The Psychotherapy of Hildegard Peplau in the Treatment of People with Serious Mental Illness
Thelander, Burton L., Perspectives in Psychiatric Care
TOPIC. The use of Peplau's interpersonal nursing theory with people suffering from serious mental disorder.
PURPOSE. To describe Peplau's theory and its application using a case study.
SOURCE. Author's own clinical work.
CONCLUSION. Peplau's theory can be used to help patients resolve symptoms by guiding them through the steps of observation, description, analysis, formulation, validation, testing, integration, utilization.
Key words: Nurse-patient relationship, Peplau's interpersonal nursing theory, psychotherapy, schizophrenia, serious mental illness
In the age of managed care, we hear little about long-term psychotherapy with people experiencing serious mental illness (SMI). This is unfortunate, because despite the biopsychopharmacological movement, the number of those diagnosed with SMI has not decreased. While it is an accepted fact today that people who are depressed recover best with a combination of psychotherapy and medication, the same has not been documented for those suffering from schizophrenia. Many believe these people cannot be helped by psychotherapy. While many of us know anecdotally of patients who have recovered, we seldom read of these in the psychiatric nursing literature.
A person with serious mental illness suffers from symptoms over an extended period of time that constantly or intermittently remit and relapse. These symptoms seriously interfere with function and quality of life in such areas as work, social interaction, recreation, intimate relationships, and meeting community standards.
Dr. Hildegard Peplau introduced an interpersonal relations paradigm for the study and practice of nursing in the late 1940s and early 1950s (Peplau, 1995). The paradigm evolved from her work with H. Sullivan, E. Fromm, F. Fromm-Reichmann, other eminent clinicians, and her experience working with seriously mentally ill patients in public and private psychiatric hospitals (O'Toole & Welt, 1989). Her Interpersonal Relations Theory has had particular relevance and usefulness in understanding and intervening to reduce symptoms, re-establish relatedness, restore a sense of self-identity, improve function, and promote health.
Practicing psychotherapy at a public psychiatric hospital, I have found interpersonal theory and interventions useful for patients with a wide variety of diagnostic labels, including schizophrenia, depression, mood disorders, borderline personality disorders, and mild mental retardation. These interventions are useful both in one-to-one therapeutic relationships and milieu interventions. The theory and interventions provide an effective adjunct for psychopharmacology and psychiatric rehabilitation, particularly with people who have complex behavioral problems refractory to psychopharmacological intervention. My anecdotal clinical experience is not consistent with Beeber's (1995) contention that the Peplau model does not fit psychiatric nursing practice in inpatient settings. Employed as a certified specialist/nurse psychotherapist with an assigned caseload of patients with complex behavior problems and as Assistant Director of Nursing responsible for milieu intervention, I sought to answer Beeber's questions:
* How do phenomena/patterns within a person's life experience create problems for the person?
* What are the contextual variables that affect the person?
* What strategies in the one-to-one relationship are effective in intervening with people experiencing these problems?
I discovered that patients are able to identify patterns and contextual variables through my use of the interpersonal paradigm and psychotherapeutic interventions suggested by Peplau (1989a, b; 1995, 1996b). This paper will briefly discuss concepts and definitions of Peplau's paradigm that help explain the reasons for the seriously mentally ill person's problems, and it concludes with a case presentation.
I will not make an effort to contrast the assumptions and expectations of this practice paradigm with the medical model, which relies primarily upon biology and neuroscience to explain etiology and pharmacological interventions to treat it. I agree with Barker & Reynolds (1996), Heifner (1996), Hummervoll (1996), Lego (1992; 1996a, b; 1997, in press), Peplau (1996a), and other nurses that the medical model may foster and result in a profound sense of hopelessness and helplessness for patients who seek recovery and the staff who work with them, while the interpersonal model creates self-direction.
The outcomes described are anecdotal in nature and not rigorously tested or contrasted with other methodology to assess effectiveness. However, I believe it is a beginning step in outcome research on the effectiveness of the nursing one-to-one relationship, especially within inpatient settings.
Peplau's Interpersonal Theory
Within Peplau's interpersonal paradigm, patients are regarded "as essentially rational, cognitive, and goal-directed beings who are capable of exercising self-control to achieve desired goals" (O'Toole & Welt, 1989, p. 361). A person's self system evolves from the mother or significant others' appraisals. These appraisals lead to self-views, self-images, self-worth, and self-esteem (Peplau, 1989c). The purpose of this self system is to reduce anxiety. When the person experiences severe anxiety, appraisals may emerge as derogatory, belittling, accusatory, blaming statements or delusions, hallucinations, and dissociation that are amenable to psychotherapeutic intervention (Peplau, 1996b).
Attributes gleaned from past events influence a person's expectations. When the person is disappointed, a repetition of earlier trauma occurs, creating anxiety and relief behaviors. Relief behaviors are viewed as pattern interactions and integration (Peplau, 1989a) essential to the functioning of the whole person. After time, they tend to become automatic and transpire without thought. I have observed patients using relief behaviors to ward off deep-rooted loneliness, a sense of abandonment, neglect, deprivation, and hopelessness that result first from the disturbed early interactions with significant others, and later from reinforcement by years in a public mental hospital without visitors. Arieti (1959b) asserted that a person's failure to adapt to the environment by developing the patterned relief behaviors should not be perceived as a negative characteristic. The important therapeutic work is to identify and describe the recurring and newly emerging patterns and determine, with the patient, how the behavior is driven by anxiety and maintains the dysfunctional self system.
Common Clinical Phenomena
I have found the following phenomena important in understanding the meaning of serious mentally illness:
Anxiety is defined as a response to stress, a subjective universal experience of discomfort following expectations that are not met, that energizes relief behaviors that can be observed, described, and understood (Peplau, 1989c). A person experiencing mild or moderate anxiety usually can focus attention and name the anxiety (Peplau). A person experiencing severe or panic anxiety has difficulty focusing attention, is not able to recognize the anxiety, and will resort to automatic relief behaviors such as withdrawal or dissociation (Peplau). For example, an anxious person may suddenly stop talking, grimace, look away, and begin moving her lips without speaking words.
Focal attention (Peplau, 1989e) is a person's ability to observe, notice an internal/external object (thing, idea, feeling), and make an effort to grasp the object intellectually.
Prototaxis is the absence of relational thought or association between ideas, and the ability to formulate connections and understand what antecedents exist. When in the prototaxic mode, the person, as in infancy, experiences no past or future. The person may repeat, "Give me a light, give me a light, give me a light." Once given the light, she may continue, "Give me a light, give me a light," and so forth.
Loneliness is defined as "an unnoticed inability to do anything while alone" (Peplau, 1989d, p. 256) as the result of early life experiences. When seriously mentally ill people experience loneliness or emptiness they may resort to fantasy, dissociation, hallucinations, or delusions to ameliorate or explain the recurrent experience. The person must deny the felt experience.
Hallucinations "consist of illusory figures, perceived as if they were real persons" when "interactions between the individual and autistically invented images or voices serve to maintain the self system" (Peplau, 1989c, p. 312). For example, a female patient mentioned wanting someone to be interested in her, began smiling at a bookcase, said she saw men smiling at her, and later decoded the experience by connecting the hallucination with her wish to be noticed.
Delusions are perceived as inadequate conclusions inferred from insufficient data about a stressful event. Delusions provide desperately needed relief from the person's self system appraisal. An example is a patient insisting her mother is dead. Exploration of this belief with "Who told you, what, when, where?" questions may result in a formulation of how this belief provides relief from anxiety.
Using Interpersonal Theory
Regardless of functional deficits such as difficulty focusing attention, remembering and describing specific situations, or communicating, interpersonal interventions are effective in clarifying behavior so it can be understood. An investigative approach that does not avoid exploring stressful situations but rather focuses upon the problems the person is experiencing is critical to the success of the therapy. This comes about by helping the patient through the steps of the learning process (Peplau, 1989e): observation, description, analysis, formulation, validation, testing, integration, utilization. Use of questions to promote description of specific episodes such as "Tell me exactly what happened before ... Whom were you with at that time? When did you begin to ...? How did you react to his question? What exactly did you say then?" are important interventions.
Promoting the use of the serious mentally ill person's capacity to use language to describe events influences thought, thought influences action, thought and action taken together evoke feelings in relation to a situation or context (Peplau, 1969). The feelings and thoughts used may be used to identify the reason and meaning of the person's behavior. As patients connect the current context with specific thought and feeling, they can begin to understand how their reaction may be related to self-appraisals such as I'm "bad," "no good," "not worthy of attention," "guilty," "ugly," "stupid" that are deeply held beliefs about the self (Peplau, 1996b). The purpose of interpersonal psychotherapeutic interventions is to explore the connection among the current situation, the self-appraisal, and resulting relief behavior, reducing the need to display relief behaviors and thus improving function.
Beginning the Psychotherapy
The clinical dilemma of initiating psychotherapy with a hospitalized person with serious mental illness and establishing relatedness while maintaining detachment, neutrality, and reducing self-disclosure has been explored (Beeber, 1995). What frequently emerges when initiating therapy in a long term hospital setting is the question "Why did you pick me?" I use a simple, straightforward approach: "You seem to be having some difficulties. It is part of my job to work with people who have such difficulties. I am available to work with you to focus on your experience and thoughts. I can meet with you once a week for 45 minutes to begin to explore specific situations so you can better understand what is taking place in you life."
I have found in my work that people are able to understand reasons for their behavior. I avoid labeling the person or establishing unrealistic expectations. The overt message is that the person is in charge of the therapy, therapy is important work that the person can take part in to get better, and the nurse therapist is available to begin the work with the person.
I believe it is very important to avoid re-creating disappointment from earlier relationships by maintaining strict detachment when questions arise about my significant others, children, vacations, residence, and so forth. Beeber (1995) wrote that patients are not satisfied with detachment and absence of self-disclosure by therapists. Others have concurred (Basescu, 1990; Jourard, 1971). I believe it is acceptable to provide brief, generic responses to such questions: "My daughter is 8 years old"; "Yes, I am divorced," without relying exclusively upon exploratory responses such as, "It is more important to focus upon describing your experience," "This is your therapy," or "What are you trying to avoid by asking about my daughter?" However, it is very important not to collaborate with the person in avoiding the work of therapy.
A patient I will call Joan had been hospitalized for six years when I initiated therapy at the request of the Treatment Team. She had begun to display assaultive behavior toward staff, frequently fell from her wheelchair or while ambulating, and did not respond satisfactorily to changes in her medication regimen. The patient experienced mood swings, delusions, and hallucinations as well. Therapy continued for approximately 200 sessions over a four-and-a-half-year period. Joan died in her sleep at the age of 50. The clinical phenomena as well as patterns and themes that emerged during therapy, the understanding she developed regarding the meaning of her experience in explaining her current mental health problems, and a brief review of outcomes will be discussed.
Therapy with Joan began by my suggesting we work on what was not going well for her. I waited for her to begin talking, and encouraged her to describe the details of specific events she mentioned. I used precise language such as, "Tell me who you were with. What did you say? When did you begin talking? Whom did you talk with first? Where were you when you began talking? When did you respond?" I asked, "Tell me about ..." instead of asking "Can you tell me ...?" to avoid infantilizing Joan.
During an early session, she said she was worried a peer, Linda, would attack her in the doctor's office. I asked, "Tell me about you and Linda." "What happened just before you entered the doctor's office?" "What did you think about just before you saw Linda?" She asked how much time was left in the session. I asked if there was something she was trying to avoid. I said "Let's try to figure what this is about."
Using specific questions prefaced with "Who, what, where, when, what did you think, do, feel?" to describe an event Joan mentioned promoted an active learning process. This process "utilizes the thinking and perceiving abilities and knowledge previously acquired for three major purposes: (1) acquiring new knowledge to explain events, (2) facilitating change, and (3) solving problems" (Peplau, 1989f, p. 348). The steps in this process include observing, describing, analyzing, formulating, validating, testing, integrating, and utilizing new behavior patterns (Peplau).
As Joan became more able to label anxiety and say she was feeling anxious, she often connected her anxious feelings to her father. This led me to ask her to tell me about one time when she was anxious with her father. This intervention connects the current felt experience of anxiety with a possible past experience with significant others, and prompts the patient to consider what connection may exist between the two events.
Requests for Nurturance
Joan often began sessions by requesting a cigarette, juice, or water. She said she was not able to provide these things for herself, fearing she would fall if she tried to walk. Initially I felt annoyed that she repeatedly asked for these items and would frame the request as an effort to avoid beginning to work during the session: "What is it you are trying to avoid by asking for juice at the beginning of each session?" In retrospect I realize I was decoding for myself the meaning of her behavior. Better questions might have been "What are you thinking now?" "What are you feeling?" and finally, "Tell me about a time in the past when you felt ..." The general pattern she was exhibiting was a need to be nourished by me and a belief she could not care for herself.
Perhaps in response to my failure to understand her, or to allow her to discover for herself the meaning of her behavior, she began a pattern of behavior I again found annoying. Joan would attempt to consume every drop of juice from the can by raising the can to her lips repeatedly long after it was empty. I began to realize that perhaps I was reacting to Joan's re-creating an experience of deprivation and neglect that she experienced with her parents and now with me. Once my countertransference was recognized, interventions such as "What do you think/feel about my giving you juice?" or "Tell me about a time when your father did not provide you with what you needed" were used to explore Joan's reaction to me and to connect it with a past experience of deprivation.
Identifying countertransference reactions can be useful in understanding contextual variables in the person's life. For example, Joan repeatedly requested a second cigarette during early sessions. I repeatedly denied the request and reiterated that Joan was avoiding therapy by insisting that she be given another cigarette. As I hardened my stance during the session, insisting that she was not focusing on the work, she became increasingly incensed about not being provided with another cigarette. We were in a power struggle that could have been resolved by trying to understand the meaning of the patient's behavior. "Tell me what you were thinking when you began to want a cigarette" and "What were you feeling?" My punitive, depriving response and Joan's reaction were not successfully explored or understood, but they may be seen as a re-creation of earlier deprivation.
Early on in our sessions Joan would suddenly smile, stop speaking, turn her head, and look over to a corner of the room. Sometimes her lips would move or she would converse overtly with the "vision" of Joey, an ex-boyfriend. The interpersonal paradigm hypothesizes that there is a specific connection between the situation when the hallucination occurs, the antecedents, felt anxiety, feeling, and the actual hallucination (Peplau, 1996b). Arieti (1959a) believed the person's inner experience is expressed as an external event when an hallucination occurs, and that the person's experience is amenable to understanding by use of specific interventions.
I attempted to explore the experience by asking Joan to describe exactly what occurred just before the hallucination: "Tell me about the so called vision you have of Joey in the corner," "You were talking about taking Joey home to your parents just before you began talking to the so-called vision of Joey in the corner," "Talk about exactly what you were thinking just before you began talking with the vision of Joey in the corner." Once the sequence of events is formulated and validated by the patient, it can be used to understand the meaning of the experience in terms of patterns that exist in the person's life.
One example occurred when Joan learned of layoffs in the hospital and feared I was going to leave. Around this time the Joey vision "occurred" in the corner of the room, and I asked what she was thinking and feeling. She replied, "I feel all alone," then immediately began conversing with Joey in the corner. The possible connection between her feeling and the hallucination was identified. The themes of loneliness and the belief she would be abandoned emerged as the hallucinatory experience was investigated.
Loneliness and Abandomnent
The themes of loneliness and abandonment often surfaced, as the patient had in reality been abandoned in the hospital, having few calls or visits from her family. She often stated, "I will never be nice again," "I'm ugly," "My father hurt me once," "I'm worse," "You aren't helping me." The intervention was to ask, "What happened?" "Who was there?" "When was it?" "Where was it?" that she first had these thoughts. After many sessions of this kind of exploration, she was finally able to express anger at her family for neglecting her.
Joan often stated, "My sister gets lots of attention." When I asked her, "Tell me about a time when your sister got attention," she invariably described her sister's wedding and her anger that day. This led over time to our formulation about her anger at her sister, and her own development of the sick role to garner the attention she so badly desired. This in turn led to the formulation that her falling and inability to walk were attempts to get this attention and "caring."
Joan also asked repeatedly about my vacations, once saying, "You didn't care about me" and "You needed a rest." I responded by asking, "What did you think/feel when I told you I was taking a vacation?" and eventually "Describe one time you believed your father neglected you." When reality situations, or unconscious countertransference led to my being late or postponing sessions, her thoughts and feelings were investigated with questions such as, "When did you notice I was not on time?" "What did you do/think/feel when you noticed?" Several times Joan noticed my eyelids sagging or closing with fatigue, and she complained she was being neglected. She also declared a few times that she was going to marry me and that she loved me. After much exploration using the questions "Who, what, when, where, what did you think? do? feel?" she was able to connect her wish to marry me to her loneliness and feelings of abandonment. Joan often talked of sex and becoming pregnant. After much exploration, she was able to formulate the notion that if she were pregnant, the baby inside couldn't leave and she wouldn't be alone.
Joan often spoke about her younger sister who was married with two children. Though she lived only two hours away, she only visited once or twice a year and never took Joan out on pass. Statements such as "I love her," "She's such a pretty sister," "I hate her" indicated deep ambivalence about her sister.
Interventions such as "Tell me about one time you thought your sister was better than you" were an effort to promote more description of the disappointments, label the feelings, and begin to understand how the disappointment in her sister related to her current behavior. She was eventually able to formulate feelings of envy, jealousy, and betrayal, in relation to her sister.
The clinical dilemma of how to effectively maintain neutrality while helping the patient explore the transference was highlighted by Joan's reaction to my separation and divorce that began around session number 100. About six weeks after the separation/divorce process began, Joan began asking, "What's wrong?" noticing my weight loss and saying "You look tired," or "Remember, life is what you make of it." Joan asked about my wife: "I hear she is beautiful," and noticed the wedding band was no longer on my ring finger. I failed to take advantage of this opportunity to explore Joan's reaction. This was significant since her own parents divorced when she was an adolescent.
Several months after Joan noticed the changes in me she suddenly said, "You care more about her than me." It became clear that Joan feared I would leave her as her father and her mother left her and as I myself had separated from my wife. She explored this, concluding, "I know you care about me." The recognition and naming of the experience of being abandoned was important and was further explored two months later when I did validate that I was divorced.
Another pattern that manifested during therapy with Joan was her fear of being attacked at night while in bed, belief that other patients were trying to physically hit her, and statements about her father that described deep ambivalence: "All my life I have hated him," "He's a psychopath," "I love my father." As the therapy progressed, Joan described a situation in a bathroom at age 13 when her father physically and sexually abused her. When Joan began describing the situation in the bathroom, I used investigative questions (who, what, where, when) to promote further description of the episode and access memory of the trauma. Initially, I did not attempt interpretation of Joan's emotional reaction to the situation.
As mention of the interaction in the bathroom became more frequent, Joan indicated that while having sex with her father was a way of getting his special attention, it ultimately led to feelings of anger, deep loneliness, abandonment, and failure to trust. As Joan continued to describe situations when she believed peers were trying to hit her, questions such as "How is that similar to your father hitting you?" "Talk about when your father hit you" were an effort to promote Joan's understanding of how past experience was contributing to current fears about trusting others. It is important to use interpersonal interventions that initially promote observation, description, and analysis before attempting to use formulation to connect the current situation with past problems.
The use of the interpersonal paradigm within a one-to-one therapeutic relationship with Joan was successful in determining how her life experience had created problems for her. Toward the end of therapy Joan made the following statements: "This stage of sickness is over," "I did this on my own," "Symptoms of being a child are over," "Reconciliation with my family may not be possible," "I've been hopeless for a long time now, getting out of it now," "What happened with my father doesn't make sense," "I'm starting to understand," "I came out of it," "He didn't want me as a daughter," "I forgive him."
By this time Joan had begun to understand the meaning of her experience, was able to use her capacity and competence to identify and label anxiety and other feelings, and understood the connection between her experience of anxiety, her behavior, and her sense of loneliness and abandonment. My clinical experience with other people within a long-term, inpatient, one-one therapeutic relationship has produced similar results, especially with people who have very complex clinical etiology and resulting behavior problems.
The results of my work with patients with severe mental illness using Peplau's interpersonal nursing theory suggest patients can experience dramatic symptom reduction. This comes about by the process of helping patients to observe, describe, analyze, formulate, validate, test, integrate, and use new behavior. Questions that help patients begin to observe and describe their behavior are "Who? What? When? Where? What did you think? Do? Feel?" In settings that allow for long-term psychotherapy, the nurse psychotherapist can use this model to produce long-term change.
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Burton L. Thelander, MS, RN, CS, is Assistant Director of Nursing, Middletown Psychiatric Center, Middletown, NY, and Chairperson, the Network of New York Clinical Specialists in Psychiatric/Mental Health Nursing.…
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Publication information: Article title: The Psychotherapy of Hildegard Peplau in the Treatment of People with Serious Mental Illness. Contributors: Thelander, Burton L. - Author. Journal title: Perspectives in Psychiatric Care. Volume: 33. Issue: 3 Publication date: July-September 1997. Page number: 24+. © Nursecom, Inc. Jan 2009. COPYRIGHT 1997 Gale Group.