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Textbook of Mental
Health Nursing, Vol- I
Dorothy D. Theodore, M.Sc.(N)
Principal, Narayana Hrudayalaya College of Nursing, Bangalore, KarnatakaTable of Contents
Cover image
Title page
Foreword I
Foreword II
1. Concepts and Theories
1. Concepts of mental health and mental illness
Historic perspectives regarding normality
Mental health
Who (2001)
American mental health counsellors’ association (2011)
Mental illness
Mental health and illness continuum
Factors along the life span affecting mental health
Review questions
Bibliography Assertiveness training
Assertiveness training
2. Theoretical models of personality development
Psychoanalytical theory
Interpersonal theory
Psychosocial theory
Theory of object relations
Theory of cognitive development
Theory of multiple intelligences
Moral development
Nursing model
Review questions
Self-concept and self-esteem promotion
Difference between self-concept and self-esteem
Theories of self-concept development
Composition of a self-concept
Methods of self-concept assessment
Factors affecting self-concept
Strategies for building a positive self-concept
Prerequisites to self-esteemCommon stressors affecting self-esteem
Nurse’s role in self-esteem promotion
3. Conceptual models of psychiatric care
Psychoanalytical model
Interpersonal model
Social model
Existential model
Communication model
Behavioural model
Medical model
Nursing model
Comparison of theories and application to psychiatric nursing
Review questions
Primary prevention
Rights of the child
Parenting to promote biopsychosocial health
Role of school health nurse practitioner
Promotion of mental health in adolescents
Early and middle adulthood
Promotion of mental health in women
Strategies for health promotion
Old age
Bibliography4. Roles and functions of a psychiatric nurse
Creating a therapeutic environment
Socializing agent
Mother surrogate
Technical nursing role
Therapeutic attitudes and qualities essential for a psychiatric nurse
Quality assurance in psychiatric health care
Scope of psychiatric nursing
Psychiatric nursing in wide range of current set-ups
Review questions
Design and layout of psychiatric nursing units
Factors influencing the design
Recommended principles to be considered while designing a mental health
Floor plan
Types of psychiatric units
Norms, policies, and protocols
5. Nursing process in psychiatric nursing
DefinitionHistorical perspectives of nursing process
Components, purpose, and steps of nursing process
Prerequisites and nursing behaviours needed
Application of nursing process in psychiatry
Review questions
Forensic nursing
Ethics related to forensic nursing
Forensic implications in different age groups
Standards of practice: Forensic mental health nursing
Objectives of forensic psychiatric nursing
The role of a forensic psychiatric nurse
Trends in forensic nursing
6. Legal and ethical aspects
The mental health act, 1987
Other laws related to mentally ill individuals
Criminal responsibility
Mentally ill, suicide, and the law
Specific rights of the mentally ill
Legal liabilities for psychiatric nurses
Harm caused by student nurses to psychiatric patientsEnsuring physician’s prescriptions
Consent for the mentally ill
Confidentiality and right to privacy
Restraints and seclusion
Nurse’s role in providing ethical psychiatric nursing
Guidelines for psychiatric nurses: Enhancing their decision making
Psychiatric nurses: Prerequisites for ethical decision making (eriksen, 1989)
Ethical decision-making model (mary townsend) adapted from model suggested
by shelly
Maintaining nursing ethics in india: Role of nurses
Professional code of conduct: Role of psychiatric nurses
Review questions
7. Standards and principles of psychiatric nursing
Standards of psychiatric and mental health nursing practice
Professional practice standards
Standards of professional performance (ANA 1991)
Principles of psychiatric nursing
Review questions
8. Documentation in psychiatric nursing
Need and purposes of documentation and records
Characteristics of good documentation
Methods of recording and documentation
Common record-keeping forms
ConclusionReview questions
9. Stress and coping in psychiatric nursing
Definition of terms
Effects of work-related stress on the individual
Management of stress/coping process
Sources of stress and burnout among psychiatric nurses
Sources of stress in psychiatric nursing: Scientific evidence from studies
Stress management for nurses
Review questions
2. Historical Perspectives
10. History of psychiatry and psychiatric nursing
Historical developments in psychiatry
Development of different viewpoints
History of psychiatry in india
Current issues and future trends
Evolution of the indian psychiatric association
History of psychiatric nursing
Current trends of psychiatric nursing in india
Review questions
3. Classification of Mental Illnesses
11. Classification of mental disordersICD-10 classification
DSM-IV-TR classification
Review questions
4. Assessment in Mental Health Nursing
12. Different forms of assessment
Other emotions
Psychiatric history
Mental status examination
Mini mental status examination
Neurological examination
Laboratory tests
Review questions
5. Therapeutic Approaches in Mental Health Nursing
13. Somatic therapies
Electroconvulsive therapy (ECT)
Insulin coma therapy (ICT)
Review questions
14. PsychopharmacologyIntroduction
History of treatment modalities
The chemical revolution
Classification of psychotropic drugs
Review questions
15. Interpersonal relationship
Components of a therapeutic nurse–patient relationship
Standards of therapeutic nurse–patient relationship
Stages/phases of the nurse–patient relationship
Warning signs
Obstacles to therapeutic relationship
Review questions
16. Therapeutic communication
Relevance of communication
Pre-existing conditions influencing communication
Elements of communication
Types of communications
Barriers of communicationTherapeutic communication techniques
Nontherapeutic communication techniques
Process recording
Guidelines for communicating with children
Utilization of the nursing process in communication
Review questions
17. Group therapy
Therapeutic techniques
Types of group therapies
Stages of group therapy
Role of the therapist
Review questions
18. Family therapy
Stages of family development
Characteristics of a functional family
Characteristics of dysfunctional family
Theoretical basis for family therapy
Nurse’s role in family therapyConclusion
Review questions
19. Behaviour modification
Definition of terms
History of behaviour therapy
Theory—the basis for behaviour therapy
Characteristics of behaviour therapy
Principles for using behaviour modification
Indications for behaviour therapy
Steps in behaviour therapy
Behavioural therapies based on classical conditioning
Cognitive behaviour therapy
Review questions
20. Crisis intervention
Terminologies used
Stages of crisis
Review questions
21. Milieu therapy
HistoryAssumptions of milieu therapy
Conditions that promote a therapeutic community
Goals of milieu therapy
Concepts and principles of milieu therapy
Elements of a therapeutic milieu
Nurse’s role in milieu therapy
Review questions
22. Cognitive behaviour therapy
Historical background
Aims of cognitive therapy
Indications for cognitive therapy
Goals of cognitive therapy
Duration of the therapy
Nature of cognitive therapy
Principles of cognitive therapy
Types of cognitive distortions
Techniques of cognitive therapy
Review questions
23. Anger and aggression management
Characteristics of angerEffects of anger
Goals of anger management
Characteristics of aggression
Etiology of aggression
Learning theories
Aggression cycle
Consequences of aggression
Techniques of anger management
Assertiveness and the conflict resolution model
Nursing management in anger or aggression management
Review questions
24. Psychological treatment
Another form of psychotherapy is cognitive therapy
Review questions
25. Play therapy
History of play therapy
Advantages of play
Functions of play
Classification of play
Play therapy in case of children with psychological problems
Principles of play therapyPhysical set-up of the play room
Indications for play therapy
Role of the therapist
Functions of the therapist
Advantages of play therapy
Review questions
26. Activity therapy
Music therapy
Dance therapy
Occupational therapy
Recreational therapy
Review questions
27. Psychoeducation
Standards of psychoeducation
Review questions
28. Complementary and alternative therapies
Energy-based therapies
Types of therapiesConclusion
Review questions
Answers of objective questions
IndexC o p y r i g h t
Textbook of Mental Health Nursing, Volume 1
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Foreword I
—Dr K. Reddemma, Nodal Officer, National Consortium for PhD in Nursing, Indian
Nursing Council
F o r m e r l y Dean, Behavioural Sciences, and, Senior Professor of Nursing, NIMHANS,
It gives me immense pleasure to write the foreword for Textbook of Mental Health
Nursing written by Ms Dorothy Deena Theodore, my former student.
Contents are arranged in a logical sequence, from concepts and theories which are
basic to understand normal and abnormal behaviour of human beings. Theoretical
models of personality development are essential to know the origin and the present
status while dealing with patients with background of various theories and theorists.
Each theorist’s beliefs in their models and understanding such models can give rise to
eclectic approach to deal with the current problems.
Chapter 4, Volume 1, deals with the role and functions of psychiatric nursing in
general irrespective of diagnostic labels. Historical aspects give insight into evolution
of mental health care through passage of time. Students of nursing should have
sound knowledge of classi cation of mental illnesses, and di erent forms of
assessment. Di erent therapeutic approaches have been comprehensively dealt with.
Volume 2 deals with the speci c areas categorizing into groups of disorders and
community mental health nursing.
A comprehensive textbook for students of nursing! I hope the students bene t and
enjoy reading this book.Foreword II
—Dr Ramachandra, Principal, College of Nursing, NIMHANS, Bangalore
It is a great sense of pleasure and privilege that I present this foreword to the
Textbook of Mental Health Nursing, Vol. 1 and 2, by Professor Dorothy Deena
Theodore. I know Professor Theodore for more than two decades. The author is a
dedicated teacher and well known to me for the last 20 years.
I have noticed students appreciating the efforts of this great teacher and her ability
to make psychiatric nursing easily comprehensible and interesting. The author
expressed her wish to write a book on psychiatric nursing quite a few years back,
tailoring to the needs of nursing students. As I can see it, simplicity and clarity have
been emphasized in the book. The students can easily assimilate the logical sequence
in which the topics have been presented, not only for them to understand the subject
but also perform well in the examinations.
In nursing, an ideal textbook is like a good travel guide. This textbook navigates
the reader through the complete information that is essential. Although Professor
Theodore has chosen to follow textbook approach, yet it looks very refreshing. The
book is well organized with recent information, which is based on evidence.
However, with all we know about psychiatric disorders, it is necessary to stay up to
date on the current facts. This book provides quick and direct access to the most
recent information about major mental disorders.
In brief, this book is an invaluable guide to details of psychiatric nursing. I trust
that this book will pilot nursing students through the enchanting realm of psychiatric
I congratulate Professor Dorothy Deena Theodore on her great effort.&
P r e f a c e
—Dorothy D. Theodore
With praises to our Lord, the giver of life from whom all good things come, I
introduce Textbook of Mental Health Nursing, Volume 1 and 2, with an immense sense
of gratitude. The conceptualization of this book began way back in the 1980s when I
myself was a baccalaureate student. I wished we had a nursing-speci c textbook for
psychiatric/mental health nursing. The thought that struck me then was that maybe
sometime I should consider writing a book. This thought gradually faded away with
Sometime in 2004 one of the publishers approached me saying one of my students
had recommended my name as someone who could write a book on mental health
nursing. Well, I gave it a thought, consulted my husband, and with his
encouragement took up this task. It is over a period of 10 years that this book has
been written.
The main objective of writing this book was to focus on the nursing care of the
mental health patients in the Indian context. Many experienced and skilled experts
have also written on the same subject. This book focuses on making it reader friendly
and at the same time focus on the current trends and developments in the speciality.
The purpose of the book is to provide the student with comprehensive information
regarding each aspect of care, including the theoretical frameworks, principles,
standards, legal aspects and ethics involved in providing mental health nursing
services. Documentation is also given its due importance.
The book also focuses on the role of the nurse in every aspect of care: care from
assessment to discharge, nurse’s role in therapies used in psychiatry, community
care, and care in terms of prevention and rehabilitation. I have tried to include the
Indian statistics of the problems discussed.
This book also focuses on organic conditions and childhood disorders.
Contemporary therapies are also included.
The end of each chapter has review questions which also include clinical exercises
to make learning more e2ective using the ‘learning by doing’ method. Due to the
constraint of space, some topics have been put up on the website
(clinicallearning.com), which can be accessed by the students who are interested in
knowing more.

A c k n o w l e d g e m e n t s
—Dorothy D. Theodore
It is with a very humble and grateful heart I place on record my sincere thanks to the
Lord Almighty, who has given me this privilege and the experience required to write
a book in the eld of my specialization. God has always been my very strength and
help at all times.
I would also like to thank my parents—Mr Theodore Christanandan and Late Mrs
Victory Koneri Theodore—who have been instrumental in bringing me to the point
where I stand today. Their encouragement and support has helped me and has been
my constant guidance.
I am indebted to my husband, Dr Praveen, for his support and sacri ce, without
which this task would be impossible. I thank him for the helping hand rendered as
the book was being written and his help with the technology. I thank him also for the
patience that he demonstrates at all times. Thank you Deepu and Kushi for sparing
me your time and for the support rendered.
Thanks go also to all my teachers who have instilled interest in psychiatric nursing
and all those who have inspired me with their knowledge and skills.
I wish to thank my colleagues who have gone through the text as I have written
the book. Thank you Priyadarshini and Uma Devi for the hours of your leisure time
spent on going through the script.
Last but not the least, thanks to all my students who I have taught over the past 23
years. It is because of you that I have honed my skills and knowledge in psychiatric
nursing and have taken up this project.
I wish to place on record my thanks to Elsevier India for considering this book for
publication. Special thanks to Mr Nitin Valecha and Mr Subodh Kumar, with whom I
have worked closely during the publication of this book.D e d i c a t i o n
I wish to dedicate this book to my mother, Mrs Victory Koneri Theodore, who
departed from this world just a few weeks ago.
Thank you Mom for being my inspiration!
I would have loved to see the pride in your eyes when the book was done, but I
know you will be beaming with pride in the place where you are.S E C T I O N 1
Concepts and Theories
1. Concepts of mental health and mental illness
1. Assertiveness training
2. Theoretical models of personality development
2. Self-concept and self-esteem promotion
3. Conceptual models of psychiatric care
3. Primary prevention
4. Roles and functions of a psychiatric nurse
4. Design and layout of psychiatric nursing units
5. Nursing process in psychiatric nursing
5. Forensic nursing
6. Legal and ethical aspects
7. Standards and principles of psychiatric nursing
8. Documentation in psychiatric nursing
9. Stress and coping in psychiatric nursing$
C H A P T E R 1
Concepts of mental health and mental
• Autonomy 7
• Competence 8
• Comprehensibility 8
• Cultural relativity 8
• Integration 6
• Integrational dependence 8
• Mental health 4
• Mental illness 8
• Normality 3
• Reality perception 7
• Self-actualization 8
• Self-efficacy 7
• Subjective well-being 7
The 17th century has been called the age of enlightenment, the 18th century as the age of reason, the 19th century as the
age of progress, and the 20th century as the age of anxiety. Although the path to a meaningful and satisfying way of
life has never been an easy one, it seems to have become increasingly difficult in modern times.
Wars and natural and manmade disasters have disrupted both personal and national life leaving grief, destruction,
and social unrest. Economic uctuation and in ation have taken their toll on unemployment, dislocation, and poverty
for millions of people. Racial prejudice and its unreasonable feeling of superiority, hatred, resentment results in
hurting both the individual and the community. The highly mobile urban society, lack of friendships, and loss of
extended family bonds causes increased stress at home. Unhappy marriages, broken homes leave emotional scars on
both the partners and children. The wasteful use of natural resources resulting in air, water, and soil pollution, and the
threat of atomic wars further aggravate anxiety. This has resulted in increased number of maladjustments and both
minor and major mental health problems giving rise to the concept of mental health and mental illness.
Since the early 1940s mental health and mental hygiene have appeared in the health care literature and in public
policy statements. These terms are now common in everyday speech and thought. Yet the concept of normality is not
The concept of normality is di, cult to de- ne as it involves value judgments, varies from one culture to another, and
is ambiguous. The World Health Organization de- ned normality as a state of complete physical, mental, and social
well-being: this de- nition again is limited because it de- nes physical and mental health simply as the absence of
physical or mental disease. The Diagnostic and Statistical Manual of Mental Disorders has not de- ned normality, but has
defined mental disorder. The concept used by them is that mental disorder is a behavioural and psychological syndrome
or pattern associated with distress or disability.
Historic perspectives regarding normality
Functional perspective
Many theoretical and clinical concepts of normality fall into four functional perspectives. They are as follows:
• Normality as health: This is the medical psychiatric approach to health and illness. Most doctors define normality
as health and view health as an almost universal phenomenon. Normality is considered in the absence of
psychopathology. Therefore according to this model, the lack of signs and symptoms indicating ill health is health.>
Therefore health in this context refers to a reasonable, optimal state of functioning. In simple terms absence of
symptoms and signs of psychological distress is health and normality.
• Normality as utopia: This model perceives normality as a harmonious and most favourable blending of the various
elements of the mental structure that result in a best possible functioning. Therefore mental health is perceived as
the mental health of an ideal person who is able to cope with complex problems. In other words the one who has
achieved highest level of functioning or self-realization is normal.
• Normality as average: This is based on a mathematic principle of the bell-shape curve. Here the middle range is
considered normal, while both the extremes are considered as abnormal or deviant. This is the statistical approach
where the average is considered normal.
• Normality as a process: This model believes in normal behaviour as the end result of interacting systems. Therefore
normality here is perceived as a process that stresses on change, development, and growth. A typical example of
this is the psychosocial theory of personality development given by Erik Erikson. This theory purports that with the
progress through life man has different tasks to achieve and the one being able to efficiently perform these tasks
and adapt with the required changes is considered normal.
Psychoanalyst theories of normality
• Sigmund Freud: Discussed normality as ‘an ideal fiction’. This concept correlates with normality as utopia.
• Kurt Eissler: Believed that normality cannot be attained because the normal person must be totally aware of his/her
thoughts and feelings.
• Melanie Klien: Described normality as strength of character, the capacity to deal with conflicting emotions, the
abilities to experience pleasure without conflict, and the ability to love.
• Erik Erikson: Defined normality as ability to master the periods of life as explained by his psychosocial theory of
personality development.
• Laurence Kubie: Defined normality as the ability to learn by experience, to be flexible, and to adapt to a changing
• Karl Menninger: Described normality as a balance, an ability to adjust to the external world with contentment and
to master the task of acculturation.
• Alfred Adler: Defined normality as individual’s capacity to develop social feelings and be productive. According to
him the ability to work heightens self-esteem and makes one capable of adaptation.
The life cycle theory
The life cycle represents the stages through which all human beings pass from birth to death. The fundamental
assumption of all life cycle theories is that the development occurs in successive, clearly de- ned stages. It also assumes
that it occurs in a particular order whether or not all stages are completed. These theories are discussed in Chapter 2.
Mental health
A number of people have attempted to de- ne the concept of mental health and many of these concepts deal with
various aspects of individual functioning. One of the few studies to examine mental health in Americans reported that
men and women use the same six dimensions in evaluating their mental health. These six dimensions were
unhappiness, lack of gratification, strain, feeling of vulnerability, lack of self-confidence, and uncertainty.
Mental health is often spoken of as a state of well-being such as happiness, satisfaction, agreement, or
accomplishment. These terms are di, cult to quantify and apply because their meaning di er according to the di erent
Mental health is not a mere absence of psychological disease but the balanced development of an individual’s
personality and emotional attitudes that enable him to live harmoniously with his fellow beings.
APA (1980) defines mental health as a simultaneous success at working, loving and creating with the capacity for mature
and flexible resolution of conflicts between instincts, conscience, important other people, and reality.
Robinson (1983) has defined mental health as a dynamic state in which thought, feelings, and behaviour that is age
appropriate and congruent with the local and cultural norms is demonstrated.
Barry (1990) defined mental health as a mentally healthy person is one with the ability to handle new situations and
handle personal problems without marked distress, and to still have enough energy to be constructive member of society the
mentally healthy person values society’s law. He is well-integrated and stable, and is able not only himself, but also to the
people about him as he and they really are. He has positive qualities of idealism, understanding, humanitarianism, honesty,
courage, justice, morality, and optimism.​
WHO (1987) defines mental health as the capacity in an individual to form harmonious relations with others and to
participate in or contribute constructively to the changes in his social and physical environment.
Report of The Surgeon General (1999) defines mental health as the successful performance of mental functions in
terms of thought, mood, and behaviour that results in productive activities, fulfilling relationships with others, and the ability
to adapt to change and to cope with adversity.
WHO (2012) states that mental health is a state of well-being in which an individual realizes his or her own abilities, can cope
with the normal stresses of life, can work productively, and is able to make a contribution to his or her community. In this
positive sense, mental health is the foundation for individual well-being and the effective functioning of a community.
Characteristics of a mentally healthy individual
Three noted scholars have tried to explain the qualities or indicators of mental health, as discussed below.
1. Abraham Maslow (1970) spoke of the hierarchy of needs (Fig. 1.1), with the optimum being self-actualization. He
also called them peak experiences. He emphasized that individuals are constantly motivated in the continuous quest
for self-actualization, which is the fulfilment of one’s highest potential. Maslow described self-actualization as being
psychologically healthy, fully human, highly evolved, and fully mature. This he believed was mental health. He has
listed down the characteristics of self-actualizers as follows:
• They perceive reality efficiently and are able to tolerate uncertainty.
• They accept themselves and others for what they are.
• They are spontaneous in thought and behaviour.
• They are problem centred rather than self- and emotion-centred.
• They have a good sense of humour.
• They are highly creative.
• They are resistant to enculturation (a degree of nonconformance), although not purposely unconventional.
• They are concerned for the welfare of mankind.
• They are capable of deep appreciation of the basic experiences of life. (They appreciate the worthwhileness,
richness, and beauty of life.)
• They establish deep, satisfying, interpersonal relationship with a few, rather than many people.
• They are able to look at life from an objective point of view.
• They have a democratic character structure and a strong sense of ethics.

FIGURE 1.1 Maslow’s hierarchy of need.
The following behaviours lead to self-actualization:
• Child-like experiencing life with wonder and amazement
• Ready to take calculated risks
• Is sensitive to one’s emotions, making decisions based on problem solving and experience rather than blind belief
• Being honest and straight forward rather than pretending
• Ready to voice one’s opinions even if it is not acceptable to others
• Accepting authority along with responsibility• Working with diligence at a task taken up
• Introspection into one’s behaviour patterns and the defences directing the behaviour, with willingness to modify
those that are pathologic or ineffective.
Maslow’s view is much more positive and optimistic. According to him, none of our innate needs are antisocial.
Aggression arises only when attempts to satisfy the basic needs are frustrated.
2. Maria Jehoda (1958) has listed certain indicators of mental health (Fig. 1.2), which are as follows:
• A positive attitude towards self: Here the individual has a realistic awareness of self and is aware of his
strengths and weaknesses, accepts himself as he is, and has a good sense of identity, wholeness, belongingness,
security, and meaningfulness.
• Growth, development, and self-actualization: Here the individual is engaged in a constant quest and is always
seeking new growth, development, and challenges. Here the individual is constantly moving in the direction of
achieving their highest potential. If the individual has successfully achieved the tasks associated at each level of
development then the individual gains motivation for advancement.
• Integration: This is the ability to maintain a balance among various life processes like what is expressed and
what is repressed, outer and inner conflicts and drives, and regulation of one’s moods and emotions. It also
includes emotional responsiveness and control, and a unified philosophy of life. This can be measured by the
person’s ability to withstand stress and cope with anxiety.
• Autonomy: Autonomy involves self-determination. It is a balance between dependence and independence and the
ability to take responsibility for the consequences of one’s actions. He is therefore responsible for himself, his
decisions, thoughts, feelings, and actions. This results in his ability to respect the autonomy and freedom of
• Reality perception: This is the individual’s ability to test his assumptions about the world by empiric thought. He
can change his perceptions in the light of more information. Thus he is able to empathize, is sensitive to the needs
of society, and respects the feelings and attitudes of others.
• Environmental mastery: This enables the person to feel success in an approved role in his society or group. (He
has achieved a satisfactory role in his society or environment.) He is socially competent and satisfied with life. He
deals effectively with the world, and is able to cope with loneliness, aggression, and frustration. He is capable of
responding to others, to love and be loved, and to cope with reciprocal relationships. He can build new
friendships and be satisfactorily involved in social groups. He adapts easily. Any disruption results in the
individual developing better abilities to deal with the next change.
3. Carl Rogers (1970) proposed the theory of personality development, named self-theory. His nondirective or
personcentred therapy assumes that each person has the motivation and the ability to change. The therapist’s task is to
simply facilitate progress towards change.​

FIGURE 1.2 Indicators of mental health.
According to Rogers, the basic force motivating the human organism is self-actualization. He has de- ned
selfactualization as a tendency towards ful- lment, towards actualization, and towards the maintenance and enhancement
of the organism. This innate motivation towards growth promotes the ability of the individual to change in a positive
direction when aware of the choices.
According to him the need for self-actualization directs the individual to seek or avoid activities depending upon
whether the experience is seen as one that will enhance the person.
Roger’s fully functioning person has the following characteristics:
• Moves away from facades that are not true to self.
• Moves away from others’ expectations of what he ought to do.
• Moves away from pleasing others who impose artificial goals on him.
• Moves towards becoming autonomous, self-directing and self-responsible.
• Is open to change and exploring his potentials.
• Is open to his own self and the lives of others.
• He trusts and values himself, and dares to express himself in new ways.
Who (2001)
The WHO report of 2001 lists the following aspects as characteristics of a healthy individual (Fig. 1.3).
• Subjective well-being: The individual has a feeling of peace with himself and surrounding leading to a sense of
well-being within oneself.
• Perceived self-efficacy: Confidence in one’s ability to carry out his or her responsibilities in a manner that is
acceptable to oneself.
• Autonomy: Confident enough to take decisions for oneself and for those who are under his or her care.
• Competence: Capable of carrying out the responsibilities on one’s shoulders that one is delegated with.
• Integrational dependence: Able to adjust and get along with others in ones’ environment in such a way that one is
comfortable and makes the others around him or her comfortable.
• Self-actualization of one’s intellectual and emotional potential.​
FIGURE 1.3 WHO characteristics of a healthy individual.
American mental health counsellors’ association (2011)
• Courage: Being to take action in the face of perceived threat
• Integrity: Matching words with deeds
• Tenacity: Ability to focus attention on a task without distractions
• Inspiration: Have a positive attitude that they tend to become role models for others
• Awareness: Awareness of oneself and others around (environment)
Mental illness
When we think of abnormal behaviour or mental illness, we picture extreme, spectacular examples that we have read
about or watched through the media. This results in an apprehension about working with patients with such problems.
But what we forget to understand is that these individuals are also people like us who due to certain predisposing,
precipitating, and perpetuating factors are in this condition. The universal concept of mental illness is di, cult owing
to the cultural factors that in uence such a de- nition. However, certain elements are associated with the individual’s
perception of mental illness regardless of the cultural origin.
Horwitz (1982) identifies two of these elements (Fig. 1.4). They are as follows:
1. Comprehensibility: This relates to the ability of the general population to understand the motivation behind
behaviour. When the observer is unable to find meaning in behaviour, there is likelihood that such behaviour will be
labelled as mental illness. He states, ‘Observers attribute labels of mental illness when the rules, conventions, and
understandings they use to interpret behaviour fail to find any intelligible motivation behind an action.’
2. Cultural relativity: These are rules, conventions, and understandings as conceived in an individual’s own culture.%

This is defined by one’s cultural or societal norms. Therefore a behaviour that is recognized as mentally ill in one
society may be defined as normal in another.
FIGURE 1.4 Elements associated with perception of mental illness.
APA (2000) de- nes mental illness or a mental disorder as a clinically signi cant behavioural or psychological syndrome or
pattern that occurs in a person and that is associated with present distress (e.g. a painful symptom), or disability (e.g.
impairment in one or more important areas of functioning), or with a signi cantly increased risk of su( ering death, pain,
disability, or an important loss of freedom . . . and is not merely an expectable and culturally sanctioned response to a
particular event.
Characteristics of a mentally ill person
A mentally ill person manifests the following characteristics.
• Self-defeating and maladaptive bizarre behaviour
• Self-destructive behaviour
• Behaviour that is deviant from social norms
• Manifestation of inappropriate emotions
• Perceptual abnormality
• Unable to resolve conflicts constructively
• Lack of motivation
• Alteration in the thought processes, which includes extremeness>

• Irrational belief
• Lack of insight or altered level of insight
• Unrealistic perception of the environment
• Alteration in the cognitive functions
• Alteration in social interaction
• Poor communication
• Poor interpersonal relationship
• Constantly anxious and fearful
• Problems with impulse control
• Ritualistic behaviour
• Difficulty with adaptation
• Excessive dependence on chemicals
Mental illness should not be viewed as a medical condition alone, but as a sociological dimension. The concept of
mental health and mental illness according to the different theories are discussed in more detail in Chapter 3.
The mental signs of stress are tension, resistance, friction, anger, guilt, being critical, tired, anxiety, evasion,
reactive, discontentment, worry, impatience, and apprehension. One may not be able to change the past, the factors
causing stress like traffic, weather, market forces, etc., but one can change their attitude towards them.
In order to maintain one’s mental health, one needs to maintain a healthy state. This includes a clear, creative,
tranquil, and alert mind in a disease-free, strong, and balanced body, and a peaceful, strong, and happy self. The
individual needs to maintain a harmonious, truthful, and loving relationship with others in an organized, just, and
peaceful society. One must live in a clean, harmonious, and balanced environment.
When one is stressed their thinking becomes unreasonable, negative, and irrational. The a ective experience is one
of panic, fear, and worry; the performance is poor, unproductive, and nonachieving, while the behaviour is
Mental health and illness continuum
In the past, most individuals and society viewed good mental health as the opposite or absence of mental disease. This
perspective totally ignores the state of health between disease and good mental health. Health is a multidimensional
concept and must be viewed from a broader perspective. A person’s state of mental health directly in uences their
daily choices, independence, individuality, and lifestyle. Therefore health is an integral part of an individual’s identity.
As nurses, we use di erent models of health to understand the relationship between the concepts of health, wellness,
and illness. One such model is the health–illness continuum model (Fig. 1.5).
FIGURE 1.5 Continuum of mental health and illness.
According to a health–illness continuum model health is a dynamic state that uctuates as a person adapts to
changes in the internal and external environments to maintain a state of physical, emotional, intellectual, social,
developmental, and spiritual well-being. Illness is a process in which the functioning of a person is diminished or>
impaired in one or more dimensions when compared with the person’s previous condition. Because health and illness
are relative qualities existing in varying degrees, they should be considered as a continuum. Here health and illness are
perceived in terms of a point on a scale or continuum rather than an absolute - gure. A high-level wellness and severe
illness (premature death) are at opposite ends of the continuum.
According to Neuman (1990), health on a continuum is the degree of patient wellness that exists at any point in
time, ranging from an optimum wellness condition, with available energy at its maximum, to death, which represents
total energy depletion. This continuum considers risk factors a ecting the state of health on the continuum. Risk
factors include genetic and physiologic variables, such as age, lifestyles, and environment. As a person progresses
through the developmental stages, certain risk factors are more common than others. An adolescent, for example, is
more likely than an adult to experience stresses related to the body image and self-concept, and an older adult is more
likely than a child to develop cardiac illness. The patient’s level of health depends on their attitude towards health,
values, beliefs, and perceptions of the physical, emotional, intellectual, social, developmental, and spiritual well-being.
The drawback of the health–illness continuum is that it is not always easy to describe a patient’s level of health in
terms of the one between two extremes. The health–illness continuum is more e ective when used to compare a
patient’s present level of health with the patient’s own previous level of health. Subsequently it is useful as it helps the
patient set goals to attain a future level of health.
In relation to the mental health–illness continuum, anxiety and grief have been identi- ed as two major primary
responses to stress. Both of these responses may be placed on a continuum according to the degree of symptom
severity. Anxiety may be classi- ed into four levels of anxiety on a continuum with mild anxiety at one end and panic
at the other. When an individual experiences mild anxiety, the person tends to use coping mechanisms, which include
seething, eating, yawning, drinking, exercise, smoking, crying, pacing, laughing, or talking it out with someone.
The second point on the continuance includes moderate anxiety, which may again be divided in to subtypes. In the
- rst subtype the patient uses ego defence mechanisms, which include compensation, denial, displacement,
identi- cation, isolation, projections, rationalization, regression, repression, sublimation, suppression, and undoing. In
the second subtype of moderate anxiety, individual manifests with psychophysiological responses, which include
headache, anorexia, arthritis, colitis, ulcers, asthma, pain, cancer, CHD, and sexual dysfunction. The next point on the
continuum refers to severe anxiety in which the patient experiences psychoneurotic responses which include phobias,
obsessions, compulsions, hypochondriasis, conversion disorder, multiple personalities, amnesia, and fugue. The other
end of the continuum of anxiety is panic in which the patient experiences psychotic responses that are manifested as
schizophrenia, schizoaffective disorder, and delusional disorder.
Grief may be classi- ed into three levels; they are mild, moderate, and severe grief reactions. Mild reactions include
life’s everyday disappointments where the patient experiences feelings of sadness. At moderate levels of grief the
patient experiences neurotic responses like dysthymia and cyclothymia. At severe levels of grief the patient experiences
psychotic responses like major depression or a bipolar disorder.
Factors along the life span affecting mental health
For an organized presentation the developmental stages are arranged in a chronological order. In this section the
mental development and factors a ecting the mental development of an individual through the stages of development
beginning with the prenatal period and progressing to old age will be discussed.
Prenatal period
After implantation of the egg, the egg begins to divide and is then called embryo. Growth and development during this
period occurred at a rapid pace and by the end of 8 weeks the embryo becomes fetus. The fetus maintains an internal
equilibrium that interacts continually with the intrauterine environment. During this phase any damage that occurs is
not restricted to just one system but is multifactorial. Therefore damage during this stage has a more global impact
than damage after birth. A lot of biologic activity occurs in the uterus. And the fetus is involved in a variety of
activities that are necessary for adaptation outside the womb. Some re exes that are present at birth exist in the uterus
also. These re exes include the grasp re ex, moro re ex, and sucking re ex. During this period certain factors a ect
the fetus (Fig. 1.6), as discussed below.
• Maternal stress: Maternal stress has deleterious effects on the fetal development. Maternal stress produces high
levels of stress hormones in the fetal bloodstream also; this acts directly on the fetal neuronal network. This
increases the blood pressure, heart rate, and the activity level. Therefore mothers with high levels of anxiety are
more likely to have babies who are hyperactive, irritable, and present with low birth weight. These children also
exhibit feeding and eating problems. A fever in the mother also causes the fetal temperature to rise. They also result
in a slower rate of motor and cognitive development.​
• Maternal infections: Maternal infection with influenza during pregnancy has been attributed to the development
of schizophrenia later in life. Other illnesses attributed to maternal infection are autism, mental retardation, and
cerebral palsy.
• Diagnostic tests: Some diagnostic tests carry risk. About 5% of women who undergo fetoscopy spontaneously abort.
Amniocentesis causes fetal damage or miscarriage in less than 1% of women tested.
• Maternal drug use: Fetal alcohol syndrome affects about one-third of all infants born to alcoholic mothers. The
syndrome is characterized by growth retardation of prenatal origin, minor abnormalities, delayed development,
hyperactivity, attention deficit, learning disability, intellectual deficits, and seizures. Smoking during pregnancy is
associated with the low average infant birth weight; these infants also tend to be dependent on nicotine. Cocaine
use during pregnancy has been correlated with a number of behavioural abnormalities, including increased
irritability and crying, and decreased desire for human contact. These major exposures to various medications can
also result in abnormalities. Common drugs with teratogenic effects include antibiotics, anticonvulsants,
carbamazepine, phenytoin, progesterone–oestrogen, lithium, and warfarin.
FIGURE 1.6 Factors during the prenatal period affecting mental health.
Factors affecting mental health (fig. 1.7)
• Genetic factors: It may be observed that there exists an inborn difference in autonomic activity and temperament
among individual infants. Nine behavioural dimensions have been identified. They are (1) activity level; (2)
rhythmicity (predictability of such functions as hunger, feeding pattern, elimination, and sleep–wake cycle); (3)
approach or withdrawal in response to new stimuli; (4) adaptability; (5) intensity of reaction; (6) threshold of
responsiveness; (7) quality of mood; (8) distractibility; and (9) attention span and persistence.• Attachment: This is the relationship that the baby develops with his/her caregivers. Infants in the first months after
birth become used to social and interpersonal interaction. They show a rapid increase in the responsiveness to the
external stimuli and environment to form a special relationship with the significant primary caregiver. Researchers
have found that the interaction between mother and baby during the attachment period influences the baby’s
current and future behaviour significantly. It is generally believed that the pattern of infant attachment experienced
will influence their adult emotional relationships. Maternal sensitivity and responsiveness are the main
determinants of secure attachment during the later stages of life. But when the attachment is insecure, the type of
insecurity expressed depends on the infant’s temperament. This may be manifested as avoidant, or anxious, or
ambivalent. Certain investigators have documented the severe developmental retardation that accompanies
maternal rejection and neglect.
• Infant response: Researchers are now beginning to view infants as important participants in the family interaction
and are partly responsible for the course of the family interaction between the infant and other members of the
family. The behaviour patterns of the infant and the mother are interrelated and interdependent. The way an infant
responds to the mother influences the mother’s response to the infant and the same is true in reverse. The mother’s
behaviour modulates the infant’s behaviour. A calm, smiling, and predictable infant is a powerful reward for tender
maternal care, while a jittery, irregular, and irritable infant tries a mother’s patience.
• Parental fit: This describes how well the mother or father relates to the newborn or infant. Here the temperamental
characteristic of both parents and the child is taken into consideration. A term that is used to characterize the
harmonious interaction between a mother and a child in the motivations, capacities, and styles of behaviour is
called the goodness of fit. The opposite of this is called poorness of fit. It is important to identify a difficult child, as it
can cause a feeling of inadequacy among the parents; and such children tend to have emotional disturbances later
in life. A range of momentum to mental patterns of different children have been identified as (1) difficult child—
they react intensely to stimuli; they cry easily, sleep poorly, eat at unpredictable times, and are difficult to comfort;
and (2) easy child—they are at ease with people they are familiar with, easily sleep, are flexible and adaptable to
change and new stimuli with minimum distress, and can be easily comforted.
• Good-enough mothering: During the last trimester of pregnancy and for the first few months of the baby’s life the
mother is in a state of primary maternal preoccupation, absorbed in fantasies about and experiences with how they
will deal. The mother needs not to be perfect, but she must provide good-enough mothering. If the mother is
sensitive to the infant’s need, she helps her baby become attuned to his/her own bodily functions and drives, which
is the basis for gradually evolving the sense of self.
• Environmental factors: An environment that is stimulating the sense organs promotes the expressive pathways in
the brain, thus promoting mental development. Therefore the child needs sensory motor stimulation of all the
senses—eyes, ears, touch, kinaesthesia, taste, and smell.​
FIGURE 1.7 Factors affecting mental health during infancy.
This is the period during which the motor and intellectual development is marked. Due to the motor development the
child begins gaining control over their actions. The language development is so rapid and is an important task to be
achieved. By the end of the toddler period, the toddler may use small sentences. In the area of emotional and social
development, the toddler looks to parents and others for emotional cues about how to respond to the situation. The
toddler manifests pleasure in discovery and development of new behaviour; he/she is able to demonstrate love in the
form of hugging and kissing. They may also protest in the form of crying, banging, biting, hitting, kicking, and
shouting. They - nd comfort in the midst of family members and experience anxiety in the midst of strangers. They
experience anxiety when they lose a loved caregiver or when their actions are not approved of.
Through imitation, reward, and coercion, the child assumes a behaviour pattern that the culture de- nes as
appropriate for their sexual role. They have an unshakeable certainty of being a male or a female. They assume the
gender role based on the behaviour that society perceives as - tting for the particular sex. This is also a period of toilet
training. The toddler may also have di, culties related to fear of the dark, which may be managed with a dim light at
night. Toddler also needs reassurance before going to bed.
Factors affecting mental health during this period (fig. 1.8)
• Parental mental health: When parents are mentally healthy to provide their wards with an emotionally and
physically secure environment the child grows up in a healthy environment that promotes mental health. The
opposite of this is a predisposing factor for mental illness.
• Environment: The toddler needs a stimulating and supportive environment for healthy development. Spending
one’s early years in an unstimulating, emotionally, and physically unsupportive environment will affect brain$

development in adverse ways, and will result in cognitive, social, and behavioural delays.
• Parenting: Parenting task involves deciding and maintaining boundaries of acceptable behaviour and
encouragement of the child’s progressive independence. Children must be allowed to operate for themselves and to
learn from their mistakes; at the same time they must be protected and assisted for challenges that are beyond their
abilities. The child may also manifest sibling rivalry as they struggle for exclusive affection and attention. They
begin to share, but show reluctance. Toilet training is another area that needs attention. Toilet training should not
be too rigid.
• Parental attachment: A key requisite for optimal child development is secure attachment to a trusted caregiver,
with consistent caring, support, and affection early in life. The extent to which the infant develops trust that the
caregiver will respond promptly and appropriately will promote their self-confidence, thus helping them explore
their environment and learn to master their environment.
FIGURE 1.8 Factors affecting mental health during the toddler period.
Preschool period
This is a period marked with physical and emotional growth. During this period of the use of language, sentences are
expansive. They also begin to think symbolically. They think intuitively and prelogically, and are unable to understand
the causal relations. Their thinking is egocentric. These children can also express complex emotions such as love,
unhappiness, jealousy, and envy. Their emotions are still easily in uenced by somatic events. The child’s capacity for
cooperation and sharing begins to emerge. Anxiety is better tolerated and is related to the loss of a person by whom
the child was loved and with a body injury. They are able to express feelings of tenderness, shame, and humiliation.
Capacity for empathy and love is developed but fragile.$
At the end of this period, the child’s conscience is established. A violation of the rules calls for absolute punishment as
they do not understand the fact that there may be more than one point of view. They also begin to distinguish reality
from fantasy. Dramatic play is common and imitation of others is seen. Imaginary friends begin to appear in children
with above average intelligence. These imaginary friends relieve loneliness and reduce anxiety.
School age period
During this period the child is able to express complex ideas in relation to several elements using language. Thinking is
more logical and the child is more interested in rules and orderliness; thus resulting in increased capacity for
selfregulation. They develop the ability to concentrate by the age of 10 years. And by the end of this period they are able
to think in abstract terms. Due to the improvement in the coordination and muscle strength the child is able to write
uently and draw artistically. These children are now capable of increased independence, learning, and socialization.
During this period their interaction becomes important, resulting in interest in relationships outside the family.
Empathy and concern for others begin to emerge. They have the capacity for long-term stable relationships with family
and peer.
Factors influencing the mental health during the preschool and school age periods (fig. 1.9)
• Birth order: The effect of birth order varies. The first-born children have been found to have higher intelligence
quotients than the younger siblings. They seem to be more achievement oriented than subsequent children. These
children achieve the most. They tend to be conservative and conformists. Second- and third-born children have the
advantage of the parent’s previous experience and also learn from their elder siblings. The youngest children may
receive too much attention and may be spoilt. They also tend to be independent and rebellious with regard to
family and cultural norms.
• Spacing of children: It is important to plan pregnancies in order to adequately space children. Studies of children
from large families show that they are more likely to have conduct disorder and have a slightly lower level of
intelligence than children from small families. Decreased parent interaction and discipline may account for this.
• Dreams and sleep: Children’s dreams can have a profound effect on their behaviour. The dream’s content may be
seen in connection with the children’s life experience, developmental stage, and sex. In early childhood, aggressive
dreams rarely occur; instead dreamers are in danger, which indicates the need for dependence. Between the ages of
3 and 6 years sleep walking, sleep talking, and nightmares are common.
• Divorce: This phenomenon is becoming more common in the Indian scenario and is affecting the development of
children. The child’s the age at the time of the parents’ divorce affects the child’s reaction to the divorce. The
immediate reaction includes behavioural and emotional disorders in all age groups. Children above 6 years of age
understand the impact of the incidence and often assume that they are responsible for the divorce. In school age
children school performance generally declines. Adolescents are aware of the situation and believe that they could
have prevented it somehow. Some children fantasize that their parents will be reunited in the future. Boys manifest
their reaction through physical aggression. The adolescent tries to spend more time away from home. Suicide
attempts may occur.
• Adoption: Informing children about their adoption reduces the possibility that the children will learn of it from
extrafamilial sources and then feel betrayed by their adoptive parents and abandoned by their biologic parents.
Emotional and behavioural disorders such as aggressive behaviour, stealing, and learning disturbances are reported
to be higher among adopted children. Throughout childhood and adolescence children may be preoccupied with
fantasies of two sets of parents. The adopted child may split the two sets of parents into good and bad parents.
Adopted children usually have a strong desire to know their biologic parents.
• Familial factors affecting child development: Many factors within the family influence the development of the
child. One important family factor is the stability of the family. Instability in the family may be caused due to
separation, divorce, and death. Any instability it the family is associated with the broad range of problems among
children, which include low self-esteem, increased incidence of mental disorders, increased risk of child abuse, and
antisocial personality disorder. The above important family factor includes parenting style. These are ways in
which children are raised.
The different styles of parenting that include the authoritarian style are characterized by strict inflexible rules, which
may result in low self-esteem, unhappiness, and social withdrawal. The indulgent permissive style, which includes a
little or a setting without limits and unpredictable parental response results in low self-reliance and aggression. The
indulgent neglectful style characterized by lack of involvement of the parents in the child’s life and rearing results
in low self-esteem, impaired self-control, and increased aggression. The most conducive style is the authoritative
reciprocal style, which is marked by firm rules and shared decision making in a warm, loving environment. This
style promotes self-reliance, self-esteem, and a sense of social responsibility.• Stress: The sources of stress among children vary with age. The sources of stress for a 6-year old may include the
following: (1) parental and authoritative figure’s expectations, (2) formal academic setting and grades, (3) high
activity levels and the child finding difficult to sit still, (4) competition, (5) shyness, (6) aggression, (7) sensitivity,
(8) teasing, (9) jealousy, (10) fears, and (11) difficulty in coping with increased independence. The sources of stress
for a 7-year old are as follows: (1) moods—the child is often moody, unhappy, and pensive; (2) continuously needs
praise and approval from peer group and parents; (3) modesty—demands privacy; (4) uncomfortable with rules,
regulations, and order, and is upset when they are disrupted; (5) hates to be interrupted when intensely involved in
an activity; (6) desires to be more like an admired idol; and (7) becomes more selective about playmates. The
sources of stress for an 8-year old are as follows: (1) self-criticism; (2) loneliness; (3) parental authority; (d) praise;
and (e) independence. The sources of stress for a 9-year old are as follows: (1) rebelliousness, (2) opposite sex, (3)
fair play, (4) interruptions, and (5) getting upset if the siblings or parents offend the child’s notion of decorum or
dignity. The factors causing stress among 10–12 year olds are as follows: (1) sexual maturation, (2) social issues, (3)
size, (4) shyness, (5) opposite sex, (6) confusion, (7) health, (8) money, (9) competition, (10) self-concept, (11)
parents, (12) idols/hero worship, (13) fair play, (14) drugs and sex, (15) peer pressure, and (16) self-criticism. If
the child is unable to cope with the above mentioned stress, his/her mental health may be affected.
• Familial environment: The environment within the family should encourage the child to explore; positively
reinforce achievements; mentor basic life skills; encourage, guide, and rehearse new skills developed; protect the
child from inappropriate ridicule; disapprove teasing and punishment; and provide an environment that is rich with
responsive language.
FIGURE 1.9 Factors influencing mental health during preschool and school periods.>
This as a period during which biologic, psychological, and social development takes place. There is a rapid physical
growth and the development takes place with the beginning of physical sexual development called puberty. During this
period secondary sexual characteristics start developing. In the psychological domain the cognitive development is
rapid and the personality traits are consolidated. In the social domain the adolescent is trying to develop peer
relationships, and intense, close relationship with people outside the family.
Adolescence may be commonly divided into three periods; they are—early adolescence between the age group of 11
and 14 years, middle adolescence between the age group of 14 and 17 years, and late adolescence between the age
group of 17 and 20 years. But the growth and development occurs as a continuum and varies from individual to
individual. Generally, it may be summarized that the development of identity is an important aspect during this period.
The di erent areas of identity development are as follows: (1) sexual identity, (2) group identity, (3) family identity,
(4) vocational identity, (5) moral identity, and (6) health identity.
Factors affecting mental health during adolescence (fig. 1.10)
• Puberty: Occurs as a result of the maturation of the hypothalamic–pituitary–adrenal–gonadal axis. This results in the
secretion of hormones related to sexual maturation—the end result of which is the development of the primary and
secondary sexual characteristics. The primary characteristics are involved with reproduction while the secondary
characteristics include devel opment of breasts and hip in females, and facial hair and changes in voice (gruff) in
the males.
Mental health may be affected in cases of being unprepared for these changes. It may also be affected if there is a
delay in the onset of these changes or the adolescent finds it difficult to adapt to these changes. Associated with
these changes are the obesity and acne. This may result in psychological problems. Any deviation can lead to
feeling of inferiority, low self-esteem, and loss of self-confidence. Due to perceived obesity, the number of eating
disorders is on the high among adolescent girls. The adolescent may develop certain disorders such as anorexia
nervosa—a disorder with both physical and psychological components. Here the individual experiences an intense
fear of gaining weight and refuses to maintain body weight at the minimal normal weight for their age and height.
The other eating disorder is bulimia nervosa. This is a form of binge eating and behaviour to prevent weight gain.
These behaviours include self-induced vomiting, misuse of laxatives, and excessive exercise. This disorder is
considered as a biopsychosocial illness.
• Psychosexual development: The sex drive is triggered by androgens like testosterones. During early adolescence
the adolescent tries to satisfy the sexual impulse through masturbation. Boys are easily aroused by stimuli. The girls
are less sexually active than boys. During the adolescence sexual behaviour and experimentation begin to occur.
Homosexual experiences are usually transient and occur during middle adolescence. These aspects need to be dealt
with among this age group. They may need counselling about dealing with sexual orientation.
• Identity: The major task of adolescence is to achieve a sense of identity of self, as may be achieved by encouraging
the cognitive development in the form of providing stimuli for abstract thinking, developing of concepts, and
encouraging an understanding and orientation to the future. Creativity may also be encouraged. The adolescents
should be provided with venues that encourage them to explore and identify their value systems and develop a
value system of their own. They slowly blend values from many sources into their own belief system. They should
also be provided with opportunities to identify their aptitudes and talents, and development of these should be
encouraged. When this does not occur, the adolescent develops the feeling of ‘identity diffusion’ resulting in
impairment of mental health.
• Body image: Body image is the forceful and changing perception of one’s body—how it looks, feels, and moves. It is
formed by the way one perceives himself, some physical sensations, and sometimes also involves the way one feels.
The way one perceives his/her body is not always constant but may change from time to time. During adolescence
because of the bodily changes that take place the adolescent is very conscious of his/her body image. Body image is
as much influenced by one’s self-esteem and self-perception as by the others’ perception of him. It is also influenced
by one’s cultural and social beliefs and standards in terms of attractiveness and appearance. The immediate effects
of an unacceptable body image are social discrimination and low self-esteem.
• Independence: As adolescence is a bridge between childhood and adulthood, the adolescent is in the process of
trying to develop independence. They try to achieve this by attempting to make decisions of their own with regard
to their clothing, friends, decisions regarding discipline, etc. In the process of developing independence they may
confront conflicts with parents and other authority figures. The behaviour may be manifested in the form of
negativism. Serious mood and behavioural disturbances occurring during adolescence should be considered as
potential symptoms of psychopathology.• Peer group: The most important relationships besides the family are relationships with people of the same age and
interests. As the adolescent attempts to establish a personal identity separate from that of his parents, he tends to
rely on peers for day-to-day support. It is important that parents continue to support the child during this period.
This parental support acts as a buffer against the effects of stress. During this period the adolescent also evaluates
himself, his clothing, and be admired through the eyes of his peers. If he does not identify with them he develops a
lowered self-esteem. It is important that parents are aware of the kind of friends their adolescent child is interacting
with. Peer relationships may be a major contributing factor for the development of certain unhealthy habits that
affect the mental health of the individual.
• Parenting: This is the period when the adolescent begins to talk of generation gaps. This gap is actually the
difference in experiences and perceptions of life events between the adolescent and the parents. The parents of
adolescents are usually in the middle adulthood age and are also coping with the demands of this stage of
development. They are sandwiched between that of adolescent child and the elderly parents. As the adolescent tries
to become independent, some parents may perceive it as a threat and find it difficult to let go. Some parents may
find it difficult to set limits, while others try to perceive their own unconscious fantasies in the child. For example, a
parent who wanted to make it big and was unable to do so may now try to pressurize his child to do so. These
aspects may interfere with the normal development of the adolescent. According to some studies about 20% of
adolescents have been diagnosed to have mental disorder. The common problems experienced during this age are
anxiety disorders and depressive disorders.
• The development of one’s own value system: During the adolescent stage of development the adolescent
internalizes these ethical principles and the control of conduct. During the adolescent stage the young adolescent
begins to visualize his rules in terms of what is good for the society at large. The highest level of morality is a
selfaccepted moral principle, in which children voluntarily comply with the rules on the basis of a concept of ethical
principles and make exceptions to rules in certain circumstances. During adolescence it is expected that the child
achieves this level of morality. This when in contrast with that of society may be perceived by society as a mentally
inappropriate behaviour.
• Vocation: Adolescence again is a period during which the adolescent is forced to seriously think about what he
would like to do with his life. A sense of individual worth as an adult depends on the kind of job, competence at the
job, and successful functioning. The adolescent must be encouraged to understand that vocation can be achieved
only through sustained motivation to master tasks that are difficult. One’s self-worth is enhanced when they gain
the respect of others and the opposite can occur when they lose the respect of others.
• Inquisitive behaviour: Curiosity is good as it encourages one to acquire the broader perspectives and knowledge.
But curiosity may result in risk-taking behaviour in adolescence. This may be in the form of trying out new things
such as drugs and alcohol. It will also result in acquisition of certain contagious diseases such as HIV/AIDS or may
result in accidents caused due to participation in certain risky games such as bungee jumping, sky diving, and
motor racing. Many adolescents take these kinds of games in order to overcome the feeling of inadequacy or due to
peer pressure. The end result may affect the mental health of the adolescent. Curiosity may also encourage the
adolescent to explore the sexual areas, resulting in problems such as teenage pregnancy, abortion, and prostitution.
This in turn affects the mental health of the adolescent.
• Violence: Violent crime by young offenders is on the increase. And homicide is the second leading cause of death
among individuals aged 15–25 years. One of the factors strongly associated with violence among adolescent boys is
growing up in a household without a father figure. The current generation spends an enormous amount of time
watching television, listening to music, and playing video and computer games, which contain content that is
violent or encourages antisocial behaviour. This may be one of the contributing factors to violent behaviour.
Another form of violence is suicide. In India, statistics reveals that the highest incidence of suicide is among the
adolescents and young adults, which is in contrast to western countries where the incidence is more among the
elderly. Suicide is the third leading cause of death among adolescents between 15 and 24 years of age. Depression
and social isolation commonly precede a suicide attempt.
• Media effects: With the onset of TV and internet the physical activity has become bare minimum resulting to
obesity, which, in turn, affects the body image of adolescents and also predisposes the adolescent to lifestyle-related
chronic illnesses. They also bear a huge impact on the adolescent’s mental framework, resulting in decreased
attention and concentration, and behavioural patterns such as smoking and drug use. Cyber dependence/addiction
and cybercrime are also effects of the misuse. Some studies have reported mild-to-moderate behavioural changes in
adolescents due to improper use of mass media.​

FIGURE 1.10 Factors influencing mental health during adolescence.
This is the period when the individual begins to assume the actual tasks of adulthood, which include choosing an
occupation and developing a sense of intimacy. This period begins after 20 years of age and progresses till 60 years.
Marriage and parenthood are important milestones during this period. During the adulthood period they need to
establish an independent identity, build and maintain their career, adjust with the life partner, raise children, and
accept the disability and death of their parents. Adjusting into these di erent rules can be stressful and can result in
psychological problems. During adulthood the individual tries to achieve the following:
• Psychologically separate from parents and achieve self-sufficiency
• Find a gratifying position in the work domain
• Experience sexual and emotional intimacy in a committed relationship
• Become noticeable
• Accept the ageing process of the body
• Integrate the growing awareness of time limitation and personal death
• Maintain physical and emotional intimacy in the face of powerful physical, psychological, and environmental
pressures of mid-life
• Facilitate the development of their children from infancy into adulthood
• Develop and sustain friendships with individuals of different ages and backgrounds
• Leave one’s heritage for future generations by facilitating the development of younger individuals
Adulthood can broadly be classi- ed into three subtypes. There are early adulthood, middle adulthood, and late
Early adulthood
Early adulthood begins at the end of adolescence and ends at around 40 years of age. This is the period when the
biologic development is at its peak and the individual assumes major social roles. A person successfully and
satisfactorily passes into adulthood if he has coped well and resolved the developmental needs of childhood and
adolescence. This period involves assuming of new roles such as that of a partner, parent, work responsibility, etc. The
developmental tasks involved during this period are as follows:
• Accepting oneself, therefore having sense of self-identity and recognizing the individuality of others
• Developing permanent adult friendships
• Developing the intimacy and an intimate relationship
• Taking up the parenting responsibility
• Developing a relationship of mutuality and sameness with parents
• Establishing an adult work identity
• Developing adult forms of play
• Combining new attitudes towards timeFactors influencing mental health during early adulthood
• Leaving the family of origin: Family of origin is the home that one is born into. During early adulthood the adult
needs to emotionally separate from his/her family of origin and may have to move for purposes such as seeking a
job or higher education, etc. This may be stressful for both the parents who experience the empty nest syndrome
and the adult who is now on his/her own. Accepting responsibility for one’s actions, deciding on personal beliefs
and values, establishing an equal relationship with parents, and becoming financially independent are aspects that
accompany leaving home. If the transition takes place uneventfully, the adult’s mental health is promoted. If not,
he may experience anxiety, depression, etc.
• Completing education: Many individuals make the transition to adulthood by entering the work force without the
college experience. Increased access to resources for advanced education may reduce negative social comparisons
and increase the likelihood of positive mental health during adulthood.
• Occupation: Some individuals enter the workforce directly after high school, while others mostly professionals
usually enter the work force after college or professional training. Healthy adjustment to work promotes creativity,
satisfactory relationship with colleagues, the sense of accomplishment, and improved self-esteem. The job
satisfaction does not depend wholly on money. Maladaptation to work can result in a decrease self-esteem, anger,
and reluctance to work. Some of the symptoms of job dissatisfaction are frequent job changes, absenteeism,
mistakes at work, and being accident-prone. This in turn affects mental health. Other aspects of occupation that
affect the mental health include unemployment, long working hours, increased stress, inability to balance both
family life and career.
• Marriage: Development of an intimate relationship is one of the developmental tasks of this age. Marriage provides
a means of sustained intimacy, perpetrates culture, and gratifies interpersonal needs. The current generation has
moved from a restrictive moral regulation to a permissive regulation, which involves live-in relationship. Marriage
involves adjustment when individuals from two different backgrounds, different practices, different value systems,
different customs, etc. come together. Both these individuals need to adapt with a little bit of ‘give-and-take’
together for the need to establish norms for their own family and in relation to their practices, value systems,
customs, etc. When this does not occur or as the couple struggles with this adjustment, mental health tends to be
affected. Adjustment promotes stability, love, and happiness. Another aspect in marriage that may affect the mental
health is marital problems. One of the courses with these problems is an irrational expectation between spouses.
Other factors include personality of the individuals involved, the interaction pattern between them, and the original
reason for the union.
• Parenthood: Parenthood involves economic burden and emotional costs. Children may remind parents of conflict
that they themselves had experienced as children. If children have chronic illnesses, this again challenges the
family’s emotional resources. This is also the period during which parents try to establish themselves in the work
occupation. Parenthood also involves the process of ‘letting go’ of their children. This process begins with schooling.
Parenting also involves disciplining the child. Discipline involves guidance and involvement. This must be done
carefully. Problems associated with this phase of life can also affect one’s mental well-being.
• Sibling relations: Sibling relationships undergo transformations as older adolescents establish independence from
their natal family and acquire adult roles. These role transitions often promote a reorganization of major life
relationships, such as those with family, friends, and romantic partners. When the relationship between siblings is
healthy, the self-esteem, performance in academics, and empathy is found to be positively associated. Although
sibling relations are not directly related to assuming the adult role, positive sibling relations are found to be
supportive during periods of change and adaptation. Some researchers have identified poor psychological
wellbeing as related to lower relationship quality between young adult siblings.
Middle adulthood
Middle adulthood begins at 40 years and extends up to 60 years. This is the period during which the adult takes stock
by reviewing the past, considering how life has gone, and deciding what the future will be like. With regard to
occupation, some adults experience incongruence between the originally set goals and the current achievement. Many
begin to evaluate whether the goals set earlier are worth pursuing. This is also the period during which children grow
up and leave home resulting in ‘an empty nest syndrome’. This is the period the adult begins by rede- ning their roles
as husband and wife. The developmental tasks of this period include the following:
• Taking stock of accomplishments and setting goals for the future
• Reassessing commitments to the family, work, marriage, and dealing with illness and death
• Continue maintaining the capacity to experience pleasure or engage in playful activity. According to Erikson, this is
the period that the adult develops generativity through the process of guiding the upcoming generations or>
improving society. If this is not achieved, the individual experiences stagnation. Some study findings reveal the
strong correlation between physical and emotional health. Those with poor psychological adjustment during college
years had a high incidence of physical illness in middle age. An overall sense of stabil ity in the parental home
predicted a well-adjusted adulthood.
Factors affecting mental well-being during middle adulthood
• Sexuality: During this period sexual functioning may decline both in men and women. Fears related to impotence
are common problems in middle-aged men. Women feel less sexually desirable and thus feel less entitled to an
adequate sex life. This is also a period where climaterium or menopause occurs due to decreased biologic and
physiologic functioning. In females oestrogen secretion decreases. Hot flushes may occur due to menopause and may
extend over several years. This may also be a period during which someone may experience anxiety and depression.
For men climaterics has no definitive answer as the hormones stay fairly consistent through the forties and fifties,
and then slowly begin to decline. At 50 years there is a slight decrease in the healthy sperm and seminal fluid.
Due to the decreased testosterone level, there may be less firm erections and decreased sexual activity. This
sometimes leads to ‘mid-life crisis’, which may be characterized by sudden changes in work or marital
relationships, severe depression, increased use of dependent drugs, etc.
• Retirement: This is also the age when the adult begins thinking about and planning for retirement. This planning
includes financial planning, planning for the utility of time after retirement, decisions regarding independence and
dependence, etc. Individuals who have kept in touch with their hobbies and other extravocational activities have
found to adjust better to retirement. Good financial planning during the early and middle adulthood helps in the
management of finances once the income is reduced. If an individual is unable to cope with this aspect of life, there
is a tendency to develop psychological problems.
• Empty nest syndrome: Another major adjustment during the middle adulthood period is when the youngest child is
about to leave home. Most parents perceive the departure of the youngest child as a relief rather than stress. But to
parents whose lives have constantly been revolving around the children, it is a major adjustment to make.
Interference in this adjustment affects mental health.
• The loss of spouse/divorce: Loss of a spouse either by death or separation is a major crisis in life. There are
different types of separations. Any of these separations can cause crisis, which may in turn result in alterations and
the mental health.
• Balance between two generations: Many middle-aged adults find themselves sandwiched between having the
responsibility of raising their own children while caring for the ageing parents. This may result in stress that may
have an impact on their mental health.
• Physical health: Obesity is a growing health concern for middle-aged adults. The health consequences of obesity
ailments are high blood pressure, diabetes, coronary heart disease, high blood cholesterol, osteoarthritis, etc. Along
with this there is a gradual deterioration in the physiological functioning such as sensory perceptual functions,
which needs attention.
Late adulthood (old age)
Late adulthood refers to the stage of life that begins at 60–65 years of age. The number of individuals over this age is
rapidly increasing. The ageing process is characterized by a gradual decline in the functioning of all the body systems.
This includes the genitourinary system, the cardiovascular system, the respiratory system, the endocrine system, and
the immune system. Not all organ systems deteriorate at the same rate. Ageing generally means the ageing of cells.
Women live longer than men. Diet and exercise play a role. Low salt intake is associated with lowered risk of
hypertension. The psychosocial aspects of ageing include decrease in social activity.
Factors affecting the mental health during late adulthood
Factors a ecting good ageing are multidimensional, which include productive involvement, a ected status, functional
status, and cognitive status.
• Financial status: Financial preparation includes investments, pensions, paying off loans, building/buying a house,
and retaining property and wealth in their own name. Encourage them to prepare others (family members) for
their retirement by talking about future activities. Occupation need not be stopped but to be slowly reduced. Some
may take up a new job with new responsibilities, which calls for adjustment into the new role. Voluntary work is
preferable as one can control the number of hours put into it.
• Marital status: This is also the period during which there is separation from the life partner either due to death,
institutionalization, or dependence. The elderly needs to cope with these changes too.
• Social support systems: Many older adults experience social isolation, and the degree of isolation experienced may$
increase with age. Isolation may be by choice (the result of a desire not to interact with others) or a response to
conditions that inhibit the ability or the opportunity to interact with others. The vulnerability of older adults to
isolation is increased with the absence of the support of other adults, which may occur with retirement. This may be
overcome to some extent by new activities that they can get involved in such as looking after grandchildren,
meeting with friends, shopping, crafts and hobbies, and sports for fitness and fun. Senior citizen clubs are some
initiatives that may be undertaken by the community to handle these problems.
• Dependence status: Older persons who are unable to carry out their daily activities are dependent on others. This is
a major adjustment that they need to make. Currently most of the children of the elderly are abroad; thus they are
unable to provide the needed support. Such parents need to adapt themselves to institutionalized care.
• Leisure time activities: The development and maintenance of leisure time activities help in the maintenance and
promotion of mental health and encourage them to practice being retired by starting activities they hope to do after
retirement even before the retirement so that the transition is smooth.
• Physical health: With the process of ageing there is a deterioration of the systems of the body resulting in physical
ill-health. This in turn affects the mental health.
• Psychosocial well-being: Elderly are prone to certain psychiatric problems such as dysthymia, depression, and
dementia. Some even resort to drug and other substance abuse. Delirium is a potentially reversible cognitive
impairment that is often caused due to physiological causes such as electrolyte imbalance, cerebral anoxia,
hypoglycaemia, cerebrovascular infections, tumours, infarction, or haemorrhage.
• Retirement: It is also a stage of transition and role change. The stressors related to this phase include role change
with spouse and family. It may also cause social isolation. When so much of life has evolved around work and
personal relationships at work, the loss of the work may be devastating causing an impact on the mental health.
This chapter has dealt with the concept of mental health, illness, and normality. We have discussed the various factors
influencing mental health throughout one’s lifespan. In conclusion, one may conclude that the concept of mental health
and illness is in uenced by the cultural beliefs and practices (cultural relativity) and by the meaning of one’s behaviour
to those witnessing the behaviour (comprehensibility).
Review questions
Long-answer questions
1. Discuss mental health in terms of its proposers.
2. Discuss the characteristics of a mentally healthy individual.
3. List and briefly discuss the characteristics of a mentally ill individual.
4. Describe the factors affecting mental health through the lifespan.
Short-answer questions
1. Discuss with example the mental health continuum.
2. Explain Maslow’s concept of mental health.
3. Define mental health and explain the same.
4. List and discuss the WHO characteristics of a healthy individual.
5. Discuss the concept of mental illness and explain why it is difficult to define mental illness.
Short notes
1. Discuss your perspective of mental health and illness.
2. Propose your perception of how mental health may be promoted among our nursing students.
Fill in the blanks
1. According to the concept of normality as ————————the absence of signs and symptoms of mental ill health is
considered as mental health.
2. Eric Erickson’s theory fits into the concept of normality as ————————.
3. ————————is the relationship that the baby develops with his or her caregivers.
4. Maternal infection with ————————during pregnancy has been attributed to the development of
State true or false1. A mentally healthy person believes that he does not need to depend on others.
2. During middle adulthood the individual begins taking stock of his accomplishments.
3. In old age the degree of isolation experienced may decrease with age.
4. The first-born child is more achievement-oriented than the subsequent children.
5. Due to the sensory development, the child begins gaining control over their actions.
1. Atkinson RL, Atkinson RC, Smith EE, Bem DJ, Nolen-Hoeksema S. 13th ed. Hilgard’s Introduction to Psychology.
New York: Harcourt. 1999.
2. Patrecia DB. 13th ed. Psychosocial Nursing Assessment and Intervention. Philadelphia: Lippincott. 1984.
3. Sadock BJ, Kaplan V. Kaplan and Sadock’s Synopsis of Psychiatry: Behavioural Sciences/Clinical Psychiatry. Tenth
North American ed. Philadelphia: Lippincott. 2007.
4. Townsend MC. 4th ed. Psychiatric Mental Health Nursing: Concepts of Care. Philadelphia: FA Davis. 2003."
Assertiveness training
• Aggressive e4
• Assertiveness e1
• Fogging e5
• Negative assertion e5
• Negative enquiry e5
• Passive e4
• Persistence e5
Assertiveness was initially described as a personality trait by Andrew Salter in 1949.
People thought that some people possessed this character, while some people did not.
Some people think that assertiveness training turns nice people into complainers or
calculating manipulators. Everyone has the right to protect oneself when something
seems unfair. Lack of assertiveness can a ect one’s relationships and quality of life,
as one fails to communicate e ectively and ends up not getting what one wants.
One’s family life, career prospects, and stress levels are a ected when one is not
assertive. Therefore assertiveness is essential both for prevention of mental illness
and for rehabilitating a psychiatric patient.
Wolpe (1958) and Lazarus (1966) de. ned assertiveness as ‘expressing personal rights
and feelings.’
Assertiveness is when an individual stands up for his/her rights in such a way that
the rights of others are not violated.
Assertiveness is an attitude and a way of relating to the outside world, supported
by a set of skills for e ective communication. To be truly assertive, one needs to . rst
perceive oneself as worthy, with a right to enjoy life. At the same time he/she values
others equally, respecting their right to their opinion and to enjoy themselves.
Assertiveness is a behavioural response that strives to maintain a balance between
passive and aggressive response patterns with a focus on equality and fairness ininterpersonal interactions, which is a result of a positive sense of self-respect and
respect for others.
Assertiveness training
It is a form of training that involves learning the basic social skills that deal with
expressing oneself, which includes ones thoughts and feelings to others in a clear
manner. It also involves following one’s goals with perseverance, even when faced
with opposition. Assertiveness also involves standing up for one’s self in the midst of
conflict or criticism in an appropriate manner.
Assertiveness training is a form of behaviour therapy designed to help people
stand up for themselves and to empower themselves.
Goal of assertiveness training
The overall aim of assertiveness training is con. dence building. Its goals are as
• Increase the understanding of oneself and others.
• Solve problems in a manner that produces better results.
• Appropriate expression of one’s thoughts and feelings.
• Decrease occasions of passive or aggressive behaviour.
History of assertiveness training
Assertiveness training has a long history in mental health. It was started in the
1970s, when it was first used to train and encourage women to assert themselves in a
manner that was appropriate. Currently, assertiveness training is used as a part of
communication training in a variety of settings such as schools, corporate
boardrooms, and psychiatric hospitals. In the psychiatric setting it is used for
patients with problems such as substance abuse, social skills’ training, vocational
programs, patients with aggressive outbursts, and responding to harassment.
Assumptions related to assertiveness training
The assumptions on which assertiveness training is based are as follows:
• People with relatively little assertive behaviour do not believe that they have a
right to their feelings, beliefs, or opinions.
• They reject the idea that people are created equal and therefore must be treated
and should treat others as equal.
• They cannot find any basis for objecting to exploitation or mistreatment.
• They have been taught in their childhood that their opinions, feelings, and wants
were less important or correct than those of others.
• They grew up doubting themselves, and depended on others for justification and
guidance.Traditional assumptions that prevent assertive behaviour
Some societies including India have certain assumptions that prevent assertive
behaviour. They are as follows:
• A person is selfish when he put his own needs before others’ needs.
• It is shameful to make mistakes. One should have an appropriate response for
every occasion.
• If one cannot convince others that one’s feelings are reasonable, these feelings
may be wrong.
• One should respect the views of others, especially if they are in a position of
• A socially acceptable person is one who keeps his differences of opinion to
• One should always try to be logical and consistent.
• One should be flexible and adjusting.
• Others have good reasons for their actions and it is not polite to question them.
• One should never interrupt people.
• Asking questions reveals ones ignorance.
• One should not waste others’ valuable time with one’s problems.
• It is not good to tell people when one feels bad, so keep it to oneself.
• People who give advice are doing a favour. Therefore their advice should be taken
• One should always adjust to others. If one does not. They will not be there when
one needs them.
• One should always be in a favourable relationship with others.
Assertive rights
A number of people have identi. ed a variety of assertive rights. Some of the rights
identified are as follows:
• The right to make the final judgment regarding one’s feelings and the right to
consider them as justifiable.
• The right to have one’s own opinions and convictions.
• The right to change one’s own mind or decide on taking a different course of
• The right to protest against unfair treatment or criticism.
• The right to interrupt and ask for clarification.
• The right to negotiate for a change.
• The right to ask for help or emotional support.
• The right to feel and express emotions.
• The right to ignore the advice of others.
• The right to receive formal recognition for one’s work and achievements.
• The right to say ‘no’ without feeling guilty.• The right to be left alone even when others prefer one’s company.
• The right not to take up responsibility for someone else’s problem.
• The right not to have to anticipate other’s needs and wishes.
• The right to choose not to respond to a situation.
• The right to be listened to and taken seriously.
Advantages of assertive training
The advantages of assertive behaviour are as follows:
• Effective in dealing with depression, anger, resentment, and interpersonal
anxiety, especially when these symptoms have been brought about by unfair
• Claim to his/her right to relax, and is able to take time for oneself.
• More effective interpersonal relationship is established.
• One can handle conflicts is a mature way.
• The ill-effects of repressed and suppressed emotions are reduced and eliminated.
Basic interpersonal styles
Before one learns assertiveness one needs to be aware of the three basic types of
styles of interpersonal behaviour. They are as follows:
Aggressive style: Here the basic purpose of this behaviour is to dominate others.
This may be of verbal or physical form. The individual may use threats. Physically
the person may manifest violent behaviour patterns. Although the individual may
get his way initially, in the long run it is self-defeating as the individual may lose
friends, feel isolated, and become lonely. The behaviour patterns observed in
these patients is fighting, accusing, threatening, and stepping on others without
giving regard to their feelings. The advantage of this behaviour is that people do
not push such people around or take them for granted. The disadvantage of this
behaviour is, as already discussed, being lonely and being avoided by others.
They are perceived as bullying, intimidating, and manipulative with lack of
concern for others, their feelings, and point of view.
Passive style: These kind of individuals let others push them around. They do not
stand up for their rights, doing as others tell them to without taking into
consideration how they feel about it. Here the individual rarely experiences
rejection. They are taken advantage of. They may carry resentment and anger
within them unable to express these feelings. These individuals are afraid of
personal conflict and social rejection. They do not express their opinions but keep
them to themselves. They present an overly nice and submissive quality. They say
the kind of things that will win the other persons approval. This result is
dishonesty in expressing self.
Assertive style: Here the individual stands up for himself and expresses his true
feeling. He does not allow others to take advantage of him. At the same time he isconcerned about the other person also. Here the individual gets what he wants
without upsetting the others. He acts in the best interest of oneself without feeling
guilty. He is aware regarding the ineffectiveness of both the aggressive and
passive styles. He is engaged constantly in a ‘win–win’ solution to problems. He
uses nonaggressive social means and methods to stand up for his rights. He
respects the rights of others in terms of their opinions and value systems, and at
the same time believes in his rights to his opinions and value systems. He accepts
social rejection as an acknowledgement of social incompatibility. Table 1
compares and contrasts the three types of styles.TABLE 1
Types of Interpersonal Styles
Characteristics Assertive Style Passive Style Aggressive Style
Meaning I am OK; you are I am not OK; you are I am OK; you are not
Main feature Stands up for Lets others push him Domination of others
himself around
Advantage One gets what one One lets others get One gets what one
wants what they want wants in the short
Social • Takes into • Undermines Undermines others
orientation consideration oneself while while considering
others’ point of considering the oneself
view others
• Acknowledges • Ignores social
social incompatibility
Conversation Speaks openly Afraid to speak up Interrupts or ‘talks
over’ others
Eye contact Maintains eye Avoids eye contact Glares/stares at
contact others
Body posture • Open posture Slouched shoulder Rigid with crossed
• Respects and withdraws arms, invades
others’ others’ personal
personal space space
Value of self Values self and Values others and Values self more than
others may have low others
Volume of Audible Soft Loud
voice conversational
Components of assertiveness training
Assertive social conversation and communication involves learning and then
practicing a number of basic skills involving self-expression, such as the following:Self-disclosure: In self-disclosure the individual learns how to reveal aspects of his
past history, opinions, values, and desires they normally would have been too
anxious to reveal in the past. One important aspect of successful assertiveness is
the ability to tolerate rejection. When this happens one does not feel inhibited to
reveal self and his past, as he will not feel the threat of rejection, which is
revealed in the thought ‘What will they think of me if I say that?’
Free information: Free information is the offering of facts about oneself in a
spontaneous or voluntary fashion. Sometimes this free information is given to the
other person just to enhance a valued relationship; sometimes free information is
offered as an invitation to the other person to relax and begin talking on a more
personal, intimate level. For example, a group counsellor talking to adolescents
may talk openly about embarrassing events during his adolescence, with the
purpose of building a rapport and encouraging free expression of self.
Persistence: Persistence is technique used mainly in social situations where we are
dealing with an administration and are facing systematic resistance to reasonable
requests. A key social skill practiced in assertiveness training is persistence.
Persistence is repeatedly coming back with the request again and again with
Broken record: Broken record involves saying what you want over and over again
without getting angry, irritated, or loud, regardless of the person, one is talking
to refuse to listen to one’s reasonable requests.
Assertively coping with criticism: Many times when people are criticized they
tend to react either by being completely intimidated or frightened by the criticism
and not standing up for themselves, or by people responding by overreacting and
becoming angry, loud, insulting, and hateful. This is because the person is either
trying to give in to the criticizer or fight the criticizer by criticizing back. Both
these approaches are unhealthy, resulting in a disturbed or destroyed
Dealing with criticism in an assertive fashion involves learning and then using the
following social skills:
Fogging: Fogging is simply agreeing with the criticism made, agreeing in principle
with the criticism, or agreeing with the chances regarding the criticism made.
Here the priority is the desires or view of the criticized situation in spite of the
criticism, without becoming defensive, angry, or threatened.
Negative assertion: Negative assertion occurs when one offers free information
about himself that they agree is negative. When offering such information, it is
done in a way that communicates that the individual accepts himself as a person
in spite of this negative trait or behaviour. When this is done it is difficult for
others to manipulate using the method of criticizing the negative traits.
Negative inquiry: Negative inquiry involves asking the person who is criticizing ifthey have any additional criticisms related to oneself, which they would like to
share. Negative inquiry communicates to the other person that the one being
criticized does not automatically reject himself, but recognizes themselves as
humans having some negative behaviours and characteristics. This helps the
individual recognize and reflect on the core issues, which may be the cause of
dissatisfaction with the one being criticized.
All assertiveness skills are designed for the following purposes:
Workable compromise: Here the one is being criticized and the other person
begins to nonmanipulatively negotiate the differences between them.
Working agreements: Here the one being criticized and the other person reach
between themselves towards a solution to the problem between them regarding
their differences.
Assertive training is conducted best in group settings from four to six sessions. It
may also be conducted as an individual therapy or as counselling sessions in order to
promote the patient’s overall skills in socialization.
Assertive behaviour is easily understood in the conceptual manner or as a theory.
What is challenging, however, is mastering the assertive social skills to the degree
that the individual utilizes them spontaneously in the midst of an argument or in a
socially conHicting situation. This can be promoted by practicing these skills in small
group settings.
Body language
An important part of assertiveness is open, secure body language. Passive body
language is that of a classic ‘victim, ’ which includes poor eye contact with a hunched
shoulder. An aggressive body language is one that manifests a tense body posture
with a clenched fist, glaring eyes, and an intrusive body language.
On the other hand an assertive individual stands upright but in a relaxed manner,
maintains good eye contact is with open hands. In assertive training the . rst step is
to practice the appropriate assertive body posture. This may be practiced through
role play.
Any skill in order to develop needs a lot of practice; this may be done in groups as
group activities or group therapy. It can also be practiced individually in the room in
front of the mirror.
Clear communication is an important part of assertiveness. This is where one shows:
Knowledge: To understand and summarize the situation.
Feelings: Explain one’s feelings about the situation.
Needs: Explain clearly what one wants or needs, giving reasons for any benefits to
the other party.Assertive communication
It is not just the content of what one says that matters; it is the way one puts it
across. Some tips related to the same are as follows:
• Be honest with self about one’s own feelings.
• Keep calm and stick to the point.
• Be clear, specific, and direct.
• If one meets objections, keep repeating the message whilst also listening to the
other’s point of view. Try to offer alternative solutions, if possible.
• Clarify in case of doubts.
• If the other person tries to divert the attention, point this out calmly and repeat
the message.
• Use appropriate body language.
• Always respect the rights and point of view of the other person.
Box 1 contains the summary of the assertive training components.
Box 1
• Being clear about what one feels, what one needs, and how it can be achieved.
• Being able to communicate calmly without attacking another person.
• Saying ‘Yes’ when one wants to, and saying ‘No’ when one means ‘no’ (rather
than agreeing to do something just to please someone else).
• Deciding on, and sticking to, clear boundaries.
• Being confident about handling conflict, if it occurs.
• Ability to negotiate if two people want different outcomes.
• Being able to talk openly about oneself and being able to listen to others.
• A confident and open body language.
• Ability to give and receive a positive feedback.
• Maintaining an optimistic outlook in life.
Steps in assertive behaviour
The following steps will promote assertive behaviour:
Respect oneself and others: It is important that one develops a respect for oneself
and at the same time develop a respect for others and their needs.
Begins with an attractive statement: Depending on the situation one is facing it
is important to use an appropriate attractive statement that will catch the
attention of the individual being spoken to.
• Compliment the other person: This must be sincere and can include the use of
the term ‘thank you.’ The word may be used in statements such as ‘Thank you
for your suggestion.’ Other statements would include ‘You are an important"
person to me.’
• Apologize: It is used when any aspect involves a mistake on the side of the
person using the assertive behaviour. It is a good thing to apologize when one
is wrong. Sentences such as ‘I am sorry for what happened’ and ‘I am sorry you
felt that way’ may be used.
• Agree with the person: When you agree with a person, state it either verbally
or nonverbally. This agreement should be genuine. Terms that may be used are
‘I agree with what you say’ ‘I understand why you said so’.
• Acknowledge their thoughts and feeling: Everyone has a need to be
understood. Acknowledging one’s thoughts and feelings promotes a better
relationship and gives them the feeling that they are being understood. This
can be done by focusing not only on what they are saying but also their body
language and their nonverbal cues. Sentences like ‘I see you are anxious.’ ‘You
seem frustrated.’ help in acknowledging the individual.
• Ask questions: Asking questions helps clarify doubts and gives a clearer picture
of the situation and their point of view. Questions may be asked as follows ‘Do
you mind me asking you a question?’
State the need: May be stated clearly in the light of how the other person may
perceive what is mentioned. Be confident; use a confident body posture and
language. Use proper/appropriate terms.
Recognize that the needs may or may not be met: Keep in mind that the request
may be accepted or rejected. Be willing to accept rejection. But if you are
convinced that you are making a rational request, prepare yourself to use the
techniques of a broken record or persistence.
Exercise or practice the assertive techniques: Practice makes man perfect.
Therefore keep practicing these techniques in all interactions.
Celebrate when successful in a situation: Every time you are successful in the
use of assertive behaviour, reward yourself.
This chapter has dealt with the meaning of assertiveness and assertiveness training.
The di erent patterns are compared and contrasted. The tips for assertiveness
training and the nurse’s role in terms of themselves developing assertive skills in
order to act as role models for patients need this training.
1. Dombeck M, Wells-Moran VJ. Available at http://www.mentalhelp.net/
Accessed 31 August Setting Boundaries Appropriately: Assertiveness Training.
2. The mind tool. Available at www.mindtools.com Accessed 31 AugustAssertiveness—Getting What You Want, In a Fair Way. 2014.
3. Townsend MC. Psychiatric Mental Health Nursing Concepts of Care 3rd ed .
Philadelphia: FA Davis. 2000.%

C H A P T E R 2
Theoretical models of personality
• Animistic thinking 41
• Autonomy 35
• Centration 41
• Cognitive development 38
• Conscious mind 29
• Electra complex 30
• Ego centrism 40
• Ego integrity 36
• Generativity 36
• Initiative 35
• Industry 35
• Interpersonal theory 31
• Intimacy 36
• Kohlberg’s theory 44
• Moral development 43
• Oedipus complex 30
• Personality 28
• Piaget’s theory 44
• Preconscious mind 29
• Psychosexual development 29
• Psychosocial theory 32
• Unconscious mind 29
Nurses use principles, concepts, and processes to guide their observations and understand the phenomena that are the
focus of their interventions. This use of theory precedes and serves as a basis for determining nursing actions to be
taken. Theory maintains that nurses need a theoretical basis and a conceptual framework for psychiatric and
psychosocial nursing practice.
According to the standards of psychiatric and mental health nursing practice, the rst standard is theory. Here the
nurse needs to apply appropriate theory that is scienti cally sound, as a basis for decisions regarding nursing practice.
All actions of the psychiatric nurse should be based on an understanding of the health–illness phenomenon. The
theoretical basis is drawn both from the nurses’ own knowledge and from other sciences.
The range of theories used by nurses includes:
• Intrapersonal theories: These theories explain the within person phenomenon and focuses on the individual level
of care.
• Interpersonal theories: These theories elaborate on interactions between two or more people.
• Systems theory: These theories aid the nurse in understanding complex networks or organizations and the way their
processes interact.
This chapter will deal with the theories of personality development, as nurses need to have a basic knowledge of
human personality development in order to understand the maladaptive behaviours observed in psychiatric patients
and issues related to that particular level of development that may in uence the behavioural pattern of this particular