Learning Objectives
By the end of this section, you will be able to:
- Define interpersonal theories and therapies
- Identify nursing application of interpersonal theories and therapies
Interpersonal theory, first described by Harry Stack Sullivan (1892–1949), holds that human behaviors can be explained through relationships with others. Influences from these relationships shape personality, ability to cope with stressors, and, ultimately, survival. Interpersonal theory is substantiated by data obtained through observation and investigation.
These theories enable the nurse to develop person-centered care, become aware of reasons behind client responses, interpret behaviors, avoid judgment, and, ultimately, teach clients self-awareness. This section will explore interpersonal theories of Harry Stack Sullivan, Hildegard Peplau, and Erik Erikson.
Definitions
Interpersonal theories posit that personality development and mental health depend upon relationships between people. With the therapeutic relationship between nurse and client being so foundational to nursing practice, these theories resonate when nurses interact with clients. In fact, many interventions have been created based on interpersonal theory. More specifically, interpersonal theories focus on how to assess, interact, and intervene with clients who may be struggling to communicate when dealing with mental health issues.
Interpersonal theory was originally created by Harry Stack Sullivan. He developed a theory founded on the belief that interpersonal interaction is the basis for the person’s behaviors and sense of self. The main mental health problem identified by Sullivan was anxiety. He believed that human anxiety was fueled by the need for human interaction. He coined the term significant other, as the main person, or a parent, from which humans have their first interpersonal interaction. He believed that this relationship was crucial for healthy emotional development.
Hildegard Peplau (1909–1999) was influenced by Sullivan’s interpersonal theory and extended it to nursing practice, thereby developing the first systematic theoretical framework for psychiatric nursing in her book, Interpersonal Relations in Nursing (1952). Peplau was the first to create and define the nurse’s interpersonal relationship with the client as the foundation for nursing practice. She changed the mindset of nursing practice from what nurses do to clients to what they do with clients. Her theory speaks to helping clients make positive changes in their health care and wellness through education. She believed that illness presents an opportunity for learning, growth, and coping, and that self-awareness/reflection and the environment are keys. The nurse-client relationship is broken down in stages in her theory: pre-orientation, orientation, working, and mutual termination. The nurse and client move through these phases in an interwoven manner over time during which the nurse encourages the client’s process of thoughts and feelings. The client’s self-awareness is increased during these interactions (Hagerty et al., 2017).
Erik Erikson (1902–1994) was an American psychoanalyst and follower of Freud’s theories. Erikson believed that a human’s personality is developed throughout their life span and created a developmental model to reflect this. Erikson’s theory described eight stages of human development, conflicts through which people negotiate individual needs against needs and demands of society in order to grow. Many of the stages involve interpersonal relations. Erikson’s work is referenced by other studies of human development in mental health, aging, and child development (Orenstein, 2022). For example, according to Orenstein (2022), the recovery stage of mental illness involves trusting the possibility of regaining health; therefore, this represents a resolution of Erikson’s stage of trust versus mistrust.
Nursing Application of Interpersonal Theories
Peplau’s most lauded contribution to nursing is the application of interpersonal theory to anxiety. She described levels of anxiety as mild, moderate, severe, and panic on perception of learning (Table 2.3). She promoted and taught different strategies to lower anxiety to a level where the client could learn and cope with life’s stresses.
| Level | Perception | Signs/Symptoms | Helpful or a Hindrance | Nursing Interventions |
|---|---|---|---|---|
| Mild | Normal experiences of everyday life, with perceived reality in sharp focus. | Slight discomfort, restlessness, irritability, mild tensions, relieving behaviors such as nail biting, foot/finger tapping, or fidgeting. | Can be constructive for the person, as this may be a signal that something needs attention or is dangerous for them. The person can ask for help. | Emotional support; encouraging communication; family /significant other support. |
| Moderate | Perceptual field narrows, details are missing. The ability to think clearly is hampered; however, learning and problem-solving can still occur, but not at the optimal level. | Tension, pounding heart, increased pulse and respiratory rate, perspiration, gastric discomfort, headache, and urinary urgency. Voice tremors and visible; shaky hands are possible. | Can be constructive for the person, as this may be a signal that something needs attention or is dangerous for them. Can also be a hindrance to a person because they are unable to focus as sharply on details outside of the anxious thoughts. |
Sitting with the client, speaking slowly and calmly, using short simple sentences. Assure client that the nurse is available, and they can ask for help if needed. Provide a quiet environment with decreased stimuli. Encourage the client to talk about their feelings and what happened prior to the symptoms/signs occurring. Ask the client, “What evidence do you have?” “Think a minute, are you basing this conclusion on fact or feeling?” Offer antianxiety medication as ordered. Help the client to problem-solve. |
| Severe | Perceptual field is greatly reduced. The person may focus only on one detail or many scattered details, but have trouble discerning what is happening in the environment, even when another person shows them. Possible confusion and may be dazed by the reality. Behavior is automatic and its purpose is to relieve anxiety. | Headache, nausea, dizziness, insomnia may increase. Trembling and experiencing a pounding heart are common. Hyperventilation and a sense of impending doom may occur. | The person needs to have intervention with this level of anxiety. They are unable to make safe or logical decisions. | Remove the client from the stimuli if possible. Stay with the client. Ask the client to discuss their feelings and what happened for the anxiety to accelerate, if possible. Same interventions as moderate anxiety. Offer antianxiety medication as ordered. |
| Panic | Unable to process what is happening and may lose touch with reality. Dysregulated behavior results. Pacing, running, shouting, screaming, or withdrawal may result. The person may experience hallucinations, or false sensory perceptions, such as seeing people or objects not seen by others. | Immobility, or severe hyperactivity, garbled speech, or inability to speak, numbness, tingling, shortness of breath, dizziness, chest pain, nausea, trembling, chills, flushing skin, palpitations. | This person needs immediate attention. They may need to be removed from the situation or stimuli. They may need to be placed in an environment where they cannot hurt themselves or others. | Help the client to move to safe space. Allow client to pace, or withdraw; however, keep the client within eyesight. Stay with the client. Help and keep client safe from injury. All interventions with severe anxiety and offer medication as needed and ordered. Once the incident is over, debrief with the client about what happened and assist the client in reframing the issues. Provide honest praise for the client’s ability to recover. |
Peplau also defined the nurse-client relationship as the connection between the professional nurse and those seeking health services (Hagerty et al., 2017). This connection is accomplished through application of the therapeutic relationship, which contains specific phases. The phases of this relationship are denoted in Figure 2.4.
These phases are interwoven and overlap as the client and nurse develop rapport, which is the process during which the nurse creates an atmosphere of safety, trust, and understanding. During this process, the nurse should use the attributes of empathy, transparency, and positive regard. The nurse assists the client with problem-solving in a practical, emotional, and situational manner. When used in a nursing context, empathy involves the nurse placing themselves in the client’s shoes, through compassion, understanding, and identification. The interpersonal process is a process where the nurse and client communicate to develop an understanding of their roles and responsibilities in the therapeutic relationship. This is often during the orientation phase of the nurse-client relationship.
Erik Erikson’s developmental theory has implications for nursing practice and development of the therapeutic relationship as well. Nurses use this theory, for instance, during the assessment of the client. Review of the client’s behavioral patterns can help identify age-appropriate, or delayed, development of interpersonal skills. Delays can hinder normal development and result in a diminished sense of self. Understanding the stages of emotional development of the client allows the nurse to interact with and assess the client in the most age-appropriate manner. Table 2.4 lists Erikson’s stages of development.
| Stage | Age (Years) | Developmental Task | Description |
|---|---|---|---|
| 1 | 0–1 | Trust vs. mistrust | Trust (or mistrust) that basic needs, such as nourishment and affection, will be met |
| 2 | 1–3 | Autonomy vs. shame/doubt | Sense of independence in many tasks develops |
| 3 | 3–6 | Initiative vs. guilt | Take initiative on some activities, may develop guilt when success not met or boundaries overstepped |
| 4 | 7–11 | Industry vs. inferiority | Develop self-confidence in abilities when competent or sense of inferiority when not |
| 5 | 12–18 | Identity vs. confusion | Experiment with and develop identity and roles |
| 6 | 19–29 | Intimacy vs. isolation | Establish intimacy and relationships with others |
| 7 | 30–64 | Generativity vs. stagnation | Contribute to society and be part of a family |
| 8 | 65– | Integrity vs. despair | Assess and make sense of life and meaning of contributions |