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MODULE:
FUNDAMENTALS OF BEHAVIOR SCIENCES

UNIT:
MEDICAL PSYCHOLOGY

Aims of the module

Health is a continuum between biological, psychological and social factors across

the lifespan .This module explores the social and psychological correlates of health
and illness within the Rwandan context. The general aim of this module is:
 To introduce the nursing student, allied health student and community health
development student to the variety of principles influencing health and
human behavior
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 To acquaint students with knowledge which will enable them to understand

particularly the effects of the social and psychological determinants on
health
 To help the nursing student, allied health student and community health
development student to deal with psychosocial factors affecting health and
illness within every day clinical practice.
 To enable students to communicate effectively so as to cause positive
behaviour change among individuals, groups, families or community.

8. Learning Outcomes

Knowledge

At the end of the module, students will be able to:

1. Critically discuss the psychological, social and environmental factors

influencing health, either positively or negatively.
2. Discuss applications of psychology and sociology, in relation to health and
care promotion
3. Describe Communication skills and explain how the relationship between
the clients and care givers can be the key factor of health promotion and
clients well being.
4. Identify the types of situations where counseling is needed
5. Describe the counseling process
6. Critically discuss the Rwanda history, the government policy, the current
civic and citizenship practice and human values promoted in the Rwandan
context.
Competences and Skills
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At the end of the module, students will be able to:

1. Establish and maintain productive relationships with clients/patients,

colleagues and teams through effective communication
2. Demonstrate use of communication skills with individuals, families and
community
3. Recognize the client who need counselling services
4. Provide effective counseling to clients
5. Use current technology for effective communication of health related
information

Attitudes

At the end of the module, students will be able to:

1. Demonstrate attitudes and ability to develop a therapeutic relationship with

clients
2. Adopt appropriate language in managing and educating patients and clients

9. Indicative content

This module introduces four areas of interest to nurse and para-medical students –
namely, health psychology, Sociology of health and illness, Civic Education,
Communication skills as applied to health and illness.

Health psychology
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Definitions and new concepts in medical psychology,

Topics covered by this module include:

 Background of psychology (Theorists, main Theory, Research Methods in
psychology)
 Introduction to Health psychology and the biopsychosocial model of health
 Stress and health
 Psychological effects of illness, the psychology of pain and pain
management
 Loss and grief
 psychosomatic disorder
 Relationship between care givers and client and family
 The role of psychology in health promotion and illness prevention
 Behaviour change

Chap I. HISTORICAL PERSPECTIVES OF PSYCHOLOGY

1.1.Introduction

Psychology touches all aspects of our lives. As society has become more
complex, psychology has assumed an increasingly important role in solving
human problems. Psychologists are concerned with an astonishing variety of
problems. What child- rearing practices produce happy and effective adults?
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How can mental illness be prevented? What family and social conditions
contribute to alienation and aggression?

Other problems are more specific. What is the best way to break a drug habit?
Can men care for infants as ably as women can? Can one recall childhood
experiences in more detail under hypnosis? What effects does prolonged stress
have on the immune system and the likelihood of illness? How effective is
psychotherapy in the treatment of depression? Can learning be improved by the
use of drugs that facilitate neural transmission? Psychologists are working on
these and many other questions.

The effect of television violence on children is of concern to parents and

psychologists. Only since studies provided evidence of the harmful
effects of such programs has it been possible to modify TV
programming policies. More brutal TV fare is gradually being replaced
with shows of other kinds. Thus psychologists and educators are trying
to make learning interesting. Fun. And effective. Because psychology
affects so many aspects of our lives, it is important, even for those who
do not intend to specialize in the field, to know something about its basic
facts and research methods. It should also help you to evaluate the
claims made in the name of psychology.
1.2. NATURE AND DEFINITION
Psychology is a relatively young science. It is about the same age as the
oldest living human being, which is about 120 years.
It is Rudolf Goeckle(1590) who used the word psychology for the first
time. Therefore, psychology has a long past but a short history. However
it was Wilhlem Wundt who established the ever first psychology
laboratory in Leipzing in 1879 that led to the separation of psychology
from philosophy.
The word psychology is derived from a combination of Greek words”
Psyche” and” Logos”. Psyche means soul and logos means knowledge.
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Thus psychology literally became to be known as the science of the soul.

Thus early thinkers (philosophers) ascribed the mental activities of
human being to power that was not tangible and which was much hidden
from the outer senses. They called it soul which was the main concern of
philosophy and religion. This definition was rejected because Aristotle
and his associates could not satisfactorily explain the relation of soul and
body. Secondly, it was rejected due to dualism nature that involves the
study of physical and spiritual matters. Later on the word soul was
replaced by the term mind. So psychology came to be known as the
study of the science of the mind. Early Greek philosophers who were
opposed to earlier definition of psychology held this definition.
However, the definition did not last because by calling it a science, it
was not automatic whether psychology was a positive or normative
science. Finally, the thinkers who used the term mind did not agree on
its nature.
Thirdly, psychology was defined as the science of consciousness. In the
of James Sully, psychology has to do with inner world and has to
employ introspection as its method. Wilhelm Wundt was of the opinion
that psychology being the study of consciousness deals with internal
experience which includes sensation, perception, thinking, reasoning and
problem resolving behaviors. This definition was later on discarded on
the ground that social thinkers who used the word consciousness did not
agree on its nature. Secondly the definition did not include unconscious
and subconscious levels of the mind.
Later on psychology came to be defined as the science of human
behavior. Watson the founder of the school of behaviorism defined
psychology as a science of behavior. William McDougall defined it as
conduct of living things. However, these definitions faced some
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criticisms. Firstly by merely calling it a science, it is not clear whether

psychology is a positive or normative science.
Secondly Watson took behavior in a very narrow sense. Behavior as
Watson saw it was merely stimulus response (S- R connection)
In the words of Woodworth psychology is” the scientific study of human
behavior and all activities in relation to his environment”. Psychology,
in the view of Woodworth, is a positive science because it studies facts.
The psychological judgments are factual. It is not concerned with values,
ought or axiological judgments.
Thus it can be realized from the foregoing explanations that the
definitions of psychology has gone through various changes during the
short period that it existed. In the 1980s, 1990s and perhaps in the 21 st
century psychology has been explicitly defined as scientific study of
behavior and mental processes.
There are three key terms in the above definitions; science, behavior and
mental process. Psychology is considered as a science because
psychologist’s main concern is to understand people’s behavior through
carefully controlled observations. It is positive science because it uses
only those methods, which are strictly scientific and which give us
knowledge that can be verified everywhere. It is therefore based on
generalizations drawn on the basis of factual data analyzed and
compared. Therefore psychology can be distinguished from mental
philosophy on the basis of its methods. It became a science when the
earlier psychologists began to perform experiments, make observations
and seek evidence more or less like in pure or natural sciences. The term
behavior refers to all overt actions that can be observed directly such as
speaking, laughing, facial expressions, etc.
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1.3.BACKGROUND OF MEDICAL PSYCHOLOGY

Definitions:
Medical Psychology is a science which studies the interactions
and the links between psychology that is the science of the
mind and medical sciences in general. Medical psychology
also known as clinical health psychology, psychosomatic
medicine, health psychology revolves around the idea that
both the body and mind are one, indivisible structure,
continuing with this line of though, all diseases whether of the
mind or of the body must be treated as if they have both been
affected.

This belief that the corporeal and the physical bodies are one is
by no means new. Socrates introduced the Greeks to this idea in
several of his works, however for a time in the early modern
period, it was lost to Rene Descartes (also know as Cartesians)
belief of the two separate bodies. Only recently has this arcane
thought been reintroduced into medical schools across the
world.

The intention of medical psychology is to apply knowledge

from all branches of psychology and medicine in the prevention
and assessment and treatment of all forms of physical diseases.
Medical psychology asserts its main function in the
determination of personality styles of coping and the
examination of attitudes of an individual to subjective and
objective stressors. Medical psychology also helps in the
determination of genetic, biochemical and physiological factors
in illness and reaction to illness. These then are joined with
psychosocial factors deemed contributory to diseases. Specific
behavioral methods are then used to help the person match
coping and management skills to the person’s abilities,
character and personal styles.

BACKGROUND
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Some doctors and philosophers today believe that Cartesian

line outdated. Some anecdotal evidence has been raised
concerning the lack of effective treatment for things such as
migraines pains and cancer and that perhaps the cure should not
only be centered on the but also the mind. Some also raise the
argument that most incurable diseases are brought about not
merely by physical ailments, but by mental problems. All
evidence is of course unproven and will likely remaining as
such for a long time to come.

The contribution of medical psychologists to general health

care increased with their use of primary care doctors in the
world’s largest WHO. These psychologists work along with
primary care physicians in order to determine optimum
treatment plans for all patients with physical and mental
illness.

Again an important contribution of medical psychology is in

the education of patient’s Psycho education in diseases
processes. Frequently such education of the patient insures
substantially better compliance with treatment
recommendations by physicians. Medical psychologists are
particularly successful in the treatment of asthma,
gastrointestinal illnesses, cardiac conditions spinal cord and
brain injuries, chronic pain, headaches and addictions like
drugs, smoking, eating, and alcohol.

Chap.II SCHOOLS OF MODERN PSYCHOLOGY

The emergence of modern psychology has been made possible

due to many approaches or schools of psychology, what
psychology studies and what methods psychology employs in
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studying behavior. The reader is alerted to take note of the fact

no approach is actually exclusive because each of them tends
explain different aspects of a complex problem.

The implication here is that there is no right or wrong

approaches were tried, criticized, rejected and replaced as we
are going to see. The schools that gave rise to modern
psychology are structuralism, functionalism, psychoanalysis,
gestalt, behaviorism and humanistic.

Structuralism school

The father of psychology, Wilhelm Wundt, championed this

approach, Wundt together with these students among them
Edward Bradford Titchener claimed that complex mental
experiences were really structures built up from simple mental
states much as chemical compounds are built from simple
chemical elements. Structuralism was considered as the study
of conscious experiences or elements such as sensations,
mental images and feelings of normal human mind into
their most basic parts. In order to explore and identify the
elements of the mind, Wundt developed a method of
introspection. This method required people to look inward
and describe or report on the workings of their minds, as
they are involved in different tasks. This method made
structuralism to be a subjective approach hence it lost some of
its credibility. A part from introspection structuralists used
experimental method in studying their subjects.

Functionalism school

The school of functionalism was championed by William

James (1842- 1910) who disagreed with he views of
structuralists who were interested in the minds structural
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pieces. James approach was focused on the relation between

conscious experience and behavior. His argument was that
the stream of consciousness is fluid and continuous.
Functionalism became the study of the function, use and
adaptability of the mind to one’s changing environment. James
insisted that mental processes couldn’t be separated from brain
processes; this made him to be considered as the father of
psychological approach. Later on John Dewey and James
Angell together with William James joined hands to propagate
how experience permits people to function more adaptively to
the environment. Functionalism however, did not last; even the
many of its ideas were absorbed by other approaches.
Functionalism used introspection and observation methods
in studying human behavior.
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Psychoanalysis school

Sigmund Freud (1856- 1939) developed psychoanalysis school

of psychology. It was a theory of personality, a method of
therapy or a technique aimed at understanding human behavior
that energy after functionalists split in 1990. Psychoanalytic
ideas were based on extensive case studies of an individual
patient rather than on laboratory experimental studies as were
in earlier approach. Freud and his associates, Carl Jung and
Alfred Adler used clinical and observation methods in studying
human behaviors. Freud probed human thought, emotions,
feelings and behaviors through observations and clinical
interviews with patients. Freud and his associates laid
emphasise on the unconscious mental processes with more
concern of understanding and curing of mental disorders. They
ignored the problems for the consciousness and focused on the
unconscious as the primary source of conflicts and mental
disorders. By unconscious processes psychoanalysts meant
fears, thoughts, wishes an individual is unaware of, Sip of the
tongue, etc. but which still control people’s behavior. They
devised techniques such as free association (uncensored
uttering of all thoughts that come to mind), dream analysis,
hypnosis to understand human behavior. However, the view of
psychoanalysts that human is driven by the same instincts as
animal (primarily sex and aggression) and are continually
struggling against a society was not fully accepted by many
psychologists. Even then the contributions of psychoanalysis
cannot be undermined, many of which cannot be refuted or
fully accepted by the modern psychologists, psychiatrists and
medics. Freud also gave the phenomena of id, ego and superego
to explain human behavior.
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Gestalt psychology

Gestalt school became popular in 1920s in Germany. Max

Wertheimer (1880- 1943) and his associates, Kurt Koffka
(1886- 1941) and Wolfgang Kohler (1887- 1967) championed
it. Kaffka and Kohlerleft Germany for the United States to
evade the Nazi persecution.

The Gestalt psychologists approach has thrown light on the fact

that perception is more than the sum of its parts. They
studied how sensations are assembled into meaningful
perceptual experiences. They laid emphasis on perception and
how perception influences thinking, reasoning, problem
solving inter alia. Perception therefore was considered to be
more than the sums of its parts. Wertheimer and his associates
believed that the whole pattern of an experience is more
important than its individual parts in determining its meaning
and even its appearance. Wertheimer et al. held an opposite
view to behaviorists by arguing that one cannot automatically
understand human nature by focusing on accumulated overt
behaviors alone. They also held opposite view in relation to
structuralists by pointing out that it is not possible to explain
human perceptions, sensation, emotions or thinking in terms of
basics units.

Gestalt psychologists strongly believed that learning can be

active and purposeful instead of being responsive and
mechanical as demonstrated by Pavlov’s experiments on dogs.
Kohler and his colleagues demonstrated that learning especially
in problem solving situations is often accomplished by insight;
Insight is a form of cognitive change that involves recognition
of previously unseen relationship to study behavior. The
methods used by Gestalt psychologists to study human
behavior included introspection, observation and
experiments.
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Behaviorism school

A group of American Psychologists called behaviorists

attracted considerable attention during the First World War
John B. Watson whose interest was in animal experimentation
and therefore discarded traditional early approaches that relied
on consciousness, introspection and unconsciousness in order
to study behavior led the behaviorists. Behaviorists such as
Watson, Pavlov, Danshiel and Skinner transferred their
technique of studying animal behavior to the study of human
behavior. Behaviorists held the view that behavior was mainly
learned and not inborn as proposed by psychoanalysts. They
believed on studying tangible aspects of behavior that can be
observed. Their contribution to the emergence of psychology is
seen in their work on conditioned responses. The behaviorists
used observation and experimental methods in their study.
Though much of Watson’s behaviorism was later behaviorists
such as Clark Hull, Edward Tolman among others carried his
systematic objective approach forward.
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Humanistic school

The humanistic approach is also known as existential

psychology. Humanistic psychology considered personality as
a dynamic integral system with an open potential for self-
actualization quality of man. Humanistic psychologists
represented a reaction to the mechanistic nature of both
behavior and Freudianism that laid emphasis on the
personality’s dependence upon its experiments and past
experiences.

In the view of humanistic psychology human nature can be

learned by studying people’s perceptions of themselves and of
their world than we can by observing their actions can learn
human nature. In other words, people are responsible for their
own actions. Humanistic approach maintained that the
individual’s behavior is determined by his present and
future. The main feature of personality as seen by humanistic
psychologists is the striving for freely realizing one’s
potentialities (Gordon Allport) ,especially creative ones
(Abraham), strengthening self- confidence and attaining the
ideal (Carl Rogers). The contribution of humanistic psychology
can be seen in the psychotherapy approach of <<client-
centered>> given by Carl Rogers (1951). The psychotherapy
requires physicians to enter into a close personal relationship
with the patient and regard an individual not as a client who
assumes responsibility for solving his own problems. The
physician acts like a counselor in creating warm emotional
atmosphere, which makes it easier for the client to recognize
the structure of his inner world and integrity of one’s
personality.
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Table 1. Important schools of psychology

Name Main Methods Leaders Approxima

Topics te Date of
Origin
1. Structuralism Sensations Introspection Wundt 1879
(psychophysic Experimenta Titchener
al) l
2. Functionalism Behavior Introspection James, 1900
(particularly Observation Angell
learning) Dewey
3. Psychoanalytic Mental Clinical Freud Jung 1900
disordes Observation Adler
Unconsciou
s Process
4. Gestalt Perception Introspection Wertheime 1912
Memory Observation r, Kholer,
Experiment Koffka and
Lewin
5. Behaviorism Stimulus Observation Pavlov 1913
Response Experiment Watson
Animal Dashiell
Behavior Skinner
6. Humanistic Personality Counselling Allport 1950
(Existential) Psychothera Rogers
py
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1.5. GOALS OF PSYCHOLOGY

There are various goals of modern psychology; some of the most
important ones are as follows:

 To orient individuals with psychological concepts to enable

them understand human nature.

 To provide knowledge about mental health of psychologists,

teachers, students, etc. is very important for efficient
functioning. From the study of psychology teachers and
psychologists can know the various factors that are responsible
for mental ill health and maladjustment of students.

 To assist learners to understand mental emotional reactions

individuals e.g. anger, pain, affection, among others.

 The goal is to study general principles that are universally

applicable to the behavior mankind.

 To assist learners and parents to understand the nature of

classroom learning and learning in general. They get to
understand people’s developmental characteristic their
abilities, influence and contribution of heredity- environment
in the process individual’s personality.

 To understand the learners in a classroom situation why they

would behave in certain ways and how they may be helped if
need be.

 To promote human relations by bringing about adjustment in

society. It has enabled me to understand each other and to
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improve relations. Hence psychology has help sociologists and

social reformers to solve various problems in the society.

 Last but by no means has the last psychology helped in

understanding of oneself which learning to the understanding
of others. It removes prejudices and eliminates hatred because
can be in a position to understand causes of differences in
behavior.
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PSYCHOANALYSIS

Psycho-dynamic class theories. Are theories based on the assumption

that personality and its development is determined by intrapsychic
events and conflicts. These happen in an individual’s mind. Sigmund
Freud- developed psycho- analytic theory which was based on the
principle of psychic determinism. Under this principle of psychic
determinism, Freud argues that all our behavior is not by accident, but
that, there is always a reason for doing something; although there are
some feelings that one may not be aware of it at a certain time, but
with time, we recall the feelings. These are known as preconscious.

Neo Freudian Theory

This theory advanced by Freud argues that human personality is

formed out of the continuous struggle between the individual’s
attempt’s to satisfy inborn instincts (those of sex and aggression) while
at the same time coping with an environment that will not tolerate
completely bad conduct.

Freud came up with structure of personality as being made up to three

components. Eg. Id, Ego and Super- ego. The Id is original or inborn
system of personality which operates through reflex action primary
process; it exists without our being aware of its presence. It includes
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primitive urges and wishes which society condemns and punishes if

they erupted.

The Ego. Is that part of our personality that is in direct contact with the
world about us. The ego controls the Id. The ego is the rational,
common sense part of our personality.

Super Ego. Is the conscience of a person. It provides the sense of wrong

and right. It keeps the ego from straying far from the path of socially
accepted behavior. Ego tries to contain both Id and super ego; thus it is
a moderator of behavior. Sometimes ego does not have enough energy
to contain both Id and Super Ego, when this happens, the person may
for example act according to Id.

Examples of Conflicts between the Components

Id Vs Ego. Choosing between small reward immediately and big reward

later. Id wants immediately but ego says wait a bit.

Id Vs Super Ego. Shopkeeper gives excess change, Id says go away with

it, but super ego says take it back..

Personality Developmental Stages

Psycho-Sexual Development

a. (1) Before Freud, people looked at childhood as a period of

innocence, the child being untouched by sex. But Freud thought
otherwise.

(2) Observations have proved that, sexual urges were present from
birth onward (e.g erect penises in male infants).
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(3) Freud argues, therefore, that adult sexuality is the growth or

development of infantile sexuality. This has led to what is now known
as the Theory of psycho-sexual development from infancy to maturity.

The term psycho- sexual- means that sex is not just a physiological
process but has psychological implications.

b. Major Points to Note about the Theory

(1) Sexual pleasure is not limited to activity that directly involves the
genial organs. There are also other areas of the body called
erogenous zones that when given appropriate stimulation produce
pleasurable sexual feelings for example, mucous membranes lining the
mouth, the anus, etc.

(2) At any given time in an individual’s development, on body area

tends to supersede the others as source of pleasure. The order of
change is the same for all persons but timing of the phases will differ
among people.

(3) An individual’s personality characteristics are affected by the

nature of his psycho- sexual development, that is to say, failure to
replace one body area by the next in sequence as a source of pleasure
will have important consequences for his adult personality
characteristics.

c. Oral Stage (O- 2 Yrs). Freud says infants sucks to get nourishment
and derive pleasure quality for infant and the mother. Sex then
according to Freud is first identified with the mouth rathe than the
genitals. Because of the pleasure derived, the child will suck any object.
When it grows teeth, the child will even bite and it may gain pleasure
from aggressive biting.
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d. Anal Stages (2-4 Yrs). The child’s pleasure organ changes to anus
prominently. The child enjoys both expelling and retaining his feaces.
The anal activity also becomes a focus of interaction between parents
and the child; for example, though toilet training parents increases the
child’s sensitivity to this area (anus). To defecate properly may bring
rewards from parents, and not doing it well may be a way of expressing
hostility to them (parents). Over strictness by parents in this stage will
lead to hostility late run adult age. Don’t care attitude by parents will
lead to clumsiness like writing with feaces on toilet walls.

e. Phallic Stage (4- 5 Yrs)

(1) Genitals become the primary source of pleasurable sensations.

Time for autocratic emphasis. A lot of pleasure is derived through self-
manipulation because the child has not matured enough for full
heterosexual act.

(2) During this stage, children may experience castration anxiety,

penis envy and Oedipus complex.

(3) Castration anxiety is a boy’s fear. Once pleasure for

masturbation ahs been realized, he may fear to loose it as a
punishment, warning of him to stop masturbation may be seen as
prelude to castration. This is heightened in their mind when they see
the girls without penises.

(4) Girls face penis envy. She lacks the boy’s source of pleasure
and therefore, become envious.

(5) Oedipus Complex. This is a situation where the boys are

sexually attracted to their mothers.
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(6) Electra complex. This is situation where girls are sexually

attracted to their father.

(7) The children express their sexual impulses by playing the

father and mother roles, and engage in premature sex.

(8) Over protection by punishment will lead to feeling of guilt in

later years. This will lead to avoidance of opposite sex in later years.

f. Latency Stage (5- 12 Yrs). This is the stage where the instincts
become controllable. The ego and the super- ego are now developed.
At this stage, parents ought to teach their children on moral values and
letting them know the repercussions of doing good and bad things.

g. Genital Stage (above 12 Yrs). Is known as the adolescence

stage. It is a stage of physiological maturity. During this stage, parents
should have close observation and control over their children otherwise
they may go wild.

BEHAVIORIM APPROACH.
Learning as conditioning
-Classical conditioning
-Operant conditioning
Conditioning is the simplest form of learning, concerned with stimuli
and responses. Though stimulus –response associations, we acquire
many behaviors. Classical conditioning
The term “Learning” is broader, referring to any change in behavior
resulting from experience, excluding maturation and physiological
adjustments.
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Classical conditioning is a process that underlies our learning of

physiological and emotional reactions. Learned reflexes apparently are
acquired in this way. After a brief transition, in which these reactions are
compared with more voluntary responses, there is also operant
conditioning. This process underlies acquisition of habits and skills.
Conditioning is typically said to occur in these two basic forms:
Classical conditioning, concerned with reflexes and emotional reactions,
and operant conditioning, involved in basic habits & skills.

Classical conditioning.
Our modern understanding of classical conditioning began with Ivan
Pavlov, a Russian physiologist interest in the study of gastric secretions.
In fact, he received a Nobel prize for his work on digestion. To study
salivation in live dog, Pavlov and his assistants made an incision in the
dog’s check and inserted rubber tubing, through which the saliva passed
into a glass container. Here it could be measured in a precise, objective
manner. When a meat was presented, the dog naturally salivated, and
then studies could be made of this process.
Pavlov called these learned reactions physic secretions to distinguish
them from the inborn physiological ones elicited by the meat itself. The
term classical means “in the established manner”. Hence classical
conditioning means the study of stimulus-response relationships in the
manner established by Ivan Pavlov.
The first step in the Pavlovian method is to ensure that the new stimulus
is neutral. It should not elicit the response in question, which in this case
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is salivation. If the sound of the footsteps does not elicit salvation, it is a

neutral stimulus for his response and perhaps can become conditioned.
Conditioning begins when the footsteps are followed each time by food,
which evokes the inborn, automate salivary response. As this pairing is
repeated, the footsteps develop the capacity to evoke salivation.
Conditioning has occurred when this sound alone, a previously neutral
stimulus, elicits the salivary response.
Footsteps-------------?
Food------------------which he called the unconditional reflex. But
when the sound of the footsteps prompted the dog to salivate, Pavlov
designated this response as a conditional reflex, which emphasized that
it depended upon a certain process the pairing of the conditional
stimulus with an automatic or natural one.
In later research it becomes a conditioned stimulus(CS),leading to a
conditioned became apparent that many conditioned reactions, strictly
speaking, one not reflexes. For these reasons, the following terms have
come into general usage today: there is the natural or unconditioned
stimulus (US), which automatically leads to an unconditioned response
(UR); there is also a neutral stimulus, which through the pairing process
response (CR). The essential feature of the classical conditioning
process is that a previously neutral stimulus acquires the capacity to
elicit a certain response.
CS------------? US----------UR/CR

(Footsteps) (Food) (Salivation).

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Also if we present a tone just prior to presenting the food.Because the

tone itself does produce salivation ,it is a neutral stimulus. But after
pairing the tone with the food several times ,we discover that salivation
will occur upon presentation of the tone. The tone can now be called a
conditioned stimulus(CS)because it produces salivation the conditioned
response (CR). In short:
CS (tone) ----- US(food) ---UR(salivation)
After several pairings of CS and US:
CS (tone) ---- CR (salivation).
This kind of experimemt has been carried out using many species
(Siamese fighting fish,rats,dogs,and humans),conditioned stimuli
(tones,lights,tastes),and unconditioned responses
(salivation,fear,nausea).It can be used in therapeutic situations to
eliminate unsatisfactory behaviors. For example, Pavlovian conditioning
may be used to cure alcoholism (Baker and Cannon, 1979). The
following case illustrates how the conditioning would proceed when
curing alcoholism.
Steven drinks a quart of vodka daily and has done so for several months.
His drunkenness interferes greatly with his work, his marriage is falling
apart, and he has been arrested twice for drunken driving. He has sought
out a dramatic form of therapy: Pavlovian aversion therapy. In the
therapist’s office, Steven gulps down a shot of his favorite vodka. He
then drinks ipecac, a drug that causes him to become nauseated within a
few minutes. He vomits. A week later, the same procedure is repeated.
The taste of vodka (CS) is paired with the ipecac (the US).The ipecac
produces nausea and vomiting (the UR). After several such sessions, a
major change in Steven’s preferences has occurred. Vodka now tastes
 27

terrible to him (CR). Merely thinking about alcohol makes him

nauseous. And, most importantly, he no longer drinks liquor.

HUMANISTIC APPROACH.

Person-centered therapy

Person-Centered Therapy (PCT), also known as Client-centered

therapy or Rogerian Psychotherapy, was developed by the humanist

psychologist Carl Rogers in the 1940s and 1950s. It is one of the most
widely used models in mental health and psychotherapy. The basic
elements of Rogerian therapy involve showing congruence
(genuineness), empathy, and unconditional positive regard toward a
client. Based on these elements the therapist creates a supportive, non-
judgmental environment in which the client is encouraged to reach their
full potential. [1]

Person-centered therapy is used to help a person achieve personal

growth and/or come to terms with a specific event or problem they are
having. PCT is based on the principle of talking therapy and is a non-
directive approach. The therapist encourages the patient to express their
feelings and does not suggest how the person might wish to change, but
by listening and then mirroring back what the patient reveals to them,
helps them to explore and understand their feelings for themselves. The
patient is then able to decide what kind of changes they would like to
make and can achieve personal growth. Although this technique has
been criticized by some for its lack of structure and set metho it has
proved to be a hugely effective and popular treatment. PCT is
predominantly used by certain types of psychologists and counselors in
psychotherapy . In client centered therapy the therapists role is mainly to
act as a facilitator and to provide a comfortable environment NOT to
drive and direct therapy outcomes.
 28

History and influences

Person-centered therapy, now considered a founding work in the

humanistic school of psychotherapies, began formally with Carl Rogers.
[2]
"Rogerian" psychotherapy is identified as one of the major school
groups, along with psychodynamic, psychoanalytic (most famously
Sigmund Freud), Adlerian, Cognitive-behavioral therapy, and Existential
therapy (such as that pioneered by Rollo May).[3]

Others[who?] acknowledge Rogers' broad influence on approach, while

naming a humanistic or humanistic-existentialist school group; there is
large debate [4] over what constitute major schools and cross-influences
with more tangential candidates such as feminist, Gestalt, British school,
self psychology, interpersonal, family systems, integrative, systemic and
communicative, with several historical influences seeding them such as
object-relations.

Rogers affirmed [2]individual personal experience as the basis and

standard for living and therapeutic effect. Rogers identified 6 conditions
which are needed to produce personality changes in clients: relationship,
vulnerability to anxiety (on the part of the client), genuineness (the
therapist is truly himself or herself and incorporates some self-
disclosure), the client's perception of the therapist's genuineness, the
therapist's unconditional positive regard for the client, and accurate
empathy;Both active and passive aspects of empathy in the therapist
have been identified. This emphasis contrasts with the dispassionate
position which may be intended in other therapies, particularly the more
extreme behavioral therapies. Living in the present rather than the past
or future, with trust, naturalistic faith in your own thoughts and the
accuracy in your feelings, and a responsible acknowledgment of your
freedom, with a view toward participating fully in our world,
contributing to other peoples' lives, are hallmarks of Roger's Person-
centered therapy.
 29

Core concepts

Rogers (1957; 1959) stated [5] that there are six necessary and sufficient
conditions required for therapeutic change:

1. Therapist-Client Psychological Contact: a relationship between

client and therapist must exist, and it must be a relationship in
which each person's perception of the other is important.
2. Client incongruence, or Vulnerability: that incongruence exists
between the client's experience and awareness. Furthermore, the
client is vulnerable to anxiety which motivates them to stay in the
relationship.
3. Therapist Congruence, or Genuineness: the therapist is
congruent within the therapeutic relationship. The therapist is
deeply his or herself - they are not "acting" - and they can draw on
their own experiences (self-disclosure) to facilitate the
relationship.
4. Therapist Unconditional Positive Regard (UPR): the therapist
accepts the client unconditionally, without judgment, disapproval
or approval. This facilitates increased self-regard in the client, as
they can begin to become aware of experiences in which their
view of self-worth was distorted by others.
5. Therapist Empathic understanding: the therapist experiences an
empathic understanding of the client's internal frame of
reference. Accurate empathy on the part of the therapist helps
the client believe the therapist's unconditional love for them.
6. Client Perception: that the client perceives, to at least a minimal
degree, the therapist's UPR and empathic understanding.
 30

Chap.III: Frustration, Conflict,& Defence Mechanism

Conflict

Conflict result when somebody wants to make a choice between

two goals, and he does not known which one to opt for. Types of
Conflict are.

a. Approach Conflict. Arises when someone is faced with

two equally attractive goals.
b. Approach Avoidance. This type arises when someone
wants to get an attractive goal but at the same time that
goal has got something unattractive about it. This type of
conflict is worse than the approach conflict, because in the
approach conflict type once a decision has been made,
conflict goes. In the approach avoidance the individual
may become neurotic.
c. Double Approach Avoidance. In this type, someone is
faced with two goals each has something attractive an
something unattractive so that when one weights the two
goals, he comes undecided about which of the goals to
pursue.
d. Avoidance Conflict. Under this type, there are two goals
which are both negative. Conflict becomes very serious
when one is engaged in avoidance behavior. When conflict
persists, it leads to behavioural problem ie. One engages in
defense- mechanisms.
 31

Frustration.
Frustration is a feeling which a person experiences when he
is unable to satisfy his desires. It occurs when there is a block to a
goal. Frustration may also be taken to mean a barrier towards
achieving a goal. Human beings react differently to frustration.

a. Effects of Frustration. There are many ill- effects that

result from frustration. These effects could generally be
categorized as either being immediate consequences or
long- term consequences.

1) Immediate Consequences.

a) Restlessness & Tension. When one is

frustrated, he becomes restless, he may
complain, be shy, sometimes he may tremble,
smoke finger bite etc.
b) Aggression. May be direct or indirect. Direct
occurs when one is ready to fight or attempt
to break the barrier forcefully. Victim may
engage in breaking things, use strong and
dirty language to let off steam.

Indirect (Displaced) occurs when one cannot

get to the goal due to suppression e.g. older
child when frustrated may end up beating
their toys. Scape goating is an example of
this kind of aggression.
 32

c) Apathy. Is the opposite of aggression and

one is withdrawn sympathetic etc. This
occurs when frustration is prolonged and one
becomes indifferent and detached. For
example, a trainee who constantly gets low
scores, may refuse to put in any more efforts
n learning. Apathy is quite evident in war
camps.
d) Fantasy. Occurs when one refuses to face
reality and instead escapes into dreamland. If
one cannot attain some goal, he imagines he
has accomplished the goal. Fantasy is
common among prisoners of war.
e) Stereo- Type/Fixation. Here one engages in
repeating various behavior even though the
behavior does not satisfy the situation e.g.
thumb sucking in children.
f) Regression. Is when someone engages in
behavior that is supposed to be done by
children. The aim is to secure back the
affection he used to get. This behavior
normally occurs when the adult feels that he
has been deprived of the affection he
deserves.

b. Long Term Consequences. When frustration continues for

long without solution, defense mechanism develop. These
are ways of protecting oneself.
 33

The Coping strategies of everyday life.

The mind is its own place It can make a heaven of hell or a hell of
heaven.This is especially the case when the mind is experiencing
conflict and anxiety.the ways in which the mind accomplishes this are
are often automatic and unconscious,occurring outside the willful
control of the individual.Sometimes it can be achieved in a direct and
conscious effort to to mitigate conflict and minimize psychic pain.We
call the ways in which the mind alters painful psychological events
coping strategies or defense mechanisms.
Repression: An unconscious but purposeful ejection of painful wishes
and memories from the conscious mind. Or the forgetting of a future
event which is dreaded.
Rationalization: T he attempt to justify actions, attitudes, or thoughts
on what are meant to be logical grounds. This defense usually involves
giving a reasonable explanation to conceal the true nature of the
underlying motive.
Sublimation: The process by which socially unacceptable motives
can find expression in a socially approved manner. The drives of sex and
aggression are apt to be regulated by this defense mechanism.
Reaction Formation: This is the tendency to develop traits or
behavior, which are the direct opposite of the motives we do not like in
ourselves. By using this defense, an individual can conceal his true
feeling by giving strong expression to its opposite.
Identification: This occurs when a person attempts to pattern himself
after another who is admired. The behavior serves as one technique by
which individuals make themselves acceptable to new groups.
 34

Displacement; An emotion, usually or aggression left toward a

person or object can be directed instead toward a substitute. This
behavior becomes more likely when circumstances do not favor direct
and open expression of the emotion.
Compensation; This is an attempt to make up for weakness or
deprivation in one area by excelling in a different or an allied activity.
The weakness to be compensated for may be real or imaginary.
Projection; The tendency to attribute one’s own thoughts and
impulses to other persons. Anxiety can be avoided or reduced by
projecting your own instinctual impulses onto the external world.

Chap.IV:MOTIVATION AND LEARNING

Motivation determines how much effort an individual puts into his
learning. If we use the example of a jet liner we can see how it will
perform best if it’s engines are in full power. A fault in one of it’s
engines may cause the plane to perform inefficiently or even crash.
Similarly in learning if for some reason the learners motivation is limited
he will not put as much energy and enthusiasm into his learning.
The engines of human motivation are interest and desire. When this are
working at full power in an individual remarkable feats of learning can
be achieved. It is therefore in the instructors interest to take trouble to
see that the learners interest and desires are aroused before learning.
Once the learners want to learn the battle is half worn.

Types of Motivation.
 35

a. Extrinsic Motivation: This is motivation that is external to an

activity. The most commonly externally imposed motivation in a
learning situation is the use of rewards and punishments. Both can take
many forms. The words can be in the form of prize, praise or words of
commendation. However , extrinsic motivation should be based on a
good instructor- trainee relationship and the rewards and punishments
should be appropriate to the age and the character of the individual.
b. Intrinsic Motivation: This on the other hand goes deep down into
our personality. We tackle a job because the task itself interest us, makes
us happy or gives us satisfaction. Instructors need to recognize that
motivation is closely linked with aims and goals and to remember that
learners have aims and their success will depend on their ability to use
the learners aims to motivate their learning.
Reinforcement
21. People often change the frequently with which they do things based
on the consequences of their actions. Learning from the consequences of
behavior is called Operant conditioning. When the consequences of a
behavior tend to increase its occurrence it is called positive
reinforcement. Negative reinforcement occurs when behavior is
strengthened because something unpleasant has been avoided. This is
not the same as punishment because in punishment the intention is to
stop an undesired behavior from being repeated again.

Modes of reinforcement
a. Continuous reinforcement
b. Intermittent reinforcement
 36

In continuous reinforcement, every correct response/behavior must be

rewarded, however in intermittent reinforcement, some of the correct
responses are rewarded, other are not. In daily life, intermittent
reinforcement is one mostly used. Intermittent reinforcement can lead to
longer persistence in the learned behavior as show below:-
Anxiety and Learning
Anxiety is a phobic response, irrational fear to protect self- esteem. It
comes when the well being of someone is threatened. Anxieties
detrimentally affects learning if it persists for an unrealistic length of
time or occurs on inappropriate occasions. The fear to fail or measure up
to standards is an obvious reaction in most students and like attitudes
can only be overcome by constant reinforcement, motivation,
understanding and less use of threats and punishment which only serve
to heighten the anxieties.
Intelligence and Learning
Intelligence is the ability to abstract or adjust to one’s environment. It is
the power of learning, understanding and reasoning; mental ability.
Intelligence is influenced by inheritance and is measured in several ways
ie Measure one’s behavior and memory and then compile his statistical
analysis to get his IQ.
Early studies of intelligence relied on the correlation method (refers to
how two sets of measurement correspond to each other). The studies
concluded that the child’s IQ and that of the parents was believed to be
0.0 but the child’s IQ and that of the siblings in the family
(sisters/brothers) was 0.5. This established that there was a high degree
of correspondence between parents and siblings. This early studies have
left may questions unanswered, and are therefore, unfavorable.
 37

IQ=MA x 100 IQ=Is Intelligence Quotient

CA
MA- Is Mental Age-level of one’s mental development, measured by
aptitude tests.
CA- Is chronological age-real age after birth
Chap.V Psychosomatic Disorder.
Psychosomatic disorder

---a mental disorder that causes somatic symptoms---

Psychosomatic or Somatoform disorders are among the most common

psychiatric disorders found in general practice.

Psychosomatic disorder ---a mental disorder that causes somatic symptoms---

Psychosomatic or Somatoform disorders are among the most common

psychiatric disorders found in general practice.

It is a condition of dysfunction or structural damage in bodily organs

through inappropriate activation of the involuntary nervous system and
the glands of internal secretion.
Psychosomatic disorder is mainly used to mean a physical disease which is thought to be caused, or
made worse, by mental factors. Some physical diseases are thought to be particularly prone to
be made worse by mental factors such as stress and anxiety.

The DSM III has dropped the category of Psychosomatic diseases, but
according to the DSM II classification it has listed 10 categories of
psycho-physiologic disorder:

1. Skin disorders
2. Muscoskeletal disorders
 38

3. Respiratory disorders
4. Cardiovascular disorders
5. Genitourinary disorders
6. Endocrine disorders
7. Disorders of organ of special sense - Chronic conjunctivitis
8. Disorders of other types - Disturbances in the nervous system in
which emotional factors play a significant role, such as multiple
sclerosis.

Sometimes a physical symptom is a metaphor for the person's

psychologic problem, as when a person with a "broken heart"
experiences chest pain. Other times, a physical symptom reflects
identification with another person's pain.

Some people also use the term psychosomatic disorder when mental
factors cause physical symptoms , but where there is no physical disease.
For example, a chest pain may be caused by stress, and no physical
disease is can be found.

Physical symptoms caused by mental factors are discussed further in a

another leaflet called 'Somatization and Somatoform Disorders'.

Increasingly doctors are recognizing the importance of dealing with

psychological and social factors in relation to physical disease. As a
result, many doctors now try to deal with the whole person. This means
taking all these factors into consideration. By doing this, it is important
to realize that the doctor is not playing down or ignoring the physical
disease. Many people with so-called psychosomatic disorders feel that
their doctor does not take them seriously. They feel that the doctor
 39

believes that it's all in the mind. The doctor will always attempt to treat
the physical illness with appropriate medical treatment if necessary. But
he will also be interested to understand more about the person who has
the illness. This will in turn help him and the patient to understand the
illness better. Sometimes psychotherapy or talking treatment can help.

Patients are given the opportunity and time to talk about their feelings
and emotions. This will help provide them with an insight into
themselves and help them understand their illness better.

Sometimes it is helpful to look at the whole lifestyle of the person

involved. This may require looking at how the stress is dealt with,
teaching techniques for stress management, as well as examining factors
such as diet and exercise.
 40

CHAP.VI COURSEWORK

Behaviouristic learning theories:

1. Contiguity -- any stimulus and response connected in time

and/or space will tend to be associated (a baseball player wearing
a certain pair of socks on the day he hits three home runs; a
student making a good grade on a test after trying several
different study techniques)

ASSOCIATED TERMINOLOGY:

1. stimulus = environmental event

2. response = action = behavior = overt behavior

2. Classical (Respondent) Conditioning -- association of stimuli (an

antecedent stimulus will reflexively elicit an innate emotional or
physiological response; another stimulus will elicit an orienting
response)

Classical Conditioning (also Pavlovian or Respondent

Conditioning) is a form of associative learning that was first
demonstrated by Ivan Pavlov [1] . The typical procedure for inducing
classical conditioning involves presentations of a neutral stimulus
along with a stimulus of some significance. The neutral stimulus
could be any event that does not result in an overt behavioural
 41

response from the organism under investigation. Pavlov referred to

this as a Conditioned Stimulus (CS).

ASSOCIATED TERMINOLOGY:

1. conditioning = learning
2. antecedent = a stimulus occuring "before" a response
3. reflexive = involuntary (e.g., involuntary responses cannot
be consciously stopped once they start)
4. innate = inborn
5. elicits = causes (to bring forth)
3. Operant (Instrumental) Conditioning -- connection of emitted
behavior and its consequences (reinforcement and punishment)

Operant Conditioning is the term used by B.F. Skinner to describe

the effects of the consequences of a particular behavior on the
future occurrence of that behavior. There are four types of
Operant Conditioning: Positive Reinforcement, Negative
Reinforcement, Punishment, and Extinction. Both Positive and
Negative Reinforcement strengthen behavior while both
Punishment and Extinction weaken behavior.
 42

In Positive Reinforcement a particular behavior is

strengthened by the consequence of experiencing a positive
condition. For example:

A hungry rat presses a bar in its cage and receives food. The food
is a positive condition for the hungry rat. The rat presses the bar
again, and again receives food. The rat's behavior of pressing the
bar is strengthened by the consequence of receiving food.

In Negative Reinforcement a particular behavior is

strengthened by the consequence of stopping or avoiding a
negative condition. For example:

A rat is placed in a cage and immediately receives a mild

electrical shock on its feet. The shock is a negative condition for
the rat. The rat presses a bar and the shock stops. The rat receives
another shock, presses the bar again, and again the shock stops.
The rat's behavior of pressing the bar is strengthened by the
consequence of stopping the shock.

In Punishment a particular behavior is weakened by the

consequence of experiencing a negative condition. For example:
 43

A rat presses a bar in its cage and receives a mild electrical shock
on its feet. The shock is a negative condition for the rat. The rat
presses the bar again and again receives a shock. The rat's
behavior of pressing the bar is weakened by the consequence of
receiving a shock.

In Extinction a particular behavior is weakened by the

consequence of not experiencing a positive condition or stopping
a negative condition. For example:

A rat presses a bar in its cage and nothing happens. Neither a

positive or a negative condition exists for the rat. The rat presses
the bar again and again nothing happens. The rat's behavior of
pressing the bar is weakened by the consequence of not
experiencing anything positive or stopping anything negative.

ASSOCIATED TERMINOLOGY:

1. emitted = voluntary (e.g., voluntary responses can be

consciously stopped)
2. consequent or consequences = a stimulus occuring "after" a
response that changes the probability the response will
occur again
 44

Note: Observational (Social) learning (learning through observing and

modeling) is sometimes considered a behavioral learning theory but is
covered with social cognition in these pages

Behaviorists assume that the only things that are real (or at leastworth
studying) are the things we can see and observe. We cannot see the mind
,the id, or the

unconscious, but we can see how people act, react and behave. From
behavior we may be able to make inferences about the minds and the
brain,but they are not the primary focus of the investigation.

Early Theorists:
Pavlov (1849-1936)

Ivan P. Pavlov is Russia's most famous scientist. He first won

greatdistinction for his research on the physiology of th digestive
system. Pavlovencountered a methodological problem that was
ultimately to prove moreimportant and more interesting than his
physiological research. He haddiscovered "conditioning".

For Pavlov, all behavior was reflexive. But how do such behaviors
differfrom the behavior commonly called "instinctive" ?
Instinctivebehavior is sometimes said to be motivated. The animal has to
be hungry, to besexually aroused, or to have nest-building hormones
before these kinds ofinstinctive behavior can occur. But Pavlov
concluded that there seems to be nobasis for distinguishing between
reflexes and what has commonly been thought ofas non reflexive
behavior. As a psychologist, Pavlov was concerned with thenervous
system, and specifically the cerebral cortex, not with any lawfulnessthat
he might find in behavior.
 45

Watson ( 1878-1958)

John B. Watson was one of the most colorful personalities in thehistory

of psychology. Although he did not invent behaviorism, he became
widelyknown as its chief spokesman and protagonist.

Watson was brought up in the prevalent tradition: Mechanism explains

behavior. In a widely used textbook (Watson, 1914) he said that the
study ofthe mind is the province of philosophy; it is the realm of
speculation andendless word games. The mind has no place in
psychology. A science ofpsychology must be based on objective
phenomena and the ultimate explanationmust be found in the central
nervous system.

It was Watson, more than Pavlov or any other one person, who
convincedpsychologists that the real explanation of behavior lay in the
nervous systemand that as soon as we understood the brain a little better,
most of themysteries would disappear. And, it was mainly because of
Watson that so manypsychologists came to believe that what they called
conditioning was soimportant. (Bolles)

Skinner (1904-1990)

B. F. Skinner is considered by many authorities to have been thegreatest

behavioral psychologist of all time.

Earlier behaviorism had been concerned with stimulus-

responseconnections. Skinner looked at the learning process in the
opposite way,investigating how learning was affected by stimuli
presented after an act wasperformed. He found that certain stimuli
caused the organism to repeat an actmore frequently. He called stimuli
with this effect the "reinforcers". Watson found that by providing
 46

reinforcement in a systematic y one couldshape the behavior in desired

directions.

GENERAL THEORIES OF MOTIVATION

Instinct theories of motivation used to be common but were soon rejected.

According to drive theory ,physiological needs that arise or within the body
create tension ,which motivates us towards its reduction.To account that for the
fact that people are to mountain an optimum level of arousal ,the Arousal
theory posit

THE PYRAMID OF HUMAN MOTIVATION

According to MASLOW all human beings are motivated to fulfill a hierarchy

of needs .At the base are physiological needs for food ,water ,and so
on .Next ,in order , are safety and security needs , the need for belonging ,and
esteem needs . Once all needs are not people strive for self actualization

BASIC HUMAN MOTIVATION

Among the basic human needs at the base of MASLOW “S pyramid are
hunger and sexual motivation .
 47

HUNGER AND EATING

Hunger is a sensation that motivates food search and consumption. The

brain monitors glucose in the blood .When glucose drops below a certain
level ,people experience hunger .Eating then raises the glucose level and
reduces the motivation to eat .

The glucose level and are monitored in or near the

hypothalamus .Psychological factors such as personal and cultural tastes , and
external food cues such as time and cultural company of other people play a
role in hunger and eating

SEXUAL MOTIVATION

Every human motive is directed toward a goal object ,and is no exception .

Every is energies to fulfill sexual disease desires ,but individual differ in
the object toward which that energy is directed .

Surveys show that men and women differ in aspect of their sexual
motivations. From on evolutionary perspective ,women are highly selective in
mate selection and seek men with economic resources or treats predictive of
future earnings . Men seek women who are young and attractive attributes
that signal fertility. Men also seek women who are not promiscuous.
 48

SOCIAL MOTIVES

People are not content merely to satisfy biological needs in addition there
are social motives for belongingness and esteem.

BELONGINGNESS MOTIVES

MASLOW”S belongingness motives are composed of two distinct needs .In

varying degrees ,people enjoy being with others a need of
affiliation .Research shows that we seek an optimum balance of social
contact but we affiliate more under stress in order to gain cognitive clarity
about the situation we are in.People also have a need for INTIMACY ,for
closing relationship that are characterize by open and confidential
communication known as SELF-DISCLOSURE.

ESTEEM MOTIVES

People differ in their level of acheivement motivation ,which is defined as the

desire to accomplish difficult tasks and to excel .Researches have shown that
people who score high rather than low on this measure work harder set more
realistic goals and achieve more.Related to this motive is the need for power a
desire to gain prestige and influence over others.there are links between the
strength of this need and various index of leadership.Those are autonomic needs
and independence and self (realization)needs which remain in aspiration do not be
fulfilled actualization needs.

2.SITUATIONIST CONCEPTION:

Envioronment in which we live influences very much on our

Behaviors and KARL MAX emphasizedon by saying :<it is not the human
conscious which determine their existence but rather his social existence determine
the conscious>

3.EMPIRST CONCEPTION: Means that the past events affect ones present and
the future behavior.
 49

Thus SIGMOND FREUD said that OEDIP situation affect the human behavior
from the childhood to adulthood.and ADLER talked about inferiority situation
lived by the children naturally weak and dependant on adults which marks them
defininitively therefore certain conduct appears as compensation.

.INTERACTIONIST CONCEPTION: it emphasizes that motivation is neither

only internal or external but also makes a combination of object and subject ,whose
characteristics interact.

PSYCHOLOGICAL THEORY OF REINFORCEMENT

They are in two types:

a.Homeostasie models and central models of motivation ,firstly were

elaborated by CANON (1934)and HULL (1943).In this theory motivation is
considered as a need because this theory can explain the sexual
conducts ,aggression etc.

b.Central theory:This theory consider motivation not only a psychologist need but
also as an interne sensitive information and memory .

All these theories have a common point <Reinforcement of conductc>

This is considered as a conduct that can be adapted for disappearing owful

sensation.It can mean that if our conduct gives us a good result we want to
reproduce it ,but it gives bad ones.We do not want to reproduce or repeat this .It is a not
of reinforcement .The first case is called <positive reinforcement > the second is called<negative
reinforcement>

MOTIVATING PEOPLE AT WORK

REWARD-BASED MOTIVATION

Out of necessity ,people work for money and other economic benefit such as vacation time ,sick
leave ,health insurance ,and retirement pensions.some of the rewards people get at work are not
 50

monetorary but symbolic for example titles,large offices ,windows,and access to parking.The
most theory of worker motivation is VICTOR VROOMS (1964) expectary theory .According to
Vroom people are rational decision markers w ho analyse the beneficts and the costs of their
possible course of action.

Research has shown that people perform well when they are given specific goals and a clear
standard for success and failure than when they are simply told to “do you will be”

INTRINSIC MOTIVATION

Psychologist have pushed out a difference between two types of motivation “intrinsic
motivation” orginate within person out of interest challenges and sheer enjoyment. Extrinsic
motivation orginates in factors outside the person (reward,recognition).Research show that
although reward increases intrinsic motivation which becomes evident once the reward is not
longer available.Reward has this effect when it is seen as bribe,but it has the opposite when
presented as positive feedback.

EQUITY MOTIVATION

Equity theory maintain that people want reward to be linked in fair way to perform relatively to
others.Thus when people feel over paid, they work harder to restore equity. Feelings of
underpayment lead people to slack off.

ENVIRONMENTAL HEALTH SCIENCE PROFFESSIONALS

After studying about motivation as the future medical professionals especially as the
ENVIRONMENT HEALTH CARE GIVERS we are going to take new vision emphasizing that
at the field we will not only sensitize people but also motivate them to follow the guidelines that
we will give them to protect our environment according to the knowledge and skills acquired in
medical psychology course.
 51

Doctor-patient relationship.

The doctor-patient relationship is central to the practice of medicine and is essential for the
delivery of high-quality health care in the diagnosis and treatment of disease. The doctor-patient
relationship forms one of the foundations of contemporary medical ethics. Most medical schools
and universities teach medical students from the beginning, even before they set foot in hospitals,
to maintain a professional rapport with patients, uphold patients’ dignity, and respect their
privacy.

Importance

A patient must have confidence in the competence of their doctor and must feel that they can
confide in him or her. For most physicians, the establishment of good rapport with a patient is
important. This being said, some medical specialties, such as psychiatry and family medicine,
emphasize the doctor-patient relationship more than others, such as pathology or radiology.

The quality of the patient-physician relationship is important to both parties. The better the
relationship in terms of mutual respect, knowledge, trust, shared values and perspectives about
disease and life, and time available, the better will be the amount and quality of information
about the patient's disease transferred in both directions, enhancing accuracy of diagnosis and
increasing the patient's knowledge about the disease. Where such a relationship is poor the
physician's ability to make a full assessment is compromised and the patient is more likely to
 52

distrust the diagnosis and proposed treatment, causing decreased compliance to actually follow
the medical advice. In these circumstances and also in cases where there is genuine divergence of
medical opinions, a second opinion from another physician may be sought or the patient may
choose to go to another doctor.

Issues

Physician superiority

The physician may be viewed as superior to the patient, because the physician has the knowledge
and credentials, and is most often the one that is on home ground.

The doctor-patient relationship is also complicated by the patient's suffering (patient derives
from the Latin patior, "suffer") and limited ability to relieve it on his/her own, potentially
resulting in a state of desperation and dependency on the physician.

A physician should at least be aware of these disparities in order to establish rapport and
optimize communication with the patient.

Benefiting or pleasing

A dilemma may arise in situations where what is the most efficient treatment (or avoidance of
treatment) is not the same as what the patient wants for various reasons. In such cases, the
physician may need to choose between the patient's physical health or other rather material
benefits on one hand and the doctor-patient relationship or other psychological or emotional
aspect on the other.

Formal or casual

There may be differences in opinion between the doctor and patient in how formal or casual the
doctor-patient relationship should be.

For instance, according to a Scottish study,[1] patients want to be addressed by their first name
more often than is currently the case. In this study, most of the patients either liked (223) or did
 53

not mind (175) being called by their first names. Only 77 disliked it, most of who were aged over
65.[1] On the other hand, most patients don't want to call the doctor by his or her first name.[1]

Perspectives

The physician-patient relationship can be analyzed from the perspective of ethical concerns, in
terms of how well the goals of non-maleficence, beneficence, autonomy, and justice are
achieved. Many other values and ethical issues can be added to these. In different societies,
periods, and cultures, different values may be assigned different priorities. For example, in the
last 30 years medical care in the Western World has increasingly emphasized patient autonomy
in decision making.

The relationship and process can also be analyzed in terms of social power relationships (e.g., by
Michel Foucault), or economic transactions. Physicians have been accorded gradually higher
status and respect over the last century, and they have been entrusted with control of access to
prescription medicines as a public health measure. This represents a concentration of power and
carries both advantages and disadvantages to particular kinds of patients with particular kinds of
conditions. A further twist has occurred in the last 25 years as costs of medical care have risen,
and a third party (an insurance company or government agency) now often insists upon a share
of decision-making power for a variety of reasons, reducing freedom of choice of healthcare
providers and patients in many ways.

In some settings, e.g. the hospital ward, the patient-physician relationship is much more
complex, and many other people are involved when somebody is ill: relatives, neighbors, rescue
specialists, nurses, technical personnel, social workers and others.
 54

Physician-Patient Relationship

There is considerable healing power in the physician-patient alliance. A patient who

entrusts himself to a physician's care creates ethical obligations that are definite and
weighty. Working together, the potential exists to pursue interventions that can significantly
improve the patient's quality of life and health status.

What is a fiduciary relationship?

Fiduciary derives from the Latin word for "confidence" or "trust". The bond of trust between the
patient and the physician is vital to the diagnostic and therapeutic process. It forms the basis for
the physician-patient relationship. In order for the physician to make accurate diagnoses and
provide optimal treatment recommendations, the patient must be able to communicate all
relevant information about an illness or injury. Physicians are obliged to refrain from divulging
confidential information. This duty is based on accepted codes of professional ethics which
recognize the special nature of these medical relationships.

How has the physician-patient relationship evolved?

The historical model for the physician-patient relationship involved patient dependence on the
physician's professional authority. Believing that the patient would benefit from the physician's
actions, a patient's preferences were generally overridden or ignored. For centuries, the concept
of physician beneficence allowed this paternalistic model to thrive.

During the second half of the twentieth century, the physician-patient relationship has evolved
towards shared decision making. This model respects the patient as an autonomous agent with a
right to hold views, to make choices, and to take actions based on personal values and beliefs.
Patients have been increasingly entitled to weigh the benefits and risks of alternative treatments,
including the alternative of no treatment, and to select the alternative that best promotes their
own values (for further discussion, see the topic page on Informed Consent).
 55

Will the patient trust me if I am a student?

Students may feel uncertain about their role in patient care. However, it is crucial for building
trust that you begin this relationship in an honest and straightforward manner. A critical part of
this is being honest about your role and letting the patient know you are a physician-in-training.
In some settings, an attending physician or resident can introduce the student to initiate a trusting
relationship. In other settings, students may need to introduce themselves. One form of
introduction would be "Hello, I am Mary Jones. I'm a third year medical student who is part of
the team that will be caring for you during your hospitalization. I'd like to hear about what
brought you into the hospital." (For further discussion of this issue, see the Student Issues topic
page.)

Many patients will feel quite close to the student on the team. Students usually have more time to
spend with a patient, listening to the patient's history and health concerns, and patients certainly
notice and appreciate this extra attention.

How much of herself should the physician bring to the physician-patient

relationship?

Many patients appreciate a physician who brings a personal touch to the physician-patient
encounter. They may feel more connected to a physician whose extracurricular activities and
interests make her seem more alive. Physicians choose to share parts of their life stories
according to their level of comfort. However, it is essential that the patient, and the patient's
concerns, be the focus of every visit.

What role should the physician's personal feelings and beliefs play in the
physician-patient relationship?

Occasionally, a physician may face requests for services, such as contraception or abortion,
which raise a conflict for the physician. Physicians do not have to provide medical services in
opposition to their personal beliefs. In addition, it is acceptable to have a nonjudgmental
discussion with a patient regarding her need for the service, and to ensure that the patient
understands alternative forms of therapy. However, it is never appropriate to proselytize. While
 56

the physician may decline to provide the requested service, the patient must be treated as a
respected, autonomous individual. Where appropriate, the patient should be provided with
resources about how to obtain the desired service.

ETHICS IN MEDICINE.

Informed Consent.

Opportunities to "consent" a patient abound on the wards. The aim of this section is to provide
you with the tools required for the "basic minimum" as well as providing a more complete
picture of the ideal informed consent process. You will find that the particular
circumstances (e.g. the patient's needs or the procedure) will determine whether a basic or
complete informed consent process is necessary. (See also Informed Consent in the OR.)

What is informed consent?

Informed consent is the process by which a fully informed patient can participate in choices
about her health care. It originates from the legal and ethical right the patient has to direct
 57

what happens to her body and from the ethical duty of the physician to involve the patient in
her health care.

What are the elements of full informed consent?

The most important goal of informed consent is that the patient have an opportunity to be an
informed participant in his health care decisions. It is generally accepted that complete
informed consent includes a discussion of the following elements:

 the nature of the decision/procedure

 reasonable alternatives to the proposed intervention

 the relevant risks, benefits, and uncertainties related to each alternative

 assessment of patient understanding

 the acceptance of the intervention by the patient

In order for the patient's consent to be valid, he must be considered competent to make the
decision at hand and his consent must be voluntary. It is easy for coercive situations to arise in
medicine. Patients often feel powerless and vulnerable. To encourage voluntariness, the
physician can make clear to the patient that he is participating in a decision, not merely signing a
form. With this understanding, the informed consent process should be seen as an invitation to
him to participate in his health care decisions. The physician is also generally obligated to
provide a recommendation and share her reasoning process with the patient. Comprehension on
the part of the patient is equally as important as the information provided. Consequently, the
discussion should be carried on in layperson's terms and the patient's understanding should be
assessed along the way.

Basic consent entails letting the patient know what you would like to do and asking them if that
will be all right. Basic consent is appropriate, for example, when drawing blood. Decisions that
merit this sort of basic informed consent process require a low-level of patient involvement
because there is a high-level of community consensus.
 58

How much information is considered "adequate"?

How do you know when you have said enough about a certain decision? Most of the literature
and law in this area suggest one of three approaches:

 reasonable physician standard: what would a typical physician say about this
intervention? This standard allows the physician to determine what information is
appropriate to disclose. However, it is probably not enough, since most research in this
area shows that the typical physician tells the patient very little. This standard is also
generally considered inconsistent with the goals of informed consent as the focus is on
the physician rather than on what the patient needs to know.
 reasonable patient standard: what would the average patient need to know in order to
be an informed participant in the decision? This standard focuses on considering what a
patient would need to know in order to understand the decision at hand.

 subjective standard: what would this patient need to know and understand in order to
make an informed decision? This standard is the most challenging to incorporate into
practice, since it requires tailoring information to each patient.

Most states have legislation or legal cases that determine the required standard for informed
consent. In the state of Washington, we use the "reasonable patient standard." The best approach
to the question of how much information is enough is one that meets both your professional
obligation to provide the best care and respects the patient as a person with the right to a voice in
health care decisions. (See also Truth-Telling and Law and Medicine.)

What sorts of interventions require informed consent?

Most health care institutions, including UWMC, Harborview, and VAMC have policies that state
which health interventions require a signed consent form. For example, surgery, anesthesia,
and other invasive procedures are usually in this category. These signed forms are really the
culmination of a dialogue required to foster the patient's informed participation in the clinical
decision.
 59

For a wide range of decisions, written consent is neither required or needed, but some
meaningful discussion is needed. For instance, a man contemplating having a prostate-specific
antigen screen for prostate cancer should know the relevant arguments for and against this
screening test, discussed in layman's terms. (See also Research Ethics.)

When is it appropriate to question a patient's ability to participate in decision

making?

In most cases, it is clear whether or not patients are competent to make their own decisions.
Occasionally, it is not so clear. Patients are under an unusual amount of stress during illness and
can experience anxiety, fear, and depression. The stress associated with illness should not
necessarily preclude one from participating in one's own care. However, precautions should be
taken to ensure the patient does have the capacity to make good decisions. There are several
different standards of decision making capacity. Generally you should assess the patient's
ability to:

 understand his or her situation,

 understand the risks associated with the decision at hand, and

 communicate a decision based on that understanding.

When this is unclear, a psychiatric consultation can be helpful. Of course, just because a patient
refuses a treatment does not in itself mean the patient is incompetent. Competent patients have
the right to refuse treatment, even those treatments that may be life-saving. Treatment refusal
may, however, be a flag to pursue further the patient's beliefs and understanding about the
decision, as well as your own.

What about the patient whose decision making capacity varies from day to day?

Patients can move in and out of a coherent state as their medications or underlying disease
processes ebb and flow. You should do what you can to catch a patient in a lucid state - even
lightening up on the medications if necessary - in order to include him in the decision making
process.
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What should occur if the patient cannot give informed consent?

If the patient is determined to be incapacitated/incompetent to make health care decisions, a

surrogate decision maker must speak for her. There is a specific hierarchy of appropriate
decision makers defined by state law (also see the DNR topic page). If no appropriate surrogate
decision maker is available, the physicians are expected to act in the best interest of the patient
until a surrogate is found or appointed.

Is there such a thing as presumed/implied consent?

The patient's consent should only be "presumed", rather than obtained, in emergency situations
when the patient is unconscious or incompetent and no surrogate decision maker is available. In
general, the patient's presence in the hospital ward, ICU or clinic does not represent implied
consent to all treatment and procedures. The patient's wishes and values may be quite different
than the values of the physician's. While the principle of respect for person obligates you to do
your best to include the patient in the health care decisions that affect his life and body, the
principle of beneficence may require you to act on the patient's behalf when his life is at stake.

Professionalism

 What does it mean to be a member of a profession?

 What is the difference between a profession and a business?

 What are the recognized obligations and values of a professional physician?

Is professionalism compatible with the restrictions sometimes placed on physician's

judgments in managed care?
 61

Because medicine is a profession and physicians are professionals, it is important to have a clear
understanding of what "professionalism" means. As a physician-in-training, you will be
developing a personal sense of what it means to be a professional. This topic page outlines some
common features. Please see the topic page on the Physician-Patient Relationship for further
discussion of the professional responsibilities of physicians.

What does it mean to be a member of a profession?

The words "profession" and "professional" come from the Latin word "professio," which means
a public declaration with the force of a promise. Professions are groups which declare in a public
way that their members promise to in certain ways and that the group and the society may
discipline those who fail to do so. The profession presents itself to society as a social benefit and
society accepts the profession, expecting it to serve some important social goal. The profession
usually issues a code of ethics stating the standards by which its members can be judged. The
traditional professions are medicine, law, education and clergy.

The marks of a profession are:

1. competence in a specialized body of knowledge and skill;

2. an acknowledgment of specific duties and responsibilities toward the individuals it
serves and toward society;

3. the right to train, admit, discipline and dismiss its members for failure to sustain
competence or observe the duties and responsibilities.

What is the difference between a profession and a business?

The line between a business and a profession is not entirely clear, since professionals may
engage in business and make a living by it. However, one crucial difference distinguishes them:
professionals have a fiduciary duty toward those they serve. This means that professionals have a
particularly stringent duty to assure that their decisions and actions serve the welfare of their
patients or clients, even at some cost to themselves. Professions have codes of ethics which
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specify the obligations arising from this fiduciary duty. Ethical problems often occur when there
appears to be a conflict between these obligations or between fiduciary duties and personal goals.

What are the recognized obligations and values of a professional physician?

Professionalism requires that the practitioner strive for excellence in the following areas which
should be modeled by mentors and teachers and become part of the attitudes, behaviors, and
skills integral to patient care:

 Altruism: A physician is obligated to attend to the best interest of patients, rather than
self-interest.
 Accountability: Physicians are accountable to their patients, to society on issues of
public health, and to their profession.

 Excellence: Physicians are obligated to make a commitment to life-long learning.

 Duty: A physician should be available and responsive when "on call," accepting a
commitment to service within the profession and the community.

 Honor and integrity: Physicians should be committed to being fair, truthful and
straightforward in their interactions with patients and the profession.

 Respect for others: A physician should demonstrate respect for patients and their
families, other physicians and team members, medical students, residents and fellows.

These values should provide guidance for promoting professional behavior and for making
difficult ethical decisions.

A Physician Charter. Medical Professionalism in the New Millenium was issued jointly by the
The American Board of Internal Medicine, the American College of Physicians and the
European Federation of Internal Medicine in 2002. Subsequently, 90 professional associations,
including most of the specialty and subspecialty groups in American medicine have endorsed the
Charter. The fundamental principles of professionalism are stated as (1) the primacy of patient
welfare; (2) patient autonomy; (3) social justice. Professional responsibilities that follow from
 63

these principles are commitment to competence, to honesty with patients, to confidentiality, to

appropriate relationship with patients, to improving quality of care, to improving access to care,
to a just distribution of finite resource, to scientific knowledge, to maintaining trust by managing
conflicts of interests and to professional responsibilities.

Is professionalism compatible with the restrictions sometimes placed on

physician's judgments in managed care?

One of the principal attributes of professionalism is independent judgment about technical

matters relevant to the expertise of the profession. The purpose of this independent judgment is
to assure that general technical knowledge is appropriately applied to particular cases. Today,
many physicians work in managed care situations that require them to abide by policies and rules
regarding forms of treatment, time spent with patients, use of pharmaceuticals, etc. In principle,
such restrictions should be designed to enhance and improve professional judgment, not limit it.
For example, requiring consultation is ethically obligatory in doubtful clinical situations;
penalizing consultation for financial reasons would be ethically wrong. Also, requiring
physicians to adhere to practice guidelines and to consult outcome studies may improve
professional judgment; requiring blind adherence to those guidelines may be a barrier to the
exercise of professional judgment. The presence of rules, policies and guidelines in managed
care settings requires the physicians who work in these settings to make such judgments and to
express their reasoned criticism of any that force the physician to violate the principles of
professionalism.
64
 65

What can hinder physician-patient communication?

There may be many barriers to effective physician-patient communication. Patients may feel that
they are wasting the physician's valuable time; omit details of their history which they deem
unimportant; be embarrassed to mention things they think will place them in an unfavorable
light; not understand medical terminology; or believe the physician has not really listened and,
therefore, does not have the information needed to make good treatment decisions.

Several approaches can be used to facilitate open communication with a patient. Physicians
should:

 sit down
 attend to patient comfort

 establish eye contact

 listen without interrupting

 show attention with nonverbal cues, such as nodding

 allow silences while patients search for words

 acknowledge and legitimize feelings

 explain and reassure during examinations

 ask explicitly if there are other areas of concern

What happens when physicians and patients disagree?

One third to one half of patients will fail to follow a physician's treatment recommendations.
Labeling such patients "noncompliant" implicitly supports an attitude of paternalism, in which
the physician knows best. Patients filter physician instructions through their existing belief
system; they decide whether the recommended actions are possible or desirable in the context of
their everyday lives.

Compliance can be improved by using shared decision making. For example, physicians can say,
"I know it will be hard to stay in bed for the remainder of your pregnancy. Let's talk about what
problems it will create and try to solve them together." Or, "I can give you a medication to help
with your symptoms, but I also suspect the symptoms will go away if you wait a little longer.
Would you prefer to try the medication, or to wait?" Or, "I understand that you are not ready to
consider counseling yet. Would you be willing to take this information and find out when the
next support group meets?" Or, "Sometimes it's difficult to take medications, even though you
know they are important. What will make it hard for you to take this medication?"

Competent patients have a right to refuse medical intervention. Dilemmas may arise when a
patient refuses medical intervention, but does not withdraw from the role of being a patient. For
instance, an intrapartum patient, with a complete placenta previa, who refuses to undergo a
 66

cesarean delivery, often does not present the option for the physician to withdraw from
participation in her care (see the Maternal/Fetal Conflict topic page). In most cases, choices of
competent patients must be respected when the patient cannot be persuaded to change them.

What can a physician do with a particularly frustrating patient?

Physicians will sometimes encounter a patient whose needs, or demands, strain the therapeutic
alliance. Many times, an honest discussion with the patient about the boundaries of the
relationship will resolve such misunderstandings. The physician can initiate a discussion by
saying, "I see that you have a long list of health concerns. Unfortunately, our appointment today
is only for fifteen minutes. Let's discuss your most urgent problem today and reschedule you for
a longer appointment. That way, we can be sure to address everything on your list." Or, "I know
that it has been hard to schedule this appointment with me, but using abusive language with the
staff is not acceptable. What do you think we could do to meet everybody's needs?"

There may be occasions when no agreeable compromise can be reached between the physician
and the patient. And yet, physicians may not abandon patients. When the physician-patient
relationship must be severed, the physician is obliged to provide the patient with resources to
locate ongoing medical care.

When is it appropriate for a physician to recommend a specific course of

action or override patient preferences?

Under certain conditions, a physician should strongly encourage specific actions. When there is a
high likelihood of harm without therapy, and treatment carries little risk, the physician should
attempt, without coercion or manipulation, to persuade the patient of the harmful nature of
choosing to avoid treatment.

Court orders may be invoked to override a patient's preferences. However, such disregard for the
patient's right to noninterference is rarely indicated. Court orders may have a role in the case of a
minor; during pregnancy; if harm is threatened towards oneself or others; with concern for
mental incompetence; or when the patient is a sole surviving parent of dependent children.
However, the use of such compulsory powers is inherently time-limited, and often alienates the
patient, making him less likely to comply once he is no longer subject to the sanctions.

Would a physician ever be justified in breaking a law requiring mandatory

reporting?

Legal obligations to break confidentiality may pose difficult choices. While the physician has a
moral obligation to obey the law, he must balance this against his responsibility to the patient. It
is essential to balance the duty to protect the patient's confidence against the physician's
responsibility to the members of the public at risk. (For a discussion on the limits of
confidentiality, see the topic page on Confidentiality.)
 67

What is the role of confidentiality?

Confidentiality provides the foundation for the physician-patient relationship. In order to make
accurate diagnoses and provide optimal treatment recommendations, the physician must have
relevant information about the patient's illness or injury. This may require the discussion of
sensitive information, which would be embarrassing or harmful if it were known to other
persons. The promise of confidentiality permits the patient to trust that information revealed to
the physician will not be further disseminated. The expectation of confidentiality derives from
the public oath which the physician has taken, and from the accepted code of professional ethics.
The physician's duty to maintain confidentiality extends from respect for the patient's autonomy.

What happens when the physician has a relationship with multiple

members of a family?

Physicians with relationships with multiple family members must honor each individual's
confidentiality. Difficult issues, such as domestic violence, sometimes challenge physicians to
maintain impartiality. In many instances, physicians can help conflicted families towards
healing. At times, physicians work with individual family members; other times, they may serve
as a facilitator for a larger group. As always, when a risk for imminent harm is identified, the
physician must break confidentiality.

Physicians can be proactive about addressing the needs of changing family relationships. For
example, a physician might tell a preteen and her family, "Soon you'll be a teenager. Sometimes
teens have questions they would like to discuss with me. If that happens to you, it's okay to tell
your parents that you'd like an appointment. You and I won't have to tell your parents what we
talk about if you don't want to, but sometimes I might encourage you to talk things over with
them."

The physician-family relationship also holds considerable healing power. The potential exists to
pursue options that can improve the quality of life and health for the entire family.

Confidentiality is one of the core tenets of medical practice. Yet daily physicians face
challenges to this long-standing obligation to keep all information between physician and patient
private.

Where does the duty of confidentiality come from?

Patients share personal information with physicians. You have a duty as a physician to respect the
patient's trust and keep this information private. This requires the physician to respect the patient's
privacy by restricting access of others to that information. Furthermore, creating a trusting environment
 68

by respecting patient privacy can encourage the patient to be as honest as possible during the course of
the visit. (See also Physician-Patient Relationship.)

What does the duty of confidentiality require?

The obligation of confidentiality both prohibits the physician from disclosing information about the
patient's case to other interested parties and encourages the physician to take precautions with the
information to ensure that only authorized access occurs. Yet the context of medical practice does
constrain the physician's obligation to protect patient confidentiality. In the course of caring for patients,
you will find yourself exchanging information about your patients with other physicians. These
discussions are often critical for patient care and are an integral part of the learning experience in a
teaching hospital. As such, they are justifiable so long as precautions are taken to limit the ability of
others to hear or see confidential information. Computerized patient records pose new and unique
challenges to confidentiality. You should follow prescribed procedures for computer access and security
as an added measure to protect patient information.

What kinds of disclosure are inappropriate?

Inappropriate disclosure of information can occur in clinical settings. When pressed for time, the
temptation to discuss a case in the elevator may be great, but in that setting it is very difficult to keep
others from hearing the information exchanges. Similarly, extra copies of handouts from teaching
conferences that contain identifiable patients should be removed at the conclusion of the session. The
patient's right to privacy is not being respected in these sorts of cases.

When can confidentiality be breached?

Confidentiality is not an absolute obligation. Situations arise where the harm in maintaining
confidentiality is greater than the harm brought about by disclosing confidential information. In general,
two such situations that may give rise to exceptions exist. In each situation, you should ask - will lack of
this specific information about this patient put a specific person you can identify at high risk of serious
harm? Legal regulations exist that both protect and limit your patient's right to privacy, noting specific
exceptions to that right. These exceptions follow.

Exception 1:

Concern for the safety of other specific persons

On the one hand, the 1974 Federal Privacy Act restricts access to medical information and records. On
the other, clinicians have a duty to protect identifiable individuals from any serious threat of harm if
they have information that could prevent the harm. As mentioned above, the determining factor in
justifying breaking confidentiality is whether there is good reason to believe specific individuals (or
groups) are placed in serious danger depending on the medical information at hand. The most famous
case of this sort of exception is that of homicidal ideation, when the patient shares a specific plan with a
physician or psychotherapist to harm a particular individual. The court has required that traditional
patient confidentiality be breached in these sorts of cases.
 69

Exception 2:

Concern for public welfare

In the most clear cut cases of limited confidentiality, you are required by state law to report certain
communicable/infectious diseases to the public health authorities. In these cases, the duty to protect
public health outweighs the duty to maintain a patient's confidence. From a legal perspective, the State
has an interest in protecting public health that outweighs individual liberties in certain cases. In
particular, reportable diseases in Washington State include (but are not limited to): AIDS and Class IV
HIV, hepatitis A and B, measles, rabies, tetanus, and tuberculosis. Suspected cases of child, dependent
adult, and elder abuse are reportable, as are gunshot wounds. Local municipal code and institutional
policies can vary regarding what is reportable and standards of evidence required. It is best to clarify
institutional policy when arriving at a new site.

What if a family member asks how the patient is doing?

While there may be cases where the physician feels compelled to share information regarding the
patient's health and prognosis with, for instance, the patient's inquiring spouse, without explicit
permission from the patient it is generally unjustifiable to do so. Except in cases where the
spouse is at specific risk of harm directly related to the diagnosis, it remains the patient's, rather
than the physician's, obligation to inform the spouse.

The Nurse Patient Relationship Is

Central to Patient Satisfaction

The nurse patient relationship, according to research by Press Ganey Associates Inc., sets
the tone of the care experience and has a powerful impact on patient satisfaction. Nurses
spend the most time with patients. Patients see nurses’ interactions with others on the care
team and draw conclusions about the hospital based on their observations. Also, nurses’
attitudes toward their work, their coworkers and the organization affect patient and family
judgments of all the things they don’t see behind the scenes.
 70

Without a positive nurse patient relationship, there cannot be patient and family
satisfaction. And there cannot be an environment that supports anxiety reduction and
healing.

By analyzing and understanding the factors that have the greatest impact on overall patient
satisfaction, you can AIM. You can focus your efforts and resources on improvements with
the greatest potential to enhance the patient experience.

On the CAHPS survey, there are two global items: “Overall rating of hospital” and “likelihood
of recommending hospital.” Based on 2007 CAHPS and Press Ganey Survey data, Press
Ganey identified “Nurse Communication” as the factor with the greatest impact on patients’
overall ratings of their hospital experience. Survey items that focus on the nurse patient
relationship drive patient ratings of their overall experience. Quality of communication in
nursing also has the highest impact on patients’ likelihood to recommend the hospital.

To hear Wendy speak about Communicating with Empathy, click the play button
below.

Patients and families want much more from nurses than competent clinical care.

Patients and families count on nurses to keep them informed, to connect them to their
physicians and other caregivers, to listen to them, to ease their anxiety, and to protect and
watch over them during their healthcare experience. Because of these high expectations of
 71

nurses, itís no wonder that nursing performance, and more specifically, the nurse patient
relationship, is so central to patient satisfaction and a quality patient experience. Click
here for a poster that makes this point.

Yet, in strategies to achieve service excellence, while some nurses are enthusiastic,
committed and supportive, many express concerns and resistance.
 Some nurses feel insulted. They think, ìIím a nursing professional! Iím with
people when theyíre sick and dying, and now Iím being told to smile more?!?î Or
they feel judged, ìHow dare anyone imply that I donít care!?!î
 Some nurses feel resentful. They think, ìWhen this organization removes the
obstacles that make my life difficult, Iíll smile more!î

 And other nurses feel cynical. They think, ìThis IS important, but it wonít stick.
This too shall pass like other things weíve tried to do here.î

Thereís more than one grain of truth in each of these sentiments.

 Often service improvement strategies in health care have emphasized cosmetic
aspects of the service relationships. Nurses are keenly aware of working with people
who are emotionally drained and emotionally charged, and facing traumatic life
circumstances. Making them happy hardly seems like a relevant goal, and nurses
perceive it as superficial and discounting of the important work they do.
 Resistance to raised service standards is also understandable when nurses perceive
leaders as doing too little to remove obstacles to provide excellent care and service.
Broken equipment, linen shortages, short staffing, inadequate support in the face of
disrespectful doctors ñ all of these and more obstacles cause nurses to say, ìDonít
pin patient dissatisfaction on us! We donít have the support we need to provide the
care we WANT to provide.î

 Cynical nurses who are very dedicated to patients and families sound their
frustration over past initiatives that raised their hopes but then fizzled due to lack of
follow-through by the organizationís leaders.

See Wendy Leebovís article in American Nurse Today that makes the case and defines a
much more relevant goal for nurses ña goal that reduces possible resistance significantly.
We need to help nurses communicate expertly and connect at a personal and emotional
level in ways that do not take more of their timeótime that they donít have.

Leaders also need to run interference. They need to remove the barriers and create the
conditions that make it possible for nurses to serve their patients and families with diligent
and compassionate care.

And finally, to engage nursesí hearts and minds in strengthening their communication with
patients and families, leaders need to ensure follow-up and follow-through. Quick fix
approaches might be compelling but not sustainable. Strengthening nursesí skills and the
hard work of supporting APPLICATION of these skills to the nurse patient relationship in
their everyday work requires a long-term investment of time and energyÖ or cynicism is the
predictable result.

Help Nurses Make Their Caring Felt

Nurses care, but patients and families may not FEEL their caring.

Nurses are so swamped. Their multiple responsibilities breed task-orientation, not people-
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orientation. Then, seeing nurses focus on the tasks and activities of their jobs, patients and
families wonder, ìWhere has all the caring gone?î

The caring is still there, but it might as well not be if patients and families donít see or feel
it. Thatís why thereís a crying need today to help nurses speak the language of caring so
that their caring reaches the people they serve. In everyday routines, there are so many
opportunities to make their caring felt and ease their patientsí anxiety. For instance, when
one nurseís shift is ending and another nurse is taking over the patientís care, the first
nurse can ease the transition for the patient by speaking the language of caring during this
important handoff.

Caring Framework for Nursing Practice

Dr. Jean Watson in ìThe Theory of Transpersonal Caringî said,

 Caring is central to the nursing role and its mission as a distinct profession.

 Caring is often the measure by which patients evaluate their ìcure-dominatedî experience.

Highlight the Meaning in the Nurseís Work

Dr. Jean Watson also said, ìCaring is transpersonal in nature, involving the one caring as
well as the one being cared for.î With nurses so fraught with multiple demands and
pressures, many lose touch with their caring mission. This is a sad shame. It leads to
fatigue and disillusionment. Some remain in the job and these effects show in their
relationships (or lack of relationships) with patients, families and coworkers. Others leave in
a cloud of cynicism and grief that may be personally damaging to the nurse and also
discouraging to future prospects for nursing careers.

Nurse Managers (also fraught with an overload of responsibilities) need to adopt as a central
priority helping their nurses rekindle and sustain their passion for the workÖ. Ask these
Three Appreciative Questions to focus your nurses on their contributions.

Services That Enhance the Nurse Patient Relationship by Wendy Leebov and
Associates will help your nurses:
 Renew their sense of caring mission and help them sustain their passion for the work
 Speak the language of caring in the full range of emotionally demanding situations
they handle daily

 Score highly on patient satisfaction survey items that focus on communication in the
nurse patient relationship and correlate highly with patient ratings of their overall
experience with your organization.

The nurse-patient relationship will prove key to effective

medication adherence
27 January, 2009 | By Alastair McLellan
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Compare and contrast the following statements: ‘Non-adherence [to medication] should not be
considered the patient’s problem’; and ‘You [the patient] should follow the course of treatment which
you have agreed.’

The two are not mutually exclusive but they reflect a tension at the heart of modern health care
and, therefore, nursing practice.

The first is from the latest NICE guidance on medicines adherence, the second from the newly
minted NHS Constitution.

Both documents promote ‘patient-centred care’ – in which treatment must be responsive to the
needs of the individual. Both set their face against the ‘doctor (or nurse) knows best’ approach of
the past.

However, the NHS Constitution makes a point of balancing patients’ rights with their
responsibilities, whereas the NICE guidance talks exclusively about what the service must do for
the patient. It recommends ‘an open, no-blame approach to patients to discuss any doubts or
concerns about treatment’.

This is the crux of the matter. Can you equate ‘blaming’ a patient with reminding them of a
‘responsibility’ to follow a
course of prescribed medication? Well, of course, that depends on how it is done.

Both the NICE guidance and the NHS Constitution stress the importance of good communication
between healthcare professionals and patients. Chief Nursing Officer for England Dame
Christine Beasley often speaks of nurses learning to become good ‘junior partners’ with patients
in the planning and delivery of care.

A nurse who has built a good relationship with a patient by informing and empowering them
will be in a strong position to have a non-judgemental conversation with them about the
importance of adherence.

It should be the responsibility of a patient to comply with prescribed medication regimens – it is

part of the deal the government has struck with the public in providing free health care. Non-
adherence is a drain on resources the NHS can ill afford. However, that responsibility only has
meaning if the NHS has done its part in delivering care which works with an individual’s needs.

Between the paternalistic poles of ‘be thankful for what you get’ and ‘we can’t expect the poor
dears to remember to take their pills’ lies a path to patient-centred care which nurses can help
blaze.
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