NURS 460 Mental Exam 1

Mental health definition

WHO definition: State of well-being in which individuals reach their own potential, cope with the normal stresses of life, work productively, and contribute to the community

• Normal: Paying for bills if you have a job, transportation, studying, relationship issues  

• Abnormal: If you got no job then paying bills can be abnormal, one person withdraws in the relationship, etc 

Traits of Mental Health

• Capacity for…

  • Rational thinking

  • Communication skills

  • Learning

  • Emotional growth important in life 

  • Resilience (how much can you take, environmental press) 

  • Self-esteem (how you view yourself) 

Mental Illness

• Psychiatric disorders with definable diagnoses (more fluid, on a spectrum) 

• Significant dysfunction in mental functioning related to

  • Developmental 

  • Biological

  • Physiological disturbances

• Culturally defined

Mental Health Continuum

• Mental Health versus Mental Illness

  • Mental Health: A sense of well-being on a daily basis 

  • Mental Illness: Individuals who may have emotional problems and experience mild to moderate discomfort and distress

  • A real middle ground exists: Stress and discomfort from everyday life

  • Conceptualized as points along a mental health continuum 

Case Study: Scenario

Mrs. M comes to the clinic reporting a feeling of hopelessness. She works full time and is dealing with a troubled teenage son and her elderly parents. She confides in you that she “can’t deal with her life right now.”

Discuss attributes you might screen for to quickly assess her overall mental health.

Support system, Suicide thoughts (will she hurt herself or others), caregiver burnout, worrying of son and elderly parents, juggling with job and caring for her own family  

Determinants of Mental Health pt 1

• Resilience

  • Ability and capacity to secure resources needed to support well-being

  • Characterized by 

    • Ability to secure needed resources

    • Capacity for regulating one’s own emotions and overcoming negative, self-defeating thoughts

  • Essential to recovery

Determinants of Mental Health pt 2

• Social and economic circumstances

  • Family help set the stage in promoting confidence and coping skills or for instilling anxiety and feelings of inadequacy 

  • Schools and peer groups

  • Socioeconomic status

  • Educational advancement

• Environmental factors

  • Political climate & cultural considerations

  • Social & economic policies 

  • Social media/entertainment 

Perceptions of Mental Health and Mental Illness

• Mental illness versus physical illness

  • Myth of mental illness are all in the head -> Leads to stigma, social shaming, disgrace, and shame 

  • Root of most mental disorders lies in intercellular abnormalities 

  • Both can impact each other 

• Nature versus nurture

  • Germ theory of diseases explained that specific environment caused it (theory abandoned)  

  • Psychological theories explained the origin of mental illness as faulty psychological processes that could be corrected by increasing personal insight and understanding

  • The scientific community began to believe that if psychiatric problems respond to medications that alter neuro-chemistry, then a disruption of intercellular components must already be present

  • Diathesis-stress model: Nurture + nature argues that both impacts mental health leading to psychiatric disorders

Diathesis-Stress Model

• Diathesis—biological predisposition

• Stress—environmental stress or trauma

• Most accepted explanation for mental illness 

• Combination of genetic vulnerability and negative environmental stressors

• Assertion: Most psychiatric disorders result from a combination of genetic vulnerability and negative environmental stressors

Case Study: Scenario

Mrs. M has a history of major depressive disorder.

“Do we have to deal with that?” she says. “Can’t we just focus on my insomnia? If I could just get something to help me sleep at night, I think I’d cope better right away. Besides—insomnia would be covered by my health insurance. It’s an uphill battle getting compensated for any treatment for the other. Fighting with insurance people is not going to help anything!”

• Need to understand that depression and insomnia are related to each other 

• Insurance/financial aspect  

• Response: I see that insomnia is affecting your life and that you want to manage it. Insomnia can be one of the signs of depression and lack of sleep can cause lost of focus and less energy during the day. How about we explore options within your insurance coverage to help manage your insomnia and depression?

National Influences on Mental Healthcare (extra info)

Consumer movement & mental health recovery 

• Promoted concept of recovery + consumer-focused process 

National Alliance on Mental Illness (NAMI) created by people with mental illnesses and their families start to resist the traditional arrangement of mental healthcare 

Decade of the Brain

• President Bush Era: More awareness of advances in neuroscience and brain research 

• Research on the nervous system has advanced understanding of genetic brain development, neurological disorders, neurotransmitters, cytokines, and neuroimaging techniques. It has also led to computational neuroscience, which combines computer modeling with laboratory research to better understand brain function and disease.

Surgeon General’s Report On Mental Health (1999)

• (1) mental health is fundamental to overall health and (2) there are effective treatments

Human Genome Project goals

• identify human genes, determine the sequence of 3 billion DNA base pairs, store and analyze genetic information, and improve research tools. 

• It also addressed the ethical, legal, and social issues related to genetic information.

President’s New Freedom Commission on Mental Health advocated for early diagnosis and treatment, adoption of principles of recovery, and increased assistance in helping people find housing and work

Institute of Medicine

• The 2005 Quality Chasm Series emphasized safe, effective, patient-centered, timely, efficient, and equitable mental health care, while addressing issues such as forced treatment and separating mental from physical health care. 

• The 2011 Future of Nursing report called for better-educated nurses trained in leadership, research, health policy, teamwork, and system improvement to meet the needs of a complex and diverse population.

Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative

• goal is to uncover new ways to prevent, treat, and cure psychiatric disorders, epilepsy, and traumatic brain injury

Research Domain Criteria (RDoC) Initiative

• challenges researchers to seek causes for mental disorders at the molecular level

Legislation and Mental Health Funding

• Mental Health Parity Act (1996) 

  • Parity = Equivalence

  • Required insurance companies to provide equal treatment coverage for psychiatric disorders

• Wellstone-Domenici Parity Act (2008) 

• required group health plans with more than 50 employees to provide mental health coverage comparable to coverage for physical health conditions. 

• This included equal treatment of deductibles, copayments, out-of-pocket costs, and treatment limitations

• Patient Protection and Affordable Care Act (2010)

  • Coverage for most uninsured Americans through expanded Medicaid eligibility (for very poor)

  • Created health insurance exchanges to offer more choices

  • “Insurance mandate” for coverage 

Epidemiology of Mental Disorders

• Epidemiology, as it applies to psychiatric-mental health, is the quantitative study of the distribution of mental disorders in human populations

• Individuals may have more than one mental disorder or another medical disorder. The presence of two or more disorders is known as comorbidity

• High risk groups: Homelessness, Healthcare workers, genetic predisposition, Older adults (loneliness),  adolescence (social media), immigrants, 

Clinical Epidemiology

• Groups treated for specific mental disorders studied for

  • Natural history of illness: no treatment and left to run its course 

  • Diagnostic screening tests

  • Observations and experimental studies of Interventions

• Results used to describe frequency of

  • Mental disorders

  • Symptoms appearing together

Case Study: Question 1

One of Mrs. M’s complaints is about insurance. Which of the following does the Mental Health Parity Act provide?

1. Coverage for most uninsured Americans through expanded Medicaid eligibility 

2. Health insurance exchanges 

3. “Insurance mandate” for coverage 

4. Equal coverage for mental health disorders

Equal coverage for mental health disorders

Classification of Mental Disorders

• The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition

  • Official medical guidelines of the American Psychiatric Association for diagnosing psychiatric disorders

  • Based on specific criteria influenced by multiprofessional clinical field trials

  • DSM-5 is the dominant method of categorizing and diagnosing mental illness in the United States and is the framework for clinical disorders in this textbook

DSM-5

• identifies and classifies mental disorders using specific diagnostic criteria and is used across various healthcare settings. 

• It also helps collect epidemiological data on psychiatric disorders

• classifies mental disorders, not people, so healthcare professionals should avoid stigmatizing labels. Instead, use person-first language, such as “an individual with schizophrenia” or “a patient with major depressive disorder.”

International Classification of Diseases ICD-10-CM

• ICD-10-CM

  • International Classification of Diseases, 10e

• Clinical descriptions of mental and behavior disorders 

  • 2 broad classifications

  • Subclassifications

Psychiatric Mental Health Nursing

• Promoting mental health through assessment, diagnosis, and treatment of behavioral and mental disorders

• Use nursing, psychosocial, neurobiological theories and research

• Work with people throughout the life span

• Employed in a variety of settings and among varied populations

Classification of Nursing Diagnoses

• International Classification for Nursing Practice (ICNP) 

  • Developed by the International Council of Nurses (ICN)

  • Provides standardized nursing diagnoses

Psychiatric-Mental Health Nurse Education Levels 

• Basic Level

  • Psychiatric mental health registered nurse (PMH-RN)

  • 2 years full-time work, 2000 clinical hours, 30 hours continuing education, followed by certification exam to add “BC” to the RN title (RN-BC)

• Advanced Practice

  • Psychiatric-mental health advanced practice registered nurse (PMH-APRN)

  • Master of Science (MSN) or Doctor of Nursing Practice (DNP)

Trends Impacting Psychiatric-Mental Health Nursing

• Educational challenges of how long patients are being cared for versus needed more skilled nurses (plus clinical placements difficulties) 

• Demand for mental health professionals

• Aging population grows 

• Cultural competence maintenance and improvements 

• Legal and ethical implications of Science, technology, and electronic healthcare

• Advocacy & legislative involvement of HIPPA, higher-authority immediate action, being active in consumer mental health groups/awareness of current mental health legislation 

PSYCHOANALYTIC THEORY (1 OF 3) 

• Freud’s Levels of Awareness - Iceberg

  • Conscious

    • Contains all the material a person is aware of at any one time

  • Preconscious

    • Contains material that can be retrieved rather easily through conscious effort

  • Unconscious

    • Includes all repressed memories, passions, and unacceptable urges lying deep below the surface

PSYCHOANALYTIC THEORY (2 OF 3) 

• Personality structure

  • Id (at birth) - unconscious/impulsive 

    • Pleasure principle

    • Reflex action

    • Primary process

  • Ego (first few years of life) - all levels of awareness 

    • Problem solver

    • Reality tester

  • Superego (3-5 yrs old) - all levels of awareness 

    • Moral component

    • contains the internalized “shoulds” and “should nots” learned from parents and society. It can cause guilt when behavior falls short of expectations and pride when behavior meets ideals.

PSYCHOANALYTIC THEORY (3 OF 3) 

• Defense mechanisms and anxiety

  • Operate on unconscious level

  • Deny, falsify, or distort reality to make it less threatening

  • Ward off anxiety by preventing conscious awareness of threatening feelings

FREUD’S PSYCHOSEXUAL STAGES OF DEVELOPMENT

• Oral (0 to 1 year)

• Anal (1 to 3 years)

• Phallic (oedipal) (3 to 6 years) 

• Latency (6 to 12 years)

• Genital (12 years and beyond)

CLASSICAL PSYCHOANALYSIS

• Seldom used today

• Intrapsychic conflict no longer considered to be the cause of all mental illness

  • Free association

  • Dream analysis

  • Defense mechanism recognition

• Valid tools and concepts

  • Transference: unconscious feelings of patient toward a healthcare worker that were originally felt in childhood for significant other 

  • Countertransference: unconscious feelings that healthcare worker has toward the patient

PSYCHODYNAMIC THERAPY

• Freud’s theory emphasizes how childhood experiences and unconscious influences shape personality and behavior. 

• Nurses can use this understanding to identify underlying causes of patient distress and provide support, education, and attentive listening to promote emotional well-being.

INTERPERSONAL THEORY

• Purpose of all behavior is to get needs met through interpersonal interactions and to reduce or avoid anxiety

  • Anxiety: painful feeling or emotion that arises from social insecurity or prevents biological needs from being satisfied 

  • Security operations: measures the individual employs to reduce anxiety and enhance security

  • Self-system: all of the security operations an individual uses to defend against anxiety and ensure self-esteem 

Interpersonal therapy is most effective in treating: 

• Grief and loss

• Interpersonal disputes with significant other 

• Role transition in life status/social role 

IMPLICATIONS OF INTERPERSONAL THEORY TO NURSING

• Foundations: Hildegard Peplau

  • Nurse as both participant & observer

    • Self-awareness helps keep focus on patient and make positive changes (keep nurses’ needs out of the equation) 

  • Application of Sullivan’s theory of anxiety (differ levels) to nursing practice

  • Lowering patients’ anxiety improves ability to think and function

BEHAVIORAL THEORY (1 OF 2)

Pavlov’s classical conditioning theory

• Pairing a behavior with a condition that reinforces/diminishes the behavior’s occurrence 

• Dog, bell, and food 

-Watson’s behavioral theory: controlling environment could mold behavior 

-Skinner’s operant conditioning theory: Learning that occurs through rewards and punishment for voluntary behavior (positive/negative reinforcement) 

• Extinction decreases a behavior by withholding a reward or reinforcement that previously encouraged it. For example, ignoring attention-seeking behavior can make the person less likely to repeat it.

• Implications for nursing

  • Modifying or replacing behaviors

  • Behavior management

BEHAVIORAL THEORY (2 OF 2) - modeling types

• Modeling for specific identified behaviors 

• Operant conditioning is the basis for behavior modification and uses positive reinforcement to increase desired 

• Exposure therapy for people who experience anxiety due to fears, phobias, or traumatic memories by exposing them to their fears 

• Aversion therapy is pairing a target behavior with a negative stimulus 

• Biofeedback is another form of behavioral therapy and help with body’s physiological response to stress and anxiety 

COGNITIVE THEORY AND THERAPIES

• Dynamic interplay between individuals and the environment

• Thoughts come before feelings and actions

• Thoughts about the world and our place in it are based on our own unique perspectives, which may or may not be based on reality.

RATIONAL-EMOTIVE THERAPY (ELLIS)

• Aims to eradicate irrational beliefs

• Recognize thoughts that are not accurate 

ABC

• A: Activating event 

• B: Beliefs about the event 

• C: Emotional consequences as a result of the event  

COGNITIVE BEHAVIORAL THERAPY (BECK)

• Active, directive, time-limited, structures approach

• Identify and test distorted beliefs and change way of thinking; reduce symptoms

• Ellis noted that, although we cannot change the past, we can change the way we are now

-Automatic thoughts are rapid, unthinking responses that can involve irrational cognitive distortions, which are common in disorders such as depression and anxiety.

-Cognitive behavioral therapy (CBT) helps patients identify, challenge, and replace distorted or negative thoughts with more realistic and positive ones.

-Homework, such as thought records, helps patients identify situations, emotions, automatic thoughts, and alternative interpretations to change unhealthy thinking patterns.

TRAUMA-FOCUSED COGNITIVE BEHAVIORAL THERAPY (TF-CBT )

• Newer treatment developed to address sexual abuse trauma in children; expanded for all ages 

• Short-term, incorporating caregivers and family therapy

• Helps children and adolescents identify feelings and how to manage them

DIALECTICAL BEHAVIORAL THERAPY (1 OF 2)

• Long-term therapy (1 to 1.5 years) that uses strategies from CBT and other skills to enhance emotional regulation

• Integration of opposites – dialectical strategies help the patient (and the therapist) to give up extreme positions

• Developed for individuals with intractable behavioral disorders involving emotional dysregulation

• Employs CBT elements

  • Mindfulness

  • Distress tolerance

  • Interpersonal effectiveness

  • Emotional regulation

IMPLICATIONS OF COGNITIVE THEORIES FOR NURSING

• Recognizing the interplay between events, negative thinking, and negative responses

• Helping the patient identify negative thought patterns

-Nurses can help patients identify negative thought patterns and cognitive distortions, using tools such as workbooks to support this process. 

-The cognitive approach also helps nurses recognize their own distorted thoughts, such as overgeneralizing or personalizing difficult situations. 

-Nurses should challenge negative thoughts that are not based on facts and replace them with more realistic and accurate perspectives.

THEORY OF HUMAN MOTIVATION

• Asserts that psychology must go beyond experiences of hate, pain, misery, guilt, and conflict to include love, compassion, happiness, exhilaration, and well-being 

• Human beings are active participants in life, striving for self-actualization

• When lower needs are met, higher needs are able to emerge

MASLOW’S HIERARCHY OF NEEDS

• Human beings are active participants in life, striving for self-actualization

• When lower needs are met, higher needs are able to emerge

  • Physiological needs

  • Safety (security, protection, stability, structure, order, limits)

  • Belonging and love needs

  • Esteem needs (competency, achievement, esteem from others) 

  • Self-actualization: one's potential is fully realized

  • Self-transcendence: personality trait that involves the expansion or evaporation of personal boundaries

IMPLICATIONS OF MOTIVATION THEORY FOR NURSING

• Emphasis on human potential and the patient’s strengths

• Prioritizing: establishes what is most important in the sequencing of nursing actions

• Following Maslow’s model as a way of prioritizing actions, the nurse meets the patient’s physiological need for stable vital signs and pain relief before collecting general information for a nursing database.

BIOLOGICAL MODEL

• Focus on 

  • Neurological

  • Chemical

  • Biological

  • Genetic

• How the body and brain interact to create

  • Emotions

  • Memories

  • Perceptual experiences

• Consider other influences that play a role in the development and treatment of mental disorders

  • Social, environmental, cultural, economic

• Focus on

  • Qualities of a therapeutic relationship

  • Understanding patient’s perspective

  • Communicating to facilitate recovery

BIOLOGICAL THERAPIES

• Pharmacotherapy

  • Use of medication to treat psychiatric illness

• Neuromodulation

  • Electroconvulsive therapy (ECT)

  • Transcranial magnetic stimulation—repetitive (TMS)

  • Vagus nerve stimulation (VNS)

  • Deep brain stimulation (DBS)

• Brain Stimulation therapies: focused electrical stimulation of brain to treat psychiatric and neurological disorders 

IMPLICATIONS THE BIOLOGICAL MODEL FOR NURSING

• Physical needs and physical care in psychiatric nursing are part of a holistic approach to healthcare. 

• Focusing on the qualities of a therapeutic relationship, understanding the patient’s perspective, and communicating in a way that facilitates the patient’s recovery take place alongside physical care

• Psychiatric nurses administer medications and monitor patients’ sleep, activity, nutrition, hydration, elimination, and other physical needs. They also prepare patients for somatic therapies such as ECT. Overall, psychiatric nursing provides holistic care that addresses both physical and mental health needs.

DEVELOPMENTAL THEORIES

• Cognitive development (Piaget)

  • Sensorimotor stage: basic reflexes to purposeful movement and coordination, with object permanence emerging around 9 months as infants learn that objects continue to exist even when they cannot see them

  • Preoperational stage: children think logically about specific objects but struggle with abstract thinking, egocentrism, and conservation, such as believing a tall, thin glass holds more liquid than a short, wide glass

  • Concrete operational stage: children develop logical and abstract thinking, can understand others’ perspectives, and solve problems using multiple solutions. They also develop conservation, classification, sequencing, and reversibility skills.

  • Formal operational stage: During adolescence, conceptual and abstract reasoning develops around puberty, allowing the child to think, problem-solve, and reason in ways similar to an adult. 

• Theory of psychosocial development (Erikson)

  • Eight stages of development: successfully completing each developmental stage leads to a positive outcome and helps individuals progress to the next stage, while failure can lead to negative outcomes. 

• During industry versus inferiority (ages 7–12), children develop competence and peer relationships, resulting in confidence if successful or feelings of failure and inferiority if unsuccessful

Personality continues to develop through old age

• Theory of object relations (Mahler)

  • Past relationships influence sense of self and present relationships

  • The term object refers to another person, particularly a significant person

  • During the first 3 years, a caregiver provides a secure base that helps the child feel safe while developing independence and exploring the environment. 

  • Consistent support, reassurance, and “good enough parenting” promote healthy separation-individuation.

STAGES OF MORAL DEVELOPMENT (KOHLBERG)

• Preconventional Level

  • Stage 1: Obedience & punishment = following rules and obeying authority to avoid punishment

  • Stage 2: Individualism & exchange = Individuals recognize that people may have different perspectives and views of rules, but breaking rules can still result in punishment

• Conventional Level

  • Stage 3: Good interpersonal relationships = Children begin to judge right and wrong based on a person’s intentions, personality, and character, while valuing harmony and shared values with others.

  • Stage 4: Maintaining social order = Individuals follow rules to maintain social order, rather than simply to avoid punishment. They recognize the importance of authority, laws, and societal structure.

• Postconventional Level

  • Stage 5: Social contract & individual rights = value social order but believe that laws should be fair and protect people’s rights. If laws are unjust or corrupt, they believe they should be changed to promote justice and protect others

  • Stage 6: Universal ethical principles = actions should promote justice and fairness for everyone, even if that means breaking unjust laws

ETHICS OF CARE THEORY (GILLIGAN)

• Worked with Kohlberg

• Later criticized his work as favoring males

• Suggests that a “morality of care” should replace Kohlberg’s “justice view” of morality

• Emphasizes relationships, banding together

• Emphasizes putting the needs of those for whom we care above the needs of strangers

• Ties progress to personal development and sense of self more than cognition

CONCEPTS CENTRAL TO THE NURSE–PATIENT RELATIONSHIP

Patient-Centered Care

• Dignity and respect

• Information sharing

• Patient and family participation

• Collaboration in policy and program development

• Clear and appropriate boundaries

THERAPEUTIC USE OF SELF

• Safe, confidential, reliable, and consistent 

• Use personality consciously and in full awareness

• Attempt to establish relatedness

• Structure nursing interventions

IMPORTANCE OF TALK THERAPY

• Advanced practice registered nurses 

• Based on psychotherapy

• Changes brain chemistry in much the same way as medication. 

• Best treatment for most psychiatric problems: a combination of medication and psychotherapy 

• Basic-level psychiatric mental health nurses uses counseling with a supportive face-to-face process that help individuals problem solve, resolve personal conflicts, and feel supported 

GOALS AND FUNCTIONS of theraputic relationship

• Facilitate communication of distressing thoughts and feelings

• Assist patient with problem solving

• Help patient examine self-defeating behaviors and test alternatives

• Promote self-care and independence

-Provide education about disorders and treatments

-Uses recovery which that begins with diagnoses and eventual management of psychiatric condition with patient being involved in their care with increasing daily and social support 

Differ RELATIONSHIPS

PERSONAL RELATIONSHIPS

• Initiated for the purpose of friendship, socialization, enjoyment, or accomplishment of a task

• Mutual needs are met

• Communication to give advice, give, or ask for help

• Content of communication superficial 

THERAPEUTIC RELATIONSHIPS

• Needs of patient identified and explored

• Clear boundaries established

• Problem-solving approaches taken

• New coping skills developed

• Behavioral change encouraged

• Clinical supervision between instructor and nursing student 

• Therapeutic encounter when nurse and patient have met few times only  

RELATIONSHIP BOUNDARIES & ROLES

• Boundary crossings: least serious form of over-involvement where something is not right and does not violate ethical standards (self-awareness and supervision can correct these types of behaviors) 

-Two common circumstances in which boundaries are crossed are (1) when the relationship slips into a personal context and (2) when the nurse’s needs (for attention, affection, and emotional support) are met at the expense of the patient’s needs.

• Boundary violations: reversal of roles where the needs of the nurse are being met rather than the needs of the patient

BLURRING OF ROLES

Transference

• Patient unconsciously and inappropriately displaces onto nurse feelings and behaviors related to significant figures in patient’s past

Countertransference

• Nurse unconsciously displaces feelings related to significant figures in the nurse’s past onto the patient 

Countertransference—nurse displaces feelings related to people in nurse’s past onto patient 

• Patient’s transference to nurse often results in countertransference in nurse

• Common sign of countertransference in nurse is overidentification with the patient 

• Recognizing and addressing transference and countertransference is important for professional growth and helping patients achieve their goals. Peer or team supervision can provide support in managing these issues and improving therapeutic relationships.

A FOCUS ON SELF-AWARENESS

Nurse’s values and beliefs

• Values: abstract standards and represent an ideal, either positive or negative 

• Beliefs: An opinion that something you hold to be true, confidence, trust, or faith, and religious tenets, creed, or faith 

• Reflect own culture/subculture

• Derived from range of choices

• Chosen from a variety of influences and role models

PEPLAU’S MODEL OF NURSE–PATIENT RELATIONSHIP

Preorientation phase

• Before meeting a psychiatric patient, nurses should review the patient’s information, recognize their own feelings, and follow safety guidelines to provide effective and safe care

Orientation phase

• first meeting between the nurse and patient, where the nurse conducts an initial interview and helps the patient express thoughts and feelings, identify problems, and establish realistic goals

• Introduction, establishing rapport, specifying a contract, and explaining confidentiality 

Working phase

• Nurses and patients identify problems, develop healthier coping behaviors, manage symptoms, and work toward goals. 

• The nurse also provides education about the disorder, medications, and treatments while evaluating the patient’s progress

Termination phase 

• Final stage of the nurse-patient relationship, where the nurse reviews goals, education, coping strategies, progress, and plans for follow-up care. 

• It also provides closure and an opportunity to address feelings about separation, while reinforcing medications, symptom management, and available support resources.

PREORIENTATION PHASE

• Preparing for your assignment 

  • Researching the patient’s history

  • Recognizing one’s own thoughts and feelings about meeting this patient

  • Anticipating and setting ground rules before the first meeting

ORIENTATION PHASE

• Establishing rapport

• Parameters of the relationship

• Formal or informal contract

• Confidentiality

• Terms of termination

WORKING PHASE

Maintain relationship

Gather further data

Promote patient’s

• Problem-solving skills

• Self-esteem

• Use of language

• Facilitate behavioral change

• Overcome resistant behaviors

• Evaluate problems and goals

  • Redefine them as necessary

• Promote practice and expression of alternative adaptive behaviors

TERMINATION PHASE

• Summarize goals and objectives achieved

• Discuss ways for patient to incorporate new coping strategies learned

• Review situations of relationship

• Exchange memories

FACTORS THAT PROMOTE PATIENTS GROWTH

• Genuineness (open, honest, and authentic interactions) 

• Empathy (not sympathy): understanding the feelings of others that conveys respect, acceptance, and validation of the patient’s strengths 

• Positive regard: Respect a person and viewing another person as being worthy of caring about and as someone who has strengths and achievement potential 

  • Attitudes

  • Actions

  • Attending (special kind of listening that refers to an intensity of presence or being with the patient 

• Suspending value judgments

-(1) recognize their presence, (2) identify how or where you learned these responses, and (3) construct alternative ways to view the patient’s thinking and behavior.

• Helping patients develop resources

Theoretical Models of Communication

• Wrong things: Personal info, playing down their feelings, false reassurance, etc

Therapeutic Communication benefits

Benefits to The Patient

• Feeling safer and protected

• More satisfied with the care

• Increased recovery rates

• Improved adherence to treatment 

The Transactional Model

• Communicators: Sender and receiver roles are fluid and interdependent; communication requires both parties to participate. 

• Message: The ideas or information being exchanged, including verbal and nonverbal cues such as tone and body language. 

• Channel: The method used to communicate, such as in person or telepsychiatry. 

• Feedback: Responses exchanged continuously between both communicators. 

• Encoding/Decoding: Encoding means creating a message; decoding means interpreting its meaning. 

• Context: Factors that influence communication: Social: Rules and norms for interaction. 

• Relational: Relationship history and type. Cultural: Cultural identity and background that influence communication. 

• Environmental Noise: Barriers that interfere with communication: 

• Physical: Loud noises, music, or announcements. 

• Physiological: Illness, pain, headache, or fatigue. 

• Psychological: Stress, worries, or lack of desire to communicate.

Peplau’s Interpersonal Theory

• Guiding Principles in Communication

• Clarity: Ensures that the meaning of the message is accurately understood by both parties (can you repeat what you said, can you rephrase what you said, etc) 

• Continuity: Promotes connections among ideas, feelings, events, and themes 

Factors That Affect Communication

Personal factors

• Depression: not thinking clearly 

• Cognition: learning disability

• Language/cultural barriers

Environmental factors

• The setting (privacy, place to talk) 

Relationship factors

• Level of equality within the relationship (openness to talk to equal the leveling field)  

Types of Communication 

Verbal Communication 

• All words a person speaks

• Communicates

• Beliefs and values

• Perceptions and meaning 

• Can convey

• Interest and understanding

• Insult and judgment

• Clear or conflicting messages

• Honest or distorted feelings

Nonverbal Communication 

• Tone of voice (important, instill an understanding that you are calm, focused, engaged, etc) 

• Emphasis on certain words

• Physical appearance

• Facial expressions

• Body posture

• Amount of eye contact

• Hand gestures

Interaction of Verbal and Nonverbal Communication

• Messages can appear to be one thing when in fact they are another.

• People are often less aware of their nonverbal messages and behaviors.

• Verbal messages can be called the content, while the nonverbal behavior is the process.

• Double-bind messages: Mutually contradictory messages, usually given by a person in power.

Therapeutic Communication Techniques vs non

Therapeutic Communication Techniques

• Silence

• Active listening

• Clarifying techniques: Paraphrasing, restating, reflecting and exploring 

• Questions

• Open-ended

• Closed-ended

• Projective (what if) 

• The miracle question

Nontherapeutic Communication Techniques

• Excessive questioning

• Giving approval or disapproval (noo noo nooo, be objective) 

• Giving advice

• Asking “why” questions (keep them open-ended)

Cultural Considerations

• Communication styles: Cultural differences can influence how emotions are expressed and interpreted, as expressive body language may be viewed as normal in some cultures but as distress or pathology in others

• Use of eye contact: nurses should not assume that avoiding eye contact means disinterest, dishonesty, or disrespect. Direct eye contact may be viewed as respectful, disrespectful, aggressive, or inappropriate depending on the person’s culture and circumstances

• Perception of touch: provide warmth, support, and comfort, but its meaning varies by culture, individual, gender, and personal experiences. Nurses should respect boundaries and follow facility “no-touch” policies, especially when caring for children or adolescents with a history of inappropriate touch

• Cultural filters: influence how we listen and interpret information, which can introduce personal and cultural biases. Recognizing that people have different perspectives, beliefs, and behaviors helps nurses reduce bias and improve cultural understanding and communication

Information Communication Technologies

• Information communication technology and telehealth improve access to psychiatric care by providing current health information and remote services, especially for people facing stigma, limited providers, or transportation barriers

Information Communication Technologies (2 of 4)

• Telehealth Technologies

• Video conferencing

• Internet sources

• Phone consultation and counseling

• Image transmission

• Interactive video sessions 

Information Communication Technologies (3 of 4)

• Mobile Applications

• Monitor, diagnose, treat, and communicate with patients

• Mobile phones are used at a high rate

• Many quickly adoptable apps available

• More research is needed

• SAMHSA free apps for suicide prevention, bullying prevention, and underage drinking prevention 

Information Communication Technologies (4 of 4)

• Some Concerns

• Privacy and confidentiality issues

• Lack of data for efficacy and safety

• Liability issues 

• Research is needed to evaluate risks versus benefits

• Professional and ethical guidelines needed

The Counseling Session

• Preparing for the session

-Pace: Match the patient’s pace; allow more time for slowed thinking and use shorter, more frequent sessions for mania.

-Setting: Choose a quiet, private, and safe environment that promotes comfort and security.

-Seating: Sit or stand at the same level as the patient, maintain comfortable positioning, and ensure the patient is not between the nurse and the exit for safety. 

• Introductions then use open ended questions with appropriately offering leads (e.g., “Go on”), making statements of acceptance (e.g., “Uh-huh”), or otherwise conveying interest

• Tactics to Avoid

• Behaviors that support counseling

Tactics to Avoid

Behaviors that Support Counseling: Attending Behaviors

• Kinesic communication is a type of nonverbal communication made by body movement. Facial expressions, body posture, and gestures are all kinesic types of communication

• Paralanguage refers to nonverbal aspects of speech, such as volume, pitch, rate, and fluency, which can show empathy, build rapport, and emphasize meaning

Evaluation of Communication Skills

• Debriefing is a structured conversation and reflection after an experience that promotes learning, growth, and clinical understanding by connecting knowledge with how and why it is applied

Process Recording

• Reviewing clinical interactions helps nurses identify communication patterns, improve interviewing skills, and prepare for different situations that may arise during patient interactions