NCLEX: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span: Behavior Modification

Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

Behavior modification is a therapeutic approach involving the application of learning principles so as to change maladaptive behavior.


Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

conditioned avoidance (also aversion therapy) a technique whereby there is a purposeful and systematic production of strongly unpleasant responses in situations to which the client has been previously attracted but now wishes to avoid.

desensitization frequent exposure in small but gradually increasing doses of anxiety-evoking stimuli until undesirable behavior disappears or is lessened (as in phobias).

token economy desired behavior is reinforced by rewards, such as candy, money, and verbal approval, used as tokens.

operant conditioning a method designed to elicit and reinforce desirable behavior (especially useful in mental retardation).

positive reinforcement giving rewards to elicit or strengthen selected behavior or behaviors.


  • Emphasis is on changing unacceptable, overt, and observable behavior to that which is acceptable; emphasis is on changed way of acting first, not of thinking.
  • Mental health team determines behavior to change and treatment plan to use.
  • Therapy is based on the knowledge and application of learning principles, that is, stimulus-response; the unlearning, or extinction, of undesirable behavior; and the reinforcement of desirable behavior.
  • Therapist identifies what events are important in the life history of the client and arranges situations in which the client is therapeutically confronted with them.
  • Two primary aspects of behavior modification:
    1. Eliminate unwanted behavior by negative reinforcement (removal of an aversive stimulus, which acts to reinforce the behavior) and ignoring (withholding positive reinforcement).
    2. Create acceptable new responses to an environmental stimulus by positive reinforcement.
  • Useful with: children who are disturbed, victims of rape, dependent and manipulative behaviors, eating disorders, obsessive-compulsive disorders, sexual dysfunction.


Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

  • Behavior is what an organism does.
  • Behavior can be observed, described, and recorded.
  • It is possible to predict the conditions under which the same behavior may recur.
  • Undesirable social behavior is not a symptom of mental illness but is behavior that can be modified.
  • Undesirable behaviors are learned disorders that relate to acute anxiety in a given situation.
  • Maladaptive behavior is learned in the same way as adaptive behavior.
  • People tend to behave in ways that “pay off.”
  • Three ways in which behavior can be reinforced:
    1. Positive reinforcer (adding something pleasurable).
    2. Negative reinforcer (removing something unpleasant).
    3. Adverse stimuli (punishing).
  • If an undesired behavior is ignored, it will be extinguished.
  • Learning process is the same for all; therefore, all conditions (except organic) are accepted for treatment.

IV. NURSING CARE PLAN/IMPLEMENTATION in behavior modification:

  • Find out what is a “reward” for the person.
  • Break the goal down into small, successive steps.
  • Maintain close and continual observation of the selected behavior or behaviors.
  • Be consistent with on-the-spot, immediate intervention and correction of undesirable behavior.
  • Record focused observations of behavior frequently.
  • Participate in close teamwork with the entire staff.
  • Evaluate procedures and results continually.
  • Health teaching: teach preceding steps to colleagues and family.

V. EVALUATION/OUTCOME CRITERIA: acceptable behavior is increased and maintained; undesirable behavior is decreased or eliminated.

Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span: Activity Therapy

Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

Activity therapy consists of a variety of recreational and vocational activities (recreational therapy [RT]; occupational therapy [OT]; and music, art, and dance therapy) designed to test and examine social skills and serve as adjunctive therapies.


Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

  • Socialization counters the regressive aspects of illness.
  • Activities must be selected for specific psychosocial reasons to achieve specific effects.
  • Nonverbal means of expression as an additional behavioral outlet add a new dimension to treatment.
  • Sublimation of sexual drives is possible through activities.
  • Indications for activity therapy: clients with low self-esteem who are socially unresponsive.


Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

A. Usually planned and coordinated by other team members, such as the recreational therapists or music therapists.

B. Goals:

  • Encourage socialization in community and social activities.
  • Provide pleasurable activities.
  • Help client release tensions and express feelings.
  • Teach new skills; help client find new hobbies.
  • Offer graded series of experiences, from passive spectator role and vicarious experiences to more direct and active experiences.
  • Free or strengthen physical and creative abilities. Increase self-esteem.


  • Encourage, support, and cooperate in client’s participation in activities planned by the adjunct therapists.
  • Share knowledge of client’s illness, talents, interests, and abilities with others on the team.
  • Health teaching: teach client necessary skills for each activity (e.g., sports, games, crafts).

IV. EVALUATION/OUTCOME CRITERIA: client develops occupational and leisure-time skills that will help provide a smoother transition back to the community.

Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span: Group Therapy

Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

Group therapy is a treatment modality in which two or more clients and one or more therapists interact in a helping process to relieve emotional difficulties, increase self-esteem and insight, and improve behavior in relations with others.


Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

A. People’s problems usually occur in a social setting; thus they can best be evaluated and corrected in a social setting.

B. Not all are amenable to group therapies. For example:

  • Brain damaged.
  • Acutely suicidal.
  • Acutely psychotic.
  • Persons with very passive-dependent behavior patterns.
  • Acutely manic.

C. It is best to match group members for complementarity in behaviors (verbal with nonverbal, withdrawn with outgoing) but for similarity in problems (obesity, predischarge group, clients with cancer, prenatal group) to facilitate empathy in the
sharing of experiences and to heighten group identification and cohesiveness.

D. Feelings of acceptance, belonging, respect, and comfort develop in the group and facilitate change and health.

E. In a group, members can test reality by giving and receiving feedback.

F. Clients have a chance to experience in the group that they are not alone (concept of universality).

G. Expression and ventilation of strong emotional feelings (anger, anxiety, fear, and guilt) in the safe setting of a group is an important aspect of the group process aimed at health and change.

H. The group setting and the interactions of its members may provide corrective emotional experiences for its members. A key mechanism operating in groups is transference (strong emotional attachment of one member to another member, to the therapist, or to the entire group).

I. To the degree that people modify their behavior through corrective experiences and identification with others rather than through personal-insight analysis, group therapy may be of special advantage over individual therapy, in that the possible number
of interactions is greater in the group and the patterns of behavior are more readily observable.

J. There is a higher client-to-staff ratio, and it is thus less expensive.

Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span


Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

  • Provide opportunity for self-expression of ideas and feelings.
  • Provide a setting for a variety of relationships through group interaction.
  • Explore current behavioral patterns with others and observe dynamics.
  • Provide peer and therapist support and source of strength for the individuals to modify present behavior and try out new behaviors; made possible through development of identity and group identification.
  • Provide on-the-spot, multiple feedback (i.e., incorporate others’ reactions to behavior), as well as give feedback to others.
  • Resolve dynamics and provide insight.


A. Nurses need to fill different roles and functions in the group, depending on the type of group, its size, its aims, and the stage in the group’s life cycle. The multifaceted roles may include:

  • Catalyst.
  • Transference object (of client’s positive or negative feelings).
  • Clarifier.
  • Interpreter of “here and now.”
  • Role model and resource person.
  • Supporter.

B. During the first sessions, explain the purpose of the group, go over the “contract” (structure, format, and goals of sessions), and facilitate introductions of group members.
C. In subsequent sessions, promote greater group cohesiveness.

  • Focus on group concerns and group process rather than on intrapsychic dynamics of individuals.
  • Demonstrate nonjudgmental acceptance of behaviors within the limits of the group contract.
  • Help group members handle their anxiety, especially during the initial phase.
  • Encourage members who are silent to interact at their level of comfort.
  • Encourage members to interact verbally without dominating the group discussion.
  • Keep the focus of discussion on related themes; set limits and interpret group rules.
  • Facilitate sharing and communication among members.
  • Provide support to members as they attempt to work through anxiety-provoking ideas and feelings.
  • Set the expectation that the members are to take responsibility for carrying the group discussion and exploring issues on their own.

D. Termination phase:

1. Make early preparation for group termination (endpoint should be announced at the first meeting).

2. Anticipate common reactions from group members to separation anxiety and help each member to work through these reactions:

  • Anger.
  • Acting out.
  • Regressive behavior.
  • Repression.
  • Feelings of abandonment.
  • Sadness.


Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

  • Physical: shows improvement in daily life activities (eating, rest, work, exercise, recreation).
  • Emotional: asks for and accepts feedback; states feels good about self and others.
  • Intellectual: is reality oriented; greater awareness of self, others, environment.
  • Social: willing to take a risk in trusting others; sharing self; reaching out to others.

Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span: Reality Orientation and Resocialization

Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span: Family Therapy

Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

Family therapy is a process, method, and technique of psychotherapy in which the focus is not on an individual but on the total family as an interactional system.


  • Physical maintenance—provide food, shelter, clothing, health care.
  • Resource allocation (physical and emotional)— allocate material goods, space, and facilities; give affection, respect, and authority.
  • Division of labor—decide who earns money, manages household, cares for family.
  • Socialization—guidelines to control food intake, elimination, sleep, sexual drives, and aggression.
  • Reproduction, recruitment, release of family member—give birth to, or adopt, children; rear children; incorporate in-laws, friends, etc.
  • Maintenance of order—ensure conformity to norms.
  • Placement of members in larger society—interaction in school, community, etc.
  • Maintenance of motivation and morale—reward achievements, develop philosophy for living; create rituals and celebrations to develop family loyalty. Show acceptance, encouragement, affection; meet crises of individuals and family.


Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

  • The ill family member (called the identified client), by symptoms, sends a message about the “illness” of the family as a unit.
  • Family homeostasis is the means by which families attempt to maintain the status quo.
  • Scapegoating is found in families who are disturbed and is usually focused on one family member at a time, with the intent to keep the family in line.
  • Communication and behavior by some family members bring out communication and behavior in other family members.
    1. Mental illness in the identified client is almost always accompanied by emotional illness and disturbance in other family members.
    2. Changes occurring in one member will produce changes in another; that is, if the identified client improves, another identified client may emerge, or family may try to place original person back into the role of the identified client.
  • Human communication is a key to emotional stability and instability—to normal and abnormal health. Conjoint family therapy is a communication centered
    approach that looks at interactions between family members.
  • Double bind is a “damned if you do, damned if you don’t” situation; it results in helplessness, insecurity; anxiety; fear, frustration, and rage.
  • Symbiotic tie usually occurs between one parent and a child, hampering individual ego development and fostering strong dependence and identification with the parent (usually the mother).
  • Three basic premises of communication*:
    1. One cannot not communicate; that is, silence is a form of communication.
    2. Communication is a multilevel phenomenon.
    3. The message sent is not necessarily the same message that is received.
  • Indications for family therapy:
    1. Marital conflicts.
    2. Severe sibling conflicts.
    3. Cross-generational conflicts.
    4. Difficulties related to a transitional stage of family life cycle (e.g., retirement, new infant, death).
    5. Dysfunctional family patterns: mother who is overprotective and father who is distant, with child who is timid or destructive, teenager who is acting out; over functioning “super wife” or “super husband” and the spouse who is under functioning, passive, dependent, and compliant; child with poor peer relationships or academic difficulties.

III. FAMILY ASSESSMENT should consider the following factors:

A. Family assessment: cultural profile:

1. Communication style:

  • Language and dialect preference (understand concept, meaning of pain, fever, nausea).
  • Nonverbal behaviors (meaning of bowing, touching, speaking softly, smiling).
  • Social customs (acting agreeable or pleasant to avoid the unpleasant, embarrassing).

2. Orientation:

  • Ethnic identity and adherence to traditional habits and values.
  • Acculturation: extent.
  • Value orientations:
    (1)Human nature: evil, good, both.
    (2) Relationship between humans and nature: subjugated, harmony, mastery.
    (3) Time: past, present, future.
    (4)Purpose of life: being, becoming, doing.
    (5) Relationship to one another: lineal, collateral, individualistic.

3. Nutrition:

  • Symbolism of food.
  • Preferences, taboos.

4. Family relationships:

  • Role and position of women, men, aged, boys, girls.
  • Decision-making styles/areas: finances, child rearing, health care.
  • Family: nuclear, extended, or tribal.
  • Matriarchal or patriarchal.
  • Lifestyle, living arrangements (crowded; urban/rural; ethnic neighborhood or mixed).

5. Health beliefs:

  • Alternative health care: self-care, folk medicine; cultural healer: herbalist, medicine man, curandero.
  • Health crisis and illness beliefs concerning causation: germ theory, maladaptation, stress, evil spirits, yin/yang imbalance, envy and hate.
  • Response to pain, hospitalization: stoic endurance, loud cries, quiet withdrawal.
  • Disease predisposition:
    (1)African Americans: sickle cell anemia; cardiovascular disease, brain attack (stroke), hypertension; high infant mortality rate; diabetes.
    (2)Asians: lactose intolerance, myopia.
    (3) Latinos: cardiovascular, diabetes, cancer, obesity, substance abuse, TB, AIDS, suicide, homicide.
    (4)Native Americans: high infant and maternal mortality rates, cirrhosis, fetal alcohol abnormalities, pancreatitis, malnutrition, TB, alcoholism.
    (5) Jews: Tay-Sachs disease.

B. Family as a social system:

1. Family as responsive and contributing unit within network of other social units.

  • Family boundaries—permeability or rigidity.
  • Nature of input from other social units.
  • Extent to which family fits into cultural mold and expectations of larger system.
  • Degree to which family is considered deviant.

2. Roles of family members:

  • Formal roles and role performance (father, child, etc.).
  • Informal roles and role performance (scapegoat, controller, follower, decision maker).
  • Degree of family agreement on assignment of roles and their performance.
  • Interrelationship of various roles—degree of “fit” within total family.

3. Family rules:

  • Family rules that foster stability and maintenance.
  • Family rules that foster maladaptation.
  • Conformity of rules to family’s lifestyle.
  • How rules are modified; respect for difference.

4. Communication network:

  • How family communicates and provides information to members.
  • Channels of communication—who speaks to whom.
  • Quality of messages—clarity or ambiguity.

C. Developmental stage of family:

  • Chronological stage of family.
  • Problems and adaptations of transition.
  • Shifts in role responsibility over time.
  • Ways and means of solving problems at earlier stages.

D. Subsystems operating within family:

  • Function of family alliances in family stability.
  • Conflict or support of other family subsystems and family as a whole.

E. Physical and emotional needs:

  • Level at which family meets essential physical needs.
  • Level at which family meets social and emotional needs.
  • Resources within family to meet physical and emotional needs.
  • Disparities between individual needs and family’s willingness or ability to meet them.

F. Goals, values, and aspirations:

  • Extent to which family members’ goals and values are articulated and understood by all members.
  • Extent to which family values reflect resignation or compromise.
  • Extent to which family will permit pursuit of individual goals and values.

G. Socioeconomic factors.


  • Establish a family contract (who attends, when, duration of sessions, length of therapy, fee, and other expectations).
  • Encourage family members to identify and clarify own goals.
  • Set ground rules:
    1. Focus is on the family as a whole unit, not on the identified client.
    2. No scapegoating or punishment of members who “reveal all” should be allowed.
    3. Therapists should not align themselves with issues or individual family members.
  • Use self to empathetically respond to family’s problems; share own emotions openly and directly; function as a role model of interaction.
  • Point out and encourage the family to clarify unclear, inefficient, and ambiguous family communication patterns.
  • Identify family strengths.
  • Listen for repetitive interpersonal themes, patterns, and attitudes.
  • Attempt to reduce guilt and blame (important to neutralize the scapegoat phenomenon).
  • Present possibility of alternative roles and rules in family interaction styles.
  • Health teaching: teach clear communication to all family members.

V. EVALUATION/OUTCOME CRITERIA: each person clearly speaks for self; asks for and receives feedback; communication patterns are clarified; family problems are delineated; members more aware of each other’s needs.

Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span: Electroconvulsive Therapy

Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

Electroconvulsive therapy (ECT) is a physical treatment that induces grand mal (generalized) convulsions by applying electric current to the head. It is also called electric shock therapy (EST).

I. CHARACTERISTICS of electroconvulsive therapy:

  • Usually used in treating: major depression with severe suicide risk, extreme hyperactivity, severe catatonic stupor, or those with bipolar affective disorders not responsive to psychotropic medication.
  • Consists of a series of treatments (6 to 25) over a period of time (e.g., 3 times per week).
  • Person is asleep through the procedure and for 20 to 30 minutes afterward.
  • Convulsion may be seen as a series of minor, jerking motions in extremities (e.g., toes). Spasms are reduced by use of muscle-paralyzing drugs.
  • Confusion is present for 30 minutes after treatment.
  • Induces loss of memory for recent events.

II. VIEWS CONCERNING SUCCESS of electroconvulsive therapy:

  • Post treatment sleep is the “curative” factor.
  • Shock treatment is seen as punishment, with an accompanying feeling of absolution from guilt.
  • Chemical alteration of thought patterns results in memory loss, with decrease in redundancy and awareness of painful memories.

III. NURSING CARE PLAN/IMPLEMENTATION in electroconvulsive therapy:

A. Always tell the client of the treatment.
B. Inform client about temporary memory loss for recent events after the treatment.
C. Pretreatment care:

  • Take vital signs.
  • See to client’s toileting.
  • Remove: client’s dentures, eyeglasses or contact lenses, and jewelry.
  • NPO for 8 hours beforehand.
  • Atropine sulfate subcutaneously 30 minutes before treatment to decrease bronchial and tracheal secretions.
  • Anesthetist gives anesthetic and muscle relaxant IV (succinylcholine chloride [Anectine]) and oxygen for 2 to 3 minutes and inserts airway. Often all three are given close together— anesthetic first, followed by another syringe with Anectine and atropine sulfate. Electrodes and treatment must be given within 2 minutes of injections, because Anectine is very short acting (2 minutes).

D. During the convulsion, the nurse must make sure the person is in a safe position to avoid dislocation and compression fractures (although Anectine is given to prevent this).

E. Care during recovery stage:

  • Put up side rails while client is confused; side position.
  • Take blood pressure, pulse (check for bradycardia), and respirations.
  • Stay until person awakens, responds to questions, and can care for self.
  • Orient client to time and place and inform that treatment is over when awakens.
  • Offer support to help client feel more secure and relaxed as the confusion and anxiety decrease.
  • Medication for nausea and headache, prn.

F. Health teaching: teach family members what to expect of client after ECT (confusion, headache, nausea); how to reorient the client.

IV. EVALUATION/OUTCOME CRITERIA: feelings of worthlessness, helplessness, and hopelessness seem diminished.

Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span: Complementary and Alternative Medicine (CAM)

Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

(Also see Appendix E for specific conditions in which CAM can be integrated into the treatment plan.)


Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

A. Complementary therapy—used to supplement or augment conventional therapy (e.g., use of guided imagery, music and relaxation techniques for pain control in combination with drug therapy).

B. Alternative therapy—generally used instead of conventional treatment (e.g., use of acupuncture instead of analgesic).

II. BASIC BELIEFS AND ASSUMPTIONS about health, health care:

A. Diseases are complex, multifaceted states of imbalance and require an approach that uses several strategies for facilitating healing.

B. Individuals can facilitate their own healing process by engaging their inner resources and becoming active participants in promoting their health.

C. Holistic nursing can be a major provider of CAM, with an underlying philosophy of caring and healing.

  • Use of an approach to the care of others that facilitates the integration, harmony, and balance of body, mind, and spirit.
  • Focus is on the whole person in the process of healing.
  • Experience of illness is an opportunity for growth that invites reflection on important dimensions of their lives and to make changes that encourage a more balanced and integrated state of being. Emphasis on: self-responsibility and self-care.
  • Client-nurse relationship is reciprocal where each benefits from the interaction and grows in self-awareness.


Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

  • Mind-body interventions.
  • Bioelectromagnetic applications in medicine.
  • Manual healing methods.
  • Pharmacological and biological treatments.
  • Herbal medicine.
  • Diet and nutrition in the prevention and treatment of chronic disease.


Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

A. Natural healing:

  • Aquatherapy.
  • Aromatherapy.
  • Color therapy.
  • Homeopathy.

B. Plant therapy:

  • Flower essence therapy.
  • Herbal medicine.

C. Nutrition and diet:

  • Diet therapies.
  • Naturopathic medicine.

D. Mobility and posture:

  • Dance therapy.
  • Rolfing.
  • Yoga.

E. The mind:

  • Meditation.
  • Music therapy.
  • Visualization, guided imagery.
  • Humor therapy.
  • Pet therapy.

F. Massage and touch:

  • Massage therapy.
  • Reflexology.
  • Energy field therapies, including therapeutic touch.

G. Eastern therapies:

  • Acupuncture.
  • Acupressure.
  • Shiatsu.
  • Chinese herbal medicine.


Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

A. Familiarize yourself with one or two basic therapies (e.g., massage, music, or guided imagery).

B. Try to eliminate own preconceived ideas.

C. Get adequate instruction before using any CAM with clients.

D. Ask clients if they use any CAM and their response to them.

E. Health teaching: Nurses can discuss and do teaching based on scientific research about effectiveness of each therapy when clients seek information about alternative and complementary therapies (because they are noninvasive, holistic [encompass mind and
spirit], and less expensive).

  • Physical tension and anxiety—can be decreased with meditation combined with guided imagery.
  • Effect of coronary heart disease—can be reversed with carefully planned nutrition, exercise, and meditation (Dr. Dean Ornish’s plan).
  • Coordination—can be improved with yoga.
  • Blood pressure and stress—can be lowered and reduced with massage.
  • Apical heart rate—can be reduced; peripheral blood flow—can be increased with music.
  • Pain in arthritic joints and back—can be relieved by localized healing touch techniques.
  • Headache pain and breaking up congestion— can be aided by healing touch.
  • Prepare client for pre- and postoperative energy and recovery—can be aided by relaxation and energy-balancing methods.















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