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 reality-
based
– 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 problem-
solving, 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
 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
 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
 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.
 THERAPEUTIC
COMMUNICATION
TECHNIQUES
• Listening
• Being silent
• Respecting the client
• Providing recognition and
acknowledgment
• Providing feedback
• Offering to assist
• Focusing and refocusing
• Clarifying and validating
 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?”
 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
 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
 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
 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
 MENTAL HEALTH
ADMISSIONS
•
AND
DISCHARGE
DISCHARGES
– 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