Foundation In Psych

FOUNDATIONS OF PSYCHIATRIC MENTAL-HEALTH NURSING

PYRAMID POINTS • Phases of the nurse-client relationship • Therapeutic communication techniques and blocks to communication • Coping and defense mechanisms • Types of mental health admissions and discharges • Client rights

MENTAL HEALTH • DESCRIPTION – A lifelong process of successful adaptation to a changing internal and external environment – The individual is in contact with reality and the environment and possesses the ability to love, work, and resolve conflicts within a framework of reason – The individual has psychobiological resilience

MENTAL HEALTH ILLNESS • DESCRIPTION – Loss of the ability to respond to the environment in ways that are in accord with one’s own or society’s expectations – Characterized by thought or behavior patterns that impair functioning and cause the individual distress

MENTAL HEALTH ILLNESS • PERSONALITY CHARACTERISTICS – Is unaccepting of self and dislikes self – Has an unrealistic perception of strengths and weaknesses – Thoughts and perceptions may not be realitybased – Is unable to find meaning and purpose in life – Lacks direction and productivity in life – Has difficulty in meeting own needs – Depends on others for thought and actions

MENTAL HEALTH ILLNESS • ADAPTATIONS TO STRESS – Feels out of control with self and with the environment – Has a negative perception of the environment – Has ineffective coping mechanisms

MENTAL HEALTH ILLNESS • INTERPERSONAL RELATIONSHIPS – Is unable to love and care for others – Is unable to feel loved by others or accept feelings from others

COPING MECHANISMS • Coping involves any effort to decrease the stress response • Coping mechanisms can be either constructive or destructive in nature, task-oriented related to direct problemsolving, or can be a defense-oriented regulating response to protect oneself • Destructive coping mechanisms often cause a mental health disorder because the problem that causes the disorder is

DEFENSE MECHANISMS • A coping mechanism (protective defense) of the ego that attempts to protect the individual from feelings of inadequacy and worthlessness and prevent awareness of anxiety • When anxiety is too painful, the individual copes by using defense mechanisms to protect the ego and decrease anxiety

TYPES OF DEFENSE MECHANISMS • COMPENSATION – Putting forth extra effort to achieve in areas where one has a real or imagined deficiency

• CONVERSION – The expression of emotional conflicts through physical symptoms

• DENIAL – Disowning consciously intolerable thoughts and impulses

TYPES OF DEFENSE MECHANISMS • DISPLACEMENT – Feelings toward one person are directed to another who is less threatening, thereby satisfying an impulse with a substitute object

• DISSOCIATION – The blocking off of an anxiety-provoking event or period of time from the conscious mind

• FANTASY – Gratification by imaginary achievements and wishful thinking

TYPES OF DEFENSE MECHANISMS • FIXATION – Never advancing to the next level of emotional development and organization; the persistence in later life of interests and behavior patterns appropriate to an earlier age

• IDENTIFICATION – The unconscious attempt to change oneself to resemble an admired person

• INSULATION – Withdrawing into passivity and becoming inaccessible in order to avoid further

TYPES OF DEFENSE MECHANISMS • INTELLECTUALIZATION – Excessive reasoning to avoid feeling; the thinking is disconnected from feelings, and situations are dealt with at a cognitive level

• INTROJECTION – A type of identification in which the individual incorporates the traits or values of another into self

• ISOLATION – Response in which a person blocks feelings associated with an unpleasant experience

TYPES OF DEFENSE MECHANISMS • PROJECTION – Transferring one’s internal feelings, thoughts, and unacceptable ideas and traits to someone else

• RATIONALIZATION – An attempt to make unacceptable feelings and behavior acceptable by justifying the behavior

• REACTION FORMATION – Developing conscious attitudes and behaviors and acting out behaviors opposite to what one really feels

TYPES OF DEFENSE MECHANISMS • REGRESSION – Returning to an earlier developmental stage to express an impulse in order to deal with reality

• REPRESSION – An unconscious process in which the client blocks undesirable and unacceptable thoughts from conscious expression

• SUBLIMATION – Replacement of an unacceptable need, attitude, or emotion with one more socially acceptable

TYPES OF DEFENSE MECHANISMS • SUBSTITUTION – The replacement of a valued unacceptable object with an object that is more acceptable to the ego

• SUPPRESSION – The conscious, deliberate forgetting of unacceptable or painful thoughts, ideas, and feelings

TYPES OF DEFENSE MECHANISMS • SYMBOLIZATION – The conscious use of an idea or object to represent another actual event or object; many times the meaning is not clear because the symbol may be representative of something unconscious

• UNDOING – Engaging in behavior that is considered to be opposite of a previous unacceptable behavior, thought, or feeling

COPING AND DEFENSE MECHANISMS • IMPLEMENTATION – Assess the client’s use of the defense mechanism – Determine if the use of the defense mechanism characterizes unhealthy adjustment – Facilitate appropriate use of defense mechanisms

COPING AND DEFENSE MECHANISMS • IMPLEMENTATION – Avoid criticizing the behavior and the use of defense mechanisms – Assist the client to identify the source of the anxiety – Assist the client to explore methods to reduce the anxiety

THE NURSE-CLIENT RELATIONSHIP • PRINCIPLES – Respect the client and value the client as an individual – Care for the client in a holistic manner – Maintain appropriate limits – Remember that empathy is therapeutic and sympathy is nontherapeutic – Maintain honest and open communication – Encourage expression of the client’s feelings – Assist the client to develop resources

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PHASES OF THE THERAPEUTIC RELATIONSHIP ORIENTATION OR INITIATION PHASE – Establish boundaries and trust with the client – Identify the expectations of the relationship – Assess the anxiety in the client – Define goals with the client

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PHASES OF THE THERAPEUTIC RELATIONSHIP WORKING OR CONTINUATION PHASE – Promote an attitude of acceptance – Assist the client to express feelings – Identify problems – Continue to assess and evaluate problems – Promote insight and the use of constructive coping mechanisms – Increase the client’s independence

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PHASES OF THE THERAPEUTIC RELATIONSHIP TERMINATION OR SEPARATION PHASE

– Prepare the client for termination and separation on initial contact – Evaluate progress and achievement of goals – Identify and deal with termination and separation issues – Encourage the client to discuss feelings about termination – Transfer the client to other support systems – Do not promise the client that the relationship will be continued

THERAPEUTIC COMMUNICATION PROCESS • PRINCIPLES – Communication includes both verbal and nonverbal expression – Successful communication includes appropriateness, efficiency, flexibility, and feedback – Anxiety in either the nurse or client impedes communication – Communication needs to be goal-directed within a professional framework

From Varcarolis, E. (1998). Foundations of psychiatric mental-health nursing, ed 3, Philadelphia: W.B. Saunders.

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THERAPEUTIC COMMUNICATION TECHNIQUES

Listening Being silent Respecting the client Providing recognition and acknowledgment Providing feedback Offering to assist Focusing and refocusing Clarifying and validating

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THERAPEUTIC COMMUNICATION TECHNIQUES

Making observations Giving information Presenting reality Summarizing Using open-ended questions Provide nonverbal encouragement Maintaining neutral responses Encouraging formulation of plan of action

BLOCKS TO COMMUNICATION • • • • • • • • •

Giving advice Changing the subject Giving approval or disapproval Challenging the client Making stereotypical comments Making value judgments Providing false reassurance Placing the client’s feelings on hold Asking the client “Why?”

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DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS A nomenclature of psychiatric diagnoses

developed by the American Psychiatric Association • A system used in clinical, research, and educational settings, in which diagnostic criteria are inclusive for each diagnosis but allow for individualized differences within a pattern of behavior • Knowledge of the criteria for a particular psychiatric diagnosis will assist the nurse in making a clinical decision about a

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MENTAL HEALTH ADMISSIONS AND DISCHARGES VOLUNTARY ADMISSION – Any citizen of lawful age may apply in writing (usually on a standard admission form) for admission to the hospital – Sought by the client or the client’s guardian if the client is too ill but voluntarily seeks assistance – Client agrees to accept treatment – Civil rights are fully retained by the client – Client is free to sign him- or herself out of the hospital

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MENTAL HEALTH ADMISSIONS AND DISCHARGES INVOLUNTARY ADMISSION – Involuntary admission may be necessary when a person is mentally ill, is a danger to self or others, or is in need of psychiatric treatment or physical care – An admission status in which a person who has the legal capacity to consent to mental health treatment refuses to do so and is involuntarily detained for treatment by the state – The client who is involuntarily admitted does not lose his or her right of informed consent

MENTAL HEALTH ADMISSIONS AND DISCHARGES

• INVOLUNTARY ADMISSION

– The length of time for hospitalization is specified by the state and varies from state to state – The client is considered legally competent until he or she been declared incompetent through a legal proceeding – If the nurse believes that a client lacks competency, action should be initiated to have a legal guardian appointed by the court

MENTAL HEALTH ADMISSIONS AND DISCHARGES

• CATEGORIES OF INVOLUNTARY ADMISSION – Evaluation and emergency care – Certification for observation and treatment – Extended or indeterminate commitment

MENTAL HEALTH ADMISSIONS AND DISCHARGES

• RELEASE FROM THE HOSPITAL – Depends on the client’s admission status – The client who sought voluntary admission has the right to demand and receive release – Some states provide for conditional release of voluntary clients, which enables the treating physician or administrator to order continued treatment on an outpatient basis if the clinical needs of the client would warrant further care

MENTAL HEALTH ADMISSIONS AND DISCHARGES • CONDITIONAL RELEASE – Usually requires outpatient treatment for a specified period to determine the client’s compliance with medication protocol, ability to meet basic needs, and ability to reintegrate into the community

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MENTAL HEALTH ADMISSIONS AND DISCHARGES CONDITIONAL RELEASE – A voluntary client who is conditionally released cannot be reinstitutionalized without the client’s consent, unless the institution complies with the procedures for involuntary admission – An involuntary client who is conditionally released may be reinstitutionalized while the commitment is still in effect without recommencement of formal admission procedures

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MENTAL HEALTH ADMISSIONS AND DISCHARGES DISCHARGE – Discharge (unconditional release) is the termination of the client-institution relationship – This release may be ordered by the psychiatrist, court-ordered, or administratively ordered – The administration officer of an institution has the discretion to discharge clients – In most states, clients can institute a court proceeding to seek a judicial discharge (writ of habeas corpus)

MENTAL HEALTH ADMISSIONS AND DISCHARGES

• DISCHARGE

– Discharge planning and follow-up care is important for the continued well-being of the client with a mental health disorder – After-care case managers are needed to facilitate the client’s adaptation back into the community and to provide early referral if the treatment plan is not followed

CLIENT RIGHTS • Right to accessible health care • Right to a coordination and continuity of health care • Right to courteous and individualized health care • Right to information about the qualifications, names, and titles of personnel delivering care • Right to refuse observation by those not directly involved in care

CLIENT RIGHTS • Right to treatment • Right to refuse treatment • Right to treatment in the least-restrictive setting • Right not to be subjected to unnecessary restraints • Right to habeas corpus; may request a hearing at any time to be released from the hospital

CLIENT RIGHTS • Right to information on the charges of service • Right to communicate with people outside the hospital through written correspondence, telephone, and personal visits • Right to keep clothing and personal effects • Right to be employed • Right to religious freedom • Right to execute wills