Psychiatric Mental Health Module 1

What is mental health?

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

What is mental illness?

Refers to all mental disorders with definable diagnoses and includes developmental, biological, and psychological disturbances in mental function.

Mental Health Continuum Scale

JUST MEMORIZE THIS OKAY!

Diathesis-Stress Model

Combination of genetic vulnerability and negative environmental stressors.

• Diathesis is biological predisposition and stress is environmental.

• Diathesis-stress model is most accepted explanation for mental illness.

• Example: Oxygen is diathesis, stress is the spark, & fire is the psychological event.

Risk Factors

• Inborn vulnerability (genetically-influenced predisposition).

• Poor social environment.

• Economic hardship.

• Poor health policy.

Protective Factors

• Resiliency - improve a person’s ability to respond to stress, trauma, and loss.

• Essential to recovery.

Occurence of Mental Disorders

• Epidemiology: Study of the distribution of mental disorders.

• Incidence: # of new cases in a given time.

• Prevalence: # of cases regardless of when they began.

• Lifetime Risk: Risk of developing a disease during lifetime.

Influences on Mental Health Care

• Legislation and Funding: Mental Health Parity Act and Patient Protection & Affordable Care Act.

• Social Support and Organization: Mental health recovery

  • EX: NAMI (National Alliance on Mental Illness).

Mental Health Diagnoses

DSM-5

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

• Official medical guidelines of the American Psychiatric Association.

• Diagnoses mental health disorders following standard criteria.

Psychiatric Mental Health Nursing

Promote mental health using nursing process.

• Use holistic approach to care for clients - biological, social, spiritual, and psychological.

• Care based on standards set by the:

  • American Nurses Association

  • American Psychiatric Nurses Association

  • International Society of Psychiatric-Mental Health Nurses

Levels of Education for Psych Nurses

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 Affecting the Future

• Educational challenges

• Demand for mental health professionals

• Aging population

• Cultural diversity

• Science, technology, and electronic healthcare

• Advocacy and legislative involvement

Psychoanalytic Therapy

• Developed by Signmund Freud.

• Classic psychoanalysis rarely used.

• Intrapsychic conflict thought to be cause for all mental illness (3-5x/wk, expensive)

• Purpose: Uncover unconscious conflicts

  • Free association

  • Dream analysis

  • Defense mechanism recognition

Transference & Countertransference in Psychoanalytic Theory

Transference: The client unconsciously projects feelings about significant people in their life onto the therapist.

Countertransference: This is the therapist’s emotional reaction to the client, which may relate to a triggering of the therapist’s own unresolved issues

Psychodynamic Theory

• Similar to psychoanalytic therapy.

• Difference is increased involvement of therapist, interacts with patient more than traditional psychoanalysis.

• Weekly sessions (may be >20 sessions).

• Focus on here and now, and not origin of conflict.

• Best candidates are relatively health, “worried well".”

Interpersonal Theory

Short-term therapy to improve interpersonal functioning and satisfaction with social relationships.

• Goal to decrease symptoms of anxiety or depression.

• 3 types of problems treated:

  • Grief and loss

  • Interpersonal disputes

  • Role transition

Behavioral Therapy

Behavior Management - modifying or replacing behaviors.

• 5 Types of Behavior Therapy

  • Modeling - therapist as role model.

  • Operant Conditioning - Positive rewards for positive behaviors.

  • Exposure & Response Prevention: Face fears and emotionally process them in safe environment.

  • Aversion Therapy - Negative stimulus on behavior to stop the behavior.

  • Biofeedback - Controlling body’s physiological response to stress and anxiety.

Cognitive Behavioral Therapy

CBT based on cognitive psychology and behavioral therapy.

• Focuses on changing thinking and behaviors to improve emotional regulation.

• 3 Phases:

  • Thoughts: What we think affects how we feel and act.

  • Behaviors: What we do affects how we think and feel.

  • Emotions: What we feel affects how we think and act.
    

Trauma Informed Care

• Recognizing trauma can affect people and groups.

• Knowing signs and responses to trauma.

• Avoid re-traumatization.

• Goal is providing safe environment - physically and psychologically and building trust.

Trauma-Focused CBT (TF-CBT)

• Short-term treatment combines trauma-sensitive interventions with CBT.

• Usually for children, includes family therapy.

• Helps identify negative thoughts and replace with more positive thoughts.

Dialectical Behavioral Therapy (DBT)

• Long-term therapy (1-1.5 yrs)

• Uses strategies from CBT

• Developed for individuals with intractable behavioral disorders involving emotional dysregulation.

• Effective treatment for depression, suicidal thoughts, hopelessness, anger, substance use, and dissociation

Humanistic Theories: Maslow’s Hierarchy of Needs

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

• When lower needs are met, higher needs can emerge.

Biological Model

• Medical model assumes that abnormal behavior is from a physical problem.

• Recognizes that mental disorders are physical in origin (like diabetes, heart disease, etc.)

• Focuses on neurological, chemical, biological, genetic.

• Locates illness or disease in body.

Biological Therapies - Pharmacotherapy

• Uses medication to treat psychiatric illness.

• 1st psych meds.

• Chlorpromazine (Thorazine) and Lithium.

• Psychotropic medication effective for treating psychosis, mania, depression, and anxiety.

Biological Therapies - Brain Stimulation Therapies

• All methods involve focused electrical stimulation of brain.

• Types of brain stimulation therapies

  • Electroconvulsive therapy (ECT)

  • Transcranial magnetic stimulation - repetitive (rTMS)

  • Vagus nerve stimulation (VNS)

  • Deep brain stimulation (DBS)

Developmental Theories

• Assess client’s developmental level.

• Helps determine what types of interventions are most likely to be effective.

• Examples of Developmental Theories:

  • Psychosocial Development = Erikson

    • 8 psychosocial life stages for personality development.

    • Personality evolves throughout life in consecutive stages.

  • Cognitive Development = Piaget

    • 4 cognitive stages.

Erikson’s Stages of Psychosocial Development

Piaget’s Stages of Cognitive Development

Outpatient Care Settings

• Primary care providers.

• Specialized psychiatric care providers

• Patient-centered medical homes (PCMHs)

  • Patient-centered

  • Comprehensive Care

  • Coordination of Care

  • Improved Access

  • Systems Approach

  • Community mental health centers

  • Psychiatric home care

  • Assertive community treatment (ACT)

  • Intensive outpatient programs and partial hospitalization.

  • Other outpatient venues for psychiatric care.

    • Telepsychiatry

    • Mobile mental health units

Emergency Care - Comprehensive Emergency Service Model

Dedicated psychiatric space and staff, often affiliated with a full-service emergency department (ED) in a hospital or medical center.

Emergency Care - Hospital-Based Consultant Model

No dedicated space or seperate staffing; psychiatric staff on-site or on-call for ED.

Emergency Care - Mobile Crisis Team Model

Stabalization in the field to assess and de-escalate.

Prevention in Outpatient Care - Primary Prevention

• Occurs before any problem appears.

• Seeks to reduce rate of new cases.

Prevention in Outpatient Care - Secondary Prevention

• Early identification of problems, screening, and prompt and effective treatment.

Prevention in Outpatient Care - Tertiary Prevention

• Treatment with a focus on preventing progression.

• Closely related to rehabilitation.

Inpatient Care Settings

• Crisis stabilization/observational units.

• General hospital and private hospitals.

• State psychiatric hospitals.

Inpatient Psychiatric Nursing Care

• Completing Comprehensive data collection that includes the patient, family, and other health care workers.

• Completing comprehensive data collection that includes the patient, family, and other health care workers.

• Developing, implementing, and evaluating plans of care.

• Assisting or supervising mental health care workers.

• Maintaining a safe and therapeutic environment.

• Facilitating health promotion through teaching.

• Monitoring behavior, affect, and mood.

• Maintaining oversight of restraint and seclusion.

• Coordinating care by the treatment team.

Rights of the Hospitalized Patient

1. Hospitalized patients retain their rghts as citizens.

2. Patient’s need for safety must be balanced against patient’s rights as a citizen

3. Mental Health facilities have written statements of patient’s rights and applicable state laws.

Teamwork and Collaboration

1. Members of each discipline are responsible for gathering data and participating in the planning of care.

2. Treatment plan or clinical pathway provides a guideline for patient’s care during hospital stay.

3. Nurse’s role is often to lead planing meetings.

4. For standardization in treatment and improved outcomes, inpatient unis use clinical pathways.

Therapeutic Milieu

• Surroundings and physical environment.

  • Managing behavioral crises.

  • Safety

  • Unit design

• Goals of unit design:

  • Promote an environment of safety and empower patients to partner with clinical staff and take ownership of their own health and safety.

Specialty Treatment Settings

• Pediatric psychiatric care

• Geriatric psychiatric care

• Veteran’s administration centers

• Forensic psychiatric care

• Alcohol and drug use disorder treatment

• Self-help options

Family Therapy

The focus is on the family as a system, rather than each person as an individual.

• Families can be health or dysfunctional in one or more areas of functioning.

Family Assessments

Include focused interviews and use of various family assessment tools.

Concepts Related to Family Dysfunction - Scapegoating

Family member with little power is blamed for all the problems within the family.

Concepts Related to Family Dysfunction - Triangulation

A third party is drawn into the relationship with two members whose relationship is unstable.

Concepts Related to Family Dysfunction - Multigenerational Issues

Emotional issues within a family that continues for at least three generations.

Areas of Functioning - Communication

• Healthy Families

  • Clear understandable messages between family members, and each member is encouraged to express individual feelings and thoughts.

• Dysfunctional Families

  • Blaming: Blame others to shift focus from own inadequacies.

  • Manipulating: Dishonest to support own agendas.

  • Placating: One member takes responsibility for problems to keep peace at all costs.

  • Distracting: Inserts irrelevant information during problem-solving.

  • Generalizing: Members use overall descriptions for a family encounters, such as “always” and “never.”

Areas of Functioning - Management

• Healthy Families

  • Adults of family agree on important issues, such as rule-making, finances, and plans for the future

• Dysfunctional Families

  • Management can be chaotic, with a child making decisions at times.

Areas of Functioning - Boundaries

• Healthy Families

  • Distinguishable family roles. Clear boundaries define roles of each member are understood by all

• Dysfunctional Families

  • Enmeshed boundaries: Individual roles are unclear because roles and feelings are blended.

  • Rigid boundaries: Rules are not flexible, family members isolate themselves, and communication is minimal.

Areas of Functioning - Socialization

• Healthy Families

  • All members interact, plan, and adopt healthy ways of coping. Children learn to function as family members, as well as members of society.

• Dysfunctional Families

  • Children do not learn healthy socialization skills within the family and have difficulty adapting in society.

Areas of Functioning - Emotional/Supportive

• Healthy Families

  • Emotional needs of family are met most of the time, and members have concerns about each other.

• Dysfunctional Families

  • Negative emotions most of the time. Members are isolated and afraid and do not show concern for each other.

Focus of Family Therapy

• Family needs and problems with family dynamics

• Improving family functioning

Goals of Family Therapy

• Learn effective ways for dealing with mental illness within the family.

• Improve understanding among family members.

• Maximize positive interactions among family members.

Interventions

• Family Psychoeducation

  • Nurses work with families to provide teaching.

  • EX: RN teaches a family on medication administration, or ways to help a family member manage their mental health disorder.

• Mobilize Family Resources

  • Improve communication and strengthen the family’s ability to cope with the illness of one member.

• Psychological Therapies

  • Role of psychiatric advanced practice nurse.

What is stress?

The brain’s natural response to any demand, can be physical or psychological stressors.

Stress Management

Ability to cope with stress.

• Too much stress or too many stressors can cause distress; stress causes anxiety.

• Effects of stressors are cumulative.

• Responses to stress are affected by multiple factors- age, gender, culture, life experiences, lifestyle.

Distress

Negative draining energy that results in anxiety, depression, confusion, helplessness, hopelessness, and fatigue.

Eustress

Normal physiological positive energy that motivates individuals and results in positive feelings and purposeful movement.

Defense Mechanism

Can be used to manage conflict in response to anxiety.

• Can be adaptive (healthy) or maladaptive (unhealthy).

• Examples of common defense mechanisms:

  • Suppression: Voluntarily deny unpleasant thoughts and feelings.

  • Repression: Unconsciously putting unacceptable thoughts and feelings out of awareness.

  • Regression: Sudden use of childlike behaviors.

  • Displacement: Shift feelings to another less threatening object, person, or situation.

  • Denial: Pretend the truth is not reality.

Signs of Acute Stress (Fight or Flight)

• Apprehension

• Unhappiness or sorrow

• Decreased appetite

• Increased respiratory rate, heart rate, cardiac output, blood pressure

• Increased metabolism and glucose use

• Depressed immune system

Prolonged Stress (Maladaptive Stress)

• Chronic anxiety or panic attacks

• Depression, chronic pain, sleep disturbances

• Weight gain or loss

• Increased risk for myocardial infarction, stroke

• Poor diabetes control, hypertension, fatigue, irritability, decreased ability to concentrate

• Increased risk for infection

• Chronic exposure to stress hormones, specific ally cortisol, weakens the immune system, resulting in increased susceptibility to illness and infection.

Protectie Factors

Increase a client’s resilience, or ability to resist the effects of stress.

• Physical health

• Strong sense of self

• Religious or spiritual beliefs

• Optimism

• Hobbies and other outside interests

• Satisfying interpersonal relationships

• Strong social support systems

• Humor

Stress Reduction Strategies

Cognitive Techniques

• Cognitive reframing - positive self-talk

• Behavioral techniques

  • Meditation - train mind for greater calm

  • Guided Imagery - guided through images to relax

  • Breathing exercises - decrease rapid breathing and promote relaxation

  • Progressive muscle relaxation - testing specific muscle groups and relaxing them

  • Physical exercise - yoga, walking, biking, etc.

Stress Reduction Strategies

• Priority Restructuring - Prioritize differently to reduce stressors.

• Biofeedback - track sleep and heart rates (i.e. device such as smart watch)

• Mindfulness - using senses to be mindful and positive of surroundings,

• Assertive training - learn to communicate in more assertive manner to decrease psychological stressors.

• Other - Music therapy, art therapy, pet therapy, journaling, etc.

Importance of Culturally Relevant Care in Psychiatric Nursing

• Increase in diverse population = psychiatric mental health nurses will care for more clients from diverse cultural groups.

• Immigrants (especially refugees) and minority groups, who may suffer from effects of low socioeconomic status (such as poverty, discrimination) are at risk for mental illness.

• Nurses should promote culturally competent and congruent care - apply evidence-based practice that corresponds with client values, beliefs, practices, and worldview.

Impact of Culture - Nonverbal Communication

• Each culture has different patterns of nonverbal communication.

• Eye contact, personal space, touch, facial expressions, and gestures.

Impact of Culture - Etiquette

• Rules for polite behavior vary between cultures

Impact of Culture - Beliefs and Values

• Enculturation - children learn from parents.

• Ethnocentrism - Universal tendency of humans to think their way of thinking and behaving is the only correct and natural way.

Cultural Barriers to Mental Health Services - Communication

• Interpreters help with language and cultural barriers.

• Interpreters should not be relatives or friends.

Cultural Barriers to Mental Health Services - Stigma of Mental Illness

• Mental illness may be associated with being weak, dangerous, or a failure.

• Stigma and shame can prevent client from seeking help.

Cultural Barriers to Mental Health Services - Misdiagnosis

• If culture has body and mind as one entity, somatization can occur (having physical problems for psychological distress).

Cultural Barriers to Mental Health Services - Cultural Concepts of Distress

• DSM-5 criteria of how groups experience, understand, and communicate problem behaviors, suffering, or troubling emotions and thoughts.

Cultural Barriers to Mental Health Services - Genetic Variation in PD

• How genes affect individual responses to medicines.

Culturally Congruent Care

• Applying EBP nursing care that corresponds with patient’s values, beliefs, and worldview (ANA).

Culturally Competent Care

• Process of demonstrating culturally congruent practice.

Cultural Awareness

Nurses recognize impact of culture on patient’s health values and practice.

Cultural Knowledge

Nurse learns about diverse cultures.

Cultural Encounters

Nurse interacts with patients from diverse cultures.

Cultural Skill

Nurse performs cultural assessment in a sensitive way.

Ethics

Study of philosophical beliefs about what is considered right or wrong in a society.

Bioethics

Used in relation to ethical dilemmas surrounds healthcare.

Ethical Dilemma

Conflict between two or more courses of action, each with favorable and unfavorable consequences.

Beneficience

The quality of doing good, can be described as charity.

Nonmaleficience

Doing no harm to the client.

Autonomy

Client’s right to make their own decisions. However, the client must accept the consequences of those decisions.

Justice

Fair and equitable treatment for all.

Fidelity

Loyalty and faithfulness to the client and to one’s duty.

Veracity

Honesty when dealing with a client.

Resources for Solving Ethical Client Issues

• Code of Ethics for Nurses

• Found at the American Nurse’s Association website

• Patient Care Partnership

  • Found at the American Hospital Association’s website

• Nurse Practice Act (state specific)

• Legal advice from attorneys

• Facility policies

• Other members of the health care team, including facility bioethics

committee (if available)

• Members of the clergy and other spiritual or ethical counselors

Voluntary Admission

• Admits self, consents to all treatment

• Can refuse treatment, including medications, unless a danger to self or others.

• Free to leave the hospital at any time, even against medical advice.

Involuntary Admission

• Client enters mental health facility against their will, based on the client’s need for psychiatric treatment, the risk of harm to self or others, or the inability to provide self-care.

• At the end of a specified time, the client must have a court hearing or be released.

• Criteria must include:

  • Presence of mental illness.

  • Poses a danger to self or others.

  • Demonstrates a severe disability or inability to meet basic necessities including food, clothing, and shelter.

  • Requires treatment but unable to seek it voluntarily related to the impact of the mental illness.

• Generally for 24-96 hours.

Temporary Emergency Admission

Admitted for emergent health care due to inability to make decisions regarding care; varied stay, less than 15 days.

Long-Term Involuntary Admission

Similar to temporary admission ut must be imposed by the courts. Usually 60-180 days, sometimes no set release date.

Marchman Act

• Applied to apprehension for substance abuse.

• Likelihood person will harm themselves or others.

Baker Act

The Florida Mental Health Act of 1971, lets people with mental illnesses be held against their will for a mental health check, called an examination, for up to 72 hours.

• Applied to apprehension for mental health care.

• Likelihood person will harm themselves or others.

Due Process in Involuntary Commitment

Writ of Habeas Corpus

• Used when patients believe they have been held without just cause.

• Challenges unlawful detention.

Least restrictive alternative doctorine

• Taking the least drastic or restrictive action.

• A nurse’s priority is to promote and provide care to a client in the least restrictive environment.

Discharge Procedures - Unconditional Release

Termination of the legal patient-institution relationship.

Discharge Procedures - Release Against Medical Advice (AMA)

A patient chooses to leave a hospital or healthcare facility before the medical team recommends discharge, despite understanding the risks, often due to personal reasons like cost, work, or feeling better, but this decision increases their risk of readmission and worsening illness.

Discharge Procedures - Conditional Release

Usually requires outpatient treatment for a specified period of time with follow-through evaluation.

Discharge Procedures - Assisted Outpatient Treatment

Similar to conditional release but court-ordered