Learn — Concepts, therapeutic communication & defence mechanisms

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Ego defence mechanisms

Ego defence mechanisms are unconscious mental strategies the ego uses to keep anxiety, unacceptable impulses and intolerable reality out of awareness so that the person can keep functioning. They are normal and adaptive in moderation, and become pathological only when they are rigid, used to excess, or so distorting that the person can no longer test reality or meet everyday demands.

Mature defences are the healthiest: sublimation channels an unacceptable impulse into a socially useful one (anger becomes competitive sport), altruism meets one's own needs by serving others, suppression is the conscious postponing of a worry, and humour discharges tension without harming anyone.
Neurotic defences include repression, the unconscious burying of a painful memory and the cornerstone of Freud's theory; suppression is its conscious counterpart and this pair is a standard examination discriminator.
Displacement redirects a feeling from the real target to a safer one, as when a nurse scolded by a doctor snaps at a student; reaction formation replaces the true feeling with its exact opposite, as when a person who resents a relative becomes conspicuously devoted.
Projection attributes one's own unacceptable feeling to somebody else, so the man who wants to drink insists his wife is pushing drink on him; introjection is the reverse, taking another person's values into oneself.
Rationalisation invents an acceptable reason for an act done for an unacceptable one; intellectualisation strips the feeling out and keeps only the facts, as in the newly diagnosed patient who recites survival statistics and never mentions fear.
Immature defences include denial, the refusal to accept an external reality, and regression, a return to an earlier developmental behaviour such as the toilet-trained 5-year-old who starts bedwetting after a hospital admission.
Splitting keeps people entirely good or entirely bad with nothing in between and is prominent in borderline personality disorder; on a ward it shows as staff being divided into an idealised group and a devalued one, and it is managed by consistent limits and a single agreed plan, not by argument.
Denial of external reality and delusional distortion are the psychotic-level defences, in which reality testing itself fails; identification, dissociation, conversion, undoing and acting out are the other named mechanisms the paper asks about.

Psychoanalytic theory — Freud

Freud's psychoanalytic theory holds that behaviour is driven largely by unconscious conflict and that the child's libido, or sexual energy, settles on a different bodily zone at each of five psychosexual stages. Excessive gratification or frustration at any stage causes fixation, in which some energy stays attached to that stage and its conflicts reappear as adult character traits or symptoms, and the theory is examined mainly for the stage names, their ages and the levels of consciousness.

Oral stage, birth to about 1 year: the mouth is the site of pleasure through sucking and biting, and fixation is linked to dependency, smoking, overeating and sarcasm.
Anal stage, about 1 to 3 years: pleasure comes from retaining and expelling faeces and the conflict is toilet training, with fixation linked to the anal-retentive traits of orderliness, obstinacy and parsimony or to the opposite messiness.
Phallic stage, about 3 to 6 years: the child discovers the genitals, and this is the stage of the Oedipus and Electra complexes, castration anxiety and the formation of the superego through identification with the same-sex parent.
Latency, about 6 to 12 years: sexual energy is dormant and is redirected into schoolwork, skills and same-sex friendships; genital stage, from puberty onward, is the mature stage of adult sexual relationships.
Freud described three levels of the mind: the conscious, which holds current awareness; the preconscious, which holds material that can be recalled at will; and the unconscious, which holds repressed material that shapes behaviour without the person knowing it.
The techniques of psychoanalysis are free association, dream analysis (dreams as the royal road to the unconscious, with manifest and latent content), and interpretation of transference, in which the patient redirects feelings about an important past figure onto the therapist; countertransference is the therapist's reciprocal reaction.
The theory's limitations are examinable: it rests on case studies rather than controlled research, its constructs are hard to measure, and it gives little weight to culture or to development after puberty, which is why Erikson's psychosocial stages are usually taught alongside it.
Contrast the theorists the paper pairs: Freud for psychosexual stages, Erikson for psychosocial stages, Piaget for cognitive stages, Kohlberg for moral development, Sullivan for interpersonal theory and Peplau for the nurse-patient relationship.

Freud structural theory of mind (id/ego/superego)

Freud's structural theory divides the mind into three agencies: the id, the ego and the superego. The id is the reservoir of instinctual drives present from birth and works on the pleasure principle demanding immediate gratification; the ego develops in infancy, works on the reality principle and negotiates between the id, the superego and the outside world; and the superego, formed around 5 to 6 years by internalising parental and social standards, supplies conscience and the ego ideal.

The id is entirely unconscious, present at birth, governed by the pleasure principle, and uses primary process thinking, which is illogical, timeless and wish-fulfilling, as seen in dreams and in psychosis.
The ego is partly conscious and partly unconscious, begins to differentiate in the first year, is governed by the reality principle, and uses secondary process thinking, which is logical and can delay gratification.
The superego holds the conscience, which punishes with guilt, and the ego ideal, which rewards with pride; it is largely formed by about 5 to 6 years through identification with the same-sex parent at the end of the phallic stage.
Anxiety is the ego's signal that a conflict between the three agencies threatens to break through, and the ego defence mechanisms are the ego's unconscious response to that signal.
A weak ego shows as poor impulse control, low frustration tolerance and, in the extreme, loss of reality testing; a harsh superego shows as excessive guilt, scrupulosity and self-punishment, which is the pattern often described in severe depression and obsessive-compulsive disorder.
Ego strength is the practical measure the nurse assesses: the ability to tolerate frustration, delay gratification, test reality and maintain relationships under stress, and it guides how much responsibility a patient can safely be given.
The structural theory (id, ego, superego) is not the same as the topographical theory (conscious, preconscious, unconscious), and papers regularly test the difference; only the id lies wholly within the unconscious.
The theory underpins psychodynamic psychotherapy, whose aim is stated as making the unconscious conscious and strengthening the ego, in contrast with cognitive behavioural therapy, which works on current thoughts and behaviour.

Bender-Gestalt test

The Bender Visual Motor Gestalt Test, devised by Lauretta Bender in 1938, asks the person to copy a set of nine geometric designs presented one at a time on cards, and then in some versions to reproduce them from memory. It is a test of visuomotor perception and integration rather than of intelligence, and it is used from about 4 years of age upward as a screen for organic brain dysfunction, for perceptual-motor maturity in children and as part of a wider psychological test battery.

The materials are nine designs, conventionally figure A followed by figures 1 to 8, copied with pencil on plain paper without a time limit; a recall trial after a short delay adds information about visual memory.
Scoring counts errors of distortion of shape, rotation, perseveration, integration failure where parts of a design are not joined, overlapping difficulty and collision between designs; the Koppitz developmental scoring system is used for children and the Pascal-Suttell system for adults.
Its main clinical uses are screening for organic brain dysfunction, assessing visuomotor maturation and school readiness in children, and contributing to the assessment of specific learning disability and of intellectual disability.
It is a screening instrument, not a diagnostic one: it can suggest that organic impairment is present but cannot say where the lesion is or what disease caused it, and a normal performance does not exclude brain damage.
Indian nursing texts commonly list it among the projective techniques because the reproductions are also interpreted qualitatively, but its core is a performance test of visuomotor function, and both descriptions appear in question papers.
Place it among the other tests the examination pairs: intelligence is measured by the Wechsler and Binet-Kamat scales; personality by the objective Minnesota Multiphasic Personality Inventory and by the projective Rorschach inkblot, Thematic Apperception Test, Draw-a-Person and sentence completion tests; and neuropsychological function by batteries such as the Luria-Nebraska and the PGI battery.
The nurse's role is preparation and observation rather than interpretation: explain the task in the person's own language, ensure spectacles are worn and the lighting and table are adequate, check that the hand is steady enough to hold a pencil, and record the conditions, because tremor, sedation, poor vision or fatigue invalidate the result.

Cognitive behavioural therapy

Cognitive behavioural therapy is a structured, collaborative, time-limited psychotherapy built on the premise that it is not the event but the person's interpretation of it that determines how they feel and what they do. Aaron Beck developed it for depression and Albert Ellis produced the parallel rational emotive behaviour therapy, and the work of each session is to identify the automatic negative thoughts and the beliefs beneath them, test them against evidence, and change behaviour so that new evidence can be gathered.

Beck's cognitive triad in depression is a negative view of the self, of the world and of the future, with automatic thoughts on the surface, intermediate beliefs in the form of rules and assumptions below them, and core schemas at the base.
The named cognitive distortions are all-or-nothing thinking, overgeneralisation, mental filter, disqualifying the positive, mind reading and fortune telling, catastrophising, emotional reasoning, should statements, labelling and personalisation.
Ellis's ABC model runs A for the activating event, B for the belief about it and C for the emotional and behavioural consequence, and the therapy works on B because A is often unchangeable.
The format is what makes it teachable: an agreed agenda each session, Socratic questioning and guided discovery rather than advice, thought records, behavioural experiments, homework between sessions and a written relapse-prevention plan, typically over 6 to 20 sessions of about an hour.
The behavioural half is not optional: behavioural activation for depression, graded exposure for phobia and panic, exposure and response prevention for obsessive-compulsive disorder, and stimulus control with sleep restriction for insomnia.
Evidence supports cognitive behavioural therapy in depression, in all the anxiety disorders, in obsessive-compulsive disorder, in post-traumatic stress disorder, in insomnia where it is recommended ahead of hypnotics, in bulimia nervosa, and as an adjunct to antipsychotics in psychosis; it is delivered individually, in groups and digitally.
In moderate to severe depression, combining cognitive behavioural therapy with an antidepressant works better than either alone, whereas in mild depression therapy alone is a reasonable first choice.
Distinguish it from its neighbours: psychoanalysis works on unconscious conflict through free association and transference over years; behaviour therapy alone uses conditioning techniques such as systematic desensitisation, aversion therapy and the token economy; interpersonal therapy targets grief, role disputes and role transitions; dialectical behaviour therapy, developed by Marsha Linehan for borderline personality disorder and repeated self-harm, adds mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness; and motivational interviewing works on ambivalence in substance use.
Nurses carry much of the delivery: psychoeducation, activity scheduling, homework review, relaxation training and outcome monitoring with tools such as the PHQ-9 and GAD-7 sit within the psychiatric nurse's role, and in India the District Mental Health Programme under the National Mental Health Programme and the Tele-MANAS helpline on 14416 extend that reach beyond the hospital.

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