Mental Healthcare Delivery System in the Philippines PDF

CARE OF CLIENTS WITH MALADAPTIVE BEHAVIOR MENTAL HEALTHCARE DELIVERY SYSTEM IN THE PHILIPPINES AND ITS IMPORTANCE AND IMPACT IN THE COMMUNITY  National information on mental health services in the STRUCTURE OF THE SYSTEM P...

CARE OF CLIENTS WITH MALADAPTIVE BEHAVIOR MENTAL HEALTHCARE DELIVERY SYSTEM IN THE PHILIPPINES AND ITS IMPORTANCE AND IMPACT IN THE COMMUNITY  National information on mental health services in the STRUCTURE OF THE SYSTEM Philippines indicates that there are substantial gaps and inconsistencies in the delivery of mental healthcare. 1. Governmental Framework  The recently enacted Mental Health Act legislation National Center for Mental Health (NCMH): The provides a platform for the delivery of comprehensive NCMH is the primary government mental health and integrated mental health services. However, there facility, providing specialized services and serving remain many challenges in the provision of accessible as a referral center for complex cases. and affordable mental healthcare. Regional and Local Hospitals: Several regional and local hospitals have psychiatric units or STATISTICS departments that provides mental health services. The World Health In the Philippines: Barangay Health Centers: These centers are the Organization (WHO) frontline in the health system, offering basic mental estimates that: health services and referrals to higher levels of care. Community-based services are increasingly 154 million people 60% of people integrated into these centers. suffer from depression attending primary care 2. Legal Framework 1 million from clinics daily are estimated to have one Mental Health Act (Republic Act No. 11036): schizophrenia Enacted in 2018, this law is the cornerstone of the 877,00 people die by or more Mental, Neurological, mental health care delivery system in the suicide every year Philippines. It mandates the integration of mental 50 million people Substance use (MNS) disorders (2004) health services into the public health system, suffer from epilepsy protects the rights of people with mental health 24 million form Mental illness and conditions, and promotes mental health education. Alzheimer’s disease mental retardation rank 3rd and 4th PhilHealth Coverage: The national health and other dementia insurance program covers certain mental health 15.3 million person respectively among services, making them more accessible to the with drug use disorder the types of disabilities in the country (2000) general population. 3. Public and Private Sector Collaboration Epilepsy accounts for 33.44% of adult and Private Hospitals and Clinics: These facilities 66.20% of pediatric provide mental health services. Often catering neurologic out-patient those who can afford out-of-pocket expenses or visits per year. (2014) have comprehensive health insurance. Drug use prevalence Non-Governmental Organizations (NGOs): among Filipinos aged NGOs plays a critical role in advocating for mental 10 to 69 years old is at health, providing services, and raising awareness. 2.3% or an estimated They often fill gaps in areas where government 1.8 million users (2015 services are limited. IMPORTANCE OF MENTAL HEALTH CARE DELIVERY In the Philippines: SYSTEM 16 % of students between 13-15 years old have 1. Improving Overall Public Health ever seriously considered attempting suicide – Mental health is a critical component of overall (2011) health. Effective mental health care reduces the Intentional self-harm is the 9th leading cause of burden of mental illnesses, which can lead to a death among the 20-24 years old (DOH, 2003) reduction in associated health problems, such as A study conducted among government employees substance abuse, chronic physical conditions, and in Metro Manila revealed that 32% out of 327 even suicide. respondents have experienced a mental health – Addressing mental health issues early and problem in their lifetime (DOH, 2006) effectively can prevent the progression of mental Based on Global Epidemiology on Kaplan and illnesses and reduce the long-term impact on Sadock’s Synopsis of Psychiatry, 2015 and individuals and communities. Kaufman’s Clinical Neurology for Psychiatrists, 7th 2. Promoting Social and Economic Development Edition, 2013 – Mental health disorders contribute significantly to a. Schizophrenia: 1% 1 million the global burden of disease and disability. By b. Bipolar 1% 1 million improving mental health care, the country can c. Major Depressive Disorder 17% 17 million enhance the productivity and well-being of its d. Dementia 5% (of older than 65) population, which is crucial foe social and e. Epilepsy: 0.6% 600,000 economic development. – Mental health care reduces absenteeism, increases work productivity, and enhances the overall quality of life, contributing positively to the economy. 1 | 18  CARE OF CLIENTS WITH MALADAPTIVE BEHAVIOR MENTAL HEALTHCARE DELIVERY SYSTEM IN THE PHILIPPINES AND ITS IMPORTANCE AND IMPACT IN THE COMMUNITY 3. Reducing Stigma and Discrimination Sustainable Development emphasize the importance of – A well-structured mental health care system, mental health for global development and advocate for combined with public education and awareness increase investment and attention to mental health campaigns, helps reduces the stigma associated issues worldwide. with mental illness. This encourages more people to seek help early, reducing the severity of mental DOH MENTAL HEALTH PROGRAM IN THE health conditions. PHILIPPINES – The Mental Health Act also provides legal protection for individuals with mental health OBJECTIVES conditions, helping to combat discrimination in the workplace, schools, and other social settings. 1. To promote participatory governance and 4. Building Resilient Communities leadership in mental health. – Community-based mental health services help 2. To strengthen coverage of mental health services build resilient communities by ensuring that mental through muti-sectoral partnership to provide high health care is accessible at the grassroots level. quality service aiming at best patient experience in These services are crucial in promoting mental a responsive service delivery network. wellness, preventing mental health issues, and 3. To harness capacities of LGUs and organized providing timely interventions. groups to implement promotive and preventive – Mental health care delivery in communities also interventions on mental health. empowers local population by involving them in 4. To leverage quality data and research evidence for mental health promotion and prevention efforts, mental health. fostering a sense of collective responsibility and 5. To set standards for compliance in different support. aspects of services. PROGRAM COMPONENTS IMPACT OF THE MENTAL HEALTH CARE DELIVERY SYSTEM IN THE COMMUNITY Wellness of Daily Living – All health/social/poverty reduction/safety and 1. Increased access to care 2. Early detection and intervention security programs and the like are protective 3. Empowerment and Education factors in general for the entire population. 4. Improved Quality of Life – Promotion of healthy lifestyle, prevention and control of diseases, family wellness programs, etc. GLOBAL MENTAL HEALTH CARE DELIVERY SYSTEM – School and workplace health and wellness programs CHALLENGES: Extreme Life Experience – Provision of mental health and psychosocial Global Burden support (MHPSS) during personal and community – Mental health disorders contribute to a significant wide disasters portion of the global burden of disease, particularly Mental Disorder in terms of years lived with disability. Neurologic Disorders Treatment Gap Substance Abuse and Other Forms of Addiction – A substantial gap exists between those who need – Provision of services for mental, neurologic, and mental health care and those who receive it. This substance use disorders at primary level from gap is especially pronounced in low- and middle- assessment treatment and management to income countries. referral; and provision of psychotropic drugs which – Stigma and Discrimination: Mental health stigma is are provided for free. a global issue, affecting people’s willingness to – Enhancement of mental health facilities under seek help and the quality of care they receive. HFEP – Workforce Shortages: There is a global shortage of trained mental health professionals, which PARTNER INSTITUTIONS exacerbates the treatment gap. National Government Agencies: DOLE, DSWD, INNOVATIVE APPROACHES DepEd, Tesda, CHED, CILG) Non-government Organizations: WHO, PVA, Telemedicine: Telehealth and digital mental health PAP, PNA, PLAE, AWIT Foundation, WAPR, NGF services have grown in response to the COVID-19 pandemic, helping to bridge the gap in mental health POLICIES AND LAWS care delivery. Task-shifting: In resource-limited settings, non- DOH Administrative Order No. 2016-0039 specialist health workers are trained to deliver basic Revised Operational Framework for a mental health care, a strategy known as task-shifting. comprehensive National Mental Health Program This approach has been successful in improving access to care in some countries. This policy aims to: Global Mental Health Movements: Initiatives such as the Lancet Commission on Global Mental Health and 2 | 18  CARE OF CLIENTS WITH MALADAPTIVE BEHAVIOR MENTAL HEALTHCARE DELIVERY SYSTEM IN THE PHILIPPINES AND ITS IMPORTANCE AND IMPACT IN THE COMMUNITY Guide all program managers, health care Prioritizes the promotion of mental health, protection of providers, various stakeholders, at all levels of the rights and freedoms of persons with mental care on the implementation of mental health diseases and the reduction of the burden and program. consequences of mental ill-health, mental and brain Define the roles and responsibilities of different disorders and disabilities. DOH offices and PHIC. Republic Act No. 11036 “Mental Health Act” TREATMENT FACILITIES FOR MENTAL ILLNESS An act establishing a National Mental Health policy for the purpose of enhancing the delivery of integrated mental The government currently runs the following mental facilities health services, promoting and protecting the rights of in the country: persons utilizing psychosocial health services, appropriating funds therefore and other purposes. Search niyo na lang public hospitals whsh The objectives of this Act are as follows: Private hospitals that offer mental care services: Strengthen effective leadership and University of Santo Tomas governance for mental health by, among Makati Medical Center others, formulating, developing, and University of the East Ramon Magsaysay Memorial implementing national policies, strategies, Medical Center programs, and regulations relating to mental Metro Psychotherapy Facility health. Nearby provinces like Bulacan, Laguna, and Rizal Develop and establish a comprehensive, have its fair share of mental facilities, too. integrated, effective, and efficient national mental health care system responsive to the MENTAL HEALTH ACT (R.A. 11036) psychiatric, neurologic, and psychosocial Seeks to establish access to comprehensive and needs of the Filipino people. integrated mental health services, while protecting the Protect the rights and freedoms of persons rights of people with mental disorders and their family with psychiatric, neurologic, and psychosocial members (Lally, et.al., 2019) health needs. Strengthen information systems, evidence and MENTAL HEALTH SERVICES research for mental health: Integrate mental health care in the basic health Budget Facilities Issues services; and Only 3-5% of 1.08 mental Overcrowding Integrate strategies promoting mental health in the total health health beds Poorly educational institutions, the workplace, and in budget is in general functioning communities. spent on hospitals and units mental health, 4.95 beds in Chronic staff Administrative Order No. 2021-0012 and 70% of psychiatric shortages Implementing Guidelines on the Medicine Access this is spent on hospitals per Funding hospital care 100,000 of constraints Program for Mental Health (MAP-MH) (WHO & DOH, the This order aims to: 2006). population (WHO, Increase service user’s access to quality 2014). essential medicines in the treatment of various National mental, neurologic, and substance use (MNS) Center for disorders, taking into consideration rational Mental drug use and availability up to the grassroots Health in level. Mandaluyong Establish a functional electronic information City, Metro management system for MAP-MH. Manila (4200 Improve primary health care in the poorest beds) and the communities by addressing the needs of the Mariveles population for essential medicines as part of Mental primary and secondary prevention of MNS Hospital in disorders. Bataan, Conduct efficient monitoring and evaluation of Luzon (500 the utilization of essential medicines for MNS beds) disorders. DOH Administrative Order No. 8 Series or 2001 the “National Mental Health Policy” 3 | 18  CARE OF CLIENTS WITH MALADAPTIVE BEHAVIOR PSYCHOBIOLOGIC BASES OF BEHAVIOR NEUROSCIENCE: BIOLOGY AND BEHAVIOR NEUROANATOMY AND NEUROPHYSIOLOGY THE BRAIN A. NEURON Cerebrum – The largest part of the brain that controls – Also called neurons or nerve cells. intelligence, memory, personality, emotion, speech, and – A specialized cell designed to transmit information ability to feel and move. It is made up of two hemispheres: to other nerve cells, muscle, or gland cell. (They are the fundamental units of the brain and nervous Left hemisphere controls the right side of the body system.) Right hemisphere controls the left side of the body Each hemisphere is divided into four lobes: 1. Frontal lobes 2. Temporal lobes 3. Parietal lobes 4. Occipital lobes Cerebellum – located below the cerebrum and is the center for coordination of movements and postural adjustments. It receives and integrates information from all areas of the body, such as the muscles, joints, organs, and other components of the CNS. Brain Stem – includes the midbrain, pons, and medulla oblongata and the nuclei for cranial nerves III through XII. FUNCTIONS Medulla oblongata contains vital centers for respiration and cardiovascular functions. Dendrites Pons bridges serving as a primary motor pathway. – Acquiring chemical impulse from other cells Limbic System – located above the brain stem that includes and neurons. the thalamus, hypothalamus, hippocampus, and amygdala – Converting the chemical signals into electrical impulses Thalamus regulates activity, sensation, and – Carrying electrical impulses towards the next emotion. part of the neuron, the cell body. Hypothalamus is involved in temperature regulation, appetite control, endocrine function, Cell Body/Soma sexual drive, and impulsive behavior associated – Supporting and organizing the functions of the with feelings of anger, rage, or excitement. whole neuron. Hippocampus and amygdala are involved in – Joining the signals received by the dendrites emotional arousal and memory. and passing them to the axons, the next part THE SPINAL CORD of neuron. The spinal cord is protected with bony vertebrae of our Axon backbone. – Helps receive signals from other neurons and Cerebrospinal fluid – a third form of protection transmit the outflow of the message to the Carries messages back and forth between the brain and adjacent connected neurons, other muscles the nerves that run throughout the body. and glands. – Myelin Sheath insulates the axon and thus Spinal cord has three sections: prevents shock and increases the speed of the 1. The cervical spinal cord sends nerves to the face flow of signals through the axon. and neck. – Nodes of Ranvier allows diffusion of ions in 2. The thoracic spinal cord sends nerves to the and out of the neuron and thus maintains the arms, chest, and abdomen. electrical potential of the neuron. 3. The lumbar-sacral spinal cord sends nerves to the lower body. B. CENTRAL NERVOUS SYSTEM  Comprises the brain, the spinal cord, and associated nerves that control voluntary acts.  The body’s processing center. 1. Grey Matter – made up of neurons, cells, and blood vessels. 2. White matter – made up of axons, which are long cords that extend from the neurons. 4 | 18  CARE OF CLIENTS WITH MALADAPTIVE BEHAVIOR PSYCHOBIOLOGIC BASES OF BEHAVIOR NEUROSCIENCE: BIOLOGY AND BEHAVIOR C. MEMORY, REPETITION, LEARNING Histamine Neuromodulator Controls alertness, NEUROTRANSMITTER gastric secretions, cardiac stimulation, MEMORY peripheral allergic responses Major Classifications: Acetylcholine Excitatory or Controls sleep and Sensory Short-term Long-term inhibitory wakefulness cycle; They are Small Refers to signals muscles to from our five amount of unlimited become alert senses information storage Neuropeptides Neuromodulator Enhance, prolong, Stored onlyin the mind information inhibit, or limit the for as longand keep it to be effects of principal as readily the maintained neurotransmitters senses available for is for long Glutamate Excitatory Results in stimulated a short periods, neurotoxicity if period of even for life. levels are too high time. y-Aminobutyric Inhibitory Modulates other REPETITION AND LEARNING acid neurotransmitters A process where it creates long term memory by eliciting or enacting strong chemical interactions at the synapse of your neuron (where neurons connect to other neurons). Creates the strongest learning- and most learning NEUROTRANSMISSION  The process where neurotransmitters fit into specific receptor cells embedded in the membrane of the dendrite, similar to a lick-and-key mechanism. NEUROTRANSMITTER  Are the chemical substances manufactured in the neuron that aid in the transmission of information throughout the body.  Either excite or stimulate an action (excitatory) or stop an action (inhibitory). Neurotransmitter Mechanism of Physiologic action Effects Dopamine Excitatory Controls complex movements, motivation, cognition; regulates emotional response Norepinephrine Excitatory Causes changes in (noradrenaline) attention, learning and memory, sleep and wakefulness, mood Epinephrine Excitatory Controls fight or (adrenaline) flight response Serotonin Inhibitory Controls food intake, sleep and wakefulness, temperature regulation, pain control, sexual behaviors, regulation of emotions 5 | 18  CARE OF CLIENTS WITH MALADAPTIVE BEHAVIOR PSYCHOBIOLOGIC BASES OF BEHAVIOR NEUROSCIENCE: BIOLOGY AND BEHAVIOR CONCEPTS AND PATTERNS OF HUMAN BEHAVIOR 4. FAMILY ROLES AND RESPONSIBILITIES Peacekeeper FAMILY DYNAMICS Scapegoat: A member of the family is chosen as  Patterns of interactions among relatives, their roles and the black sheep or the scapegoat who bears the relationships, and the various factors that shape the collective sins of the rest of the family, thereby interactions. acting as a “release” mechanism for unresolved issues. 6 TYPES OF FAMILY DYNAMICS Caretaker Mascot: a.k.a. the “front man of the family who uses 1. Authoritarian: All about following the rules without humor, achievements, talents or personality traits any exceptions. In this family dynamic, one family to ease the stress and divert attention away from member is very controlling. They expect others to any difficulties. follow them without negotiation or questioning. Hero: Uses achievement and talents to distract 2. Authoritative: Authoritative dynamic involves Lost child: One or more family member “fly under rules and consequences. One individual sets the the radar” by keeping quiet and keeping to rules while validating other family members’ themselves. feelings and respecting the opinions. 3. Competitive: Family members are continuously 5. FAMILY MEMBER GOALS competing with one another. There Is a sense of 6. FAMILY VALUES rivalry within the household, as members try to  Family’s behavioral and moral values affect overall outshine their relatives. This competition could ne family structure. Families with members who share for many things such as attention, recognition, or very similar values likely prioritize similar things, power. which can have a positive effect on family 4. Uninvolved: Family members aren’t present to dynamics. one another. Individuals don’t really know what the oner members of the family are doing. There is 7. DISABILITIES/SPECIAL NEEDS IN THE FAMILY often a lack of support and guidance.  This unique family situation often comes with 5. Communal: Emphasized the family as a increased stress on the family, even in young community in which every member makes a children who may not understand the situation contribution. Individual opinions are respected, and entirely. The family unit will need to learn to all voices are heard. cooperate with another to form healthy 6. Alliance-based: Alliance-based dynamics lead to relationships. members of the family grouping together and playing off each other. Certain family members 8. FAMILY EVENTS, HARDSHIP, OR TRAUMA form alliances in order to gain leverage over other members of the family. They agree to work together FUNCTIONAL FAMILIES for mutual interest. This can be explicit or implied. 1. Functional families carry out effectively their 8 FACTORS AFFECTING FAMILY DYNAMICS economic function. 2. Apply a fair distribution of activities so that each 1. FAMILY STRUCTURES member is responsible for its implementation and does not overload a single person with all duties. 6 Types of Families 3. There’s a sense of belonging to their family and at Childless Family: couple without children the same time the family stimulate the personal Nuclear Family: two parents with one or more identity and autonomy of each of its members. children 4. Apply clear limits, psychological boundaries that other members should not overcome and ensure Single-parent Family: one parent with one or more good coexistence at home. children 5. There is flexibility that facilitates arrangements and Blended Family: Two or more related adults, like an solutions based on family well-being. adult child and their parent, living together to raise 6. There is an adequate distribution of hierarchy children or grandchildren levels. Grandparent Family: Grandparent(s) who care for 7. Clear communication where all members can and raise their grandchild(ren) express what they think and feel assertively and without harming others. 2. FAMILY MEMBERS PERSONALITIES 8. Each member feels accepted within the family  Personalities could create positive dynamics in where he finds an emotional security source. which everyone feels care for, secure, respected, 9. The family grows alongside its members, so the but they can also clash to the __ of creating toxic or mistakes are learning experiences that strengthen narcissistic family dynamics. them. 10. Ther family is flexible enough to adapt to 3. FAMILY RELATIONSHIPS: PAST AND PRESENT circumstances. 6 | 18  CARE OF CLIENTS WITH MALADAPTIVE BEHAVIOR PSYCHOBIOLOGIC BASES OF BEHAVIOR NEUROSCIENCE: BIOLOGY AND BEHAVIOR DYSFUNCTIONAL FAMILIES 1. Promote the over-dependence of some of its members. 2. Establish a too open relationship so the family feelings are canceled. 3. It does not apply clear rules and limits so that members do not know what their duties and rights are. 4. It does not respect the generational distance and reverse the hierarchy of power. 5. At the base of dysfunctional families there are often communication problems. Members do not want to express their feelings or ideas. 6. Applies rigid roles and behavior patterns that prevent members from adapting to change. B. FRUSTRATION AND CONFLICT 7. Its members are not empathetic and sensitive to others. FRUSTRATION 8. There is a low level of tolerance. 9. Practice bad behaviors, such as humiliation,  Results when stress becomes sufficiently great and contempt or the lack of respect. reaches a point above the threshold of the individual. 10. There are models of emotional manipulation through which family members are controlled. MAJOR RESPONSES TO FRUSTRATION PATTERNS OF BEHAVIOR 1. Aggression – a response which represents some form of attack and is in general destructive.  Behavior pattern is a recurrence of two or more 2. Resignation – an individual retreats from the responses which occur in a prescribed arrangement or source of frustration. order consciously and unconsciously. 3. Regression – an individual shows some childish quality in attempt to revert once effecting form of TYPES OF BEHAVIOR PATTERNS coping behavior. Fixed Behavior Patterns: Sequences of innate 4. Fixation – a response which is strong and behavior that are often performed in a seemingly persistent, and which cannot be changed by usual fixed and stereotypical manner. methods of retraining. Growth Behavior Patterns: Growth behavior CONFLICT patterns are when someone slowly changes their behavior over time. These types of behavior  Mental struggle resulting from incompatible or opposing patterns are characterized by a gradual change. needs, drives, wishes, or external or internal demands Waves Behavior Patterns: Waves behavior patterns are when someone’s behavior peeks and C. ANXIETY, ANXIETY DISORDERS troughs over time. Cycles Behavior Patterns: Cycles behavior  Anxiety is an emotion characterized by feelings of patterns are when someone’s behavior goes in tension, worried thoughts and physical changes like complete cycle before. increased blood pressure. (American Psychological CONCEPTS OF HUMAN BEHAVIOR Association)  Anxiety is a normal reaction to stress and can be A. NEEDS beneficial in some situations. Anxiety disorders differ from normal feelings of nervousness or anxiousness A psychological feature that prompts an individual to and involve excessive fear or anxiety. take action toward a goal and the purpose for the action,  Anxiety also refers to anticipation of a future concern giving purpose and guidance for behavior. and is more associated with muscle tension and avoidance behavior.  Anxiety disorders can cause people to try to avoid situations that trigger or worsen their symptoms.  In general, for a person to be diagnose with an anxiety disorder, the fear of anxiety must: - Be out of proportion to the situation or age- inappropriate - Hinder ability to function normally 7 | 18  CARE OF CLIENTS WITH MALADAPTIVE BEHAVIOR PSYCHOBIOLOGIC BASES OF BEHAVIOR NEUROSCIENCE: BIOLOGY AND BEHAVIOR  The duration or severity of an anxious feeling can TYPES OF ANXIETY sometimes be out of proportion to the original trigger or stressor. Generalized anxiety disorder  The APA describes a person with anxiety disorder as Panic disorder “having recurring intrusive thoughts or concerns.” Once Specific phobia anxiety reaches the stage of disorder, it can interfere Agoraphobia with daily function. Selective mutism  Anxiety disorders comprise a group of conditions that Social anxiety disorder, or social phobia share a key feature of excessive anxiety with ensuing Separation anxiety disorder behavioral, emotional, cognitive, and physiological responses. POSSIBLE CAUSES OF ANXIETY ANXIETY AS A RESPONSE TO STRESS Environmental stressors Genetics Stress is the wear and tear that life causes on the body. Each Medical factors person handles stress differently; one person can thrive in a Brain chemistry situation that creates great distress for another. Withdrawal from an illicit substance Hans Selye (1957, 1974), and endocrinologist, identified the SYMPTOMS physiological aspects of stress, which he labeled general adaptation syndrome. Restlessness, and a feeling of being “on-edge” 1. ALARM REACTION STAGE: Stress stimulates the Uncontrollable feelings of worry body to send messages from the hypothalamus to Increased irritability the glands and organs to prepare for potential Concentration difficulties defense needs. Sleep difficulties, such as problems in falling or staying 2. RESISTANCE STAGE: The digestive system asleep reduces function to shunt blood to areas needed for TREATMENT defense. 3. EXHAUSTION STAGE: Occur when the person 1. Self-Treatment has responded negatively to anxiety and stress; It is the first step toward addressing anxious feelings Autonomic nervous system responses to fear and anxiety and often involves several exercises and actions to help generate the involuntary activities of the body that are a person cope with milder, more focused, or shorter- involved in self-preservation. Sympathetic nerve fibers term anxiety disorders, including: “charge up” the vital signs at any hint of danger to prepare the body’s defenses. – Stress management – Relaxation techniques PHYSIOLOGIC RESPONSE: Anxiety causes – Exercises to replace negative thoughts with uncomfortable cognitive, psychomotor, physiological positive ones responses, such as difficulty with logical thought, – Support network increasingly agitated motor activity, and elevated vital signs. – Exercise Negative responses to anxiety can result in maladaptive behaviors. 2. Counseling and therapy: This can include LEVELS OF ANXIETY psychotherapy, cognitive-behavioral therapy (CBT), or a combination of therapies. Mild Anxiety is a positive state of heightened 3. Medications: Several types of medications can support awareness and sharpened senses. Sensory stimulation the treatment of an anxiety disorder. These include increases and helps the person focus attention to learn, tricyclic medications, antidepressants, solve problems, think, act, feel, and protect him or benzodiazepines, and beta-blockers. herself. PREVENTIONS Moderate Anxiety involves a decreased perceptual field; the person can learn new behavior or solve Reduce intake of caffeine, tea, cola, and chocolate. problems with assistance. Another person can redirect Before using over the counter (OTC) or herbal the person to the task. remedies, check with a doctor or pharmacist for any Severe anxiety involves feelings of dread or terror. The chemicals that may make anxiety symptoms worse. person cannot be redirected to a task; he or she focuses Maintain a healthy diet. only on scattered details and has physiologic symptoms Keep a regular sleep pattern. of tachycardia, diaphoresis, and chest pain. Avoid alcohol, cannabis, and other recreational drugs. Panic anxiety can involve loss of rational thought, delusions, hallucinations, and complete physical immobility and muteness. 8 | 18  CARE OF CLIENTS WITH MALADAPTIVE BEHAVIOR PSYCHOBIOLOGIC BASES OF BEHAVIOR NEUROSCIENCE: BIOLOGY AND BEHAVIOR D. PATTERNS OF ADAPTATION resources, intolerance of violence, support of diversity among people, mastery of environment, a positive (yet realistic) view of one’s world.  Adaptation is a concept in the theory of evolution that is a trait in an organism that evolved through natural selection to serve a specific function.  Mental Illness can be caused by chemical imbalances in the brain, by transfer of drugs across the placenta  The term adaptation can also be used colloquially to barrier, or by organic changes within the brain. The refer to healthy behavioral changes. disorder is not limited to relation between the person  The term adaptation can also be used to describe and society. The illness is characterized by symptoms behaviors that serve a person well. The term sometimes and/or impairment in functioning. refers to deliberate changes in response to the environment. MENTAL HEALTH MENTAL ILLNESS Accepts self and others Feels inadequate; has poor PHYSIOLOGIC ADAPTATION self-concept Is able to cope with or Is unable to cope  A productivity toward a certain behavior or thought tolerate stress pattern. Can return to normal Exhibits maladaptive GENERAL ADAPTATION SYNDROME functioning if temporarily behavior disturbed Is able to form long and Is unable to establish a  Alarm reaction – “fight or flight” response lasting relationships meaningful relationship  Resistance – balancing hormones and Uses sound judgment to Displays poor judgment physiological response make decisions  Exhaustion – body’s alarm reaction was triggered Accepts responsibility for Is irresponsible or unable actions to accept responsibilities HEDONIC ADAPTATION for actions Optimistic Pessimistic  “hedonic treadmill” Recognizes limitations Does not recognize  Research-proven tendency of people to revert fairly (abilities and deficiencies) limitations quickly to stable levels of happiness after a painful Can function effectively Exhibits dependency or pleasurable event and independently needs because of feelings of inadequacy ROY ADAPTATION Is unable to distinguish Is unable to perceive reality imagined circumstances  Physiologic mode – responses from reality  Self-concept – defines Is able to develop potential Does not recognize  Role function – position and talents to the fullest potential and talents  Interdependence – relationships extent because of poor self- concept CONCEPTS OF MENTAL HEALTH AND MENTAL Is able to solve problems Avoids problems rather ILLNESS than coping with them or attempting to solve them  Mental health is a positive state in which one is Can delay gratification Desires or demands responsible, displays self-awareness, is self-directive, immediate gratification is reasonably worry-free and can cope with usual daily tensions.  Cultural beliefs influence how mental health and mental illness are determines. For instance, acceptable CRISIS behavior in one cultural group may or may not be  Crisis is a turning point in an individual’s life that tolerated in another group. produces an overwhelming emotional response; FACTORS INFLUENCING MENTAL HEALTH wherein, the use of customary coping skills are not effective. Individual or personal factors – biologic makeup,  Crisis is self-limiting. The crisis does not last indefinitely autonomy and independence, self-esteem, but usually exists for 4-6 weeks. capacity for growth, vitality, ability to find meaning STAGES OF CRISIS in life, emotional resilience, hardiness, sense of belonging, reality orientation, and coping/stress The person is exposed to stressor, experiences management capabilities. anxiety and tries to cope in a customary manner. Interpersonal or relationship factors – effective Anxiety increases customary coping skills are communication, ability to help others, intimacy, and ineffective a balance of separateness and connectedness. The person makes all possible efforts to deal with Social/Cultural or Environmental factors – the stressor, including attempts at new methods of sense of community, access to adequate coping 9 | 18  CARE OF CLIENTS WITH MALADAPTIVE BEHAVIOR PSYCHOBIOLOGIC BASES OF BEHAVIOR NEUROSCIENCE: BIOLOGY AND BEHAVIOR When coping attempts fail, the person experiences disequilibrium and significant distress. Crisis occur in response to lie situations/events and fall into three categories: Maturational crises or developmental crises are predictable events in normal course of life. Situational crises are unanticipated or sudden events that threatens the individual’s integrity. Adventitious crises or social crises include natural disasters, war, terrorist attack, riots and violent crimes. 3 factors that influence whether or not an individual experience a crisis: Individuals/s perception of the event The availability of emotional supports The availability of adequate coping mechanisms The crisis is resolved in the following ways: The person returns to precrisis level The person begins to function at a higher level The person’s functioning stabilizes at a level lower than precrisis functioning. CRISIS INTERVENTION Crisis intervention includes a variety of techniques based on the assessment of the individual. Direct interventions are designed to assess the person’s health status and promote problem- solving, such as offering new information, raising the person’s self-awareness and directing the person’s behavior. Supportive interventions aim at dealing with the person’s needs for empathetic understanding, such as encouraging the person to identify and discuss feelings. 10 | 18  CARE OF CLIENTS WITH MALADAPTIVE BEHAVIOR THERAPEUTIC MODELS AND ITS RELEVANCE TO NURSING PRACTICE PSYCHOANALYTIC MODEL PRECONSCIOUS SIGMUND FREUD  The preconscious level of the mind contains all those elements that are not conscious but can Developed psychoanalytic theory in the late 19thand become conscious either quitter readily or with early 20th centuries in Vienna some difficulty. His theory supports the notion that all human behavior  For example, an adult remembering what he or she is caused and can be explained (deterministic theory). did, thought, or felt as a child. Freud believed that repressed sexual impulses and  Freud believed that ideas could slip past the vigilant desires motivate much human behavior. censor and enter into the preconscious in a He developed his initial ideas and explanation of human disguised form. behavior from his experiences with a few clients (women) Sources of Preconscious Unusual displayed unusual behaviors such as disturbances of sight and speech, inability to eat, and Conscious Perception paralysis of limbs – What a person perceived is conscious for only a Freud considered them to be ”hysterical” or neurotic transitory period. behavior. – It quickly passes into the preconscious when the Many of their problems resulted from childhood trauma focus of attention shifts to another idea. or failure to complete tasks of psychosexual development. Unconscious The “hysterical” or neurotic behaviors resulted from these unresolved conflicts. – Ideas could slip past the vigilant censor and enter into the preconscious in a disguised form. LEVELS OF MIND OR HUMAN CONSCIOUSNESS Other images from q unconscious do gain admission to consciousness, but only because their true nature is UNCONSCIOUS cleverly disguised through the dream process, a slip of the tongue, or an elaborate defensive measure.  It contains all those drives, urges, or instincts that are beyond our awareness but that nevertheless CONSCIOUS motivate most of our words, feelings, and actions.  This realm includes most defense mechanisms and  Defined as those mental elements in awareness at some instinctual drives or motivations. any given point in time.  For example: A man may know that he is attracted  It is the only level of mental life directly available to to a woman but may not fully understand all the us. reasons for the attraction, some of which may even  Ideas can reach consciousness from two different seem irrational. directions: – Perceptual Conscious System: It is what we Because the unconscious is not available to the perceive through our sense organs, if NOT conscious mind, how can one know if it really exists? TOO THREATENING, enters into consciousness.  Freud felt that its existence could be proved only – Preconscious & Unconscious: It includes indirectly. nonthreatening ideas from the preconscious  To him, the unconscious is the explanation for the as well as menacing but well-disguised images meaning behind dreams, slips of tongue, and from the unconscious. certain kinds of forgetting, called REPRESSION.  Dreams serve as a particularly rich source of PERSONALITY COMPONENTS unconscious material.  For example, Freud believed that childhood THE ID experiences can appear in adult dreams even though the dreamer has no conscious recollection  At the core of personality and completely of these experience. unconscious is the physical region called the id.  According to Freud’s theories, the person  Id, a term derived from the impersonal pronoun represses the memory of traumatic events that are meaning “the it”, or the not-yet owned component too painful to remember into the unconscious. of personality.  REPRESSION: It occurs when a thought, memory,  The id has no contact with reality, yet it strives or feeling is too painful for an individual, so the constantly to reduce tension by satisfying basic person unconsciously pushes the information out of desires. consciousness and becomes unaware of its  Because sole function is to seek pleasure, we say existence. that the id serves the pleasure principle.  Example: A newborn infant is the personification of an id unencumbered by restrictions of ego and superego. The infant seeks gratification of needs without regard for what is possible (that is, 11 | 18  CARE OF CLIENTS WITH MALADAPTIVE BEHAVIOR THERAPEUTIC MODELS AND ITS RELEVANCE TO NURSING PRACTICE demands of the ego) or what is proper (that is,  Guilt is the result when the ego acts or even intends restraints of the superego). Instead, it sucks when to act contrary to the moral standards of the the nipple is either present or absent and gains superego (conscience). pleasure in either situation.  Feelings of inferiority arise when the ego is unable to meet the superego’s standards of perfection THE EGO (ego-ideal).  It strives blindly and unrealistically toward  The ego, or I, is the inly region of the mind in perfection. contact with the reality.  The superego, however, is like the id in that it is  It grows out of the id during infancy and becomes a completely ignorant of, and unconcerned with the person’s sole source of communication with the practicability of its requirements. external world.  It is governed by the reality principle. DREAM ANALYSIS  The ego becomes the decision making or executive branch of personality. Dream analysis, a primary technique used in  The ego constantly tries to reconcile or balance the psychoanalysis, involves discussing a client’s dreams to blind, irrational claims of the id and the superego discover their true meaning and significance. with the realistic demands of the external world. – For example, a client might report having recurrent  The ego reacts in a predictable manner-it becomes frightening dreams about snakes chasing her. The anxious. woman fears intimacy with men; she would view  It then uses repression and other defense the snake as a phallic symbol, representing the mechanisms to defend itself against this anxiety. penis.  Example: A woman’s ego may consciously Quick responses: Another method used to gain access motivate her to choose excessively neat, well- to subconscious thoughts and feelings Is free tailored clothes because she feels comfortable association, in which the therapist tries to uncover the when well dressed. At the same time, she may be client’s true thoughts and feelings by saying a word and only dimly (I.e., preconsciously) aware of previous asking the client to respond quickly with the first thing experiences of being rewarded for choosing nice that comes to mind. clothes. In addition, she may be unconsciously Quick responses would be likely to uncover motivated to be excessively neat and orderly due subconscious or repressed thoughts or feelings. to early childhood experiences of toilet training. Thus, her decision to wear neat clothes can take DEFENSE MECHANISMS place in all three levels of mental life. Methods of attempting to protect the self and cope with THE SUPEREGO basic drives or emotionally painful thoughts feelings or events  The superego, or above-I, represents the moral when carried on extreme they lead to compulsive, and ideal aspects of personality. repetitive, and neurotic behavior.  It is guided by the moralistic and idealistic principles The ego’s purpose in establishing defense mechanism as opposed to the pleasure principle of the id and to avoid dealing directly with sexual and aggressive the realistic principle of the ego. impulses and to defend itself against anxiety that  The superego grows out of the ego, it has no accompanies them. energy of its own.  It has no contact with the outside world and COMPENSATION therefore is unrealistic in its demands for perfection.  Overachievement in one area to offset real or perceived deficiencies in another area The Two Subsystems  Example: Nurse with low self-esteem working Conscience Ego-ideal double shifts so that her superior will like her Conscience results from The ego-ideal develops experiences with from experiences with CONVERSION punishments for improper rewards for proper behavior and tells us what behavior and tells us what  Expression of an emotional conflict through the we should not do. we should do. development of a physical symptom, usually sensorimotor in nature  A well-developed superego acts to control sexual  Example: Teenager is forbidden to see X-rated and aggressive impulses through the process of movies is tempted to do so by friends and develop repression. blindness, and the teenager is unconcerned about the loss of sight  It cannot produce repression by itself, but it can order the ego to do so. DISPLACEMENT  The superego watches closely over the ego, judging its actions and intentions.  Intense feelings toward persons less threatening than one who aroused those feelings 12 | 18  CARE OF CLIENTS WITH MALADAPTIVE BEHAVIOR THERAPEUTIC MODELS AND ITS RELEVANCE TO NURSING PRACTICE  Example: person who is mad at the boss yells at  Example: Woman who never wanted to have a his or her spouse child becomes a supermom. DENIAL REGRESSION  Failure to admit the reality of a situation or how one  Moving back to a previous developmental stage to enables the problem to continue feel safe or have needs met  Example: diabetic person eating chocolate candy  Example: A 5-year-old asks for a bottle when new baby brother is being fed. DISSOCIATION RESISTANCE  Dealing with emotional conflict by a temporary alteration in consciousness or identity  Overt or covert antagonism toward remembering or  Example: Adult remembers nothing of childhood processing anxiety-producing information. sex abuse  Example: Nurse is too busy with tasks to spend time talking to a dying patient. FIXATION REPRESSION  Immobilization of a portion of the personality resulting from unsuccessful completion of tasks in  Excluding emotionally painful or anxiety-provoking a developmental stage thoughts and feelings from conscious awareness  Example: Lack of a clear sense of identity as an  Example: Woman who has no memory before age adult 7, when she was removed from abusive parents. IDENTIFICATION SUBLIMATION  Modeling actions and opinions of influential others  Substituting a socially acceptable activity for an while searching for identity impulse that is unacceptable  Example: A nursing student becoming a critical  Example: Person who has quit smoking sucks on care nurse because this is the specially of an hard candy when the urge to smoke arises instructor she admires SUBSTITUTION INTELLECTUALIZATION  Replacing the desired gratification with one that is  Separation of the emotions of a peaceful event or more reality available situation from the facts involved, acknowledging  Example: Woman who would like to have her own the facts but not the emotions children opens a day care center  Examples: Person shows no emotional expression when discussing serious car accident. SUPPRESSION INTROJECTION  Conscious exclusion of unacceptable thoughts and feelings from conscious awareness.  Accepting another person's attitudes, beliefs, and  Example: A student decides not to think about values as one’s own parent’s illness to study for a test.  Example: Person who dislikes guns becomes an avid hunter, just like as best friend. UNDOING PROJECTION  Exhibiting acceptable behavior to make up for or negate unacceptable behavior/  Unacceptable blaming of unacceptable inclinations  Example: Person who cheats on a spouse brings or thoughts on an external object the spouse a bouquet of flowers.  Example: Man, who has thought about same- gender sexual relationship, but never had one, FIVE STAGES OF PSYCHOSEXUAL DEVELOPMENT beats a man who is gay. Freud based his theory of childhood development on RATIONALIZATION the belief that sexual energy, termed libido, was the driving force of human behavior.  Excusing own behavior to avoid guilt, responsibility, Psychopathology results when a person has difficulty conflict, anxiety, or loss of self-respect making the transition from one stage to the next or when  Example: Man says he beats his wife because she a person remains stalled at a particular stage or does not listen to him. regresses to an earlier stage. REACTION FORMATION  Acting the opposite of what one thinks or feels. 13 | 18  CARE OF CLIENTS WITH MALADAPTIVE BEHAVIOR THERAPEUTIC MODELS AND ITS RELEVANCE TO NURSING PRACTICE Oral: Birth to 18 months Are automatic and unconscious in the therapeutic relationship.  Major site of tension and gratification is the mouth, For example, an adolescent female client working with lips, and tongue; includes biting and sucking a nurse who is about the same age as the teen’s parents activities. might react to the nurse like she reacts to her parents.  Id is present a t birth. She might experience intense feelings of rebellion or  Ego develops gradually from rudimentary structure make sarcastic remarks; these reactions are actually present at birth. based on her experiences with her parents, not with the  Fixation at the oral stage is associated with nurse. passivity, gullibility, and dependence; the use of sarcasm; may develop orally focused habits (e.g., COUNTERTRANSFERENCE smoking, nail-biting) Occurs when the therapist displaces onto the client Anal: 18-36 months attitudes or feelings from his or her past. For example, a female nurse who has teenage children  Anus and surrounding area are major source of and who is experiencing extreme frustration with an interest. adolescent client may respond by adopting a parental  Voluntary sphincter control (toilet training) is or chastising tone. acquired. The nurse is countertransfering her own attitudes and  Fixation at the anal stage is associated with anal feelings toward her children onto the client. retentiveness (stinginess, rigid thought patterns, Nursing responsibility: Nurses can deal with obsessive-compulsive disorder) or anal-expulsive countertransference by examining their own feelings character (messiness, destructiveness, cruelty). and responses, using self-awareness, and talking with colleagues. Phallic/Oedipal: 3-5 years Implications for psychiatric mental health nursing:  Genital is the focus of interest, stimulation, and excitement. First, the theory offers a comprehensive  Penis organ of interest for both sexes. explanation of complex human processes.  Masturbation is common. Suggests that the formation of a patient's  Penis envy (wishes to possess penis) is seen in personality is strongly influenced by childhood girls. experiences.  Oedipal complex (wish to marry opposite-sex Freud theory of the unconscious mind is particularly parent and be rid of the same-sex parent) is seen valuable the baseline for considering the in boys and girls. complexity of human behavior.  Fixation may result in reckless, self-assured, and By considering conscious and unconscious narcissistic person. Lack of resolution may result in influences, unless we can identify and begin to inability to love and difficulties with sexual identity. think about the root causes of patients suffering. Freud emphasized the importance of individual talk Latency: 5-11 or 13 years sessions characterized by attentive listening, with a focus on underlying themes as an important tool of  Resolution of oedipal complex. healing in psychiatric care.  Sexual drive channeled into socially appropriate activities such as schoolwork and sports. THEORY OF PSYCHOSOCIAL DEVELOPMENT  Formation of the superego. ERIK ERIKSON  Final stage of psychosexual development.  Fixations can result in difficulty identifying with 1902-1994 others and in developing social skills, leading to a German born psychoanalyst sense of inadequacy and inferiority. In 1950, he published Childhood and Society in which he described eight psychosocial stages of development. Genital: 11-13 years In each stage, the person must accomplish life/developmental task that is essential to his or her  Begins with puberty and the biologic capacity for well-being and mental health. orgasm; involves the capacity for to intimacy. These tasks allow the person to achieve life’s virtues:  Inability to negotiate this stage may derail hope, purpose, fidelity, love, caring, and wisdom. emotional independence, may impair personal identity and future goals, disrupt ability to form EIGHT STAGES OF DEVELOPMENT satisfying intimate relationships. 1. Trust vs. Mistrust (Infancy) TRANSFERENCE – Occurring in the first year of life (Infant) – Virtue: Hope Occurs when the client displaces onto the therapist – Maldevelopment: Withdrawal attitudes and feelings that the client originally – Task: Viewing the world as safe and reliable; experienced in other relationships. relationships as nurturing, stable, and dependable 14 | 18  CARE OF CLIENTS WITH MALADAPTIVE BEHAVIOR THERAPEUTIC MODELS AND ITS RELEVANCE TO NURSING PRACTICE  The Erickson Psychosocial Stage Inventory (EPSI) 2. Autonomy vs. Shame and Doubt (Toddler based on Erikson's stages, and the modified – Occurring during first three years of life (toddler) version following it (MEPSI) is a reliable tool used – This stage has important implications in the to assess psychosocial development. development of independence and identity during  A model of psychodynamic psychotherapy is based adolescence. on the concept and staging of Erikson's theory. – Virtue: Will – Maldevelopment: Compulsion INTERPERSONAL RELATIONSHIP THEORY – Task: Achieving a sense of control and free will HARRY STACK SULLIVAN 3. Initiative vs. Guilt (Preschool) 1892-1949 – Virtue: Purpose American Neo-Freudian psychiatrist and psychoanalyst – Maldevelopment: Inhibition Developed a theory of psychiatry based on – Task: Beginning development of a conscience; interpersonal relationships. learning to manage conflict and anxiety. His work on interpersonal relationships became the foundation of interpersonal psychoanalysis. 4. Industry vs. Inferiority (School age) Extended the theory of personality development include – Virtue: Competence the significance of interpersonal relationships. – Maldevelopment: Inertia (passivity) He beloved that one’s personality involves more than – Task: Emerging confidence in own abilities; taking individual characteristics, particularly how one interacts pleasure in accomplishments with others. 5. Identity formation vs. Identity Confusion FIVE LIFE STAGES (Adolescence) – Virtue: Fidelity INFANCY STAGE – Maldevelopment: Repudiation – Task: Formulating a sense of self and belonging  Birth to onset of language  Primary need exists for bodily contact and 6. Intimacy vs. Isolation (Early adulthood) tenderness. – Virtue: Love  Prototaxic mode dominates (no relation between – Maldevelopment: Distantiation experiences) – Task: Forming adults, loving relationships, and  Primary zones are oral and anal. meaningful attachments to others.  If needs are met, infant has sense of well-being.  If needs are unmet, infants lead to dread and 7. Generativity vs. Stagnation (Middle Adulthood) anxiety. – Virtue: Care – Maldevelopment: Rejectivity CHILDHOOD STAGE – Task: Being creative and productive; establishing  Language to 5 years old the next generation  Parents are viewed as source of praise and acceptance. 8. Ego Integrity vs. Despair (Old Age) – Focused on self-reflection in one’s life  Shift to parataxic mode; experiences are connected – Virtue: Wisdom in sequence to each other. – Maldevelopment: Disdain  Primary zone is anal. – Rask: Accepting responsibility for oneself and life  Gratification leads to positive self-esteem/  Moderate anxiety leads to uncertainty and A ninth stage was added by Erik Erikson’s wife, Joan insecurity. Erikson. It considers new challenges experienced with  Severe anxiety results in self-defeating patterns of continued aging and incorporates aspects from all behavior. previous eight stages of psychosocial development. JUVENILE STAGE In his view, psychosocial growth occurs in sequential phases and each stage is dependent on completion of  5 to 8 years of age the previous stage and life task.  Shift to the syntaxic mode begins (thinking about self and others based on analysis of experiences in a variety of situations). CLINICAL SIGNIFICANCE  Opportunities for approval and acceptance of others.  Serve as a basis of treatment for different recovery  Learn to negotiate own needs. stages of mental illness. For example, the initial stage of trust versus mistrust parallels the mental  Severe anxiety may result in a need to control or in illness recovery stage concerning the acceptance restrictive, prejudicial attitudes. of the mental illness and trusting the idea of recovery. 15 | 18  CARE OF CLIENTS WITH MALADAPTIVE BEHAVIOR THERAPEUTIC MODELS AND ITS RELEVANCE TO NURSING PRACTICE PREADOLESCENCE STAGE skills, giving one another feedback about behavior, and working cooperatively as a group to solve day-to-day  8 to 12 years old problems.  Move to genuine intimacy with friend of the same Sullivan coined the term participant observer for the sex. therapist’s role, meaning that the therapist both  Move away from family as a source of satisfaction participates in and observes the progress of the in relationships. relationship. It is where the therapist provides a  Major shift to syntaxic mode occurs. corrective interpersonal relationship for the client.  Capacity for attachment, love, and collaboration The concept of therapeutic community or milieu is seen emerges or fails to develop. as beneficial, and the treatment emphasizes the role of this client-to-client interaction. ADOLESCENCE STAGE However, in today’s health care environment, inpatient hospital stays are often too short for clients to develop  Puberty to adulthood meaningful relationships with one another. Therefore,  Lust is added to interpersonal equation. the concept of milieu therapy receives little attention.  Need for special sharing relationship shifts to the Nevertheless, management of milieu, or environment, is opposite sex. still a primary role for the nurse in terms of providing  New opportunities for social experimentation led to safety and protection for all clients and promoting social the consolidation of self-esteem or self-ridicule. interaction.  If the self-system is intact, areas of concern expand to include values, ideals, career decisions, and DIFFERENT COGNITIVE MODELS social concerns. JEAN PIAGET THREE DEVELOPMENTAL COGNITIVE MODS Swiss psychologist Piaget in Paris: It is where he devotes his interest to 1. PROTOTAXIC MODS study the reasoning ability of young children.  States that the characteristic of infancy and Human intelligence progresses through a series of childhood, involves brief, unconnected experiences stages based on age. that have no relationship to one another. Biologic changes and maturation were responsible for  Adults with schizophrenia exhibit persistent cognitive development. prototaxic experiences. He then proposes four stages of cognitive development. 2. PARATAXIC MODS FOUR STAGES OF COGNITIVE DEVELOPMENT  This mod begins in early childhood as the child begins to connect experiences in sequence. 1. Sensorimotor – birth to 2 years: The child begins to  The child may not make logical sense of the interact with the environment. The child develops a experiences and may see them as