I. Mental Health and Mental Illness
Mental health - is a state of emotional, psychological, and social wellness evidenced by satisfying interpersonal relationships, effective behavior and coping, positive self-concept, and emotional stability.
Factors:
- Autonomy and independence
- Maximization of one’s potential
- Tolerance of life’s uncertainties
- Self-esteem
- Mastery of the environment:
- Reality orientation
- Stress management
Mental Illness/Mental disorder - a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom – (American Psychiatric Nursing)
General characteristics:
- dissatisfaction with one’s characteristics, abilities, and accomplishments
- ineffective or non-satisfying relationships
- dissatisfaction with one’s place in the world
- ineffective coping with life events
- lack of personal growth
- Self-concept is distorted
- Perception of strengths and weaknesses is unrealistic.
- Thoughts and perceptions may not be reality-based
Mental Health Mental Illness
The Diagnostic and Statistical Manual of Mental Disorders (4th Edition, Text Revision; DSM-IV-TR)
- published by the American Psychiatric Association
- describes all mental disorders, outlining specific diagnostic criteria for each based on clinical experience and research
Multi-axis Classification System
- Axis I is for identifying all major psychiatric disorders except mental retardation and personality disorders. Examples include depression, schizophrenia, anxiety, and substance-related disorders.
- Axis II is for reporting mental retardation and personality disorders as well as prominent maladaptive personality features and defense mechanisms.
- Axis III is for reporting current medical conditions that are potentially relevant to understanding or managing the person’s mental disorder as well as medical conditions that might contribute to understanding the person
- Axis IV is for reporting psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders. Included are problems with primary support group, social environment, education, occupation, housing, economics, access to health care, and legal system.
- Axis V presents a Global Assessment of Functioning (GAF), which rates the person’s overall psychological functioning on a scale of 0 to 100.
Type of Mental Health Admission
- Voluntary admission
- The client (or the client’s guardian) seeks admission for care.
- The voluntary client is free to sign out of the hospital with physician notification and prescription.
- Detaining a voluntary client against her or his will is termed false imprisonment.
2. Involuntary admission
- Involuntary admission may be necessary when a person is mentally ill, is a danger to self or others, or needs psychiatric treatment or physical care
- The client loses the right to refuse treatment when he or she poses an immediate danger to self or others, requiring immediate action by the health care team.
II. Communication
Therapeutic Communication
- Broad openings—allowing the client to take the initiative in introducing the topic
“What would you like to work on today?”
“What is one of the best things that happened to you this week?”
- Giving recognition— acknowledging, indicating awareness
“I notice you are wearing a new dress. You look very nice.”
- Exploring—delving further into a subject or idea
“How does your girlfriend feel about your being to the hospital?”
“Tell me about what was happening at home just before you came in the hospital?”
- Clarifying - To check whether understanding is accurate, or to better understand, the nurse restates an unclear or ambiguous message to clarify the sender’s meaning.
“I’m not sure I understand what you mean by ‘sicker than usual’, what is different now?”
- Focusing—concentrating on a single point
“Could we continue talking about you and your dad right now?”
“This point seems worth looking at more closely.”
- Encouraging the formulation of a plan of action
“What do you think you can do the next time you feel that way?”
“How might you handle your anger in a non-threatening way?”
- Giving information— making available the facts that the client needs
“My name is . . .” “Visiting hours are . . .” “My purpose in being here is . . .”
- General leads—giving encouragement to continue
“Go on.” “And then?” “Tell me about it.”
- Making observations— verbalizing what the nurse perceives
“You appear tense.” “I notice that you’re biting your lip.”
- Reflecting—directing client actions, thoughts, and feelings back to client
Client: “Do you think I should tell the doctor . . .?” Nurse: “Do you think you should?”
Client: “My brother spends all my money and then has nerve to ask for more.” Nurse: “This causes you to feel angry?”
- Restating—repeating the main idea expressed
Client: “I can’t sleep. I stay awake all night.” Nurse: “You have difficulty sleeping.”
Client: “I’m really mad, I’m really upset.” Nurse: “You’re really mad and upset.”
- Suggesting collaboration— offering to share, to strive, to work with the client for his or her benefit
“Perhaps you and I can discuss and discover the triggers for your anxiety.”
“Let’s go to your room, and I’ll help you find what you’re looking for.”
- Summarizing—organizing and summing up that which has gone before
“Have I got this straight?” “You’ve said that . . .”
“During the past hour, you and I have discussed . . .”
- Voicing doubt—expressing uncertainty about the reality of the client’s perceptions
Client: Zombies inside me are eating my flesh”
Nurse: “Isn’t that unusual?”
“That’s hard to believe.”
Blocks to therapeutic Communication
- Advising—telling the client what to do
“Why don’t you . .”
“I think you should ..”
- Agreeing—indicating accord with the client
“That’s right.” “I agree.”
- Belittling feelings expressed—Misjudging the degree of the client’s discomfort
Client: “I have nothing to live for . . . I wish I was dead.”
Nurse: “Everybody gets down in the dumps.” OR “I’ve felt that way myself.”
- Challenging—demanding proof from the client
“But how can you be President of the United States?”
“If you’re dead, why is your heart beating?”
- Defending—attempting to protect someone or something from verbal attack
“This hospital has a fine reputation.”
“I’m sure your doctor has your best interests in mind.”
- Disagreeing—opposing the client’s ideas
“That’s wrong.” “I definitely disagree with . . .” “I don’t believe that.”
- Disapproving—denouncing the client’s behavior or ideas
“That’s bad.” “I’d rather you wouldn’t . . .”
- Giving approval— sanctioning the client’s behavior or ideas
“That’s good.” “I’m glad that . . .”
- Introducing an unrelated topic—changing the subject
Client: “I’d like to die.” Nurse: “Did you have visitors last evening?”
- Making stereotyped comments—offering meaningless clichés or trite comments
“It’s for your own good.”
“Keep your chin up.”
- Probing—persistent questioning of the client
“Now tell me about this problem. You know I have to find out.”
“Tell me your psychiatric history.”
- Reassuring—indicating there is no reason for anxiety or other feelings of discomfort
“I wouldn’t worry about that.”
“Everything will be all right.”
- Rejecting—refusing to consider or showing contempt for the client’s ideas or behaviors
“Let’s not discuss . . .” “I don’t want to hear about . . .”
- Requesting an explanation— asking the client to provide reasons for thoughts, feelings, behaviors, events
“Why do you think that?” “Why do you feel that way?”
III. Therapeutic Nurse-Client Relationship
A nurse-client interaction that focuses on client needs and is goal-specific, theory-based, and open to supervision.
Components:
- TRUST and RESPECT
- GENUINE INTEREST
- EMPATHY
- ACCEPTANCE
Phases of a therapeutic nurse-client relationship
- Pre-interaction phase
- The pre-interaction phase begins before the nurse’s first contact with the client.
- The nurse’s task in the pre-interaction phase is to focus on his or her own preconceived ideas, stereotypes, biases, and values that may impinge on the nurse-client relationship.
- Orientation or introductory phase
- Acceptance, trust, and boundaries are established.
- Expectations and the time frame of the relationship are identified (establishing a contract).
- Client-centered goals are defined.
- Termination and separation of the relationship are discussed in anticipation of the time-limited nature of the relationship.
- Working phase
- Exploring, focusing on, and evaluating the client’s concerns and problems occurs; an attitude of acceptance and active listening assists the client to express thoughts and feelings.
- Encouraging independence in the client facilitates recovery and leads to readiness for termination.
Client transference is the unconscious process of displacing feelings for significant people in the past onto the nurse in the present relationship.
Counter-transference is the nurse’s emotional reaction to clients based on feelings for significant people in the past.
4. Termination or separation phase
- Prepare the client for termination and separation on initial contact.
- Evaluate progress and achievement of goals.
- Identify responses related to termination and separation, such as anger, distancing from the relationship, are turn of symptoms, and dependency.
- Encourage the client to express feelings about termination.
- Identify the client’s strengths and anticipated needs for follow-up care.
- Refer the client to community resources and other support systems.
