mental health exam 1

stigma

negative attitudes, beliefs, or discrimination towards a person because of a mental health condition

effects of stigma

May cause clients to:

• Avoid treatment

• Feel ashamed or embarrassed

• Isolate themselves

• Have decreased self-esteem

• Delay seeking help

• Can contribute to poorer mental health outcomes.

adverse childhood experiences (ACE)

traumatic events occurring in childhood that may impact mental health

abuse, neglect, household dysfunction

ACEs can increase the risk for

• Mental health disorders

• Substance use

• Depression/anxiety

• Difficulty with relationships

• Chronic health conditions

• Poor coping

trauma informed care

• Promote safety

• Give the client choices

• Avoid unnecessary retraumatization

• Build trust

• Don't force disclosure of traumatic experiences.

social determinants of health

conditions in which people live, work, learn, and age that affect health

• Economic stability

• Education

• Health care access

• Neighborhood/environment

• Social/community relationships

social determinants of mental health

• Cannot afford medications

• Are homeless

• Lack transportation

• Are unemployed

• Have limited access to mental health services

• Lack social support

history of mental health

Mental illness was historically misunderstood and often associated with:

• Supernatural causes

• Punishment

• Possession

• Moral weakness

Treatment was often:

• Isolation

• Institutionalization

• Restraint

• Poor living conditions

modern mental health care

• Dignity

• Human rights

• Evidence-based treatment

• Community-based care

• Least restrictive interventions

• Recovery

inpatient mental health treatment

used when pt requires 24 hr monitoring/care

Examples:

• Severe suicidal risk

• Psychosis

• Severe mania

• Danger to self/others

• Unable to care for basic needs

Nursing priorities:

• Safety

• Assessment

• Medication

• Stabilization

• Structured environment

partial hospitalization program (PHP)

pt receives intensive treatment during the day but does not stay overnight

Useful for clients who:

• Need more support than outpatient care

• Do not require 24-hour hospitalization

home health

care occurs in the pt’s home

May involve:

• Medication management

• Mental health assessment

• Patient education

• Monitoring

• Connecting client with resources

goal: help the pt remain safely in the community

assertive community treatment (ACT)

provides intensive community based services for pts with severe/persistent mental illness

Services can include:

• Medication management

• Housing assistance

• Counseling

• Daily living support

• Crisis intervention

primary prevention

prevent the problem before it occurs

Examples:

• Mental health education

• Stress-management education

• Parenting education

• Suicide-prevention education

secondary prevention

identify and treat a problem early

Examples:

• Screening for depression

• Early identification of substance use

• Crisis intervention

tertiary prevention

reduce complications and promote recovery after the condition exists

Examples:

• Rehabilitation

• Relapse prevention

• Support groups

• Long-term treatment

milieu therapy

therapeutic environment

• Safety

• Trust

• Responsibility

• Social interaction

• Coping

• Independence

cultural competence

The nurse should recognize that culture can influence:

• Beliefs about mental illness

• Treatment preferences

• Communication

• Family roles

• Spirituality

• Expressions of distress

• Health-seeking behaviors

Avoid assumptions

Don't assume:

• Everyone from the same culture thinks the same way.

• A cultural behavior automatically represents a mental illness.

• Your own beliefs are the "correct" beliefs.

• best approach= ask the pt

therapeutic nurse-patient relationship

professional

nurses goal is to help the pt meet health goals

• Trust

• Respect

• Empathy

• Confidentiality

• Professional boundaries

• Client-centered care

stages of the nurse-patient relationship

1. preinteraction

2. orientation

3. working

4. termination

preinteraction

before meeting the pt

Nurse:

• Reviews available information

• Examines personal feelings/biases

• Prepares for interaction

orientation

nurse and pt meet

• Establish trust

• Establish roles

• Establish boundaries

• Identify problems

• Establish goals

working

major therapeutic work occurs

Nurse:

• Helps client identify problems

• Develops coping skills

• Works toward goals

• Provides interventions

termination

the relationship ends

Nurse:

• Reviews progress

• Discusses feelings about termination

• Reviews future plans

• Reinforces coping strategies

transference

the pt transfers feelings about another person onto the nurse

countertransference

the nurse transfers personal feelings onto the pt

barriers to therapeutic communication

• giving advice

• asking why

• false reassurance

• changing the subject

• minimizing

• judging

• approving/disapproving

therapeutic communication techniques

• broad openings

• reflection

• restating

• clarification

• silence

• focusing

• exploring

• offering self

confidentiality

nurse can not disclose pt information to unauthorized people

Confidentiality can be limited when required by law, such as situations involving:

• Serious threat of harm

• Abuse/neglect reporting

• Court/legal requirements

involuntary admission

occurs when a pt is hospitalized without volunarily agreeeing when legal criteria are met

Usually associated with concerns such as:

• Danger to self

• Danger to others

• Severe inability to care for self

emergency hold

allows a person to be held for evaluation/treatment when legal criteria for an emergency psychiatric situation are met

It generally allows time for:

• Assessment

• Stabilization

• Psychiatric evaluation

• Determination of further treatment

against medical advice (AMA)

a competent pt generally has the right to refuse treatment or leave treatment

If client wants to leave AMA:

1. Assess client's understanding.

2. Explain risks of leaving.

3. Notify provider as appropriate.

4. Provide education.

5. Document the interaction.

6. Follow facility policy.

7. Don't threaten or force the client to stay unless legal criteria apply.

seclusion and restraints

last resort interventions

restraints are not punishment

Use only when:

• Less restrictive interventions have failed

• There is an immediate safety concern

• The intervention is clinically/legal appropriate

Before restraints/seclusion:

• Attempt less restrictive interventions.

• Assess safety.

• Follow provider orders and facility policy.

During:

• Monitor the client frequently.

• Assess circulation and physical/psychological status.

• Provide basic needs.

• Maintain dignity.

group therapy

• Interact with others

• Share experiences

• Practice communication

• Develop coping skills

• Receive feedback

• Reduce isolation

cognitive behavioral therapy (CBT)

Focus:
Thoughts → feelings → behaviors

Goal:
Identify and change unhealthy thought patterns.

behavioral therapy

Focuses on changing behaviors.

Techniques may include:

• Reinforcement

• Exposure

• Behavior modification

psychoanalytic/psychodynamic therapy

Focuses on:

• Unconscious thoughts

• Past experiences

• Conflicts

• Early relationships

family therapy

focuses on relationships and interactions within the family

useful when family dynamics affect the pt’s mental health

DSM-5

diagnostic and statistical manual of mental disorders 5th edition

it is used by mental health professionals to:

• Classify mental disorders

• Establish diagnostic criteria

• Guide diagnosis

autonomy

right to make your own decisions

beneficence

do good

nonmaleficence

do no harm

justice

treat people fairly

fidelity

keep promises/commitments

veracity

tell the truth

confidentiality

protect private information

assessment and screening

identifies mental health symptoms and risks

advocacy

protects pt rights and supports pt needs

guiding principles

holistic biopsychosocial-spiritual care

person-first/recovery-oriented/strengths based care

mental health exists on a continuum

safety is the first priority

trust vs. mistrust

0-1 yr

infancy

autonomy vs. shame/doubt

1-3 yr

toddler

initiative vs. guilt

3-6 yr

preschool

industry vs. inferiority

6-12 yr

school age

identity vs. role confusion

12-20 yr

adolescence

intimacy vs. isolation

20-40 yr

young adult

generativity vs. stagnation

40-65 yr

middle adult

integrity vs. despair

65+ yr

older adult

Id personality

unconscious

pleasure-seeking

wants immediate gratification

Ego personality

reality tester

mediates between the id and superego

deals with reality

Superego personality

morals

values

conscience

denial defense mechanism

refusing to accept reality

regression defense mechanism

returning to an earlier developmental behavior

projection defense mechanism

putting your own unacceptable feelings onto someone else

rationalization defense mechanism

creating a logical sounding explanation for behavior

displacement defense mechanism

redirecting feelings toward a safer target

sublimation defense mechanism

redirecting unacceptable impulses into an acceptable activity

reaction formation defense mechanism

acting opposite to one’s actual feelings

compensation defense mechanism

focusing on strengths to make up for perceived weaknesses

suppression defense mechanism

consciously choosing to push uncomfortable thoughts aside

repression defense mechanism

unconsciously blocking painful thoughts/memories

maslow’s hierarchy of needs

physiologic

safety

love/belonging

self-esteem

self-actualization

mental health parity and addiction equity act (MHPAEA)

2008

The basic idea is that mental health/substance-use benefits should receive parity with medical/surgical benefits in covered plans

affordable care act (ACA)

2010

associated with expanding access to health insurance and includes provisions affecting mental health and substance-use coverage

health care and education reconciliation act (HCERA)

2010

It was enacted alongside the ACA and is part of the legislation associated with health-care reform

public stigma

negative beliefs help by society

self stigma

person internalizes negative beliefs about their own condition

implicit bias

A person may have an unconscious association or attitude that influences behavior without realizing it

operant conditioning

behavior is influenced by its consequences

positive reinforcement

adding something desirable to increase behavior

negative reinforcement

remove something unpleasant to increase behavior

systematic desensitization

Gradual exposure to an anxiety-producing stimulus while using relaxation/coping

flooding

intense exposure to the feared stimulus

aversion therapy

pairs an unwanted behavior with an unpleasant stimulus

modeling

pt learns by observing another person

thought stopping/cognitive reframing

helps identify and change unhelpful thought patterns