as a disease process 1990s: Decade of the Brain Implications for Nursing Risk of excluding other theoretical perspectives; overemphasis on biochemistry and not environment; important to psych nurses to remain holistic in their viewpoints

REFERENCES Clay, Rebecca A. (2002) A renaissance for humanistic psychology. The field explores new niches while building on its past. American Psychological Association Monitor, Volume 33, No. 8 September Rowan, John (1976) Ordinary Ecstasy: The Dialectics of Humanistic Psychology Brunner-Routledge (1 March 2001) Dorothea Dix: New England Reformer, by Thomas Brown (Harvard University Press, 1998) Voice for the Mad: The life of Dorothea Dix, by David Gollaher (Free Press, 1995)