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112 Cards in this Set

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3 Objectives of Psychosocial Approach
Emphasizes the impact of the sociocultural context on human development and behavior

Emphasizes the interaction between the individual and his/her social environment which makes demands or exerts pressures in the form of social expectations, norms and values

Considers family, neighborhood or community and the culture
4 Elements of Psychosocial Dynamics
The individual and his/her belief system

The family as a system

The community as a context

The culture as the wider context
Core Beliefs
most deeply held internal messages
Values
those concepts held about everyday living, behavior and institutions
Attitudes
those perspectives which come out of our core beliefs and values
6 Examples of Core Beliefs
The world
Nature of self
Nature of others
The purpose of life
Nature of God
What is family
7 Examples of Values
Work
Education
Conduct of relations with others
Emotions
Honesty
Religion
Prejudice and discrimination
4 Examples of Attitude
TV
Abortion
Welfare
Politics
4 Characteristics of Functional Families
Display consistent caring and love for its members

Display mutual respect for each other’s boundaries and roles

Tend to communicate their problems openly

May tend to follow treatment regimens or let their provider know why not
6 Characteristics of Dysfunctional Families
Tend not to display consistent caring and love for their members
Tend not to display mutual respect for the boundaries and roles of their members
Members may tend to be poor communicators
Members may tend to be noted for manipulative behaviors
Members may tend to be non-compliant with treatment regimens
May appear normal
9 Causes of Dysfunctional Families
Poverty
Low education
Poor self-esteem
Isolation
Inadequate communication skills
Chemical/behavioral addictions
Abuse
Rigid control
Maintain a “family secret rule”
9 Modern Family Patterns
Nuclear family
Multigenerational extended family
Single parent family with grandparents
Single parent family
Multigenerational family group
Blended Family
Same gender couple with children
Two single persons living together without children
Several single persons of either/both genders living together
Culture
a collection of beliefs, values, ideals, and customs handed down in history and commonly accepted either by a society or a large group within that society (a subculture)
Norms
rules of behavior generally accepted in a culture or subculture
Ethnic Groups
groups that exist on the basis of sentiments that bind individuals into solidarity on some cultural basis
Race
a classification for a group with distinct observable biological features such as skin color, hair texture and eyelid shape
Prejudice
attitude which arises when visual differences are assigned negative cultural meanings by the dominant culture
6 Roots of American Culture
Judeo-Christian
Puritanical
Western European
Dominant white majority
Multi-ethnic
Multi-racial
3 Effects of Culture on Patient-Provider Interactions
Language difficulties
Nonverbal communication
Attitudes toward health care
2 Examples of Language Difficulties
Understanding pitch, rhythm, inflection
Taboo subjects
3 Examples of Nonverbal Communication
Eye contact
Smiling (Japanese, Korean)
Spacing
4 Examples of Attitudes toward Health Care
Home remedies
Magical remedies
Fear
Hostility toward the provider
4 Reasons for Limited Access to Health Care
Low income
Lack of community health services
High cost of health insurance
Absence of “culturally competent providers”
6 Areas of Excess Death Rates Due to Limited Access to Health Care
Cancer
Cardiovascular disease and stroke
Chemical dependency
Diabetes
Homicide and accidental injuries
Infant mortality
Patients are individuals exhibiting much variability due to:
Separation/assimilation into dominant white culture
Level of education
Level of or previous contact with health care
4 American Subcultures
Hispanics
African-Americans (Blacks)
Native Americans
Asian American and Pacific Islanders
Problems for Hispanic Americans
Dropping out of school
Alcoholism
Drug Abuse
HIV/AIDS
Problem of Illegals
6 Attributes of Hispanic Americans
Assimilation by second generation
Family and extended family very important
Unit decisions
Does not question the authority of older generation
Reluctance to disagree
Machismo
"The American Dilemma"
The contradiction between American ideals and racist practices

(Cf., African Americans)
7 African American Common Health Problems
HIV/AIDS (51% = African Americans)
Hypertension
Neonatal complications
Substance abuse/alcoholism
Diabetes
Cardiovascular disease and stroke
Stress
4 Problems of Differing Values for African Americans
Ancestral healing practices
Strong sense of communalism
Powerful kinship ties
Problem of Extended Family in Decision Making
5 Native American Common Health Problems
Alcoholism
Diabetes
Hypertension
Cardiovascular disease
Obesity
4 Problems of Differing Values for Native Americans
Suspicion and distrust of a system engaged in ethnic cleansing
Societal sharing
Holistic concept of health which integrates traditional spiritual beliefs with mind and body
Cure includes restoration of balance and harmony
5 Health Beliefs of Native Americans
Medicine defined as everything being alive and including natural elements
Medicine = healing = healing is everywhere
Harmony allows for acceptance of living in balance in one’s world
Relation is being connected to one’s world
Vision is honoring one’s nature, life’s gifts, and one’s purpose.
Problems of Communication for Native Americans
Traditional, or marginal, or middle class, or pan-Indian
Possible discomfort with Western medicine
Problems of Time for Native Americans
Fluid sense of time out of step with those of the American culture
5 Largest Groups of Asian Americans
Japanese
Chinese
Filipino
Korean
East Indian
6 Groups of Southeast Asians
Vietnam
Cambodia
Laos
Thailand
Malaysia
Singapore
5 Groups of Pacific Islanders
Indonesians
Filipinos
Hawaiians
Samoans
Micronesians
5 Problems of Differing Values for Asian Americans and PIs
Collectivist orientation – personal identity defined as a member of the family, group or society
Interdependence and reliance on the group
Tao = harmony and equilibrium in relations with others
Karma = performance in previous lives determines one’s fate
Suppression of inner needs and emotions
4 Problems of Communication for Asian Americans and PIs
Silent communication (bad luck to talk about illness and death)
Taboo subjects
Whole family needs to be involved in health decisions
Decision may be abdicated to health provider seen as wise and benevolent
7 Problems in Rural Areas
Higher infant mortality rates
Higher maternal deaths
Increasing incidence of HIV infections in women and children
Excessive death rates from violence
High frequency of adolescent pregnancy
High incidence of TB
High incidence of deaths from injuries
9 Problems with Differing Values for Rural Areas
Manual work over academic learning
Traditionalism
Strong identification with the land and the home place
Traditional gender based family roles
Familism (reliance on kinship ties)
Neighborliness and friendships
Xenophobia
Rugged individualism
Fatalism
7 Problems of Communication for Rural Areas
Reluctance to ask for help
Reluctance to admit to any health problems
Desultory, evasive, or ambiguous answers on interview
Ambiguous names/terms for health problems
Inadequate understanding of body functions/anatomy
Body shyness
Poor awareness and self observation
4 Theorists of Human Development
Sigmund Freud
Erik Erikson
Jean Piaget
Lawrence Kohl
2 Commonalities Between the 4 Theorists of Human Development
All examined measurement of emotional, cognitive, social and moral development

All held a common concept that there are sequential developmental tasks at each stage that are building blocks for the subsequent stage
Sigmund Freud
A psychodynamic model of personality development
Human development driven by libido (biologically based sex drives)
Divided into 5 stages
Sigmund Freud's 5 Stages of Human Development
Infancy = oral and anal stage
Early childhood = phallic stage including an aggressive drive and anal retentive and passive-aggressive behavior
Early childhood = phallic stage (Oedipus complex and Electra complex)
Mid-late childhood = latency stage
Adolescence = genital stage
Important Concept of Freud's Theory
psychological conflicts and trauma which are not resolved at each stage become the determinants of the motivations and behaviors throughout the life span
Erik Erikson's Theory of Human Development
psychological conflicts and trauma which are not resolved at each stage become the determinants of the motivations and behaviors throughout the life span
Erik Erikson's 7 Stages of Life
Infancy = Trust vs Mistrust
Toddler = Autonomy vs Shame
Early childhood = Initiative vs Guilt
Mid-late childhood = Industry vs Inferiority
Adolescence = Identity vs Role Confusion
Early adulthood = Intimacy vs Isolation
Middle adulthood = Generativity vs Stagnation
Late adulthood = Ego Integrity vs Despair
Jean Piaget's Theory of Human Development
Ability to process information = intelligence
Intelligence is adaptive, arising out of interaction with the psychosocial environment
Four stages (of increasing complexity)
Jean Piaget's 4 Stages of Human Development
Sensorimotor = reality and objects exist only through the infant’s sensory experience
Preoperational = child develops the ability to represent things in the mind
Concrete operational = child develops the ability to sort and classify objects
Formal operational = ability to think conceptually and abstractly and use formal logic
Important Concept of Piaget's Theories
Only those who receive sufficient physical, social and intellectual stimulation and nurture will develop the cognitive structure necessary to reach the final stage
Lawrence Kohlberg's Theory of Human Development
Model of moral development
Six stages
Lawrence Kohlberg's 6 Stages of Human Development
Pre-conventional morality = acts in obedience to superior force of parents
Stage One -To avoid punishment
Stage Two -To attain rewards

Conventional morality = motivation to be good
Stage Three – To gain social approval
Stage Four – To conform to rules and uphold order

Post-conventional morality (some people never reach this level)
Stage Five = Morality of Individual Ethics, Tolerance
Stage Six = Morality of universal ethical principles
Life Course Model
Specific phases or stages defined by events/psychological circumstances
Characterized by tasks or challenges
Normative
Non-normative (unexpected)
Family as context
Family as Context
No specific family constellation or living arrangement is inherently functional or dysfunctional for the personal growth/development of its members
Functional families adapt to changes in a healthy way
Dysfunctional families have difficulty accommodating change
Formation of a couple --Tasks
Need to blend two sets of family values and traditions
Need to reach agreement on how to divide family chores, manage money, establish a mutually satisfying sexual relationship, and find balance between togetherness and privacy
Need to cope with disillusions regarding the other
Need to decide which faith to follow
Need to find ways to achieve agreement/compromise and resolve conflict
4 Couple's Difficulties
Idealistic childlike expectations
Disillusionment
Resentment
Power struggles
Parenting – Tasks
Reorganizing family division of labor
Adjusting intimacy time
Finding energy/love to support one another
Renegotiating boundaries with extended families
Parenting Difficulties
Pregnancy may exacerbate unresolved issues
Pregnancy may threaten a partner’s primacy
Domestic violence
Overwhelmed mothers
Depression
Unreasonable fears
Preschool to Middle School Tasks
Guiding growing independence of the child/children
Setting appropriate limits
Socializing the child into family beliefs/values
Adjusting to evolving demands of the child and changing parental role
Preschool to Middle School Difficulties
Emerge when parents lack knowledge about the changing phases of child development
Emerge when parents have their own unresolved issues with dependency
Emerge when parents resist the child’s natural process of individuation and try to keep the child dependent
Emerge when parents attempt to rigidly control the child’s peer contacts
Emerge when children begin to express values different from the norms practiced at home
Adolescent Tasks
Acquiring autonomy
Coping with everyday life situations
Dealing with pubertal physical development
Finding reference values
Establishing a stable relationship with friends
Establishing an intimate relationship
Successfully completing one’s school career
Preparing for integration into a work setting
Achieving economic independence
Preparing for the responsibility of having one’s own family
Adolescent Difficulties
Frayed parent relations
Lack of guidance
Issues of
sexual behavior
substance abuse
identity formation
gender orientation
College/Extended Adolescent Tasks
Dealing with family separation
Adapting to living with others
Adopting mutually acceptable behaviors with others
Arriving at mutually satisfying levels of commitment, emotional nurture, and sexual activity within a romantic relationship
Polishing communication, decision-making, and social skills for careers and life
College/Extended Adolescent Difficulties
Engaging in unhealthy behaviors
Substance abuse
Feelings of isolation and alienation
High levels of anxiety and stress
Adult Tasks and Challenges
Occurs in multiple dimensions over long period of time
Divided into 5 broad spheres of activity
Family
Work/career
Social relationships
Health
Spirituality
Elements Effecting Life Model
The level of competency in one area is likely to affect fulfillment in others
Sequence is neither uniform nor age graded
Factors affecting management of tasks include
Individual genetic predispositions (Intelligence, Temperament, Physical health)
Core values and beliefs from family and subculture
Cohort – generation or group
Events, cultural fashions, or patterns of current times
Normative and non-normative events
Socioeconomic status – lower status leading to
Advanced state of health problems
Emotional problems
Higher incidence of child abuse and domestic violence
Career Tasks
Find balance between career demands and family life/obligations/responsibilities
Find time for leisure, personal, social and spiritual growth
Midlife crisis
Crisis of values
Disillusionment with life patterns
Disenchanted by stress load
Crisis of identity
Life Course Model 5 Disruptions by Unexpected Events
Issues with children/grandchildren
Sudden death of spouse/family members
Divorce
Job disruptions
Health problems
5 Life Course Model Stages
Preschool to Middle School
Adolescent
College/Extended Adolescent
Coupling
Parenting
Basic Counseling and Communication Skills
Communication is the key to Understanding
Communication is complex as it occurs on different levels
Litigation – often due to patients feeling rushed, receiving no explanations, feeling ignored, or having insufficient time spent on their care
Factors Affecting Patient Communication
Patient’s
psychosocial issues
cultural beliefs
language barriers

Provider’s
beliefs
values
stress/fatigue levels
inner conflicts
Communication Channels
Verbal communication – what a person says
30-35% of social meaning

Nonverbal communication
Visual form = facial expression, gestures, posture, and appearance
Kinesthetic form = eye contact and distance maintained
Auditory form (paralanguage)= pitch of voice, voice tone, volume, rhythm, inflections and hesitations
Factors Influencing Output
Immediate situation
Psychosocial issues
Cultural factors
Which is more accurant, verbal or nonverbal accuracy?
Nonverbal is often more accurate because it is unintentional and uncensored
Non-verbal Leakage
signifies rejection, disagreement or ambivalence
Respiratory avoidance response (frequent throat clearing)
Nose rub
4 Communication Tasks
Engage
Empathize
Educate
Enlist
2 Biomedical Tasks
Find it
Fix it
5 Barriers to Engagement
Medical terms/terminology
Patient’s impaired ability to listen or focus
Patient’s preoccupation with emotions
Patient’s ambivalence and anxiety
Provider’s memories, feelings, or associations and sensitivities
9 Assists to Engagement
Provider thinks back to similar situation
“Universalizing” = Provider acknowledges patient’s feelings
Provider extends a “warm welcome”
Patient is comfortable
Provider uses good (but not overpowering) eye contact
Provider “listens” “listens” “listens” attentively and without interruption
Provider is curious about the patient
Provider seeks some common linkage in Experience, Background, Identity, Acquaintances
Provider elicits patient’s agenda--complaints
Empathy
Is an active concern and curiosity about the patient that lets the provider see and hear the patient
Is the provider’s ability to see things as the patient sees them from his/her perspective
Is the provider’s ability to understand the patient’s emotions
Allows a safe psychological space to be created
Assures the patient that the provider is paying attention to them
11 Ways to Express Empathy
Don’t listen and write at the same time
Remain silent (for more than 10 seconds)
Practice patience
Acknowledge the patient’s feelings, values and thoughts
Don’t ignore anger
Communicate your understanding of the patient’s reason for being angry, sad, upset, etc.
Observe thought processes
Use open-ended questions
Use reflective listening to refocus rambling
Don’t make early judgments as to whether the patient is Manageable, Treatable, Likable
If the patient is reluctant/indirect about a health condition, respond indirectly with positive remarks about other persons with the condition
Educate
Two-way street = provider educates the patient and the patient has information the provider needs (?self diagnosis)
5 Characteristics of Education
Assesses patient’s understanding
Assesses patient’s response to the health challenge
Illustrates the patient’s concerns, fears or dismissals
Provides clues towards patient’s willingness to change habits and to follow a treatment plan
Illustrates patient’s internal reality map
Imparts information but also creates understanding
Actively involved patients remember more and understand more
Enlists patient’s cooperation and responsibility for treatment adherence
7 Things the Patient Wants to Know
What has happened to me?
Why has this happened to me?
What is going to happen to me? short/long term
What are you doing to me?
Why are you doing this to me?
Will it hurt/harm me?
When/how will you know what this means?
Important Question to Ask When Educating the Patient
Will you tell me what you understand at this point?
Two parts to enlisting the patient’s participation
Decision making
Encouraging adherence
3 Aspects to Decision Making
Solicit patient suggestions about treatment
Respect patient suggestions
Solicit joint discussion of the issues in treatment and come to agreement
6 Aspects to Encouraging Adherance
Keep the regimen simple
Write it down
Give specifics about the benefits and timetable
Assure that the patient knows potential side effects
Discuss obstacles to carrying out the treatment
Get feedback
Maintaining Professionalism
Expressing emotion appropriately is OK
Maintain clear role boundaries
Phenomena of “transference” and “counter transference”
Phenomena of “transference” and “counter transference”
Feelings from our past triggered by someone and our projection of those feelings on them
Can be positive or negative
Occur frequently
Happen on an unconscious level
Often propel provider into inappropriate intimacy with a patient
Counter transference
projection from provider to patient
Transference
projection from patient to provider
How to manage transference and counter transference
Acknowledge they are normal and common
Bring transference and counter transference into conscious awareness
How to bring transference and counter transference into conscious awareness
Examining one’s own feelings--overworked, undervalued

Bring issue into open with the patient

If romantic/sexual feelings involved, inform a colleague and speak to the patient immediately:
Remember and say “Against professional ethics”
Never be alone with the patient
Refer patient to a colleague

Avoid dual relationships
Termination Issues
Occur when an established professional relationship between a patient and a health care provider comes to an end due to departure of either or a change in insurance coverage.
4 Steps to Termination of Patient/Provider Relationship
Notifying patients is an ethical requirement
If temporary, arrange backup coverage
If permanent, refer patients to colleagues
Transfer medical records to the practice location of new providers
Processing Social Information
A patient’s anxiety, fear or anger can lead a provider to an adverse evaluation of the patient’s like-ability, manageability or treatability and thus interfere with appropriate treatment.

A provider’s prejudices similarly can create a barrier which can cloud professional judgment and interfere with appropriate treatment.
3 Things Social Psychology Explains
Human beings form impressions of others, often subconsciously and fairly quickly after meeting for the first time
People seek certainty about how to relate to the other person
This process is based on the most fundamental level of instinctual survival
What Snap Judgements Are Based On
gender, race, ethnicity, religion, age, socioeconomic status, gender orientation, physical and mental disabilities, physical fitness and/or appearance
Results of Snap Judgements
We automatically categorize and stereotype others
We group ourselves and others as either “belonging” or “not belonging” (to the in-group)
We give negative names
Judgments and prejudices translated into actions denying out-groups of rights and privileges is called discrimination
Discrimination in Health Care
Health care providers are expected to provide care and “to do no harm”

Care without reservation is assumed

Providers have a special responsibility to be aware of their own human tendencies
Examples of Racial and Ethnic Prejudices in Healthcare
1999 lung cancer report finding that African-American patients were less likely than White patients to get surgery for early stages of lung cancer
Tuskegee study
Women having criteria for heart surgery receive it less frequently than men
Homophobia and Heterosexism in Healthcare
Special health care needs ignored in literature and in practice
Inappropriate, inaccurate stereotyping
Messages that homosexuality is abnormal, sick, and perverted
Studies indicate that health care professionals are less tolerant of GLBT patients
Age, mental illness and other prejudices in Healthcare
Infantilizing the elderly
Unflattering labels
Stigmas
Blaming smokers and other addicts for their illnesses
Failing to assess for depression in the elderly or obese
What can be done?
Seek contact and interaction with minority target groups
Address prejudice and discrimination in the workplace
Be proactive to assure an open and accepting work environment
How to be proactive to assure an open and accepting work environment
Clearly written office policies
Strict and consistent implementation
Exemplary role model
How HC Providers can overcome homophobia/heterosexism
Health care providers can educate themselves on the etiology of gender orientation and develop understanding
HC providers can learn to use non-heterosexist language in health care delivery (sexual histories, health discussions)
HC providers can allow partners of GLBT patients to have family privileges