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Townsend(F)-FM 7/3/07 12:29 PM Page 2

C O N T E N T S I N B R I E F

UNIT ONE Chapter 15 Schizophrenia and Other Psychotic

Disorders 304
Introduction to Psychiatric/
Mental Health Concepts Chapter 16 Mood Disorders 332
Chapter 1 Mental Health and Mental Illness 3 Chapter 17 Anxiety Disorders 379
Chapter 2 Concepts of Personality Chapter 18 Anxiety-Related Disorders 413
Development 15
Chapter 19 Disorders of Human Sexuality 448
Chapter 3 Biological Implications 31
Chapter 20 Eating Disorders 476
Chapter 4 Ethical and Legal Issues 50
Chapter 21 Personality Disorders 495
Chapter 5 Cultural and Spiritual Concepts
Relevant to Psychiatric/Mental Health UNIT FOUR
Nursing 66
Psychiatric/Mental Health Nursing of
Special Populations
UNIT TWO
Chapter 22 Children and Adolescents 525
Psychiatric/Mental Health Nursing
Interventions Chapter 23 Victims of Abuse or Neglect 561
Chapter 6 Relationship Development and Chapter 24 The Aging Individual 581
Therapeutic Communication 95
Chapter 25 Community Mental Health Nursing
Chapter 7 The Nursing Process in 611
Psychiatric/Mental Health Nursing 115
Chapter 26 The Bereaved Individual 642
Chapter 8 Milieu Therapy—The Therapeutic
Community 140 APPENDICES
Chapter 9 Intervention in Groups 149 Appendix A. DSM-IV-TR Classification: Axes I and II
Chapter 10 Intervening in Crises 162 Categories and Codes 663

Chapter 11 Psychopharmacology 182 Appendix B. NANDA Nursing Diagnoses:

Taxonomy II Domains, Classes, and
Chapter 12 Complementary and Psychosocial Diagnoses 670
Therapies 212
Appendix C. Assigning Nursing Diagnoses to Client
Behaviors 674
UNIT THREE
Appendix D. Mental Status Assessment 676
Care of Clients with Psychiatric
Disorders Appendix E. Glossary 678
Chapter 13 Delirium, Dementia, and Amnestic Appendix F. Answers to Review Questions 699
Disorders 237
Index 703
Chapter 14 Substance-Related Disorders 262
Townsend(F)-FM 7/3/07 12:29 PM Page 6
Townsend(F)-FM 7/3/07 7:52 PM Page v

FOURTH EDITION

Essentials of
Psychiatric
Mental Health
Nursing
Concepts of Care in Evidence-Based Practice
MARY C. TOWNSEND, DSN, APRN, BC
Clinical Specialist/Nurse Consultant
Adult Psychiatric Mental Health Nursing

Former Assistant Professor and Coordinator,

Mental Health Nursing
Kramer School of Nursing
Oklahoma City University
Oklahoma City, Oklahoma
Townsend(F)-FM 7/3/07 12:30 PM Page vi

F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com

Copyright © 2008 by F. A. Davis Company

Copyright © 1999, 2002, 2005 by F. A. Davis Company. All rights reserved. This product is
protected by copyright. No part of it may be reproduced, stored in a retrieval system, or trans-
mitted in any form or by any means, electronic, mechanical, photocopying, recording, or oth-
erwise, without written permission from the publisher.

Printed in the United States of America

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Publisher, Nursing: Robert G. Martone

Developmental Editor: William F. Welsh
Senior Project Editor: Danielle J. Barsky
Design Manager: Carolyn O’Brien

As new scientific information becomes available through basic and clinical research, recom-
mended treatments and drug therapies undergo changes. The author(s) and publisher have
done everything possible to make this book accurate, up to date, and in accord with accepted
standards at the time of publication. The author(s), editors, and publisher are not responsible
for errors or omissions or for consequences from application of the book, and make no war-
ranty, expressed or implied, in regard to the contents of the book. Any practice described in
this book should be applied by the reader in accordance with professional standards of care
used in regard to the unique circumstances that may apply in each situation. The reader is ad-
vised always to check product information (package inserts) for changes and new information
regarding dose and contraindications before administering any drug. Caution is especially
urged when using new or infrequently ordered drugs.

Library of Congress Cataloging-in-Publication Data

Townsend, Mary C., 1941-

Essentials of psychiatric mental health nursing / Mary C. Townsend. — 4th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-8036-1611-0
ISBN-10: 0-8036-1611-2
1. Psychiatric nursing. I. Title.
[DNLM: 1. Psychiatric Nursing—methods. 2. Mental Disorders—nursing. WY 160 T749e
2008]
RC440.T689 2008
616.89′0231—dc22 2007024871

Authorization to photocopy items for internal or personal use, or the internal or personal
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$.10.
Townsend(F)-FM 7/3/07 12:30 PM Page vii

D E D I C A T I O N

To my best friend, Jimmy

Townsend(F)-FM 7/3/07 12:30 PM Page viii
Townsend(F)-FM 7/3/07 12:30 PM Page ix

A C K N O W L E D G M E N T S

My special thanks to:

Robert G. Martone, Publisher, Nursing, F. A. Davis

Company, for your sense of humor and continuous opti-
mistic outlook about the outcome of this project.
William F. Welsh, Developmental Editor, Nursing,
F. A. Davis Company, for all your help and support in
preparing the manuscript for publication.
Jane K. Brody, Associate Professor, Nursing
Department, Nassau Community College; Golden
M. Tradewell, Chair, Department of Nursing,
Southern Arkansas University; and Cherie R. Rebar,
Assistant Professor, Kettering College of Medical
Arts, for your assistance in preparing test questions
to accompany this textbook.
Berta Steiner, Director of Production, Bermedica
Production Ltd., for your support and competence in the
final editing and production of the manuscript.
The nursing educators, students, and clinicians, who
provide critical information about the usability of the text-
book, and offer suggestions for improvements. Many
changes have been made based on your input.
Those individuals who critiqued the manuscript for
this edition and shared your ideas, opinions, and sugges-
tions for enhancement. I sincerely appreciate your
contributions to the final product.
MARY C. TOWNSEND

ix
Townsend(F)-FM 7/3/07 12:30 PM Page x
Townsend(F)-FM 7/3/07 12:30 PM Page xi

T O T H E I N S T R U C T O R

here is a saying that captures the spirit of our its final report to the President. The Commission iden-
T times—the only constant is change. The twenty-
first century continues to bring about a great deal of
tified the following barriers: fragmentation and gaps in
mental health care for children, adults with serious
change in the health care system in general and to nurs- mental illness, and the elderly; and high unemployment
ing in particular. The body of knowledge in nursing and disability for people with serious mental illness.
continues to grow and expand as rapidly as nursing un- The report also pointed out that the fact that the U.S.
dergoes change. Nurses must draw upon this research has failed to identify mental health and suicide preven-
base to support the care that they provide for their tion as national priorities has put many lives as stake.
clients. This fourth edition of Essentials of Psychiatric The Commission outlined the following goals and rec-
Mental Health Nursing strives to present a holistic ap- ommendations for mental health reform:
proach to psychiatric nursing practice based on sound
● To address mental health with the same urgency as
research principles.
physical health
Research in nursing has been alive for decades. But
● To align relevant Federal programs to improve ac-
over the years there has always existed a significant gap
cess and accountability for mental health services
between research and practice. Evidence-based nurs-
● To ensure appropriate care is available for every
ing has become a common theme within the nursing
child with a serious emotional disturbance and every
community. It has been defined as a process by which
adult with a serious mental illness
nurses make clinical decisions using the best available
● To protect and enhance the rights of people with
research evidence, their clinical expertise, and client
mental illness
preferences. Nurses are accountable to their clients to
● To improve access to quality care that is culturally
provide the highest quality of care based on knowledge
competent
of what is considered best practice. Change occurs so
● To improve access to quality care in rural and geo-
rapidly that what is considered best practice today may
graphically remote areas
not be considered so tomorrow, based on newly ac-
● To promote mental health screening, assessment,
quired scientific data.
and referral services
Included in this fourth edition are a number of new
● To accelerate research to promote recovery and re-
research studies that support psychiatric nursing inter-
silience, and ultimately to cure and prevent mental
ventions. As nurses, we are bombarded with new in-
illness
formation and technological content on a daily basis.
● To advance evidence-based practices using dissemi-
Not all of this information yields knowledge that can be
nation and demonstration projects, and create a
used in clinical practice. There is still a long way to go
public-private partnership to guide their implemen-
toward evidence-based practice in psychiatric nursing,
tation
and research utilization is the foundation from which to
● To improve and expand the workforce providing
advance the progression.
evidence-based mental health services and supports
Well into the first decade of the new century, there
● To promote the use of technology to access mental
are many new challenges to be faced. In 2002, Presi-
health care and information
dent George W. Bush established the New Freedom
Commission on Mental Health. This commission was If these proposals become reality, it would surely
charged with the task of conducting a comprehensive mean improvement in the promotion of mental health
study of the United States mental health service deliv- and the care of mentally ill individuals. Many nurse
ery system. They were to identify unmet needs and bar- leaders see this period of health care reform as an op-
riers to services and recommend steps for improvement portunity for nurses to expand their roles and assume
in services and support for individuals with serious key positions in education, prevention, assessment, and
mental illness. In July 2003, the commission presented referral. Nurses are, and will continue to be, in key

xi
Townsend(F)-FM 7/3/07 12:30 PM Page xii

xii TO THE INSTRUCTOR

positions to assist individuals with mental illness to re- lems and interventions. Compared to the commonly
main as independent as possible, to manage their ill- used column format care plans, concept map care plans
ness within the community setting, and to strive to are more succinct. They are practical, realistic, and
minimize the number of hospitalizations required. time saving, and they serve to enhance critical-thinking
In 2020, the ten leading causes of mortality through- skills and clinical reasoning ability. Fifteen (15) care
out the world are projected to include heart disease; map care plans have been included with major diag-
cerebrovascular disease; pulmonary disease; lower res- nostic categories in this textbook.
piratory infections; tracheal, bronchial and lung can- New boxes that define core concepts (all chapters).
cers; traffic accidents; tuberculosis; stomach cancer; Core concepts have been identified at the beginning of
HIV/AIDS; and suicide. Behavior is an important ele- each chapter. Boxes with the definitions of these core
ment in prevention of these causes of mortality and in concepts appear at the appropriate point within the
their treatment. In 2020, the three leading causes of text.
disability throughout the world are projected to include NANDA Taxonomy II (2007) from the NANDA
heart disease, major depression, and traffic accidents. Nursing Diagnoses: Definitions & Classification 2007-
Behavior is once again an important underpinning of 2008 (NANDA International). Used throughout the
these three contributors of disability, and behavioral text.
and social science research can lower the impact of New and updated psychotropic medication infor-
these causes of morbidity and mortality. Many of these mation (Chapter 11 and in relevant clinical chapters).
issues are addressed in this new edition. New research studies with implications for evidence
based practice. (In all relevant clinical chapters).

CONTENT AND FEATURES NEW

FEATURES THAT HAVE BEEN
TO THIS EDITION
RETAINED IN THE 4TH EDITION
All content has been updated to reflect current state
The concept of holistic nursing is retained in the
of the discipline of nursing.
fourth edition. An attempt has been made to ensure
New chapter on Cultural and Spiritual Concepts
that the physical aspects of psychiatric/mental health
relevant to Psychiatric/Mental Health Nursing.
nursing are not overlooked. Both physical and psy-
(Chapter 5)
chosocial nursing diagnoses are included for physio-
New content related to Neurobiological processes.
logical disorders (such as asthma, migraine headache,
(Chapters 13, 15, 16, 17, and 23). The neurobiology of
and HIV disease) and for psychological disorders (such
dementia, schizophrenia, depression, anxiety disorders,
as somatoform and eating disorders). In all relevant sit-
and violence is presented in the chapters that deal with
uations, the mind/body connection is addressed.
these disorders. Illustrations of the neurotransmitter
Nursing process is retained in the fourth edition as
pathways and discussion of areas of the brain affected
the tool for delivery of care to the individual with a psy-
and the medications that target those areas are pre-
chiatric disorder or to assist in the primary prevention
sented.
or exacerbation of mental illness symptoms. The six
New medication tables (in addition to the chapter
steps of the nursing process, as described in the Amer-
on Psychopharmacology). (Chapters 13, 15, and 16).
ican Nurses Association Standards of Clinical Nursing
New medication tables have been added to provide
Practice are used to provide guidelines for the nurse.
convenient, easy access to information related to med-
These standards of care are included for the DSM-IV-
ications that are relevant to specific psychiatric disor-
TR diagnoses, as well as the aging individual, the be-
ders (dementia, schizophrenia, depression, mania).
reaved individual, victims of abuse and neglect, and as
New content on Concept Mapping. Concept map-
examples in several of the therapeutic approaches. The
ping is discussed in Chapter 7. Concept mapping is a
six steps include:
diagrammatic teaching and learning strategy that al-
lows students and faculty to visualize interrelationships ● Assessment: Background assessment data, including
between medical diagnoses, nursing diagnoses, assess- a description of symptomatology, provides an exten-
ment data, and treatments. The concept map care plan sive knowledge base from which the nurse may draw
is an innovative approach to planning and organizing when performing an assessment. Several assessment
nursing care. Basically, it is a diagram of client prob- tools are also included.
Townsend(F)-FM 7/3/07 12:30 PM Page xiii

TO THE INSTRUCTOR xiii

● Diagnosis: Analysis of the data is included, from Assigning nursing diagnoses to client behaviors.
which nursing diagnoses common to specific psy- (Appendix C).
chiatric disorders are derived. Taxonomy and diagnostic criteria from the DSM-IV-
● Outcome Identification: Outcomes are derived from TR (2000). Used throughout the text.
the nursing diagnoses and stated as measurable A Student CD that contains practice test questions,
goals. learning activities, concept map care plans, and client
● Planning: A plan of care is presented with selected teaching guides.
nursing diagnoses for all DSM-IV-TR diagnoses, as
well as for the elderly client, the bereaved individ-
ual, victims of abuse and neglect, the elderly home- ADDITIONAL EDUCATIONAL
bound client, and the primary caregiver of the client RESOURCES
with a severe and persistent mental illness. The plan-
ning standard also includes tables that list topics for Faculty may also find the following teaching aids that
educating clients and families about mental illness. accompany this textbook helpful:
New to this edition: Concept map care plans for Instructor’s Resource Disk (IRD). This IRD con-
all major psychiatric diagnoses. tains:
● Implementation: The interventions that have been
identified in the plan of care are included along with • Approximately 500 multiple choice questions (in-
rationale for each. Case studies at the end of each cluding new format questions reflecting the latest
DSM-IV-TR chapter assist the student in the practi- NCLEX blueprint)
cal application of theoretical material. Also included • Lecture outlines for all chapters
as a part of this particular standard is Unit Two of • Learning activities for all chapters (including an-
the textbook: Psychiatric/Mental Health Nursing swer key)
Interventions. This section of the textbook ad- • Answers to the Critical Thinking Exercises from
dresses psychiatric nursing intervention in depth, the textbook
and frequently speaks to the differentiation in scope • PowerPoint Presentation to accompany all chap-
of practice between the basic level psychiatric nurse ters in the textbook
and the advanced practice level psychiatric nurse. It is my hope that the revisions and additions to this
Advanced practice nurses with prescriptive authority fourth edition continue to satisfy a need within psychi-
will find the extensive chapter on psychopharmacol- atric/mental health nursing practice. The mission of
ogy particularly helpful. this textbook has been, and continues to be, to provide
● Evaluation: The evaluation standard includes a set both students and clinicians with up-to-date informa-
of questions that the nurse may use to assess whether tion about psychiatric/mental health nursing. Many of
the nursing actions have been successful in achieving the changes reflect feedback that I have received from
the objectives of care. users of the previous editions. To those individuals I ex-
Internet references with web site listings for infor- press a heartfelt thanks. I welcome comments in an ef-
mation related to DSM-IV-TR diagnoses and other fort to retain what some have called the “user
mental health topics. friendliness” of the text. I hope that this fourth edition
Tables that list topics for client education. (Clinical continues to promote and advance the commitment to
chapters). psychiatric/mental health nursing.
Boxes that include current research studies with im-
plications for evidence based nursing practice. (Clini- MARY C. TOWNSEND
cal chapters).
Townsend(F)-FM 7/3/07 12:30 PM Page xiv
Townsend(F)-FM 7/24/07 3:13 PM Page xv

C O N T E N T S

Unit One Phase III: Separation-Individuation

I NTRODUCTION TO P SYCHIATRIC / (5 to 36 Months) 24
Relevance of Object Relations Theory to Nursing
M ENTAL H EALTH C ONCEPTS
Practice 25
Chapter 1 A Nursing Model—Hildegard E. Peplau 25
Mental Health and Mental Illness 3 Peplau’s Stages of Personality Development 26
Introduction 4 Learning to Count on Others 26
Learning to Delay Satisfaction 26
Mental Health 4 Identifying Oneself 27
Mental Illness 5 Developing Skills in Participation 27
Relevance of Peplau’s Model to Nursing
Physical and Psychological Responses to Stress 5 Practice 28
Physical Responses 5
Psychological Responses 6 Summary 28

The DSM-IV-TR Multiaxial Evaluation System 11 Chapter 3

Summary 12 Biological Implications 31
Chapter 2 Introduction 32
Concepts of Personality Development 15 Neurophysiological Influences 32
Introduction 16 The Nervous System 32
The Neuroendocrine System 39
Psychoanalytic Theory 16
Structure of the Personality 16 Implications for Psychiatric Illness 43
Topography of the Mind 17 Schizophrenia 43
Dynamics of the Personality 17 Mood Disorders 43
Freud’s Stages of Personality Development 18 Anxiety Disorders 44
Relevance of Psychoanalytic Theory to Nursing Anorexia Nervosa 44
Practice 19 Alzheimer’s Disease 45
Interpersonal Theory 19 Diagnostic Procedures Used to Detect Altered
Sullivan’s Stages of Personality Development 20 Brain Function 45
Relevance of Interpersonal Theory to Nursing Electroencephalography 45
Practice 20 Computerized EEG Mapping 46
Computed Tomographic Scan 46
Theory of Psychosocial Development 21
Magnetic Resonance Imaging 46
Erikson’s Stages of Personality Development 21
Positron Emission Tomography 46
Relevance of Psychosocial Development Theory to
Single Photon Emission Computed
Nursing Practice 23
Tomography 46
Theory of Object Relations 23
Implications for Nursing 46
Phase I: The Autistic Phase (Birth to 1 Month) 23
Phase II: The Symbiotic Phase (1 to 5 Months) 24 Summary 47

xv
Townsend(F)-FM 7/3/07 12:30 PM Page xvi

xvi CONTENTS

Chapter 4 Unit Two

Ethical and Legal Issues 50 P SYCHIATRIC /M ENTAL H EALTH
N URSING I NTERVENTIONS
Introduction 51

Ethical Considerations 51 Chapter 6

Theoretical Perspectives 51 Relationship Development
Ethical Egoism 52 and Therapeutic Communication 95
Ethical Dilemmas 52
Introduction 96
Ethical Principles 53
A Model for Making Ethical Decisions 54 The Therapeutic Nurse-Client Relationship 96
Ethical Issues in Psychiatric/Mental Therapeutic Use of Self 97
Health Nursing 54 Conditions Essential to Development of a
Legal Considerations 55 Therapeutic Relationship 97
Nurse Practice Acts 56 Rapport 97
Types of Law 56 Trust 97
Classifications Within Statutory Respect 98
and Common Law 56 Genuineness 98
Legal Issues in Psychiatric/Mental Empathy 98
Health Nursing 57 Phases of a Therapeutic Nurse-Client
Summary 62 Relationship 99
The Preinteraction Phase 99
Chapter 5 The Orientation (Introductory) Phase 100
Cultural and Spiritual Concepts The Working Phase 100
Relevant to Psychiatric/Mental The Termination Phase 101
Health Nursing 66 Boundaries in the Nurse-Client Relationship 101
Cultural Concepts 67 Interpersonal Communication 102
How do Cultures Differ? 68 The Impact of Pre-existing Conditions 102
Communication 68 Nonverbal Communication 104
Space 68 Therapeutic Communication Techniques 106
Social Organization 68 Nontherapeutic Communication Techniques 106
Time 69 Process Recordings 106
Environmental Control 69 Active Listening 106
Biological Variations 69 Feedback 108

Application of the Nursing Process 69 Summary 112

Background Assessment Data 69
Culture-Bound Syndromes 76 Chapter 7
Diagnosis Outcome Identification 79 The Nursing Process in Psychiatric/
Planning/Implementation 79 Mental Health Nursing 115
Evaluation 81
Introduction 116
Spiritual Concepts 81
The Nursing Process 116
Spiritual Needs 82
Definition 116
Religion 84
Standards of Care 116
Assessment of Spiritual and Religious
Standard I. Assessment 116
Needs 84
Standard II. Diagnosis 117
Diagnoses/Outcome Identification/
Standard III. Outcome Identification 117
Evaluation 86
Standard IV. Planning 117
Planning/Implementation 86
Standard V. Implementation 126
Summary 86 Standard VI. Evaluation 127
Townsend(F)-FM 7/3/07 12:30 PM Page xvii

CONTENTS xvii

Why Nursing Diagnosis? 127 Phases of Group Development 153

Phase I. Initial or Orientation Phase 153
Nursing Case Management 129
Phase II. Middle or Working Phase 153
Critical Pathways of Care 129
Phase III. Final or Termination Phase 153
Applying the Nursing Process in the
Leadership Styles 154
Psychiatric Setting 131
Autocratic 154
Concept Mapping 132 Democratic 154
Laissez-Faire 154
Documentation of the Nursing Process 134
Problem-Oriented Recording 134 Member Roles 154
Focus Charting 134
Psychodrama 155
The PIE Method 135
Electronic Documentation 136 The Family as a Group 156

Summary 137 The Role of the Nurse in Group

Interventions 157
Chapter 8
Summary 157
Milieu Therapy—The Therapeutic
Community 140
Chapter 10
Introduction 141
Intervening in Crises 162
Milieu, Defined 141
Introduction 163
Current Status of the Therapeutic
Characteristics of a Crisis 163
Community 141

Basic Assumptions 141 Phases in the Development of a Crisis 163

Conditions that Promote a Therapeutic Types of Crises 164

Community 142 Class 1: Dispositional Crises 164
Class 2: Crises of Anticipated Life Transitions 165
The Program of the Therapeutic Class 3: Crises Resulting from Traumatic
Community 143 Stress 165
The Role of the Nurse 143 Class 4: Maturational/Developmental Crises 165
Class 5: Crises Reflecting Psychopathology 166
Summary 146 Class 6: Psychiatric Emergencies 166
Chapter 9 Crisis Intervention 166
Intervention in Groups 149 Phases of Crisis Intervention: The Role of the
Introduction 150 Nurse 167
Phase 1. Assessment 167
Functions of a Group 150 Phase 2. Planning of Therapeutic Intervention 168
Types of Groups 150 Phase 3. Intervention 168
Task Groups 150 Phase 4. Evaluation of Crisis Resolution and
Teaching Groups 150 Anticipatory Planning 168
Supportive/Therapeutic Groups 151 Crisis on the Inpatient Unit: Anger/Aggression
Self-Help Groups 151 Management 169
Physical Conditions that Influence Assessment 169
Group Dynamics 151 Diagnosis/Outcome Identification 170
Seating 151 Outcome Criteria 170
Size 151 Planning/Implementation 170
Membership 152 Evaluation 170

Curative Factors 152 Disaster Nursing 170

Townsend(F)-FM 7/3/07 12:30 PM Page xviii

xviii CONTENTS

Application of the Nursing Process Unit Three

to Disaster Nursing 173 C ARE OF C LIENTS WITH P SYCHIATRIC
Background Assessment Data 173 D ISORDERS
Nursing Diagnoses/Outcome
Identification 173 Chapter 13
Planning/Implementation 174 Delirium, Dementia, and Amnestic
Evaluation 174 Disorders 237
Summary 174 Introduction 238

Chapter 11 Delirium 238

Etiological Implications 239
Psychopharmacology 182
Dementia 239
Introduction 183
Etiological Implications 241
Historical Perspectives 183
Amnestic Disorders 245
How do Psychotropics Work? 183 Etiological Implications 246
Applying the Nursing Process in Application of the Nursing Process 247
Psychopharmacological Therapy 186 Assessment 247
Antianxiety Agents 186 The Client History 247
Antidepressants 189 Physical Assessment 247
Mood-Stabilizing Agents 195 Diagnostic Laboratory Evaluations 247
Antipsychotic Agents 200 Diagnosis/Outcome Identification 251
Sedative-Hypnotics 205 Planning/Implementation 251
Agents for Attention-Deficit/Hyperactivity Client/Family Education 253
Disorder (ADHD) 206 Evaluation 253
Summary 208 Medical Treatment Modalities 253
Delirium 253
Chapter 12 Dementia 253
Complementary and Psychosocial Cognitive Impairment 254
Therapies 212 Agitation, Aggression, Hallucinations, Thought
Disturbances, and Wandering 255
Complementary Therapies 213
Depression 255
Introduction 213 Anxiety 256
Sleep Disturbances 256
Commonalities and Contrasts 214
Summary 256
Types of Complementary Therapies 215
Herbal Medicine 215 Chapter 14
Acupressure and Acupuncture 216
Substance-Related Disorders 262
Diet and Nutrition 216
Chiropractic Medicine 224 Introduction 263
Therapeutic Touch 224
Substance-Use Disorders 263
Massage 225
Substance Abuse 263
Yoga 225
Substance Dependence 264
Pet Therapy 225
Substance-Induced Disorders 264
Psychosocial Therapies 226
Substance Intoxication 264
Individual Psychotherapies 226
Substance Withdrawal 265
Relaxation Therapy 228
Assertiveness Training 229 Classes of Psychoactive Substances 265
Cognitive Therapy 230
Etiological Implications 265
Summary 231 Biological Factors 265
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CONTENTS xix

Psychological Factors 266 Undifferentiated Schizophrenia 311

Sociocultural Factors 266 Residual Schizophrenia 311
Schizoaffective Disorder 311
The Dynamics of Substance-Related
Brief Psychotic Disorder 311
Disorders 267
Schizophreniform Disorder 312
Alcohol Abuse and Dependence 267
Delusional Disorder 312
Sedative, Hypnotic, or Anxiolytic Abuse
Shared Psychotic Disorder 312
and Dependence 271
Psychotic Disorder Due to a General Medical
CNS Stimulant Abuse and Dependence 274
Condition 313
Inhalant Abuse and Dependence 277
Substance-Induced Psychotic Disorder 313
Opioid Abuse and Dependence 278
Opioid Intoxication 280 Application of the Nursing Process 313
Hallucinogen Abuse and Dependence 281 Background Assessment Data 313
Cannabis Abuse and Dependence 283 Positive and Negative Symptoms 316
Diagnosis/Outcome Identification 316
Application of the Nursing Process 285
Planning/Implementation 317
Assessment 285
Client/Family Education 321
Dual Diagnosis 288
Evaluation 321
Diagnosis/Outcome Identification 289
Planning/Implementation 292 Treatment Modalities for Schizophrenia
Evaluation 294 and Other Psychotic Disorders 321
Psychological Treatments 321
Treatment Modalities for Substance-Related
Social Treatment 324
Disorders 294
Organic Treatment 325
Alcoholics Anonymous 294
Pharmacotherapy 296 Summary 327
Counseling 297
Group Therapy 297 Chapter 16
Psychopharmacology for Substance
Mood Disorders 332
Intoxication and Substance
Withdrawal 298 Introduction 333

Summary 299 Historical Perspective 333

Chapter 15 Epidemiology 334

Gender 334
Schizophrenia and Other Psychotic Age 334
Disorders 304 Social Class 334
Introduction 305 Race and Culture 334
Marital Status 335
Nature of the Disorder 305
Seasonality 335
Prognosis 307
Types of Mood Disorders 335
Etiological Implications 307
Depressive Disorders 335
Biological Influences 307
Bipolar Disorders 336
Genetics 307
Other Mood Disorders 338
Physiological Influences 309
Psychological Influences 309 Depressive Disorders 339
Environmental Influences 310 Etiological Implications 339
Theoretical Integration 310 Developmental Implications 342

Types of Schizophrenia and Other Psychotic Application of the Nursing Process to Depressive
Disorders 310 Disorders 345
Disorganized Schizophrenia 310 Background Assessment Data 345
Catatonic Schizophrenia 310 Diagnosis/Outcome Identification 347
Paranoid Schizophrenia 311 Planning/Implementation 348
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xx CONTENTS

Client/Family Education 352 Behavior Therapy 406

Evaluation of Care for the Depressed Client 352 Group/Family Therapy 407
Psychopharmacology 407
Bipolar Disorder (Mania) 352
Etiological Implications 352 Summary 409
Developmental Implications 353
Chapter 18
Application of the Nursing Process to Bipolar
Disorder (Mania) 355 Anxiety-Related Disorders 413
Background Assessment Data 355 Introduction 414
Diagnosis/Outcome Identification 356
Planning/Implementation 357 Historical Aspects 414
Client/Family Education 358 Epidemiological Statistics 415
Evaluation of Care for the
Manic Client 358 Application of the Nursing Process 416
Background Assessment Data—Types of
Treatment Modalities for Mood Psychophysiological Disorders 416
Disorders 360 Diagnosis/Outcome Identification 422
Psychological Treatments 360 Planning/Implementation 423
Organic Treatments 362 Client Family Education 423
Suicide 366 Evaluation 423
Epidemiological Factors 366 Background Assessment Data—Types of Somatoform
Disorders 426
Application of the Nursing Process with Diagnosis/Outcome Identification 428
the Suicidal Client 366 Planning/Implementation 429
Assessment 366 Evaluation 434
Diagnosis/Outcome Identification 369 Treatment Modalities for Somatoform
Planning/Implementation 369 Disorders 434
Evaluation 372 Background Assessment Data—Types of Dissociative
Summary 372 Disorders 434
Diagnosis/Outcome Identification 437
Chapter 17 Planning/Implementation 438
Anxiety Disorders 379 Evaluation 438
Treatment Modalities for Dissociative
Introduction 380 Disorders 438
Historical Aspects 380 Summary 443
Epidemiological Statistics 380
Chapter 19
How Much is Too Much? 381
Disorders of Human Sexuality 448
Application of the Nursing Process 381
Introduction 449
Panic Disorder 381
Panic Disorder with Agoraphobia 382 Development of Human Sexuality 449
Generalized Anxiety Disorder 382 Birth Through Age 12 449
Phobias 387 Adolescence 450
Obsessive-Compulsive Disorder 391 Adulthood 450
Posttraumatic Stress Disorder 398 The “Middle” Years—40 to 65 451
Anxiety Disorder Due to a General Medical
Sexual Disorders 451
Condition 404
Paraphilias 451
Substance-Induced Anxiety Disorder 404
Sexual Dysfunctions 455
Treatment Modalities 404 Application of the Nursing Process to Sexual
Individual Psychotherapy 404 Disorders 459
Cognitive Therapy 405 Treatment Modalities for Sexual Dysfunctions 462
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CONTENTS xxi

Variations in Sexual Orientation 467 Application of the Nursing Process 504

Homosexuality 467 Borderline Personality Disorder 504
Transsexualism 469 Antisocial Personality Disorder 509
Bisexuality 469
Treatment Modalities 513
Sexually Transmitted Diseases 470 Interpersonal Psychotherapy 513
Summary 470 Psychoanalytical Psychotherapy 516
Milieu or Group Therapy 516
Chapter 20 Cognitive/Behavioral Therapy 516
Eating Disorders 476 Psychopharmacology 516

Introduction 477 Summary 518

Epidemiological Factors 477

Unit Four
Application of the Nursing Process 478
Background Assessment Data P SYCHIATRIC /M ENTAL H EALTH
(Anorexia Nervosa) 478 N URSING OF S PECIAL P OPULATIONS
Background Assessment Data
(Bulimia Nervosa) 478 Chapter 22
Etiological Implications for Anorexia Children and Adolescents 525
Nervosa and Bulimia Nervosa 479
Background Assessment Data (Obesity) 480 Introduction 526
Etiological Implications for Obesity 481 Mental Retardation 526
Diagnosis/Outcome Identification 482 Etiological Implications 526
Planning/Implementation 482 Application of the Nursing Process to Mental
Client/Family Education 482 Retardation 527
Evaluation 482 Diagnosis/Outcome Identification 528
Treatment Modalities 488 Planning/Implementation 528
Behavior Modification 488 Evaluation 528
Individual Therapy 488
Autistic Disorder 530
Family Therapy 489
Etiological Implications 530
Psychopharmacology 489
Application of the Nursing Process to Autistic
Summary 490 Disorder 530

Chapter 21 Attention-Deficit/Hyperactivity Disorder 531

Etiological Implications 533
Personality Disorders 495
Application of the Nursing Process
Introduction 496 to ADHD 534
Historical Aspects 496 Conduct Disorder 540
Types of Personality Disorders 497 Etiological Implications 540
Paranoid Personality Disorder 497 Application of the Nursing Process to Conduct
Schizoid Personality Disorder 498 Disorder 541
Schizotypal Personality Disorder 499
Oppositional Defiant Disorder 542
Antisocial Personality Disorder 499
Etiological Implications 542
Borderline Personality Disorder 500
Application of the Nursing Process to Oppositional
Histrionic Personality Disorder 500
Defiant Disorder 544
Narcissistic Personality Disorder 501
Avoidant Personality Disorder 501 Tourette’s Disorder 545
Dependent Personality Disorder 502 Etiological Implications 547
Obsessive-Compulsive Personality Disorder 503 Application of the Nursing Process to Tourette’s
Passive-Aggressive Personality Disorder 503 Disorder 547
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xxii CONTENTS

Separation Anxiety Disorder 550 Sociocultural Aspects of Aging 590

Etiological Implications 550 Sexual Aspects of Aging 591
Application of the Nursing Process to Separation
Special Concerns of the Elderly Population 592
Anxiety Disorder 551
Retirement 592
General Therapeutic Approaches 553 Long-Term Care 594
Behavior Therapy 553 Elder Abuse 595
Family Therapy 553 Suicide 597
Group Therapy 553
Application of the Nursing Process 598
Psychopharmacology 555
Assessment 598
Summary 555 Diagnosis/Outcome Identification 599
Planning/Implementation 600
Chapter 23 Evaluation 600
Victims of Abuse or Neglect 561
Summary 605
Introduction 562

Historical Perspectives 562

Chapter 25
Community Mental Health Nursing 611
Etiological Implications 563
Biological Theories 563 Introduction 612
Psychological Theories 563
The Changing Focus of Care 612
Sociocultural Theories 563
The Public Health Model 613
Application of the Nursing Process 565
Background Assessment Data 565 The Community as Client 614
Diagnosis/Outcome Identification 571 Primary Prevention 614
Planning/Implementation 572 Secondary Prevention 620
Evaluation 572 Tertiary Prevention 623
Treatment Modalities 572 The Homeless Population 629
Crisis Intervention 572 Historical and Epidemiological Aspects 629
Summary 576 Community Resources for the Homeless 635
The Homeless Client and the Nursing
Chapter 24 Process 636
The Aging Individual 581 Summary 638
Introduction 582
Chapter 26
How Old is Old? 582
The Bereaved Individual 642
Epidemiological Statistics 583
The Population 583 Introduction 643
Marital Status 583 Theoretical Perspectives on Loss
Living Arrangements 583 and Bereavement 643
Economic Status 583 Stages of Grief 643
Employment 583
Health Status 584 Length of the Grief Process 646

Theories of Aging 584 Anticipatory Grief 647

Biological Theories 584
Maladaptive Responses to Loss 647
Psychosocial Theories 585
Delayed or Inhibited Grief 647
The Normal Aging Process 586 Distorted (Exaggerated) Grief Response 648
Biological Aspects of Aging 586 Chronic or Prolonged Grieving 648
Psychological Aspects of Aging 588 Normal versus Maladaptive Grieving 648
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CONTENTS xxiii

Application of the Nursing Process 648 Domain 4: Activity/Rest 671

Background Assessment Data: Concepts
Domain 5: Perception/Cognition 671
of Death—Developmental Issues 648
Background Assessment Data: Concepts Domain 6: Self-Perception 671
of Death—Cultural Issues 650
Domain 7: Role Relationships 672
Nursing Diagnosis/Outcome Identification 652
Planning/Implementation 652 Domain 8: Sexuality 672
Evaluation 652
Domain 9: Coping/Stress Tolerance 672
Additional Assistance 654
Domain 10: Life Principles 672
Hospice 654
Advance Directives 657 Domain 11: Safety/Protection 673
Summary 657 Domain 12: Comfort 673

Appendix A Domain 13: Growth/Development 673

DSM-IV-TR Classification: Appendix C
Axes I and II Categories and Codes 663
Assigning Nursing Diagnoses
Disorders Usually First Diagnosed in Infancy, to Client Behaviors 674
Childhood, or Adolescence 663
Delirium, Dementia, and Amnestic and Other
Appendix D
Cognitive Disorders 664 Mental Status Assessment 676
Mental Disorders Due to a General Medical Identifying Data 676
Condition Not Elsewhere Classified 664
General Description 676
Substance-Related Disorders 664
Emotions 676
Schizophrenia and Other Psychotic
Thought Processes 677
Disorders 666
Perceptual Disturbances 677
Mood Disorders 667
Sensorium and Cognitive Ability 677
Somatoform Disorders 667
Impulse Control 677
Factitious Disorders 667
Judgment and Insight 677
Dissociative Disorders 667
Sexual and Gender Identity Disorders 667 Appendix E
Eating Disorders 668 Glossary 678

Sleep Disorders 668 Appendix F

Other Conditions That May Be a Focus of Clinical Answers to Review Questions 699
Attention 669 Chapter 1. Mental Health and Mental
Additional Codes 669 Illness 699
Chapter 2. Concepts of Personality
Appendix B Development 699
NANDA Nursing Diagnoses: Taxonomy II
Domains, Classes, and Diagnoses 670 Chapter 3. Biological Implications 699
Chapter 4. Ethical and Legal Issues 699
Domain 1: Health Promotion 670
Chapter 5. Cultural and Spiritual Concepts
Domain 2: Nutrition 670
Relevant to Psychiatric/Mental Health
Domain 3: Elimination and Exchange 670 Nursing 699
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xxiv CONTENTS

Chapter 6. Relationship Development and Chapter 16. Mood Disorders 700

Therapeutic Communication 699
Chapter 17. Anxiety Disorders 700
Chapter 7. The Nursing Process in
Chapter 18. Anxiety-Related Disorders 700
Psychiatric/Mental Health Nursing 699
Chapter 19. Disorders of Human Sexuality 700
Chapter 8. Milieu Therapy—The Therapeutic
Community 700 Chapter 20. Eating Disorders 700

Chapter 9. Intervention in Groups 700 Chapter 21. Personality Disorders 700

Chapter 10. Intervening in Crises 700 Chapter 22. Children and Adolescents 700

Chapter 11. Psychopharmacology 700 Chapter 23. Victims of Abuse or Neglect 701

Chapter 12. Complementary and Psychosocial Chapter 24. The Aging Individual 701
Therapies 700
Chapter 25. Community Mental Health
Chapter 13. Delirium, Dementia, and Amnestic Nursing 701
Disorders 700
Chapter 26. The Bereaved Individual 701
Chapter 14. Substance-Related Disorders 700
Index 703
Chapter 15. Schizophrenia and Other Psychotic
Disorders 700
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UNIT ONE

Introduction
to Psychiatric/
Mental Health
Concepts
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1
C H A P T E R

Mental Health
and Mental Illness
CHAPTER OUTLINE
OBJECTIVES THE DSM-IV-TR MULTIAXIAL
INTRODUCTION EVALUATION SYSTEM
MENTAL HEALTH SUMMARY
MENTAL ILLNESS REVIEW QUESTIONS
PHYSICAL AND PSYCHOLOGICAL
RESPONSES TO STRESS

KEY TERMS

anticipatory grief ego defense mechanisms neurosis

bereavement overload fight-or-flight syndrome psychosis
Diagnostic and Statistical Manual
of Mental Disorders, Fourth
Edition, Text Revision (DSM-
IV-TR)

CORE CONCEPTS
anxiety grief

OBJECTIVES
After reading this chapter, the student will be able to:
1. Define mental health and mental illness. 4. Discuss the concepts of anxiety and grief as psy-
2. Discuss cultural elements that influence atti- chological responses to stress.
tudes toward mental health and mental illness. 5. Describe the DSM-IV-TR multiaxial evaluation
3. Identify physiological responses to stress. system for classification of mental disorders.

3
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4 UNIT I ● INTRODUCTION TO PSYCHIATRIC/MENTAL HEALTH CONCEPTS

INTRODUCTION
The concepts of mental health and mental illness are
culturally defined. Some cultures are quite liberal in the
range of behaviors that are considered acceptable, SELF-
ACTUALIZATION
whereas others have very little tolerance for behaviors (The individual
possesses a
that deviate from the cultural norms. A study of the his- feeling of self-
fulfillment and
tory of psychiatric care reveals some shocking truths the realization
of his or her
highest potential.)
about past treatment of mentally ill individuals. Many
were kept in control by means that could be considered SELF-ESTEEM
ESTEEM-OF-OTHERS
(The individual seeks self-respect
less than humane. and respect from others, works to
achieve success and recognition in
Primitive beliefs regarding mental disturbances took work, and desires prestige from
accomplishments.)
several views. Some thought that an individual with
mental illness had been dispossessed of his or her soul LOVE AND BELONGING
(Needs are for giving and receiving of
and that the only way wellness could be achieved was if affection, companionship, satisfactory
interpersonal relationships, and
the soul returned. Others believed that evil spirits or identification with a group.)

supernatural or magical powers had entered the body. SAFETY AND SECURITY
The “cure” for these individuals involved a ritualistic (Needs at this level are for avoiding harm, maintaining
comfort, order, structure, physical safety, freedom from
exorcism to purge the body of these unwanted forces fear, and protection.)

that often consisted of brutal beatings, starvation, or PHYSIOLOGICAL NEEDS

other torturous means. Still others considered that the (Basic fundamental needs include food, water, air, sleep, exercise,
elimination, shelter, and sexual expression.)
mentally ill individual may have broken a taboo or
sinned against another individual or God, for which rit- FIGURE 1–1 Maslow’s hierarchy of needs.
ualistic purification was required or various types of
retribution were demanded. The correlation of mental evolved, and fully mature.” He believed that healthy,
illness to demonology or witchcraft led to some men- or self-actualized, individuals possessed the following
tally ill individuals being burned at the stake. characteristics:
This chapter defines mental health and mental ill-
● An appropriate perception of reality
ness and describes physical and psychological responses
● The ability to accept oneself, others, and human
to stress. The Diagnostic and Statistical Manual of Men-
tal Disorders, 4th Edition, Text Revision (DSM-IV-TR), nature
● The ability to manifest spontaneity
multiaxial evaluation system is also presented.
● The capacity for focusing concentration on problem-
solving
● A need for detachment and desire for privacy
MENTAL HEALTH
● Independence, autonomy, and a resistance to encul-
A number of theorists have attempted to define the turation
● An intensity of emotional reaction
concept of mental health, which in many cases deals
● A frequency of “peak” experiences that validate the
with various aspects of individual functioning. Maslow
(1970) emphasized an individual’s motivation in the worthwhileness, richness, and beauty of life
● An identification with humankind
continuous quest for self-actualization. He identified a
● The ability to achieve satisfactory interpersonal re-
“hierarchy of needs,” the lower ones requiring fulfill-
ment before those at higher levels can be achieved, with lationships
● A democratic character structure and strong sense
self-actualization being fulfillment of one’s highest po-
tential. An individual’s position within the hierarchy of ethics
● Creativity
may fluctuate based on life circumstances. For exam-
● A degree of nonconformance
ple, an individual facing major surgery who has been
working on tasks to achieve self-actualization may be- The American Psychiatric Association (APA, 2003)
come preoccupied, if only temporarily, with the need defines mental health as “A state of being that is rela-
for physiological safety. A representation of the needs tive rather than absolute. The successful performance
hierarchy is provided in Figure 1–1. of mental functions shown by productive activities, ful-
Maslow described self-actualization as the state of filling relationships with other people, and the ability to
being “psychologically healthy, fully human, highly adapt to change and to cope with adversity.”
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CHAPTER 1 ● MENTAL HEALTH AND MENTAL ILLNESS 5

Townsend (2006) defines mental health as “The suc- BOX 1–1 Cultural Aspects of Mental Illness
cessful adaptation to stressors from the internal or ex-
ternal environment, evidenced by thoughts, feelings, 1. It is usually members of the lay community rather than
and behaviors that are age-appropriate and congruent a psychiatric professional who initially recognize that
an individual’s behavior deviates from the social norms.
with local and cultural norms.” (p.16) 2. People who are related to an individual or who are of
This definition of mental health is used for purposes the same cultural or social group are less likely to label
of this text. that individual’s behavior as mental illness than some-
one who is relationally or culturally distant. Family
members (or people of the same cultural or social
group) try to “normalize” the behavior and try to find
MENTAL ILLNESS an explanation for the behavior.
3. Psychiatrists see a person with mental illness most
A universal concept of mental illness is difficult to de- often when the family members can no longer deny the
fine because of the cultural factors that influence such a illness and often when the behavior is at its worst. The
concept. However, certain elements are associated with local or cultural norms define pathological behavior.
4. Individuals in the lowest socioeconomic class usually
individuals’ perceptions of mental illness, regardless of display the highest amount of mental illness symptoms.
cultural origin. Horwitz (2002) identifies two of these However, they tend to tolerate a wider range of be-
elements as incomprehensibility and cultural relativity. haviors that deviate from societal norms and are less
Incomprehensibility relates to the inability of the gen- likely to consider these behaviors as indicative of men-
eral population to understand the motivation behind a tal illness. Mental illness labels are most often applied
by psychiatric professionals.
behavior. When observers are unable to find meaning 5. The higher the social class, the greater the recognition
or comprehensibility in behavior, they are likely to label of mental illness behaviors (as defined by societal
that behavior as mental illness. Horwitz states, “Ob- norms). Members of the higher socioeconomic classes
servers attribute labels of mental illness when the rules, are likely to be self-labeled or labeled by family mem-
conventions, and understandings they use to interpret bers or friends. Psychiatric assistance is sought soon
after the first signs of emotional disturbance.
behavior fail to find any intelligible motivation behind 6. The more highly educated the person, the greater the
an action.” recognition of mental illness behaviors. However, even
The element of cultural relativity considers that these more relevant than amount of education is type of edu-
rules, conventions, and understandings are conceived cation. Individuals in the more humanistic types of pro-
within an individual’s own particular culture. Behavior fessions (e.g., lawyers, social workers, artists, teachers,
nurses) are more likely to seek psychiatric assistance
is categorized as “normal” or “abnormal” according to than other professionals such as business executives,
one’s cultural or societal norms. Therefore, a behavior computer specialists, accountants, and engineers.
that is recognized as evidence of mental illness in one 7. In terms of religion, Jewish people are more likely to
society may be viewed as normal in another society, and seek psychiatric assistance than are people who are
vice versa. Horwitz identified a number of cultural as- Catholic or Protestant.
8. Women are more likely than men are to recognize the
pects of mental illness, which are presented in Box 1–1. symptoms of mental illness and seek assistance.
In the DSM-IV-TR (APA, 2000), the APA defines 9. The greater the cultural distance from the mainstream
mental illness or a mental disorder as: “A clinically sig- of society (i.e., the fewer the ties with conventional so-
nificant behavioral or psychological syndrome or pat- ciety), the greater the likelihood of a negative response
tern that occurs in an individual and that is associated by society to mental illness. For example, immigrants
have a greater distance from the mainstream than the
with present distress (e.g., a painful symptom) or dis- native born, blacks more than whites, and “bohemians”
ability (i.e., impairment in one or more important areas more than bourgeoisie. They are more likely to be sub-
of functioning), or with a significantly increased risk of jected to coercive treatment, and involuntary psychi-
suffering death, pain, disability, or an important loss of atric commitments are more common.
freedom…and is not merely an expectable… response Source: Adapted from Horwitz (2002).
to a particular event.” (p. xxxi)
Townsend (2006) defines mental illness as: “Mal-
adaptive responses to stressors from the internal or ex- PHYSICAL AND PSYCHOLOGICAL
ternal environment, evidenced by thoughts, feelings, RESPONSES TO STRESS
and behaviors that are incongruent with the local and
cultural norms, and interfere with the individual’s so-
cial, occupational, and/or physical functioning.” (p. 17)
Physical Responses
This definition of mental illness is used for purposes In 1956, Hans Selye published the results of his research
of this text. concerning the physiological response of a biological
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6 UNIT I ● INTRODUCTION TO PSYCHIATRIC/MENTAL HEALTH CONCEPTS

system to a change imposed on it. After the initial pub- the hypothalamus stimulates the pituitary gland to
lication of his findings, he revised his definition of stress release hormones that produce the following effects:
to “the state manifested by a specific syndrome which ● Adrenocorticotropic hormone (ACTH) stimulates

consists of all the nonspecifically-induced changes the adrenal cortex to release glucocorticoids and
within a biologic system” (Selye, 1976, p. 64). This syn- mineralocorticoids, resulting in increased gluco-
drome of symptoms has come to be known as the fight- neogenesis and retention of sodium and water and
or-flight syndrome. Selye called this general decreased immune and inflammatory responses.
reaction of the body to stress the general adaptation syn- ● Vasopressin (antidiuretic hormone) increases

drome. He described the reaction in three distinct stages: fluid retention and also increases blood pressure
through constriction of blood vessels.
1. Alarm reaction stage. During this stage, the phys-
● Growth hormone has a direct effect on protein,
iological responses of the fight or flight syndrome
carbohydrate, and lipid metabolism, resulting in
are initiated.
increased serum glucose and free fatty acids.
2. Stage of resistance. The individual uses the phys-
● Thyrotropic hormone stimulates the thyroid
iological responses of the first stage as a defense in
gland to increase the basal metabolic rate.
the attempt to adapt to the stressor. If adaptation oc-
● Gonadotropins cause a decrease in secretion of sex
curs, the third stage is prevented or delayed. Physi-
hormones, resulting in decreased libido and im-
ological symptoms may disappear.
potence.
3. Stage of exhaustion. This stage occurs when there
is a prolonged exposure to the stressor to which the This “fight-or-flight” response undoubtedly served
body has become adjusted. The adaptive energy is our ancestors well. The Homo sapiens who had to face
depleted, and the individual can no longer draw from the giant grizzly bear or the saber-toothed tiger as a
the resources for adaptation described in the first two facet of their struggle for survival must have used these
stages. Diseases of adaptation (e.g., headaches, men- adaptive resources to their advantage. The response was
tal disorders, coronary artery disease, ulcers, colitis) elicited in emergencies, used in the preservation of life,
may occur. Without intervention for reversal, ex- and followed by restoration of the compensatory mech-
haustion and even death ensues (Selye, 1956, 1974). anisms to the pre-emergent condition (homeostasis).
Biological responses associated with the “fight-or- Selye performed his extensive research in a con-
flight syndrome” include the following: trolled setting with laboratory animals as subjects. He
elicited physiological responses with physical stimuli,
● The immediate response. The hypothalamus such as exposure to heat or extreme cold, electric shock,
stimulates the sympathetic nervous system, which injection of toxic agents, restraint, and surgical injury.
results in the following physical effects: Since the publication of Selye’s original research, it has
● The adrenal medulla releases norepinephrine and become apparent that the fight-or-flight syndrome oc-
epinephrine into the bloodstream. curs in response to psychological or emotional stimuli,
● The pupils dilate. just as it does to physical stimuli. The psychological or
● Secretion from the lacrimal (tear) glands is in- emotional stressors are often not resolved as rapidly as
creased. some physical stressors; therefore the body may be de-
● In the lungs, the bronchioles dilate and the respi- pleted of its adaptive energy more readily than it is
ration rate is increased. from physical stressors. The fight-or-flight response
● The force of cardiac contraction increases, as does may be inappropriate or even dangerous to the lifestyle
cardiac output, heart rate, and blood pressure. of today, wherein stress has been described as a psy-
● Gastrointestinal motility and secretions decrease, chosocial state that is pervasive, chronic, and relentless.
and sphincters contract. It is this chronic response that maintains the body in
● In the liver, there is increased glycogenolysis and the aroused condition for extended periods that pro-
gluconeogenesis and decreased glycogen synthesis. motes susceptibility to diseases of adaptation.
● The bladder muscle contracts and the sphincter

relaxes; there is increased ureter motility.

● Secretion from the sweat glands is increased.
Psychological Responses
● Lipolysis occurs in the fat cells. Anxiety and grief have been described as two major,
● The sustained response. When the stress response primary psychological response patterns to stress. A va-
is not relieved immediately and the individual re- riety of thoughts, feelings, and behaviors are associated
mains under stress for a prolonged period of time, with each of these response patterns. Adaptation is de-
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CHAPTER 1 ● MENTAL HEALTH AND MENTAL ILLNESS 7

termined by the degree to which the thoughts, feelings, and emotional symptoms (e.g., confusion, dread,
and behaviors interfere with an individual’s functioning. horror) may be evident. Discomfort is experienced
to the degree that virtually all overt behavior is
aimed at relieving the anxiety.
● Panic anxiety. In this most intense state of anxiety,
the individual is unable to focus on even one detail
Anxiety within the environment. Misperceptions are com-
A diffuse apprehension that is vague in nature and is as- mon, and a loss of contact with reality may occur.
sociated with feelings of uncertainty and helplessness. The individual may experience hallucinations or
delusions. Behavior may be characterized by wild
and desperate actions or extreme withdrawal.
Anxiety Human functioning and communication with oth-
Feelings of anxiety are so common in our society that ers are ineffective. Panic anxiety is associated with a
they are almost considered universal. Anxiety arises feeling of terror, and individuals may be convinced
from the chaos and confusion that exists in the world that they have a life-threatening illness or fear that
today. Fears of the unknown and conditions of ambi- they are “going crazy,” are losing control, or are
guity offer a perfect breeding ground for anxiety to take emotionally weak (APA, 2000). Prolonged panic anx-
root and grow. Low levels of anxiety are adaptive and iety can lead to physical and emotional exhaustion
can provide the motivation required for survival. Anx- and can be life threatening.
iety becomes problematic when the individual is unable
to prevent the anxiety from escalating to a level that in- A variety of behavioral adaptation responses occur at
terferes with the ability to meet basic needs. each level of anxiety. Figure 1–2 depicts these behav-
Peplau (1963) described four levels of anxiety: mild, ioral responses on a continuum of anxiety ranging from
moderate, severe, and panic. Nurses must be able to mild to panic.
recognize the symptoms associated with each level
to plan for appropriate intervention with anxious indi- Mild Anxiety
viduals. At the mild level, individuals use any of a number of
coping behaviors that satisfy their needs for comfort.
● Mild anxiety. This level of anxiety is seldom a prob-
Menninger (1963) described the following types of
lem for the individual. It is associated with the
coping mechanisms that individuals use to relieve anx-
tension experienced in response to the events of day-
iety in stressful situations:
to-day living. Mild anxiety prepares people for ac-
tion. It sharpens the senses, increases motivation for ● Sleeping
productivity, increases the perceptual field, and re- ● Eating
sults in a heightened awareness of the environment. ● Physical exercise
Learning is enhanced and the individual is able to ● Smoking
function at his or her optimal level. ● Crying
● Moderate anxiety. As the level of anxiety increases, ● Yawning
the extent of the perceptual field diminishes. The ● Drinking
moderately anxious individual is less alert to events ● Daydreaming
occurring within the environment. The individual’s ● Laughing
attention span and ability to concentrate decrease, ● Cursing
although he or she may still attend to needs with di- ● Pacing
rection. Assistance with problem-solving may be re- ● Foot swinging
quired. Increased muscular tension and restlessness
are evident.
● Severe anxiety. The perceptual field of the severely Mild Moderate Severe Panic
anxious individual is so greatly diminished that con-
centration centers on one particular detail only or
Psycho- Psycho-
on many extraneous details. Attention span is ex- Coping
mechanisms
Ego
defense physiological neurotic
Psychotic
responses
responses responses
tremely limited, and the individual has much diffi- mechanisms

culty completing even the simplest task. Physical FIGURE 1–2 Adaptation responses on a continuum
symptoms (e.g., headaches, palpitations, insomnia) of anxiety.
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8 UNIT I ● INTRODUCTION TO PSYCHIATRIC/MENTAL HEALTH CONCEPTS

● Fidgeting Severe Anxiety

● Nail biting
●
Extended periods of repressed severe anxiety can result
Finger tapping
●
in psychoneurotic patterns of behaving. Neurosis is no
Talking to someone with whom one feels com-
longer a separate category of disorders in the DSM-IV-
fortable
TR (APA, 2000). However, the term is still used in the
Undoubtedly there are many more responses too nu- literature to further describe the symptomatology of
merous to mention here, considering that each indi- certain disorders. Neuroses are psychiatric disturbances,
vidual develops his or her own unique ways to relieve characterized by excessive anxiety that is expressed di-
anxiety at the mild level. Some of these behaviors are rectly or altered through defense mechanisms. It ap-
much more adaptive than others are. pears as a symptom, such as an obsession, a compulsion,
a phobia, or a sexual dysfunction (Sadock & Sadock,
Mild to Moderate Anxiety 2003). The following are common characteristics of
people with neuroses:
Sigmund Freud (1961) identified the ego as the reality
component of the personality that governs problem- ● They are aware that they are experiencing distress.
solving and rational thinking. As the level of anxiety in- ● They are aware that their behaviors are maladaptive.
creases, the strength of the ego is tested, and energy is ● They are unaware of any possible psychological
mobilized to confront the threat. Anna Freud (1953) causes of the distress.
identified a number of defense mechanisms employed ● They feel helpless to change their situation.
by the ego in the face of threat to biological or psy- ● They experience no loss of contact with reality.
chological integrity (Table 1–1). Some of these ego de-
The following disorders are examples of psychoneu-
fense mechanisms are more adaptive than others are,
rotic responses to severe anxiety as they appear in the
but all are used either consciously or unconsciously as
DSM-IV-TR:
protective devices for the ego in an effort to relieve
mild to moderate anxiety. They become maladaptive ● Anxiety disorders. Disorders in which the charac-
when an individual uses them to such a degree that teristic features are symptoms of anxiety and avoid-
there is interference with the ability to deal with real- ance behavior (e.g., phobias, obsessive–compulsive
ity, with interpersonal relations, or with occupational disorder, panic disorder, generalized anxiety disor-
performance. der, posttraumatic stress disorder).
● Somatoform disorders. Disorders in which the
Moderate to Severe Anxiety characteristic features are physical symptoms for
which there is no demonstrable organic pathology.
Anxiety at the moderate to severe level that remains un- Psychological factors are judged to play a signifi-
resolved over an extended period can contribute to a cant role in the onset, severity, exacerbation, or
number of physiological disorders. The DSM-IV-TR maintenance of the symptoms (e.g., hypochondria-
(APA, 2000) describes these disorders as “the presence sis, conversion disorder, somatization disorder, pain
of one or more specific psychological or behavioral fac- disorder).
tors that adversely affect a general medical condition.” ● Dissociative disorders. Disorders in which the
The psychological factors may exacerbate symptoms characteristic feature is a disruption in the usually
of, delay recovery from, or interfere with treatment of integrated functions of consciousness, memory,
the medical condition. The condition may be initiated identity, or perception of the environment (e.g., dis-
or exacerbated by an environmental situation that the sociative amnesia, dissociative fugue, dissociative
individual perceives as stressful. Measurable patho- identity disorder, depersonalization disorder).
physiology can be demonstrated. The DSM-IV-TR
states:
Panic Anxiety
Psychological and behavioral factors may affect the course
of almost every major category of disease, including car-
At this extreme level of anxiety, an individual is not ca-
diovascular conditions, dermatological conditions, en- pable of processing what is happening in the environ-
docrinological conditions, gastrointestinal conditions, ment and may lose contact with reality. Psychosis
neoplastic conditions, neurological conditions, pulmonary is defined as a loss of ego boundaries or a gross im-
conditions, renal conditions, and rheumatological condi- pairment in reality testing (APA, 2000). Psychoses are
tions. (p. 732) serious psychiatric disturbances characterized by the
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CHAPTER 1 ● MENTAL HEALTH AND MENTAL ILLNESS 9

TA B L E 1 – 1 Ego Defense Mechanisms

Defense Mechanism Example Defense Mechanism Example

Compensation Projection
Covering up a real or per- A physically handicapped boy Attributing feelings or impulses Sue feels a strong sexual attrac-
ceived weakness by em- is unable to participate in unacceptable to one’s self to tion to her track coach and
phasizing a trait one football, so he compensates another person. tells her friend, “He’s coming
considers more desirable by becoming a great scholar. on to me!”
Denial Rationalization
Refusing to acknowledge A woman drinks excess alcohol Attempting to make excuses or John tells the rehab nurse, “I
the existence of a real sit- every day and cannot stop, formulate logical reasons to drink because it’s the only
uation or the feelings as- failing to acknowledge that justify unacceptable feelings way I can deal with my bad
sociated with it she has a problem. or behaviors marriage and my worse job.”
Displacement Reaction Formation
The transfer of feelings A client is angry at his doctor, Preventing unacceptable or un- Jane hates nursing. She attended
from one target to an- does not express it, but be- desirable thoughts or behav- nursing school to please her
other that is considered comes verbally abusive with iors from being expressed by parents. During career day,
less threatening or that is the nurse. exaggerating opposite she speaks to prospective stu-
neutral thoughts or types of behaviors dents about the excellence of
nursing as a career.
Identification Regression
An attempt to increase self- A teenaged boy who required Responding to stress by retreat- When 2-year-old Jay is hos-
worth by acquiring cer- lengthy rehabilitation after ing to an earlier level of devel- pitalized for tonsillitis he will
tain attributes and an accident decides to be- opment and the comfort drink only from a bottle, al-
characteristics of an indi- come a physical therapist as measures associated with that though his mother states he
vidual one admires a result of his experiences. level of functioning has been drinking from a cup
for 6 months.
Intellectualization Repression
An attempt to avoid ex- Susan’s husband is being trans- Involuntarily blocking unpleas- An accident victim can remem-
pressing actual emotions ferred with his job to a city ant feelings and experiences ber nothing about the acci-
associated with a stressful far away from her parents. from one’s awareness dent.
situation by using the in- She hides anxiety by ex-
tellectual processes of plaining to her parents the
logic, reasoning, and advantages associated with
analysis the move.
Introjection Sublimation
Integrating the beliefs and Children integrate their par- Rechanneling of drives or im- A mother whose son was killed
values of another individ- ents’ value system into the pulses that are personally or by a drunk driver channels
ual into one’s own ego process of conscience for- socially unacceptable into ac- her anger and energy into
structure mation. A child says to tivities that are constructive being the president of the
friend, “Don’t cheat. It’s local chapter of Mothers
wrong.” Against Drunk Drivers.
Isolation Suppression
Separating a thought or Without showing any emo- The voluntary blocking of un- Scarlett O’Hara says, “I don’t
memory from the feeling tion, a young woman de- pleasant feelings and experi- want to think about that now.
tone or emotion associ- scribes being attacked and ences from one’s awareness I’ll think about that tomor-
ated with it raped. row.”
Undoing
Symbolically negating or cancel- Joe is nervous about his new job
ing out an experience that one and yells at his wife. On his
finds intolerable way home he stops and buys
her some flowers.
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10 UNIT I ● INTRODUCTION TO PSYCHIATRIC/MENTAL HEALTH CONCEPTS

presence of delusions or hallucinations and the impair- true!” The reality of the loss is not acknowledged.
ment of interpersonal functioning and relationship to Denial is a protective mechanism that allows the in-
the external world. The following are common char- dividual to cope within an immediate time frame
acteristics of people with psychoses: while organizing more effective defense strategies.
● Stage 2—Anger: “Why me?” and “It’s not fair!” are
● They exhibit minimal distress (emotional tone is flat,
comments often expressed during the anger stage.
bland, or inappropriate).
Envy and resentment toward individuals not affected
● They are unaware that their behavior is maladaptive.
by the loss are common. Anger may be directed at
● They are unaware of any psychological problems.
the self or displaced on loved ones, caregivers, and
● They are exhibiting a flight from reality into a less
even God. There may be a preoccupation with an
stressful world or into one in which they are at-
idealized image of the lost entity.
tempting to adapt. ● Stage 3—Bargaining: “If God will help me through
Examples of psychotic responses to anxiety include this, I promise I will go to church every Sunday and
the schizophrenic, schizoaffective, and delusional dis- volunteer my time to help others.” During this stage,
orders. which is usually not visible or evident to others, a
“bargain” is made with God in an attempt to reverse
or postpone the loss. Sometimes the promise is as-
sociated with feelings of guilt for not having per-
formed satisfactorily, appropriately, or sufficiently.
Grief ● Stage 4—Depression: During this stage, the full
Grief is a subjective state of emotional, physical, and
impact of the loss is experienced. The sense of loss is
social responses to the loss of a valued entity.
intense, and feelings of sadness and depression pre-
vail. This is a time of quiet desperation and disen-
gagement from all association with the lost entity.
Grief
This stage differs from pathological depression in
Most individuals experience intense emotional anguish that it represents advancement toward resolution
in response to a significant personal loss. A loss is any- rather than fixation in an earlier stage of the grief
thing that is perceived as such by the individual. Losses process.
may be real, in which case it can be substantiated by ● Stage 5—Acceptance: The final stage brings a feel-
others (e.g., death of a loved one, loss of personal pos- ing of peace regarding the loss that has occurred. It
sessions), or they may be perceived by the individual is a time of quiet expectation and resignation. The
alone and unable to be shared or identified by others focus is on the reality of the loss and its meaning for
(e.g., loss of the feeling of femininity following a mas- the individuals affected by it.
tectomy). Any situation that creates change for an in-
Not all individuals experience each of these stages in
dividual can be identified as a loss. Failure (either real
response to a loss, nor do they necessarily experience
or perceived) also can be viewed as a loss.
them in this order. Some individuals’ grieving behav-
The loss, or anticipated loss, of anything of value to
iors may fluctuate, and even overlap, among the stages.
an individual can trigger the grief response. This pe-
riod of characteristic emotions and behaviors is called
Anticipatory Grief
mourning. The “normal” mourning process is adaptive
and is characterized by feelings of sadness, guilt, anger, When a loss is anticipated, individuals often begin the
helplessness, hopelessness, and despair. Indeed, an ab- work of grieving before the actual loss occurs. This is
sence of mourning after a loss may be considered mal- called anticipatory grief. Most people re-experience
adaptive. the grieving behaviors once the loss occurs, but having
this time to prepare for the loss can facilitate the
Stages of Grief process of mourning, actually decreasing the length and
intensity of the response. Problems arise, particularly in
Kübler-Ross (1969), in extensive research with termi-
anticipating the death of a loved one, when family
nally ill patients, identified five stages of feelings and
members experience anticipatory grieving and the
behaviors that individuals experience in response to a
mourning process is completed prematurely. They dis-
real, perceived, or anticipated loss:
engage emotionally from the dying person, who then
● Stage 1—Denial: This is a stage of shock and dis- may feel rejected by loved ones at a time when psycho-
belief. The response may be one of “No, it can’t be logical support is so important.
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CHAPTER 1 ● MENTAL HEALTH AND MENTAL ILLNESS 11

Resolution include responses that are prolonged, delayed or in-

hibited, or distorted. The prolonged response is charac-
The grief response can last from weeks to years. It can-
terized by an intense preoccupation with memories of
not be hurried, and individuals must be allowed to
the lost entity for many years after the loss has oc-
progress at their own pace. After the loss of a loved one,
curred. Behaviors associated with the stages of denial
grief work usually lasts for at least a year, during which
or anger are manifested, and disorganization of func-
the grieving person experiences each significant “an-
tioning and intense emotional pain related to the lost
niversary” date for the first time without the loved one
entity are evidenced.
present.
In the delayed or inhibited response, the individual be-
Length of the grief process may be prolonged by a
comes fixed in the denial stage of the grieving process.
number of factors. If the relationship with the lost en-
The emotional pain associated with the loss is not
tity had been marked by ambivalence or if there had
experienced, but anxiety disorders (e.g., phobias,
been an enduring “love–hate” association, reaction to
hypochondriasis) or sleeping and eating disorders (e.g.,
the loss may be burdened with guilt. Guilt lengthens
insomnia, anorexia) may be evident. The individual
the grief reaction by promoting feelings of anger to-
may remain in denial for many years until the grief re-
ward the self for having committed a wrongdoing or
sponse is triggered by a reminder of the loss or even by
behaved in an unacceptable manner toward that which
another, unrelated loss.
is now lost. It may even lead to a feeling that one’s be-
The individual who experiences a distorted response
havior has contributed to the loss.
is fixed in the anger stage of grieving. In the distorted
Anticipatory grieving is thought to shorten the grief
response, all the normal behaviors associated with
response in some individuals who are able to work
grieving, such as helplessness, hopelessness, sadness,
through some of the feelings before the loss occurs. If
anger, and guilt, are exaggerated out of proportion to
the loss is sudden and unexpected, mourning may take
the situation. The individual turns the anger inward on
longer than it would if individuals were able to grieve
the self, is consumed with overwhelming despair, and is
in anticipation of the loss.
unable to function in normal activities of daily living.
Length of the grieving process is also affected by the
Pathological depression is a distorted grief response.
number of recent losses experienced by an individual
and whether he or she is able to complete one grieving
process before another loss occurs. This is particularly
true for elderly individuals who may be experiencing
THE DSM-IV-TR MULTIAXIAL
numerous losses—such as spouse, friends, other rela- EVALUATION SYSTEM
tives, independent functioning, home, personal posses-
sions, and pets—in a relatively short time. As grief The APA (2000) endorses case evaluation on a multi-
accumulates, a type of bereavement overload occurs, axial system, “to facilitate comprehensive and system-
which for some individuals presents an impossible task atic evaluation with attention to the various mental
of grief work. disorders and general medical conditions, psychosocial
Resolution of the process of mourning is thought to and environmental problems, and level of functioning
have occurred when an individual can look back on the that might be overlooked if the focus were on assessing
relationship with the lost entity and accept both the a single presenting problem.” (p. 27) Each individual is
pleasures and the disappointments (both the positive evaluated on five axes. They are defined by the DSM-
and the negative aspects) of the association (Bowlby & IV-TR in the following manner:
Parkes, 1970). Disorganization and emotional pain ● Axis I—Clinical Disorders and Other Conditions
have been experienced and tolerated. Preoccupation
That May Be a Focus of Clinical Attention: This
with the lost entity has been replaced with energy and
includes all mental disorders (except personality
the desire to pursue new situations and relationships.
disorders and mental retardation).
● Axis II—Personality Disorders and Mental Re-
Maladaptive Grief Responses
tardation: These disorders usually begin in child-
Maladaptive responses to loss occur when an individual hood or adolescence and persist in a stable form into
is not able to progress satisfactorily through the stages adult life.
of grieving to achieve resolution. Usually in such situ- ● Axis III—General Medical Conditions: These in-
ations, an individual becomes fixed in the denial or clude any current general medical condition that is
anger stage of the grief process. Several types of grief potentially relevant to the understanding or man-
responses have been identified as pathological. They agement of the individual’s mental disorder.
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12 UNIT I ● INTRODUCTION TO PSYCHIATRIC/MENTAL HEALTH CONCEPTS

TA B L E 1 – 2 Example of a Psychiatric with the local and cultural norms, and interfere with
Diagnosis the individual’s social, occupational, and/or physical
functioning.”
Axis I 300.4 Dysthymic Disorder Most cultures label behavior as mental illness on the
Axis II 301.6 Dependent Personality Disorder
Axis III 244.9 Hypothyroidism
basis of incomprehensibility and cultural relativity. When
Axis IV Unemployed observers are unable to find meaning or comprehensi-
Axis V GAF
65 (current) bility in behavior, they are likely to label that behavior
as mental illness. The meaning of behaviors is deter-
mined within individual cultures.
Selye, who has become known as the founding father
● Axis IV—Psychosocial and Environmental Prob-
of stress research, defined stress as “the state manifested
lems: These are problems that may affect the diag-
by a specific syndrome which consists of all the non-
nosis, treatment, and prognosis of mental disorders
specifically-induced changes within a biological sys-
named on axes I and II. These include problems re-
tem” (Selye, 1976, p. 64). He determined that physical
lated to primary support group, social environment,
beings respond to stressful stimuli with a predictable
education, occupation, housing, economics, access
set of physiological changes. He described the response
to health care services, interaction with the legal sys-
in three distinct stages: (1) the alarm reaction stage, (2)
tem or crime, and other types of psychosocial and
the stage of resistance, and (3) the stage of exhaustion.
environmental problems.
Many illnesses, or diseases of adaptation, have their ori-
● Axis V—Global Assessment of Functioning: This
gin in this aroused state, which is the preparation for
allows the clinician to rate the individual’s overall
“fight or flight.”
functioning on the Global Assessment of Function-
Anxiety and grief have been identified as the two
ing (GAF) Scale. This scale represents in global
major, primary responses to stress. Peplau (1963) de-
terms a single measure of the individual’s psycho-
fined anxiety by levels of symptom severity: mild, mod-
logical, social, and occupational functioning.
erate, severe, and panic. Behaviors associated with
Table 1–2 is an example of a psychiatric diagnosis levels of anxiety include coping mechanisms, ego de-
using the multiaxial system: fense mechanisms, psychophysiological responses, psy-
The DSM-IV-TR outline of Axes I and II categories choneurotic responses, and psychotic responses.
and codes is presented in Appendix A. Grief is a response to loss of a valued entity. Stages of
normal mourning as identified by Kübler-Ross (1969)
are denial, anger, bargaining, depression, and accept-
SUMMARY ance. Anticipatory grief is grief work that is begun, and
sometimes completed, before the loss occurs. Resolu-
A number of definitions of mental health and mental tion is thought to occur when an individual is able to
illness can be found in the literature. For purposes remember and accept both the positive and negative
of this text, mental health is defined as “the success- aspects associated with the lost entity. Grieving is
ful adaptation to stressors from the internal or exter- thought to be maladaptive when the mourning process
nal environment, evidenced by thoughts, feelings, is prolonged, delayed or inhibited, or becomes dis-
and behaviors that are age-appropriate and congru- torted and exaggerated out of proportion to the situa-
ent with local and cultural norms.” Mental illness is tion. Pathological depression is considered to be a
defined as “maladaptive responses to stressors from distorted reaction. The DSM-IV-TR multiaxial system
the internal or external environment, evidenced by of diagnostic classification defines five axes in which
thoughts, feelings, and behaviors that are incongruent each individual case is evaluated.
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CHAPTER 1 ● MENTAL HEALTH AND MENTAL ILLNESS 13

REVIEW QUESTIONS
SELF-EXAMINATION
Please answer the questions based on the following case study:
Anna is 72 years old and has been a widow for 20 years. When Anna’s husband had been dead for a
year, Anna’s daughter gave her a puppy, which she named Lucky. Lucky was a happy, lively mutt of
unknown origin, and he and Anna soon became inseparable. Lucky lived to the ripe old age of 16 and
died in Anna’s arms 3 years ago. Anna’s daughter has consulted the community mental health nurse
practitioner about her mother, stating, “She doesn’t do a thing for herself anymore, and all she wants
to talk about is Lucky. She visits his grave every day! She still cries when she talks about him. I don’t
know what to do!”
1. Anna’s behavior would be considered maladaptive because:
a. It has been more than 3 years since Lucky died.
b. Her grief is too intense just over the loss of a dog.
c. Her grief is interfering with her functioning.
d. People in this culture would not comprehend such behavior over loss of a pet.
2. Anna’s grieving behavior would most likely be considered to be:
a. Delayed
b. Inhibited
c. Prolonged
d. Distorted
3. Anna is most likely fixed in which stage of the grief process?
a. Denial
b. Anger
c. Depression
d. Acceptance
4. Anna is of the age when she may have experienced many losses coming close together.
What is this called?
a. Bereavement overload
b. Normal mourning
c. Isolation
d. Cultural relativity
5. Anna’s daughter has likely put off seeking help for Anna because:
a. Women are less likely to seek help for emotional problems than men.
b. Relatives often try to “normalize” the behavior, rather than label it mental illness.
c. She knows that all old people are expected to be a little depressed.
d. She is afraid that the neighbors “will think her mother is crazy.”
6. Lucky got away from Anna while they were taking a walk. He ran into the street and was hit by a
car. Anna cannot remember any of these circumstances of his death. This is an example of what
defense mechanism?
a. Rationalization
b. Suppression
c. Denial
d. Repression

(continued on following page)

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14 UNIT I ● INTRODUCTION TO PSYCHIATRIC/MENTAL HEALTH CONCEPTS

7. Lucky sometimes refused to obey Anna, and indeed did not come back to her when she called to
him on the day he was killed. But Anna continues to insist, “He was the very best dog. He always
minded me. He always did everything I told him to do.” This represents the defense mechanism of:
a. Sublimation
b. Compensation
c. Reaction formation
d. Undoing
8. Anna’s maladaptive grief response may be attributed to:
a. Unresolved grief over loss of her husband.
b. Loss of several relatives and friends over the last few years.
c. Repressed feelings of guilt over the way in which Lucky died.
d. Any or all of the above.
9. For what reason would Anna’s illness be considered a neurosis rather than a psychosis?
a. She is unaware that her behavior is maladaptive.
b. She exhibits inappropriate affect (emotional tone).
c. She experiences no loss of contact with reality.
d. She tells the nurse, “There is nothing wrong with me!”
10. Which of the following statements by Anna might suggest that she is achieving resolution of her
grief over Lucky’s death?
a. “I don’t cry anymore when I think about Lucky.”
b. “It’s true. Lucky didn’t always mind me. Sometimes he ignored my commands.”
c. “I remember how it happened now. I should have held tighter to his leash!”
d. “I won’t ever have another dog. It’s just too painful to lose them.”

R E F E R E N C E S
American Psychiatric Association. (APA). (2000). Diagnostic and sta- Sadock, B.J., & Sadock, V.A. (2003). Synopsis of psychiatry: Behavioral
tistical manual of mental disorders (4th ed.). Text revision. Washing- sciences/clinical psychiatry (9th ed.). Baltimore: Lippincott Williams
ton, DC: American Psychiatric Publishing. & Wilkins.
American Psychiatric Association. (APA). (2003). A psychiatric glos- Townsend, M.C. (2006). Psychiatric/mental health nursing: Con-
sary (8th ed.). Washington, DC: American Psychiatric Publishing. cepts of care in evidence-based practice (5th ed.). Philadelphia:
Horwitz, A.V. (2002). The social control of mental illness. Clinton Cor- F.A. Davis.
ners, NY: Percheron Press.

C L A S S I C A L R E F E R E N C E S
Bowlby, J., & Parkes, C.M. (1970). Separation and loss. In E. J. An- Maslow, A. (1970). Motivation and personality (2nd ed.). New York:
thony & C. Koupernik (Eds.), International yearbook for child psy- Harper & Row.
chiatry and allied disciplines: The child and his family (Vol. 1). New Menninger, K. (1963). The vital balance. New York: Viking Press.
York: John Wiley & Sons. Peplau, H. (1963). A working definition of anxiety. In S. Burd & M.
Freud, A. (1953). The ego and mechanisms of defense. New York: Inter- Marshall (Eds.), Some clinical approaches to psychiatric nursing. New
national Universities Press. York: Macmillan.
Freud, S. (1961). The ego and the id. In Standard edition of the com- Selye, H. (1956). The stress of life. New York: McGraw-Hill.
plete psychological works of Freud, Vol. XIX. London: Hogarth Press. Selye, H. (1974). Stress without distress. New York: Signet Books.
Kübler-Ross, E. (1969). On death and dying. New York: Macmillan. Selye, H. (1976). The stress of life (rev. ed.). New York: McGraw-Hill.
Townsend(F)-02 6/28/07 2:58 PM Page 15

2
C H A P T E R

Concepts of
Personality
Development
CHAPTER OUTLINE
OBJECTIVES THEORY OF OBJECT RELATIONS
INTRODUCTION A NURSING MODEL—HILDEGARD
PSYCHOANALYTIC THEORY E. PEPLAU
INTERPERSONAL THEORY SUMMARY
THEORY OF PSYCHOSOCIAL DEVELOPMENT REVIEW QUESTIONS

KEY TERMS

counselor psychodynamic nursing technical expert

ego superego temperament
id surrogate
libido symbiosis

CORE CONCEPT
personality

OBJECTIVES
After reading this chapter, the student will be able to:
1. Define personality. b. Interpersonal theory—Sullivan
2. Identify the relevance of knowledge associated c. Theory of psychosocial development—
with personality development to nursing in the Erikson
psychiatric/mental health setting. d. Theory of object relations development—
3. Discuss the major components of the following Mahler
developmental theories: e. A nursing model of interpersonal develop-
a. Psychoanalytic theory—Freud ment—Peplau

15
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16 UNIT I ● INTRODUCTION TO PSYCHIATRIC/MENTAL HEALTH CONCEPTS

INTRODUCTION and maladaptive and cause either significant functional

impairment or subjective distress do they constitute
The DSM-IV-TR (American Psychiatric Association personality disorders (APA, 2000).
[APA], 2000) defines personality as “enduring patterns
of perceiving, relating to, and thinking about the envi-
ronment and oneself that are exhibited in a wide range PSYCHOANALYTIC THEORY
of social and personal contexts” (p. 686). Nurses must
have a basic knowledge of human personality develop- Sigmund Freud (1961), who has been called the father
ment to understand maladaptive behavioral responses of psychiatry, is credited as the first to identify devel-
commonly seen in psychiatric clients. Developmental opment by stages. He considered the first 5 years of a
theories identify behaviors associated with various stages child’s life to be the most important, because he be-
through which individuals pass, thereby specifying lieved that an individual’s basic character had been
what is appropriate or inappropriate at each develop- formed by the age of 5.
mental level. Freud’s personality theory can be conceptualized ac-
Specialists in child development believe that infancy cording to structure and dynamics of the personality,
and early childhood are the major life periods for topography of the mind, and stages of personality de-
the origination and occurrence of developmental velopment.
change. Specialists in life cycle development believe
that people continue to develop and change throughout Structure of the Personality
life, thereby suggesting the possibility for renewal and
Freud organized the structure of the personality into
growth in adults.
three major components: the id, ego, and superego.
Developmental stages are identified by age. Behav-
They are distinguished by their unique functions and
iors can then be evaluated for age-appropriateness. Ide-
different characteristics.
ally, an individual successfully fulfills all the tasks
associated with one stage before moving on to the next
Id
stage (at the appropriate age). Realistically, however,
this seldom happens. One reason is related to tem- The id is the locus of instinctual drives—the “pleasure
perament, the inborn personality characteristics that principle.” Present at birth, it endows the infant with
influence an individual’s manner of reacting to the en- instinctual drives that seek to satisfy needs and achieve
vironment, and ultimately his or her developmental immediate gratification. Id-driven behaviors are im-
progression (Chess & Thomas, 1986). The environ- pulsive and may be irrational.
ment may also influence one’s developmental pattern.
Individuals who are reared in a dysfunctional family Ego
system often have retarded ego development. Accord-
The ego, also called the rational self or the “reality prin-
ing to specialists in life-cycle development, behaviors
ciple,” begins to develop between the ages of 4 and
from an unsuccessfully completed stage can be modi-
6 months. The ego experiences the reality of the exter-
fied and corrected in a later stage.
nal world, adapts to it, and responds to it. As the ego
Stages overlap, and an individual may be working on
develops and gains strength, it seeks to bring the influ-
tasks associated with several stages at one time. When
ences of the external world to bear upon the id, to sub-
an individual becomes fixed in a lower level of develop-
stitute the reality principle for the pleasure principle
ment, with age-inappropriate behaviors focused on ful-
(Marmer, 2003). A primary function of the ego is one
fillment of those tasks, psychopathology may become
of mediator, that is, to maintain harmony among the
evident. Only when personality traits are inflexible
external world, the id, and the superego.

Superego
If the id is identified as the pleasure principle, and the
ego the reality principle, the superego might be referred
Personality to as the “perfection principle.” The superego, which
The combination of character, behavioral, temperamen- develops between ages 3 and 6 years, internalizes the
tal, emotional, and mental traits that are unique to each
values and morals set forth by primary caregivers. De-
specific individual.
rived from a system of rewards and punishments, the
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CHAPTER 2 ● CONCEPTS OF PERSONALITY DEVELOPMENT 17

TA B L E 2 – 1 Comparing Id, Ego, and Superego

Id Ego Superego

“I found this wallet; I will keep “I already have money. This money doesn’t “It is never right to take something that doesn’t
the money.” belong to me. Maybe the person who owns belong to you.”
this wallet doesn’t have any money.”
“Mom and Dad are gone. “Mom and Dad said no friends over while “Never disobey your parents.”
Let’s party!!!!!” they are away. Too risky.”
“I’ll have sex with whomever “Promiscuity can be very dangerous.” “Sex outside of marriage is always wrong.”
I please, whenever I please.”

superego is composed of two major components: the addresses once known but little used and feelings as-
ego-ideal and the conscience. When a child is consistently sociated with significant life events that may have oc-
rewarded for “good” behavior, his or her self-esteem is curred at some time in the past. The preconscious
enhanced, and the behavior becomes part of the ego- enhances awareness by helping to suppress unpleasant
ideal; that is, it is internalized as part of his or her value or nonessential memories from consciousness. It
system. The conscience is formed when the child is is thought to be partially under the control of
consistently punished for “bad” behavior. The child the superego, which helps to suppress unacceptable
learns what is considered morally right or wrong from thoughts and behaviors.
feedback received from parental figures and from soci- ● The unconscious includes all memories that one is un-
ety or culture. When moral and ethical principles or able to bring to conscious awareness. It is the largest
even internalized ideals and values are disregarded, the of the three topographical levels. Unconscious ma-
conscience generates a feeling of guilt within the indi- terial consists of unpleasant or nonessential memo-
vidual. The superego is important in the socialization ries that have been repressed and can be retrieved only
of the individual because it assists the ego in the control through therapy, hypnosis, and with certain sub-
of id impulses. When the superego becomes rigid and stances that alter the awareness and have the capac-
punitive, problems with low self-confidence and low ity to restructure repressed memories. Unconscious
self-esteem arise. material may also emerge in dreams and in seem-
For behavioral examples of id, ego, and superego, see ingly incomprehensible behavior.
Table 2–1.
Dynamics of the Personality
Topography of the Mind Freud believed that psychic energy is the force or impe-
Freud classified all mental contents and operations into tus required for mental functioning. Originating in the
three categories: the conscious, the preconscious, and id, it instinctually fulfills basic physiological needs.
the unconscious. Freud called this psychic energy (or the drive to fulfill
basic physiological needs such as hunger, thirst, and
● The conscious includes all memories that remain sex) the libido. As the child matures, psychic energy is
within an individual’s awareness. It is the smallest of diverted from the id to form the ego and then from the
the three categories. Events and experiences that are ego to form the superego. Psychic energy is distributed
easily remembered or retrieved are considered to be within these three components, with the ego retaining
within one’s conscious awareness. Examples include the largest share to maintain a balance between the im-
telephone numbers, birthdays of self and significant pulsive behaviors of the id and the idealistic behaviors
others, dates of special holidays, and what one had of the superego. If an excessive amount of psychic en-
for lunch today. The conscious mind is thought to ergy is stored in one of these personality components,
be under the control of the ego, the rational and log- behavior reflects that part of the personality. For in-
ical structure of the personality. stance, impulsive behavior prevails when excessive psy-
● The preconscious includes all memories that may have chic energy is stored in the id. Overinvestment in
been forgotten or are not in present awareness but, the ego reflects self-absorbed, or narcissistic, behaviors;
with attention, can readily be recalled into con- an excess within the superego results in rigid, self-
sciousness. Examples include telephone numbers or deprecating behaviors.
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18 UNIT I ● INTRODUCTION TO PSYCHIATRIC/MENTAL HEALTH CONCEPTS

Freud used the terms cathexis and anticathexis to de- TA B L E 2 – 2

Freud’s Stages of
scribe the forces within the id, ego, and superego that Psychosexual Development
are used to invest psychic energy in external sources to
satisfy needs. Cathexis is the process by which the id Major Developmental
invests energy into an object in an attempt to achieve Age Stage Tasks
gratification. An example is the individual who instinc- Birth–18 months Oral Relief from anxiety through
tively turns to alcohol to relieve stress. Anticathexis is oral gratification of needs
the use of psychic energy by the ego and the superego 18 months– Anal Learning independence and
to control id impulses. In the example cited, the ego 3 years control, with focus on the
excretory function
would attempt to control the use of alcohol with ra- 3–6 years Phallic Identification with parent of
tional thinking, such as, “I already have ulcers from the same sex; development
drinking too much. I will call my AA sponsor for sup- of sexual identity; focus on
port. I will not drink.” The superego would exert con- genital organs
trol with such thinking as, “I shouldn’t drink. If I drink, 6–12 years Latency Sexuality repressed; focus on
relationships with same-
my family will be hurt and angry. I should think of how sex peers
it affects them. I’m such a weak person.” Freud believed 13–20 years Genital Libido reawakened as genital
that an imbalance between cathexis and anticathexis re- organs mature; focus on
sulted in internal conflicts, producing tension and anx- relationships with mem-
iety within the individual. Freud’s daughter Anna bers of the opposite sex
devised a comprehensive list of defense mechanisms be-
lieved to be used by the ego as a protective device
against anxiety in mediating between the excessive de- ability to trust others are derived out of gratification
mands of the id and the excessive restrictions of the from fulfillment of basic needs during this stage.
superego (see Chapter 1).
Anal Stage: 18 Months to 3 Years
Freud’s Stages of
The major task in the anal stage is gaining independ-
Personality Development ence and control, with particular focus on the excre-
Freud described formation of the personality through tory function. Freud believed that the manner in which
five stages of psychosexual development. As mentioned the parents and other primary caregivers approach the
earlier, he placed much emphasis on the first 5 years of task of toilet training may have far-reaching effects on
life and believed that characteristics developed during the child in terms of values and personality character-
these early years bore heavily on one’s adaptation pat- istics. When toilet training is strict and rigid, the child
terns and personality traits in adulthood. Fixation in an may choose to retain the feces, becoming constipated.
early stage of development almost certainly results Adult retentive personality traits influenced by this type
in psychopathology. An outline of these five stages is of training include stubbornness, stinginess, and miser-
presented in Table 2–2. liness. An alternate reaction to strict toilet training is
for the child to expel feces in an unacceptable manner
Oral Stage: Birth to 18 Months or at inappropriate times. Far-reaching effects of this
behavior pattern include malevolence, cruelty to oth-
During the oral stage, behavior is directed by the id,
ers, destructiveness, disorganization, and untidiness.
and the goal is immediate gratification of needs. The
Toilet training that is more permissive and accepting
focus of energy is the mouth, and behaviors include
attaches the feeling of importance and desirability to
sucking, chewing, and biting. The infant feels a sense of
feces production. The child becomes extroverted, pro-
attachment and is unable to differentiate the self from
ductive, and altruistic.
the person who is providing the mothering. This in-
cludes feelings such as anxiety. Because of this lack of
differentiation, a pervasive feeling of anxiety on the part
Phallic Stage: 3 to 6 Years
of the mother may be passed on to her infant, leaving In this stage, the focus of energy shifts to the genital
the child vulnerable to similar feelings of insecurity. area. Discovery of differences between genders results
With the beginning of development of the ego at age 4 in a heightened interest in the sexuality of self and oth-
to 6 months, the infant starts to view the self as separate ers. This interest may be manifested in sexual self-
from the mothering figure. A sense of security and the exploratory or group-exploratory play. Freud proposed
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CHAPTER 2 ● CONCEPTS OF PERSONALITY DEVELOPMENT 19

that the development of the Oedipus complex (males) or personal relationships. Before the development of his
Electra complex (females) occurred during this stage of own theoretical framework, Sullivan embraced the con-
development. He described this as the child’s uncon- cepts of Freud. Later, he changed the focus of his work
scious desire to eliminate the parent of the same gen- from the intrapersonal view of Freud to one with a more
der and to possess the parent of the opposite gender for interpersonal flavor in which human behavior could be
himself or herself. Guilt feelings result with the emer- observed in social interactions with others. His ideas,
gence of the superego during these years. Resolution which were not universally accepted at the time, have
of this internal conflict occurs when the child develops been integrated into the practice of psychiatry through
a strong identification with the parent of the same gen- publication only since his death in 1949. Sullivan’s
der and internalizes that parent’s attitudes, beliefs, and major concepts include the following:
value system.
Anxiety is a feeling of emotional discomfort, toward the
Latency Stage: 6 to 12 Years relief or prevention of which all behavior is aimed.
Sullivan believed that anxiety is the “chief disruptive
During the elementary school years, the focus changes
force in interpersonal relations and the main factor
from egocentrism to one of more interest in group ac-
in the development of serious difficulties in living.”
tivities, learning, and socialization with peers. Sexuality
It arises out of one’s inability to satisfy needs or
is not absent during this period but remains obscure
achieve interpersonal security.
and imperceptible to others. Children of this age show
Satisfaction of needs is the fulfillment of all requirements
a distinct preference for same-gender relationships,
associated with an individual’s physiochemical envi-
even rejecting members of the opposite gender.
ronment. Sullivan identified examples of these
requirements as oxygen, food, water, warmth, ten-
Genital Stage: 13 to 20 Years
derness, rest, activity, sexual expression—virtually
In the genital stage, the maturing of the genital organs anything that, when absent, produces discomfort in
results in a reawakening of the libidinal drive. The focus the individual.
is on relationships with members of the opposite gender Interpersonal security is the feeling associated with relief
and preparations for selecting a mate. The development from anxiety. When all needs have been met, one ex-
of sexual maturity evolves from self-gratification to be- periences a sense of total well-being, which Sullivan
haviors deemed acceptable by societal norms. Interper- termed interpersonal security. He believed individuals
sonal relationships are based on genuine pleasure have an innate need for interpersonal security.
derived from the interaction rather than from the more Self-system is a collection of experiences, or security
self-serving implications of childhood associations. measures, adopted by the individual to protect against
anxiety. Sullivan identified three components of the
Relevance of Psychoanalytic self system, which are based on interpersonal experi-
ences early in life:
Theory to Nursing Practice ● The “good me” is the part of the personality that
Knowledge of the structure of the personality can assist develops in response to positive feedback from
nurses who work in the mental health setting. The the primary caregiver. Feelings of pleasure, con-
ability to recognize behaviors associated with the id, tentment, and gratification are experienced. The
the ego, and the superego assists in the assessment child learns which behaviors elicit this positive re-
of developmental level. Understanding the use of sponse as it becomes incorporated into the self-
ego defense mechanisms is important in making deter- system.
minations about maladaptive behaviors, in planning ● The “bad me” is the part of the personality that
care for clients to assist in creating change (if desired), develops in response to negative feedback from
or in helping clients accept themselves as unique indi- the primary caregiver. Anxiety is experienced,
viduals. eliciting feelings of discomfort, displeasure, and
distress. The child learns to avoid these negative
feelings by altering certain behaviors.
INTERPERSONAL THEORY ● The “not me” is the part of the personality that de-
velops in response to situations that produce in-
Sullivan (1953) believed that individual behavior and tense anxiety in the child. Feelings of horror, awe,
personality development are the direct result of inter- dread, and loathing are experienced in response
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20 UNIT I ● INTRODUCTION TO PSYCHIATRIC/MENTAL HEALTH CONCEPTS

TA B L E 2 – 3 Stages of Development in Sullivan’s Interpersonal Theory

Age Stage Major Developmental Tasks

Birth–18 months Infancy Relief from anxiety through oral gratification of needs
18 months–6 years Childhood Learning to experience a delay in personal gratification without undue anxiety
6–9 years Juvenile Learning to form satisfactory peer relationships
9–12 years Preadolescence Learning to form satisfactory relationships with persons of same gender initi-
ating feelings of affection for another person
12–14 years Early adolescence Learning to form satisfactory relationships with persons of the opposite gen-
der; developing a sense of identity
14–21 years Late adolescence Establishing self-identity; experiencing satisfying relationships; working to
develop a lasting, intimate opposite-gender relationship

to these situations, leading the child to deny these Preadolescence: 9 to 12 Years

feelings in an effort to relieve anxiety. These feel-
The tasks of the preadolescence stage focus on devel-
ings, having then been denied, become “not me,”
oping relationships with persons of the same gender.
but someone else. This withdrawal from emotions
One’s ability to collaborate with and show love and af-
has serious implications for mental disorders in
fection for another person begins at this stage.
adult life.
Early Adolescence: 12 to 14 Years
Sullivan’s Stages of
Personality Development During early adolescence, the child is struggling with
developing a sense of identity, separate and independ-
Sullivan described six stages of personality develop- ent from the parents. The major task is formation of
ment. An outline of the stages of personality develop- satisfactory relationships with members of the opposite
ment according to Sullivan’s interpersonal theory is gender. Sullivan saw the emergence of lust in response
presented in Table 2–3. to biological changes as a major force occurring dur-
ing this period.
Infancy: Birth to 18 Months
During this beginning stage, the major developmental Late Adolescence: 14 to 21 Years
task for the child is the gratification of needs. This is The late adolescent period is characterized by tasks as-
accomplished through activity associated with the sociated with the attempt to achieve interdependence
mouth, such as crying, nursing, and thumb sucking. within the society and the formation of a lasting,
intimate relationship with a selected member of the op-
Childhood: 18 Months to 6 Years posite gender. The genital organs are the major devel-
At ages 18 months to 6 years, the child learns that in- opmental focus of this stage.
terference with fulfillment of personal wishes and de-
sires may result in delayed gratification. He or she Relevance of Interpersonal
learns to accept this and feel comfortable with it, rec- Theory to Nursing Practice
ognizing that delayed gratification often results in
The interpersonal theory has significant relevance to
parental approval, a more lasting type of reward. Tools
nursing practice. Relationship development is a major
of this stage include the mouth, the anus, language, ex-
concept of this theory, and is also a major psychiatric
perimentation, manipulation, and identification.
nursing intervention. Nurses develop therapeutic rela-
tionships with clients in an effort to help them gener-
Juvenile: 6 to 9 Years alize this ability to interact successfully with others.
The major task of the juvenile stage is formation of sat- With knowledge about the behaviors associated with
isfactory relationships within the peer group. This is all levels of anxiety and methods for alleviating anxiety,
accomplished through the use of competition, cooper- nurses can help clients achieve interpersonal security
ation, and compromise. and a sense of well-being. Nurses use the concepts of
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CHAPTER 2 ● CONCEPTS OF PERSONALITY DEVELOPMENT 21

Sullivan’s theory to help clients achieve a higher degree culty with interpersonal relationships. The task
of independent and interpersonal functioning. remains unresolved when primary caregivers fail to
respond to the infant’s distress signal promptly and
consistently.
THEORY OF PSYCHOSOCIAL
DEVELOPMENT Autonomy versus Shame and
Doubt: 18 Months to 3 Years
Erikson (1963) studied the influence of social processes Major Developmental Task
on the development of the personality. He described
eight stages of the life cycle during which individuals The major task in this stage is to gain some self-control
struggle with developmental “crises.” Specific tasks as- and independence within the environment.
sociated with each stage must be completed for resolu- ● Achievement of the task results in a sense of self-
tion of the crisis and for emotional growth to occur. An control and the ability to delay gratification, as
outline of Erikson’s stages of psychosocial development well as a feeling of self-confidence in one’s ability to
is presented in Table 2–4. perform. Autonomy is achieved when parents en-
courage and provide opportunities for independent
Erikson’s Stages of activities.
Personality Development ● Nonachievement results in a lack of self-confidence,
a lack of pride in the ability to perform, a sense of
Trust versus Mistrust: Birth to 18 Months
being controlled by others, and a rage against the
Major Developmental Task self. The task remains unresolved when primary
caregivers restrict independent behaviors, both
In this stage, the major task is to develop a basic trust
physically and verbally, or set the child up for fail-
in the mothering figure and be able to generalize it to
ure with unrealistic expectations.
others.
● Achievement of the task results in self-confidence, Initiative versus Guilt: 3 to 6 Years
optimism, faith in the gratification of needs and de-
Major Developmental Task
sires, and hope for the future. The infant learns to
trust when basic needs are met consistently. During this stage the goal is to develop a sense of pur-
● Nonachievement results in emotional dissatisfaction pose and the ability to initiate and direct one’s own
with the self and others, suspiciousness, and diffi- activities.

TA B L E 2 – 4 Stages of Development in Erikson’s Psychosocial Theory

Age Stage Major Developmental Tasks

Infancy Trust versus mistrust To develop a basic trust in the mothering figure and be able to
(Birth–18 months) generalize it to others
Early childhood Autonomy versus shame and doubt To gain some self-control and independence within the environ-
(18 months–3 years) ment
Late childhood Initiative versus guilt To develop a sense of purpose and the ability to initiate and direct
(3–6 years) own activities
School age Industry versus inferiority To achieve a sense of self-confidence by learning, competing, per-
(6–12 years) forming successfully, and receiving recognition from significant
others, peers, and acquaintances
Adolescence Identity versus role confusion To integrate the tasks mastered in the previous stages into a secure
(12–20 years) sense of self
Young adulthood Intimacy versus isolation To form an intense, lasting relationship or a commitment to
(20–30 years) another person, cause, institution, or creative effort
Adulthood Generativity versus stagnation To achieve the life goals established for oneself, while also consid-
(30–65 years) ering the welfare of future generations
Old age Ego integrity versus despair To review one’s life and derive meaning from both positive and
(65 years–death) negative events, while achieving a positive sense of self-worth
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22 UNIT I ● INTRODUCTION TO PSYCHIATRIC/MENTAL HEALTH CONCEPTS

● Achievement of the task results in the ability to ex- Identity versus Role Confusion:
ercise restraint and self-control of inappropriate 12 to 20 Years
social behaviors. Assertiveness and dependability in-
crease, and the child enjoys learning and personal Major Developmental Task
achievement. The conscience develops, thereby con- At this stage, the goal is to integrate the tasks mastered
trolling the impulsive behaviors of the id. Initiative in the previous stages into a secure sense of self.
is achieved when creativity is encouraged and per-
● Achievement of the task results in a sense of confi-
formance is recognized and positively reinforced.
● Nonachievement results in feelings of inadequacy dence, emotional stability, and a view of the self as a
and a sense of defeat. Guilt is experienced to an ex- unique individual. Commitments are made to a value
cessive degree, even to the point of accepting liabil- system, to the choice for a career, and to relation-
ity in situations for which one is not responsible. ships with members of both genders. Identity is
The child may view him- or herself as evil and de- achieved when adolescents are allowed to experience
serving of punishment. The task remains unresolved independence by making decisions that influence
when creativity is stifled and parents continually their lives. Parents should be available to offer sup-
expect a higher level of achievement than the child port when needed but should gradually relinquish
produces. control to the maturing individual in an effort to en-
courage the development of an independent sense of
Industry versus Inferiority: 6 to 12 Years self.
● Nonachievement results in a sense of self-con-
Major Developmental Task sciousness, doubt, and confusion about one’s role in
The major task of this stage is to achieve a sense of self- life. Personal values or goals for one’s life are absent.
confidence by learning, competing, performing suc- Commitments to relationships with others are non-
cessfully, and receiving recognition from significant existent or superficial and brief. A lack of self-confi-
others, peers, and acquaintances. dence is often expressed by delinquent and rebellious
behavior. Entering adulthood, with its accompany-
● Achievement of the task results in a sense of satis- ing responsibilities, may be an underlying fear. This
faction and pleasure in the interaction and involve- task can remain unresolved for many reasons (e.g.,
ment with others. The individual masters reliable when independence is discouraged by the parents
work habits and develops attitudes of trustwor- and the adolescent is nurtured in the dependent
thiness. He or she is conscientious, feels pride in position; when discipline within the home has
achievement, and enjoys play, but desires a balance been overly harsh, inconsistent, or absent; and when
between fantasy and “real-world” activities. Indus- parental rejection or frequent shifting of parental
try is achieved when encouragement is given to per- figures has occurred).
formance of activities and responsibilities in the
school and community, as well as those within the
Intimacy versus Isolation: 20 to 30 Years
home, and recognition is given for accomplishments.
● Nonachievement results in difficulty in interper- Major Developmental Task
sonal relationships because of feelings of personal
The objective during this stage is to form an intense,
inadequacy. The individual can neither cooperate
lasting relationship or a commitment to another per-
and compromise with others in group activities nor
son, a cause, an institution, or a creative effort (Murray
problem solve or complete tasks successfully. He or
& Zentner, 2001).
she may become either passive and meek or overly
aggressive to cover up for feelings of inadequacy. If ● Achievement of the task results in the capacity for
this occurs, the individual may manipulate or violate mutual love and respect between two people and the
the rights of others to satisfy his or her own needs or ability of an individual to pledge a total commitment
desires; he or she may become a “workaholic” with to another. The intimacy goes far beyond the sexual
unrealistic expectations for personal achievement. contact between two people. It describes a commit-
This task remains unresolved when parents set un- ment in which personal sacrifices are made for
realistic expectations for the child, when discipline another, whether it be another person, or if one
is harsh and tends to impair self-esteem, and when chooses, a career or other type of cause or endeavor
accomplishments are consistently met with negative to which an individual elects to devote his or her life.
feedback. Intimacy is achieved when an individual has devel-
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CHAPTER 2 ● CONCEPTS OF PERSONALITY DEVELOPMENT 23

oped the capacity for giving of oneself to another. not. The individual derives a sense of dignity from
This is learned when one has been the recipient of his or her life experiences and does not fear death,
this type of giving within the family unit. rather viewing it as another stage of development.
● Nonachievement results in withdrawal, social isola- Ego integrity is achieved when individuals have suc-
tion, and aloneness. The individual is unable to form cessfully completed the developmental tasks of the
lasting, intimate relationships, often seeking intimacy other stages and have little desire to make major
through numerous superficial sexual contacts. No ca- changes in the ways their lives have progressed.
reer is established; he or she may have a history of ● Nonachievement results in self-contempt and dis-
occupational changes (or may fear change and thus gust with how life has progressed. The individual
remain in an undesirable job situation). The task re- would like to start over and have a second chance at
mains unresolved when love in the home has been life. He or she feels worthless and helpless to change.
denied or distorted during the younger years (Mur- Anger, depression, and loneliness are evident. The
ray & Zentner, 2001). One fails to achieve the ability focus may be on past failures or perceived failures.
to give of the self without having been the recipient Impending death is feared or denied, or ideas of sui-
of such giving early on from primary caregivers. cide may prevail. The task remains unresolved if ear-
lier tasks are not fulfilled: self-confidence, a concern
Generativity versus Stagnation for others, and a strong sense of self-identity were
or Self-Absorption: 30 to 65 Years never achieved.

Major Developmental Task Relevance of Psychosocial

The major task of this stage is to achieve the life goals Development Theory to
established for oneself while also considering the wel- Nursing Practice
fare of future generations.
Erikson’s theory is particularly relevant to nursing prac-
● Achievement of the task results in a sense of gratifi- tice in that it incorporates sociocultural concepts into
cation from personal and professional achievements the development of personality. Erikson provided a sys-
and from meaningful contributions to others. The tematic, stepwise approach and outlined specific tasks
individual is active in the service of and to society. that should be completed during each stage. This in-
Generativity is achieved when the individual ex- formation can be used quite readily in psychiatric/men-
presses satisfaction with this stage in life and demon- tal health nursing. Many individuals with mental health
strates responsibility for leaving the world a better problems are still struggling to accomplish tasks from
place in which to live. a number of developmental stages. Nurses can plan
● Nonachievement results in lack of concern for the care to assist these individuals in fulfilling the tasks and
welfare of others and total preoccupation with the in moving on to a higher developmental level.
self. He or she becomes withdrawn, isolated, and
highly self-indulgent, with no capacity for giving of
the self to others. The task remains unresolved when THEORY OF OBJECT RELATIONS
earlier developmental tasks are not fulfilled and the
individual does not achieve the degree of maturity Mahler (Mahler, Pine, & Bergman, 1975) formulated a
required to derive gratification out of a personal theory that describes the separation–individuation
concern for the welfare of others. process of the infant from the maternal figure (primary
caregiver). She described the process as progressing
Ego Integrity versus Despair: through three major phases, and further delineated
65 Years to Death phase III, the separation–individuation phase, into four
subphases. Mahler’s developmental theory is outlined
Major Developmental Task in Table 2–5.
The goal of this stage is to review one’s life and derive
meaning from both positive and negative events, while Phase I: The Autistic Phase
achieving a positive sense of self. (Birth to 1 Month)
● Achievement of the task results in a sense of self- In this phase, also called normal autism, the infant exists
worth and self-acceptance as one reviews life goals, in a half-sleeping, half-waking state and does not per-
accepting that some were achieved and some were ceive the existence of other people or an external envi-
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24 UNIT I ● INTRODUCTION TO PSYCHIATRIC/MENTAL HEALTH CONCEPTS

TA B L E 2 – 5 Stages of Development in Mahler’s Theory of Object Relations

Age Phase/Subphase Major Developmental Tasks

Birth–1 month I. Normal autism Fulfillment of basic needs for survival and comfort
1–5 months II. Symbiosis Development of awareness of external source of need fulfillment
III. Separation–Individuation
5–10 months a. Differentiation Commencement of a primary recognition of separateness from the mother-
ing figure
10–16 months b. Practicing Increased independence through locomotor functioning; increased sense of
separateness of self
16–24 months c. Rapprochement Acute awareness of separateness of self; learning to seek “emotional refuel-
ing” from mothering figure to maintain feeling of security
24–36 months d. Consolidation Sense of separateness established; on the way to object constancy (i.e., able
to internalize a sustained image of loved object/person when it is out of
sight); resolution of separation anxiety

ronment. The fulfillment of basic needs for survival and pendence. He or she is now able to move away from,
comfort is the focus and is merely accepted as it occurs. and return to, the mothering figure. A sense of om-
nipotence is manifested.
Phase II: The Symbiotic Phase
(1 to 5 Months) Subphase 3—Rapprochement
(16 to 24 Months)
Symbiosis is a type of “psychic fusion” of mother and
child. The child views the self as an extension of the This third subphase is extremely critical to the child’s
mother but with a developing awareness that it is she healthy ego development. During this time, the child
who fulfills the child’s every need. Mahler suggested becomes increasingly aware of his or her separateness
that absence of, or rejection by, the maternal figure at from the mothering figure, while the sense of fearless-
this phase can lead to symbiotic psychosis. ness and omnipotence diminishes. The child, now rec-
ognizing the mother as a separate individual, wishes to
Phase III: Separation– re-establish closeness with her but shuns the total re-
Individuation (5 to 36 Months) engulfment of the symbiotic stage. The child needs the
mothering figure to be available to provide “emotional
This third phase represents what Mahler called the refueling” on demand. Critical to this subphase is the
“psychological birth” of the child. Separation is defined mothering figure’s response to the child. If the moth-
as the physical and psychological attainment of a sense ering figure is available to fulfill emotional needs as
of personal distinction from the mothering figure. In- they are required, the child develops a sense of security
dividuation occurs with a strengthening of the ego and in the knowledge that he or she is loved and will not be
an acceptance of a sense of “self,” with independent ego abandoned. However, if emotional needs are inconsis-
boundaries. Four subphases through which the child tently met or if the mother rewards clinging, depend-
evolves in his or her progression from a symbiotic ex- ent behaviors and withholds nurturing when the child
tension of the mothering figure to a distinct and sepa- demonstrates independence, feelings of rage and fear
rate being are described. of abandonment develop and often persist into adult-
hood.
Subphase 1—Differentiation
(5 to 10 Months) Subphase 4—Consolidation
The differentiation phase begins with the child’s initial (24 to 36 Months)
physical movements away from the mothering figure. A With achievement of consolidation, a definite individ-
primary recognition of separateness commences. uality and sense of separateness of self are established.
Objects are represented as whole, with the ability to in-
Subphase 2—Practicing (10 to 16 Months)
tegrate both “good” and “bad.” A degree of object con-
With advanced locomotor functioning, the child expe- stancy is established as the child is able to internalize
riences feelings of exhilaration from increased inde- a sustained image of the mothering figure as enduring
Townsend(F)-02 6/28/07 2:58 PM Page 25

CHAPTER 2 ● CONCEPTS OF PERSONALITY DEVELOPMENT 25

and loving, while maintaining the perception of her as ● Resource person is one who provides specific,
a separate person in the outside world. needed information that helps the client under-
stand his or her problem and the new situation.
Relevance of Object Relations ● Counselor is one who listens as the client reviews

Theory to Nursing Practice feelings related to difficulties he or she is experi-

encing in any aspect of life. “Interpersonal tech-
Understanding the concepts of Mahler’s theory of ob- niques” have been identified to facilitate the
ject relations helps the nurse assess the client’s level of nurse’s interaction in the process of helping the
individuation from primary caregivers. The emotional client solve problems and make decisions con-
problems of many individuals can be traced to lack cerning these difficulties.
of fulfillment of the tasks of separation/individuation. ● Teacher is one who identifies learning needs and
Examples include problems related to dependency and provides information to the client or family that
excessive anxiety. The individual with borderline per- may aid in improvement of the life situation.
sonality disorder is thought to be fixed in the rap- ● Leader is one who directs the nurse–client inter-
prochement phase of development, harboring fears action and ensures that appropriate actions are
of abandonment and underlying rage. This knowledge undertaken to facilitate achievement of the desig-
is important in providing nursing care to these indi- nated goals.
viduals. ● Technical expert is one who understands various

professional devices and possesses the clinical

A NURSING MODEL— skills necessary to perform the interventions that
are in the best interest of the client.
HILDEGARD E. PEPLAU ● Surrogate is one who serves as a substitute figure

for another.
Peplau (1991) applied interpersonal theory to nursing ● Phases of the nurse–client relationship are stages of
practice and, most specifically, to nurse–client rela-
overlapping roles or functions in relation to health
tionship development. She established a framework for
problems, during which the nurse and client learn
psychodynamic nursing, the interpersonal involve-
to work cooperatively to resolve difficulties. Peplau
ment of the nurse with a client in a given nursing situ-
identified four phases:
ation. Peplau stated, “Nursing is helpful when both the
● Orientation is the phase during which the client,
patient and the nurse grow as a result of the learning
nurse, and family work together to recognize,
that occurs in the nursing situation.”
clarify, and define the existing problem.
Peplau correlated the stages of personality develop-
● Identification is the phase after which the client’s
ment in childhood to stages through which clients ad-
initial impression has been clarified and during
vance during the progression of an illness. She also
which he or she begins to respond selectively to
viewed these interpersonal experiences as learning sit-
persons who seem to offer the help that is needed.
uations for nurses to facilitate forward movement in the
Clients may respond in one of three ways: (1) on
development of personality. She believed that when
the basis of participation or interdependent rela-
there is fulfillment of psychological tasks associated
tions with the nurse, (2) on the basis of independ-
with the nurse–client relationship, the personalities of
ence or isolation from the nurse, or (3) on the
both can be strengthened. Key concepts include the
basis of helplessness or dependence on the nurse
following:
(Peplau, 1991).
● Nursing is a human relationship between an individ- ● Exploitation is the phase during which the client

ual who is sick, or in need of health services, and a proceeds to take full advantage of the services of-
nurse especially educated to recognize and to re- fered to him or her. Having learned which services
spond to the need for help. are available, feeling comfortable within the set-
● Psychodynamic nursing is being able to understand ting, and serving as an active participant in his or
one’s own behavior, to help others identify felt diffi- her own health care, the client exploits the serv-
culties, and to apply principles of human relations to ices available and explores all possibilities of the
the problems that arise at all levels of experience. changing situation.
● Roles are sets of values and behaviors that are specific ● Resolution occurs when the client is freed from

to functional positions within social structures. Pe- identification with helping persons and gathers
plau identified the following nursing roles: strength to assume independence. Resolution is
Townsend(F)-02 6/28/07 2:58 PM Page 26

26 UNIT I ● INTRODUCTION TO PSYCHIATRIC/MENTAL HEALTH CONCEPTS

the direct result of successful completion of the such as inherited biological components, personality
other three phases. characteristics (temperament), individual intllectual ca-
pacity, and specific cultural or environmental influ-
Peplau’s Stages of ences. Peplau related these to the same “raw materials”
Personality Development with which an infant comes into this world. The new-
born is capable of experiencing both comfort and dis-
Psychological tasks are developmental lessons that must comfort. He or she soon learns to communicate feelings
be learned on the way to achieving maturity of the per- in a way that results in the fulfillment of comfort needs
sonality. Peplau (1991) identified four psychological by the mothering figure who provides love and care un-
tasks that she associated with the stages of infancy and conditionally. However, fulfillment of these depend-
childhood described by Freud and Sullivan. She stated, ency needs is inhibited when goals of the mothering
When psychological tasks are successfully learned at each figure become the focus, and love and care are contin-
era of development, biological capacities are used pro- gent upon meeting the needs of the caregiver rather
ductively and relations with people lead to productive liv- than the infant.
ing. When they are not successfully learned they carry Clients with unmet dependency needs regress dur-
over into adulthood and attempts at learning continue in ing illness and demonstrate behaviors that relate to this
devious ways, more or less impeded by conventional adap- stage of development. Other clients regress to this level
tations that provide a super-structure over the baseline of
because of physical disabilities associated with their ill-
actual learning. (p. 166)
ness. Peplau believed that, when nurses provide un-
In the context of nursing, Peplau (1991) related these conditional care, they help these clients progress toward
four psychological tasks to the demands made on more mature levels of functioning. This may involve
nurses in their relations with clients. She maintained the role of “surrogate mother,” in which the nurse ful-
that: fills needs for the client with the intent of helping him
…nursing can function as a maturing force in society.
or her grow, mature, and become more independent.
Since illness is an event that is experienced along with feel-
ings that derive from older experiences but are reenacted Learning to Delay Satisfaction
in the relationship of nurse to patient, the nurse-patient
relationship is seen as an opportunity for nurses to help Peplau related this stage to that of toddlerhood, or the
patients to complete the unfinished psychological tasks of first step in the development of interdependent social
childhood in some degree. (p. 159) relations. Psychosexually, it is compared to the anal
stage of development, when a child learns that, because
Peplau’s psychological tasks of personality develop- of cultural mores, he or she cannot empty the bowels
ment include the following four stages. An outline of for relief of discomfort at will, but must delay to use
the stages of personality development according to Pe- the toilet, which is considered more culturally accept-
plau’s theory is presented in Table 2–6. able. When toilet training occurs too early or is very
rigid, or when appropriate behavior is set forth as
Learning to Count on Others a condition for receiving love and caring, tasks associ-
Nurses and clients first come together as strangers. ated with this stage remain unfulfilled. The child feels
Both bring to the relationship certain “raw materials,” powerless and fails to learn the satisfaction of pleasing

TA B L E 2 – 6 Stages of Development in Peplau’s Interpersonal Theory

Age Stage Major Developmental Tasks

Infancy Learning to count on others Learning to communicate in various ways with the primary caregiver to
have comfort needs fulfilled
Toddlerhood Learning to delay satisfaction Learning the satisfaction of pleasing others by delaying self-gratification
in small ways
Early childhood Identifying oneself Learning appropriate roles and behaviors by acquiring the ability to per-
ceive the expectations of others
Late childhood Developing skills in participation Learning the skills of compromise, competition, and cooperation with
others; establishing a more realistic view of the world and a feeling of
one’s place in it
Townsend(F)-02 6/28/07 2:58 PM Page 27

CHAPTER 2 ● CONCEPTS OF PERSONALITY DEVELOPMENT 27

others by delaying self-gratification in small ways. He ally (i.e., with behaviors that correspond to their feel-
or she may also exhibit rebellious behavior by failing ings) learn to improve on and reconstruct behavioral
to comply with demands of the mothering figure in an responses at their own pace. Peplau (1991) stated,
effort to counter the feelings of powerlessness. The
The ways in which adults appraise the child and the way
child may accomplish this by withholding the fecal he functions in relation to his experiences and perceptions
product or failing to deposit it in the culturally accept- are taken in or introjected and become the child’s view of
able manner. himself. (p. 213)
Peplau cites Fromm (1949) in describing the follow-
ing potential behaviors of individuals who have failed to In nursing, it is important for the nurse to recognize
complete the tasks of the second stage of development: cues that communicate how the client feels about him-
or herself, and about the presenting medical problem.
● Exploitation and manipulation of others to satisfy In the initial interaction, it is difficult for the nurse to
their own desires because they are unable to do so perceive the “wholeness” of the client, for the focus is
independently on the condition that has caused him or her to seek
● Suspiciousness and envy of others, directing hostil- help. Likewise, it is difficult for the client to perceive
ity toward others in an effort to enhance their own the nurse as a “mother (or father)” or “somebody’s wife
self-image (or husband)” or as having a life aside from being there
● Hoarding and withholding possessions from others; to offer assistance with the immediate presenting prob-
miserliness lem. As the relationship develops, nurses must be able
● Inordinate neatness and punctuality to recognize client behaviors that indicate unfulfilled
● Inability to relate to others through sharing of feel- needs and provide experiences that promote growth.
ings, ideas, or experiences For example, the client who very proudly announces
● Ability to vary the personality characteristics to those that he or she has completed activities of daily living in-
required to satisfy personal desires at any given time dependently and wants the nurse to come and inspect
When nurses observe these types of behaviors in her room may still be craving the positive reinforce-
clients, it is important to encourage full expression and ment that is so necessary at lower levels of development.
to convey unconditional acceptance. When the client Nurses must also be aware of the predisposing fac-
learns to feel safe and unconditionally accepted, he or tors that they bring to the relationship. Attitudes and
she is more likely to let go of the oppositional behavior beliefs about certain issues can have a deleterious effect
and advance in the developmental progression. Peplau on the client and interfere not only with the therapeu-
(1991) stated: tic relationship but also with the client’s ability for
growth and development. For example, a nurse who
Nurses who aid patients to feel safe and secure, so that has strong beliefs against abortion may treat a client
wants can be expressed and satisfaction eventually
who has just undergone an abortion with disapproval
achieved, also help them to strengthen personal power
and disrespect. The nurse may respond in this manner
that is needed for productive social activities. (p. 207)
without even realizing he or she is doing so. Attitudes
and values are introjected during early development
Identifying Oneself and can be integrated so completely as to become a part
“A concept of self develops as a product of interaction of the self-system. Nurses must have knowledge and
with adults” (Peplau, 1991, p. 211). A child learns to appreciation of their own concept of self to develop the
structure self-concept by observing how others interact flexibility required to accept all clients as they are, un-
with him or her. Roles and behaviors are established conditionally. Effective resolution of problems that
out of the child’s perception of the expectations of oth- arise in the interdependent relationship can be the
ers. When children have the impression that adults means for both client and nurse to reinforce positive
expect them to maintain more or less permanent roles personality traits and modify those more negative views
as infants, they perceive themselves as helpless and of self.
dependent. When the perceived expectation is that the
child must behave in a manner beyond his or her
maturational level, the child is deprived of the fulfill-
Developing Skills in Participation
ment of emotional and growth needs at the lower lev- Peplau cites Sullivan’s (1953) description of the “juve-
els of development. Children who are given freedom nile” stage of personality development (ages 6 through
to respond to situations and experiences uncondition- 9). During this stage, the child develops the capacity
Other documents randomly have
different content
General Hill reported:

“Under the impression that the enemy was entirely routed, my own
two divisions exhausted by some six hours’ hard fighting, prudence
led me to be content with what had been gained.”

The failure of Ewell to follow up the repulse and capture Cemetery

Hill and Culp’s Hill, defended by a weak line of the Union forces,
enabled the Union commanders to establish during the night a line of
defence that was secure against attack. By many military critics, this
is generally considered Lee’s lost opportunity.

Formation of Union Line.

The retreating Union soldiers were met at East Cemetery Hill by
Generals Hancock and Howard, who directed them to positions, the
1st Corps on Cemetery Ridge and Culp’s Hill, and the 11th on 16
East Cemetery Hill. The 12th Corps arrived on the Baltimore
Pike, and soon after Sickles’ 3rd Corps came up from Emmitsburg.

Hancock had been instructed by Meade to take command and report

if he thought the ground a suitable place to continue the battle. A
battle-line was at once established on Cemetery Ridge. Geary’s
Division of the 12th Corps was ordered to the extreme left to occupy
Little Round Top. Hancock sent word to General Meade that the
position was strong, but that it might be easily turned. He then
turned over the command to Slocum, his senior, and returned to
Taneytown to report in person. Meade had already ordered a rapid
concentration of all his forces at Gettysburg.
 Barlow’s Knoll.—The extreme right of the Union line on the first day

General Lee’s Report.

For the day, the Confederate commander reported:

“The leading division of Hill met the enemy in advance of

Gettysburg on the morning of July 1. Driving back these troops to
within a short distance of the town, he there encountered a larger
force, with which two of his divisions became engaged. Ewell
coming up with two of his divisions by the Heidlersburg road,
joined in the engagement. The enemy was driven through
Gettysburg with heavy loss, including about 5,000 prisoners and
several pieces of artillery. He retired to a high range of hills south
and east of the town. The attack was not pressed that afternoon,
the enemy’s force being unknown, and it being considered
advisable to await the arrival of the rest of our troops. Orders were
sent back to hasten their march, and, in the meantime, every effort
was made to ascertain the numbers and position of the enemy, and
find the most favorable point of attack. It had not been intended to
fight a general battle at such a distance from our base, 17
unless attacked by the enemy, but, finding ourselves
unexpectedly confronted by the Federal Army, it became a matter
of difficulty to withdraw through the mountains with our large
trains.... Encouraged by the successful issue of the engagement of
the first day, and in view of the valuable results that would ensue
from the defeat of the army of General Meade, it was thought
advisable to renew the attack.”
 FIRST DAY HIGHLIGHTS

Death of Major-General Reynolds

Major-General John Fulton Reynolds, killed at Gettysburg while

commanding the 1st Corps, was born in Lancaster, Pa., on the 21st
day of September, 1820. His father, John Reynolds, also a native of
Lancaster County, was the son of William Reynolds, who came to
America in 1760 from Ireland. His mother’s maiden name was Lydia
Moore, daughter of Samuel Moore, who held a commission in the
Revolutionary Army. He had an elder brother, William, who served as
Admiral in our Navy with great distinction, and also two other
brothers who served in the war, one as paymaster, and the other, the
youngest of the four, as Quartermaster-General of Pennsylvania.

William and John went first to an excellent school at Lititz, in

Lancaster County, going thence to Long Green, Md., and from there
they returned to the Lancaster Academy. Through the influence of
James Buchanan, they received appointments, one as midshipman in
the Navy, and the other as cadet at West Point. John was graduated
from West Point on June 22nd, 1841, at the age of twenty-one. He
served with distinction during the Mexican War, and at the outbreak
of the Civil War entered the Union Army. At the battle of Gaines’ Mill,
on June 28th, 1862, he was captured, and after a confinement of six
weeks in Libby Prison, he was exchanged for General Barksdale.

General Reynolds was six feet tall, with dark hair and eyes. He was
erect in carriage and a superb horseman, so much at ease in the
saddle as to be able to pick a dime from the ground while riding at
full speed. He was killed in the grove now known as Reynolds’ Grove
on the morning of July 1st, between 10 and 11 o’clock, while
directing the attack of Meredith’s brigade against Archer’s
Confederate brigade. His body was first taken to the Seminary, and
later to Lancaster, where it was interred in the family graveyard.

The 26th Emergency Regiment

The 26th Emergency Regiment met the advance of Gordon’s brigade

of Early’s Division of Ewell’s Corps in their advance into Gettysburg.
Company A consisted of students of the Lutheran Theological
Seminary, Pennsylvania (now Gettysburg) College, and citizens of the
town. H. M. M. Richards, of Company A gives the following sketch of
the services of the regiment:

“Upon the first indication of an invasion of Pennsylvania, the 26th

Regiment, P. V. M., was organized and mustered into the United
States service at Harrisburg, under the command of Colonel W. W.
Jennings of that city. Company A of this regiment, to which I
belonged, was composed of students from the Lutheran Theological
Seminary and the Pennsylvania College at Gettysburg, and of citizens
of the town; one other company came from Hanover, but a few miles
distant.

“On June 23rd we left Harrisburg for Gettysburg, to be used, I

believe, as riflemen among the hills at or near Cashtown. A railroad
accident prevented this plan from being carried out, and kept 18
us from reaching Gettysburg until the 26th, by which time
General Early had reached Cashtown. In accordance with orders
received from Major Granville O. Haller, acting aide-de-camp to
General Couch, commanding the Department of the Susquehanna,
we were marched out on the Chambersburg Pike at 10 A.M., June
26th, for a distance of about three and a half miles, accompanied by
Major Robert Bell, who commanded a troop of horse, also raised, I
understand, in Gettysburg. Having halted, our colonel, accompanied
by Major Bell, rode to the brow of an elevation and there saw General
Early’s troops a few miles distant.
“We, a few hundred men at most, were in the toils; what should be
done? We would gladly have marched to join the Army of the
Potomac, under Meade, but where was it? Our colonel, left to his own
resources, wisely decided to make an effort to return to Harrisburg,
and immediately struck off from the pike, the Confederates capturing
many of our rear-guard after a sharp skirmish, and sending their
cavalry in pursuit of us. These later overtook us in the afternoon at
Witmer’s house, about four and a half miles from Gettysburg on the
Carlisle Road, where, after an engagement, they were repulsed with
some loss. After many vicissitudes, we finally reached Harrisburg,
having marched 54 out of 60 consecutive hours, with a loss of some
200 men.

“It should be added that Gettysburg, small town as it was, had

already furnished its quota to the army. Moreover, on the first day of
the battle, hundreds of the unfortunate men of Reynolds’s gallant
corps were secreted, sheltered, fed, and aided in every way by the
men and women of the town.”

The First Soldier Killed at Gettysburg

George W. Sandoe, the first Union soldier killed at Gettysburg, was a

member of Company B Independent 21st Pennsylvania Cavalry. Upon
arriving at Gettysburg, June 26th, 1863, General Gordon sent out a
picket line on the Baltimore Pike. As these pickets reached the
Nathaniel Lightner property, George W. Sandoe and William Lightner,
also a member of Company B, approached the pike, coming across
the McAllister field from the direction of Rock Creek. Owing to a
growth of bushes and trees along the fence, they did not discover the
Confederate pickets until they were ordered to halt. Lightner at once
jumped his horse across the fence and escaped by riding rapidly
down the pike. Sandoe’s horse fell in making the leap, and in
attempting to escape by riding back in the direction from which he
came, Sandoe was shot. He lies buried at Mount Joy Church, in
Mount Joy, Adams County.
 A Mysterious Letter

Having passed through Gettysburg on June 28th, General John B.

Gordon, of Lee’s army, went on to York and Wrightsville before
returning on July 1st. In his “Reminiscences of the Gettysburg
Campaign” he tells the following story:

“We entered the city of York on Sunday morning. Halting on the main
street, where the sidewalks were densely packed, I rode a few rods
in advance of my troops, in order to speak to the people from my
horse. As I checked him and turned my full dust-begrimed face upon
a bevy of ladies very near me, a cry of alarm came from their midst;
but after a few words of assurance from me, quiet and apparent
confidence were restored. I assured these ladies that the troops
behind me, though ill-clad and travel-stained, were good men and
brave; that beneath their rough exteriors were hearts as loyal to
women as ever beat in the breasts of honorable men; that their own
experience and the experience of their mothers, wives, and sisters at
home had taught them how painful must be the sight of a hostile
army in their town; that under the orders of the Confederate 19
commander-in-chief both private property and non-combatants
were safe; that the spirit of vengeance and of rapine had no place in
the bosoms of these dust-covered but knightly men; and I closed by
pledging to York the head of any soldier under my command who
destroyed private property, disturbed the repose of a single home, or
insulted a woman.

“As we moved along the street after this episode, a little girl,
probably twelve years of age, ran up to my horse and handed me a
large bouquet of flowers in the center of which was a note in delicate
handwriting, purporting to give the numbers and describe the
position of the Union forces of Wrightsville, toward which I was
advancing. I carefully read and reread this strange note. It bore no
signature and contained no assurance of sympathy for the Southern
cause, but it was so terse and explicit in its terms as to compel my
confidence. The second day we were in front of Wrightsville, and
from the high ridge on which this note suggested that I halt and
examine the position of the Union troops, I eagerly scanned the
prospect with my field-glasses, in order to verify the truth of the
mysterious communication or detect its misrepresentations.

“There, in full view of us, was the town, just as described, nestling on
the banks of the Susquehanna. There was the blue line of soldiers
guarding the approach, drawn up, as indicated, along an intervening
ridge and across the pike. There was the long bridge spanning the
Susquehanna and connecting the town with Columbia on the other
bank. Most important of all, there was the deep gorge or ravine
running off to the right and extending around the left bank of the
Federal line and to the river below the bridge. Not an inaccurate
detail in that note could be discovered. I did not hesitate, therefore,
to adopt its suggestion of moving down the gorge in order to throw
my command on the flank, or possibly in the rear of the Union
troops, and force them to a rapid retreat or surrender. The result of
this movement vindicated the strategic wisdom of my unknown and—
judging by the handwriting—woman correspondent, whose note was
none the less martial because embedded in roses, and whose evident
genius for war, had occasion offered, might have made her a captain
equal to Catherine.”

The Flag of the 16th Maine

A marker showing the position of the 16th Maine Infantry Regiment

on the afternoon of the first day’s battle stands at the intersection of
Doubleday Avenue and the Mummasburg Road, and contains the
following inscription:

Position Held July 1, 1863, at 4 o’Clock P.M.

by the 16th Maine Infantry
1st Brig., 2nd Div., 1st Corps
 WHILE THE REST OF THE DIVISION WAS RETIRING, THE REGIMENT
HAVING MOVED FROM THE POSITION AT THE LEFT WHERE ITS
MONUMENT STANDS, UNDER ORDERS TO HOLD THIS POSITION AT ANY
COST.

It Lost on This Field

Killed 11, Wounded 62, Captured 159
Out of 275 Engaged.

When almost surrounded, the regiment withdrew to the left of the

railroad cut to help cover the withdrawal of Stewart’s battery, which
was also almost surrounded. The regiment had two flags, the Stars
and Stripes and the flag of Maine.

Finally, assaulted by the flank and rear, they determined not to

surrender their colors, but tore them from their staffs and into small
bits, each man taking a star or a bit of silk which he placed in 20
his pocket. Some of these fragments were carried through the
southern prisons and finally home to Maine, where they are still
treasured as precious relics by the relatives and friends of the brave
men of the regiment.

The Barlow-Gordon Incident

Barlow’s Knoll, a short distance northeast of Gettysburg, is named in

honor of Brigadier-General Francis C. Barlow, in command of the 1st
Division of the 11th Corps. In his “Reminiscences of the Civil War,”
General Gordon describes his meeting with Barlow:

“Returning from the banks of the Susquehanna, and meeting at

Gettysburg, July 1, 1863, the advance of Lee’s forces, my command
was thrown quickly and squarely on the right flank of the Union
Army. A more timely arrival never occurred. The battle had been
raging for four or five hours. The Confederate General Archer, with a
large part of his brigade, had been captured. Heth and Scales,
Confederate generals, had been wounded. The ranking Union officer
on the field, General Reynolds, had been killed, and General Hancock
was assigned to command. The battle, upon the issue of which hung,
perhaps, the fate of the Confederacy, was in full blast. The Union
forces, at first driven back, now reënforced, were again advancing
and pressing back Lee’s left and threatening to envelop it. The
Confederates were stubbornly contesting every foot of ground, but
the Southern left was slowly yielding. A few moments more and the
day’s battle might have been ended by a complete turning of Lee’s
flank. I was ordered to move at once to the aid of the heavily pressed
Confederates. With a ringing yell, my command rushed upon the line
posted to protect the Union right. Here occurred a hand-to-hand
struggle. That protecting Union line, once broken, left my command
not only on the right flank, but obliquely in rear of it.

“Any troops that were ever marshalled would, under like conditions,
have been as surely and swiftly shattered. Under the concentrated
fire from front and flank, the marvel is that they escaped. In the
midst of the wild disorder in his ranks, and through a storm of
bullets, a Union officer was seeking to rally his men for a final stand.
He, too, went down pierced by a minie ball. Riding forward with my
rapidly advancing lines, I discovered that brave officer lying upon his
back, with the July sun pouring its rays into his pale face. He was
surrounded by the Union dead, and his own life seemed to be rapidly
ebbing out. Quickly I dismounted and lifted his head. I gave him
water from my canteen, and asked his name and the character of his
wounds. He was Major-General Francis C. Barlow, of New York, and
of Howard’s Corps. The ball had entered his body in front and passed
out near the spinal cord, paralyzing him in legs and arms. Neither of
us had the remotest thought that he could survive many hours. I
summoned several soldiers who were looking after the wounded, and
directed them to place him upon a litter and carry him to the shade in
the rear. Before parting, he asked me to take from his pocket a
package of letters and destroy them. They were from his wife. He
had one request to make of me. That request was that, if I lived to
the end of the war and ever met Mrs. Barlow, I would tell her of our
meeting on the field of Gettysburg and his thoughts of her in his last
moments. He wished to assure me that he died doing his duty at the
front, that he was willing to give his life for his country, and that his
deepest regret was that he must die without looking upon her face
again. I learned that Mrs. Barlow was with the Union Army, and near
the battlefield. When it is remembered how closely Mrs. Gordon
followed me, it will not be difficult to realize that my sympathies were
especially stirred by the announcement that his wife was so near to
him. Passing through the day’s battle unhurt, I despatched, at its
close, under a flag of truce, the promised message to Mrs. Barlow. I
assured her that she should have safe escort to her husband’s side.

“In the desperate encounters of the two succeeding days, and 21

the retreat of Lee’s army, I thought no more of Barlow, except
to number him with the noble dead of the two armies who have so
gloriously met their fate. The ball, however, had struck no vital point,
and Barlow slowly recovered, though his fate was unknown to me.
The following summer, in battles near Richmond, my kinsman with
the same initials, General J. B. Gordon of North Carolina, was killed.
Barlow, who had recovered, saw the announcement of his death, and
entertained no doubt that he was the Gordon whom he had met on
the field of Gettysburg. To me, therefore, Barlow was dead; to Barlow
I was dead. Nearly fifteen years passed before either of us was
undeceived. During my second term in the United States Senate, the
Hon. Clarkson Potter of New York was the member of the House of
Representatives. He invited me to dinner in Washington to meet a
General Barlow who had served in the Union Army. Potter knew
nothing of the Gettysburg incident. I had heard that there was
another Barlow in the Union Army, and supposed of course, that it
was this Barlow with whom I was to dine. Barlow had a similar
reflection as to the Gordon he was to meet. Seated at Clarkson
Potter’s table, I asked Barlow: ‘General, are you related to the Barlow
who was killed at Gettysburg?’ He replied: ‘Why, I am the man, sir.
Are you related to the Gordon who killed me?’ ‘I am the man, sir,’ I
responded. No words of mine can convey any conception of the
emotions awakened by these startling announcements. Nothing short
of an actual resurrection of the dead could have amazed either of us
more. Thenceforward, until his untimely death in 1896, the friendship
between us which was born amidst the thunders of Gettysburg was
cherished by both.”

General Ewell Is Hit by a Bullet

General Gordon gives an account of an amusing incident of the first

day:

“Late in the afternoon of this first day’s battle, when the firing had
greatly decreased along most of the lines, General Ewell and I were
riding through the streets of Gettysburg. In a previous battle he had
lost one of his legs, but prided himself on the efficiency of the
wooden one which he used in its place. As we rode together, a body
of Union soldiers, posted behind some dwellings and fences on the
outskirts of the town, suddenly opened a brisk fire. A number of
Confederates were killed or wounded, and I heard the ominous thud
of a minie ball as it struck General Ewell at my side. I quickly asked:
‘Are you hurt, sir?’ ‘No, no,’ he replied; ‘I’m not hurt. But suppose that
ball had struck you: we would have had the trouble of carrying you
off the field, sir. You see how much better fixed I am for a fight than
you are. It don’t hurt a bit to be shot in a wooden leg.’

“Ewell was a most interesting and eccentric character. It is said that

in his early manhood he had been disappointed in a love affair, and
had never fully recovered from its effects. The fair maiden to whom
he had given his affections had married another man; but Ewell, like
the truest of knights, carried her image in his heart through long
years. When he was promoted to the rank of brigadier or major-
general, he evidenced the constancy of his affections by placing upon
his staff the son of the woman whom he had loved in his youth. The
meddlesome Fates, who seem to revel in the romances of lovers, had
decreed that Ewell should be shot in battle and become the object of
solicitude and tender nursing by this lady, Mrs. Brown, who had been
for many years a widow. Her gentle ministrations soothed his weary
weeks of suffering, a marriage ensued, and with it came the
realization of Ewell’s long-deferred hope. He was a most devoted
husband. He never seemed to realize, however, that marriage had
changed her name, for he proudly presented her to his friends as ‘My
wife, Mrs. Brown, sir.’”

22

The School Teachers’ Regiment

The 151st Pennsylvania Infantry, commanded by Lieutenant-Colonel

George F. McFarland, included Company D, made up mainly of the
instructors and students of the Lost Creek Academy, of McAlisterville,
Juniata County, of which Colonel McFarland was principal. For this
reason it was called the “Schoolteachers’ Regiment.” The material
throughout was excellent, many of the men being experienced
marksmen. The regiment went into battle with 21 officers and 446
men, and sustained a loss in killed, wounded, and missing of 337, or
over 75 per cent.

The casualties of the 26th North Carolina Regiment, against which

they were engaged, were 588 out of 800, just about the same
percentage.

Colonel McFarland lost his right leg and had the left permanently
disabled, but survived until 1891. On the twenty-fifth anniversary of
the battle, he delivered the dedicatory address at the unveiling of the
regimental monument, exactly twenty-five years to the hour after his
engagement in battle.

An Incident of the First Day

An incident, similar to that described by Browning in his poem “An
Incident of the French Camp,” occurred at the railroad cut early on
the first day.

An officer of the 6th Wisconsin Regiment, active in the capture of the

Mississippians belonging to the 2nd and 42nd Regiments, who had
taken shelter in the railroad cut after turning the right of Cutler’s line,
approached Colonel Rufus R. Dawes after the engagement was over.
Colonel Dawes supposed, from the erect appearance of the man, that
he had come for further orders, but his compressed lips told a
different story. With great effort the officer said: “Tell them at home I
died like a man and a soldier.” He then opened his coat, showed a
ghastly wound on his breast, and dropped dead.

Dormitory of Gettysburg College.—The dormitory of Gettysburg (then

Pennsylvania) College sheltered many Union and Confederate
wounded
 23

THE SECOND DAY

The scene of the engagements of the second and third days shifted
to the south and southeast of Gettysburg. General Meade arrived on
the field from his headquarters at Taneytown, Md., at 1 A.M., July
2nd, and established his headquarters at the Leister House, on the
Taneytown Road, in rear of the line of the 2nd Corps. As soon as it
was light he inspected the position already occupied and made
arrangements for posting the several corps as they should reach the
ground.

The Union Line of Battle.

Starting on the right with Slocum’s 12th Corps, Williams’ Division
extended from Rock Creek by way of Spangler’s Spring to Culp’s Hill,
with Geary’s Division on the hill. The line between Culp’s Hill and
Cemetery Hill was held by Wadsworth’s Division of the 1st Corps.
Barlow’s Division of the 11th Corps under Ames was located at the
foot of East Cemetery Hill. Carman, Colgrove, Slocum, Geary, and
Wainwright avenues follow these lines of battle.

On Cemetery Hill, across the Baltimore Pike, the line was held by
Schurz and on his left Steinwehr, both of the 11th Corps. Robinson’s
Division of the 1st Corps extended across the Taneytown Road to
Ziegler’s Grove. Beyond lay Hancock’s 2nd Corps, with the Divisions
of Hays, Gibbon, and Caldwell from right to left. To the left of
Hancock, Sickles’ 3rd Corps, consisting of the Divisions of Humphreys
and Birney, prolonged the line to the vicinity of Little Round Top.
Beginning at the Taneytown Road, Hancock and Sedgwick avenues
follow these lines of battle.

Arriving later in the day, the 5th Corps, under General Sykes, was
posted on the Baltimore Pike, at the Rock Creek crossing. Later it
occupied the ground about Round Top to the left of the 3rd Corps.
The 6th Corps, under General Sedgwick, reaching the field still later
after a march of over 30 miles, was posted in reserve back of Round
Top, from which position portions were moved as circumstances
demanded. The lines held by the 5th and 6th Corps coincide with
Sykes, Ayres, Wright, and Howe Avenues.

24

Stevens’ Knoll.—Arriving on Stevens’ Knoll at the end of the first day,

General Slocum brought supporting troops. The lunettes protecting
the cannon remain intact.

Gamble’s and Devin’s brigades of Buford’s Cavalry, which had had an

active part in the battle of the first day, were on the left between
Cemetery and Seminary Ridges until 10 A.M. when they were ordered,
by some mistake, to move to Westminster, Md., before the arrival of
Gregg’s Division on its way from Hanover, and Merritt’s brigade of
Buford’s Division from Mechanicsburg (now Thurmont), Md.

General Meade’s line, shaped like a fishhook, was about 3 miles long.
The right faced east, the center over Cemetery Hill, north, and the
left from Cemetery Hill to Round Top nearly west. The whole line was
supported by artillery brigades belonging to the different corps.

Confederate Line of Battle.

General Lee’s line was nearly the same shape as General Meade’s
but, being the outer line, was about 6 miles long. On the right, facing
the two Round Tops, were Hood’s and McLaws’ Divisions of
Longstreet’s Corps. On the left of McLaws, extending along the line of
Seminary Ridge, were the Divisions of Anderson and Pender of Hill’s
Corps, with Heth’s Division in the rear in reserve. On the left of
Pender, extending through the town along the line of West Middle
Street, was Rodes’ Division of Ewell’s Corps, then Early’s and
Johnson’s Divisions, the latter reaching to Benner’s Hill, east of 25
Rock Creek. Pickett’s Division of Longstreet’s Corps was at
Chambersburg, guarding trains, and Law’s Brigade of Hood’s Division
of Longstreet’s Corps at New Guilford, guarding the rear. The latter
arrived at noon on the 2nd in time to participate in the day’s
engagement. Pickett’s Division arrived later and was not engaged
until the afternoon of the 3rd. The artillery was posted according to
the different corps to which it was attached.

General Lee’s line coincides with the present West Confederate

Avenue along Seminary and Warfield or Snyder Ridges, west of the
town, then runs through the town to coincide with East Confederate
Avenue. The distance between the Union and Confederate lines is
three-fourths of a mile to a mile.
Military critics agree that General Meade held the stronger position.
Both flanks presented precipitous and rocky fronts, difficult to attack,
and it was possible to send reinforcements by short distances from
point to point.

Sickles’ Change of Line.

As already stated, General Sickles’ 3rd Corps was on the left of
General Hancock’s 2nd Corps on Cemetery Ridge, and Birney’s
Division was near the base of Little Round Top, replacing Geary’s
Division after its withdrawal to be posted on Culp’s Hill. Humphreys’
Division was on low ground to the right between Cemetery Ridge and
the Emmitsburg Road.

Anxious to know what was in his front, Sickles sent the Berdan
Sharpshooters and the 3rd Maine Infantry forward on a
reconnaissance. On reaching the Pitzer Woods, beyond the
Emmitsburg Road, they found the Confederates there in force, and
after a sharp engagement with Wilcox’s Brigade, withdrew and
reported.

Believing that Lee planned a flank movement on his line, and that the
Emmitsburg Road afforded better positions for the artillery, Sickles
moved his Corps forward and posted Humphreys’ Division on the
right along the Emmitsburg Road and his left extending to the Peach
Orchard. Birney’s Division prolonged the line from the Peach Orchard
across the Wheatfield to Devil’s Den. This new line formed a salient
at the Peach Orchard and therefore presented two fronts, one to the
west, the other to the south.

About 3 P.M. Sickles was called to General Meade’s headquarters to a

conference of corps commanders. Upon the sound of artillery, 26
the conference adjourned, and Meade, Sickles, and Warren,
Meade’s Chief Engineer, rode to inspect Sickles’ change of line. The
artillery was already engaged, and believing it too late to make any
changes since the enemy was present, Meade decided to attempt to
hold the new position by sending in supports. After reviewing the
new line, General Warren left the other members of the party and
rode up Little Round Top. He found the height unoccupied except by
the personnel of a signal station.
General Meade’s Statue.—General Meade viewed Pickett’s Charge from
the center of the Union line. This statue, like those of Reynolds and
Sedgwick, is the work of Henry K. Bush-Brown.
General Lee’s Plan.
Lee as well as Meade occupied the forenoon in the arrangement of
his line of battle. After a conference with Ewell, he decided to attack
Meade’s left. In his report, Lee says:

“It was determined to make the principal attack upon the enemy’s
left, and endeavor to gain a position from which it was thought
that our artillery could be brought to bear with effect. Longstreet
was directed to place the division of McLaws and Hood on the right
of Hill, partially enveloping the enemy’s left, which he was to drive
in.

“General Hill was ordered to threaten the enemy’s center to

prevent reinforcements being drawn to either wing, and coöperate
with his right division in Longstreet’s attack.

“General Ewell was instructed to make a simultaneous

demonstration upon the enemy’s right, to be converted into a real
attack should opportunity offer.”

When General Lee arranged this plan of attack he believed Meade’s

left terminated at the Peach Orchard; he did not know that Sickles’
advance line extended to the left from the salient at the Peach
Orchard to Devil’s Den. In plain view of the Union signal station on
Little Round Top, some of his forces were compelled to make a wide
detour via the Black Horse Tavern on the Fairfield Road in order to
avoid observation.

27

Little Round Top.

Meanwhile, General Warren on Little Round Top saw the importance
of the hill as a tactical position on Meade’s left. The signal officers
were preparing to leave; he ordered them to remain and to keep
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