covering process were identified. Interventions that
assisted patients in recovering instilled hope were
psychoeducational in nature, included cognitive in-
terventions that change thinking styles, and pro-
vided for individualized treatment.
Peden’s study (1996) concluded with the realiza-
tion that more information was needed on the
symptom of negative thinking. To understand a
phenomenon, one must analyze its etiology, its
cause, its meaning, and any clues to successful in-
tervention (Peplau, 1989c). At the suggestion of
Peplau (personal communication, January 16,
1993), work began, returning to the first step of the
process to gather more information about the
symptom of negative thinking.
Negative Thinking
A qualitative study (Peden, 2000) was designed to
describe the nature or inherent quality of negative
thoughts, their content or subject matter, and the
origins of the negative thoughts experienced by
women with major depression. The participants
also shared strategies they used to manage the neg-
ative thoughts. The sample consisted of six women
with a diagnosis of major depression who were ex-
periencing or had experienced negative thoughts
and were willing to talk about the experiences. The
women participated in a series of six group inter-
views, the purpose of which was to elicit negative
views/thoughts held by the group participants. The
group interviews focused on the women’s life expe-
riences, views of self and significant others,
lifestyles, and past experiences.
Researchers examined transcripts for regulari-
ties (Peplau, 1989b) and developed a coding guide.
Codes were derived from available literature and
were based on recommendations from Peplau (per-
sonal communication, January 16, 1993) and other
codes that emerged from the initial review of the
data. Codes included negative thinking related to
self, negative thinking related to significant others,
interactions with significant others, and developing
view of self. After coding the data, researchers
looked for recurring themes (Peplau, 1989a).
For the six women who participated in the study,
the negative thoughts had their origins in child-
hood. Common childhood experiences included
suppression of emotion, restrictive parenting,
learning to be passive, lack of praise or compli-
ments, high parental expectations, stifled commu-
nication, and lack of emotional support. The
negative thoughts focused primarily on self, being
different, disappointing self and others, not being
perfect, and always failing. The women described
their self-talk as constant, negative, and demeaning.
They identified various means of managing the
negative thoughts. Once again, the use of affirma-
tions, positive self-talk, and learning to change
thinking were identified as reducing negative think-
ing. Steps one and two of the process of practice-
based theory development had provided direction
for moving into the third step, design of an inter-
vention.
Testing an Intervention
A six-week group intervention was designed specif-
ically to incorporate cognitive-behavioral tech-
niques to assist in reducing negative thinking in
depressed women. As described earlier, thought
stopping and positive self-talk (or affirmations)
were identified as key strategies in reducing nega-
tive thoughts. The intervention was designed using
specific content from Gordon and Tobin’s (1991)
Insightprogram, Copeland’s (1992) The Depression
Workbook,and the investigator’s own clinical expe-
riences with depressed women. Affirmations, direct
actions, thought stopping, and information on dis-
torted thinking styles were introduced to the group
members. Guided by Peplau’s (1952) theory of in-
terpersonal nursing, the introduction of cognitive-
behavioral techniques did not occur until the
second group session. The focus of the first week
was on enhancing the development of the nurse-
patient relationship to decrease anxiety, increase
trust and security within the group, and lay the
foundation for the intervention.
To pilot-test the intervention, 13 women with
a diagnosis of major depression were randomly
assigned either to a control or to an experimental
group. All subjects were under psychiatric care in
an outpatient clinic and receiving antidepressant
medication. The experimental group participated
in the six-week cognitive-behavioral group inter-
vention for one hour per week. The control group
continued with routine psychiatric care.
Pre- and post-test measures were collected on
depression using the Beck Depression Inventory
(BDI) (Beck, Ward, Mendelson, Mock, & Erbaugh,
1961) and on negative thinking using the Crandall
Cognitions Inventory (Crandall & Chambless,
1986) and the Automatic Thoughts Questionnaire
(Hollon & Kendall, 1980). Feedback from the fiveCHAPTER 6 Hildegard E. Peplau’s Process of Practice-based Theory Development and Its Applications 63