Chapter 54

1. Chapter 54 Psychological Responses to Illness

2. Learning Objectives • Define mental health. • Discuss the concepts of stress, anxiety, adaptation, and homeostasis. • Discuss how age and cultural and spiritual beliefs affect an individual’s ability to cope with illness. • Identify some basic coping strategies (defense mechanisms). • Discuss the concepts of anxiety, fear, stress, loss, grief, helplessness, and powerlessness in relation to illness. • Describe several factors that may precipitate adaptive or maladaptive coping behaviors in response to illness. • Discuss implementation of the nursing process to enhance a patient’s mental health as the patient deals with the stresses of illness.

3. Definition of Mental Health A dynamic process in which a person’s physical, cognitive, affective, behavioral, and social dimensions interact with one another and the environment Mentally healthy individuals are able to Perceive reality accurately Manage how emotions are experienced and expressed Think clearly and logically Communicate effectively Anticipate events and solve problems Initiate and maintain meaningful relationships Develop a positive self-concept Behave in ways that promote personal growth and development

4. Stress Stress is caused by a stressor Anything that necessitates person’s adaptive response Necessary for growth and development Mild stress produces mild anxiety and enables people to use energy focused exclusively on the problem Result can be successful problem solving, which in turn promotes self-esteem Can also be harmful Examples: loss of a job or the death of a family member

5. Stress Adaptation to stress affects whole organism The dimensions of the person—physical, cognitive, affective, behavioral, and social—are not separate entities These dimensions interact, resulting in the development of a unique human being

6. Homeostasis Stress, response, and adaptation a process of maintaining homeostasis or equilibrium If stressors are mild and the person is able to respond and adapt, mental health is maintained If the person is overwhelmed by many stressors or cannot cope, illness or crisis may ensue Results in inner tension and anxiety, which may affect an individual’s ability to function

7. Growth and Development Process of evolution from conception until death As human beings move through sequential stages of development, they become increasingly complex Each individual shaped throughout life by all of the events and perceived interactions with others, the community, and the environment Development stages correspond to a specific age-group Developmental tasks: moving through each stage In part, successful development depends on how individuals negotiate each stage

8. Growth and Development Infancy and early childhood: nurturing is critical and exploration of the world begins Preschoolers must learn to handle joint decision making and interpersonal conflicts Middle childhood: learning to deal with frustration and unfavorable events while also celebrating good things and feeling pleasure Teenagers learn to develop as individuals, become independent, and begin to think for themselves

9. Growth and Development In early adulthood, most people find a life partner and life work and may begin a family Adults progressing through middle age look at the effect their lives have had or could have Older age: time of introspection, when elders look back on their lives, accept what has been, and attempt to face increasing frailty with grace

10. Behavioral Theory All behaviors are learned responses Conditioning is one type of learning Theorists such as B.F. Skinner, Albert Bandura, and Joseph Wolpe have based their theories on the idea that all behavior is learned and is a series of habitual responses to familiar stimuli

11. Psychological Responses to Illness

12. Coping with Illness Factors that affect coping with illness Age Illness can interfere with developmental progress, and the patient’s developmental stage can influence how he or she responds to illness Differences in the way people of different ages respond to illness Illness not only disrupts the developmental process of the individual but also has a traumatic effect on spouses, children, and other loved ones

13. Coping with Illness Cultural beliefs Can affect attitudes toward health and illness, diet and eating practices, reaction to pain, and death and dying Not all people who look as if they belong to a specific ethnic group because of language, surname, or physical characteristics necessarily identify with any specific group

14. Coping with Illness Spirituality Patients often turn to their spiritual beliefs and values to find meaning in the experience Patients who perhaps had not thought of themselves as being religious may suddenly have a need to visit with a spiritual counselor Many experience spiritual distress when under the stress of an illness

15. Coping with Illness Self-concept Affected by changes in self-esteem as well as changes in body image Perception of these changes and ability or inability to cope with them result in stress, fear, and anxiety Adolescents especially vulnerable to changes in body image because they have a strong need to look like their peers

16. Coping with Illness Family and community resources Family’s ability to provide support for the patient depends on quality of relationships among family members and the family’s ability to access needed resources Because of increasing stresses on the family unit, many families are not able to provide as much support as the patient may need

17. Coping with Illness Emotions Stress: any physiologic or psychological tension that threatens a person’s total equilibrium Fear: denotes a response to a specific threat Anxiety: vague/intense sense of impending doom or apprehension that may appear to have no clearly identifiable cause Loss: related to the involuntary separation from the self of someone or something loved or treasured Grief: subjective, emotional response that evolves from sense of loss. Mourning is the process through which grief is faced and ultimately resolved or altered

18. Defense Mechanisms Compensation: attempt to make up for real or imagined weakness Denial: refusal to acknowledge a real situation Displacement: transferring the feelings associated from one source to another that is considered less threatening Identification: the emulation of admirable qualities in another to enhance one’s self-esteem Rationalization or intellectualization: use of logic, reasoning, and analysis to avoid unacceptable feelings Introjection: internalizing or taking on the values and beliefs of another person

19. Defense Mechanisms Isolation: separation of emotion from an associated thought or memory Projection: unacceptable feelings or impulses transferred to another Reaction formation: avoidance of unacceptable thoughts/behaviors by expressing opposing thoughts/behaviors Regression: withdrawing to an earlier level of development to benefit from the associated comfort levels of the previous level Repression: unconscious defense mechanism in which unacceptable ideas, impulses, and memories are kept out of consciousness

20. Defense Mechanisms Somatization: transfer of painful feelings to body parts, thus person’s feelings expressed as a physical symptom Sublimation: transformation of unacceptable impulses or drives into constructive or more acceptable behavior Suppression: conscious or voluntary inhibition of unacceptable ideas, impulses, and memories Undoing: actually or symbolically attempting to cancel out an action that was unacceptable Substitution: individual replaces a highly valued, unattainable object with a less valued, attainable object

21. Defense Mechanisms Conversion: emotional conflict is turned into a physical symptom, which provides the individual with some sort of benefit Ideally, unhealthy defense mechanisms are shed and replaced by more realistic and efficient methods of adaptation as the individual matures

22. Conscious Coping Strategies Purposeful behaviors used to make an unfamiliar situation into one that is perceived as more controllable and predictable They are attempts to help people feel less stressed and anxious about their illness Some methods provide only temporary relief, whereas others provide more permanent results

23. Conscious Coping Strategies Relaxation techniques: imagery, relaxation strategies, therapeutic touch, and music therapy Provide clients with self-control during stress Elicit the relaxation response that reduces the effects of stress and decreases anxiety Relaxation strategies: biofeedback, meditation, deep breathing exercises, yoga, and Zen Therapeutic touch: environmental and universal energy through the therapist’s mental concentration Music therapy may help the patient cope by enhancing the relaxation response and facilitating positive imagery

24. Maladaptive Coping Mechanisms and Strategies Helplessness Occurs when individuals have had repeated exposure to events they perceive as being uncontrollable Leads to loss of motivation, feelings of despair or anxiety, and cognitive impairment The individual may begin to express anger as a means of diminishing feelings of helplessness Can be prevented by allowing individuals to control as many events as possible within the constraints imposed by treatment and their energy level

25. Maladaptive Coping Mechanisms and Strategies Powerlessness A feeling that one’s actions cannot affect an outcome or that one lacks personal control over certain events or situations Characteristics of powerlessness: passivity; nonparticipation in care and decision making; dependence on others, which may lead to anger, resentment, or guilt; and verbal expression of loss of control over situations or outcomes

26. Maladaptive Coping Mechanisms and Strategies Denial Subconscious blocking out of emotional experiences Several forms: verbal denial, minimizing severity of the illness, displacing symptoms onto another organ system, and engaging in behaviors contrary to medical advice Can lead to negative consequences if people fail to engage in appropriate problem-focused behaviors Maladaptive when patient’s behavior interferes significantly with obtaining appropriate care

27. The Nursing Process in Illness

28. Assessment Effectiveness of individual coping strategies― seek answers to the following Do individuals see themselves as effective in coping with their illness? What efforts have individuals made to seek information about their situation? How skillful are individuals in caring for themselves? What resources do individuals believe are available to them in dealing with their illness? Do individuals effectively adhere to their medical regimen?

29. Assessment Questions Do individuals feel they have been able to keep a sense of normality in their life despite their illness? How have individuals and their families been able to cope with any role modification that the illness has brought about? Have individuals been able to maintain a sense of hope in spite of the demands of the illness? Do individuals feel that the important relationships in their life remain intact?

30. Nursing Diagnoses Interrupted Family Processes Delayed Growth and Development Ineffective Role Performance Ineffective Sexuality Pattern Anxiety Disturbed Body Image Caregiver Role Strain Defensive Coping Decisional Conflict Grieving

31. Nursing Diagnoses Fatigue Fear Impaired Adjustment Ineffective Coping Disabled Family Coping Ineffective Denial Disturbed Personal Identity Powerlessness Risk for Loneliness

32. Nursing Diagnoses Risk for Situational Low Self-Esteem Sexual Dysfunction Disturbed Sleep Pattern Social Isolation Spiritual Distress

33. Nursing Goals, Outcome Criteria, and Interventions Goal of nursing care is to help people manage and successfully cope with their illness With coping strategies, patients can manage their illness and adapt to a new lifestyle that incorporates healthy behaviors and realistic goals Patients should emerge from the process with a positive self-concept and self-esteem