NBMH3913 Mental Health Care - Vapr20 PDF

NBMH3913
Mental Health Care
Copyright © Open University Malaysia (OUM)

NBMH3913
MENTAL HEALTH
CARE
Utharas Arumugam

Project Directors: Prof Dr Widad Othman
Dr Raziana Che Aziz
Open University Malaysia
Module Writer: Utharas Arumugam
Moderator: Narima Zainal
Enhancer: Mispan Mangon

Developed by: Centre for Instructional Design and Technology

First Edition, April 2020

Copyright © Open University Malaysia (OUM), April 2020, NBMH3913
All rights reserved. No part of this work may be reproduced in any form or by any means without
the written permission of the President, Open University Malaysia (OUM).

Table of Contents
Course Guide ix–xiv
Topic 1 Introduction to Mental Health 1

1.1 What is Mental Health? 2
1.2 Mental Health Problems 4
1.2.1 Fears and Concerns of Mental Health Personnel 5
– Talk About It
1.2.2 Role of Mental Health Personnel 6
Summary 9
Key Terms 10
References 10
Topic 2 Psychosocial Assessment in Mental Health 11

2.1 Nature of Your Relationship with Your Patient 12
2.2 Therapeutic relationship 13
2.2.1 What is Therapeutic Relationship? 13
2.2.2 Therapeutic Relationship Ideals 14
2.3 Factors that Influence Assessment 15
2.3.1 How to Conduct the Assessment 16
2.3.2 Subjective and Objective Data 16
2.3.3 Questioning Skills 17
2.3.4 What to Assess 18
Summary 24
Key Terms 25
References 25
Topic 3 Caring for People with Mental Health Problems: 26

Anxiety Disorders
3.1 The Dynamic Relationship between Cognition, Behaviour 27
and Emotion
3.2 Understanding Anxiety 28
3.3 Physiology of Arousal 29
3.4 Anxiety as Unhealthy Negative Emotion 30
3.5 Anxiety-related Disorders 31
3.6 Care and Treatment of People Suffering from Anxiety 33
Disorders

iv  TABLE OF CONTENTS
3.6.1 Behavioural Intervention 34

3.6.2 Drug Treatment 36
Summary 37
Key Terms 37
References 38
Topic 4 Caring for People with Mental Health Problems: Depression 40

and Bipolar Disorder
4.1 Traditional Psychiatric Approach to Affective Disorders 41
4.2 Diagnosis of Major Depression 41
4.3 Treatment of Depression 42
4.3.1 Psychopharmacology 42
4.3.2 Electroconvulsive Therapy (ECT) 43
4.3.3 Psychosocial Assessment 43
4.3.4 Psychosocial Intervention 44
4.4 Bipolar Disorder 46
4.4.1 Treatment of Bipolar Disorder 47
4.4.2 Healthcare Interventions 48
Summary 50
Key Term 50
References 51
Topic 5 Caring for People with Mental Health Problems: Schizophrenia 53

5.1 Schizophrenia 53
5.1.1 Characteristics of Schizophrenia 53
5.1.2 Types of Schizophrenia 56
5.1.3 Treatment of Schizophrenia 57
5.2 Psychosocial Interventions (PSI) 58
Summary 61
Key Terms 62
References 62
Topic 6 Behavioural and Freudian Ideas in Mental Health Care 63

6.1 Principles of Behavioural Theory 64
6.1.1 Classical Conditioning 65
6.1.2 Operant Conditioning 67
6.1.3 Reinforcement 68
6.2 Psychodynamic Perspective in Mental Health Care 72
6.2.1 Levels of Consciousness 72
6.2.2 Id, Ego and Superego 73
6.3 Psychological Defence Mechanisms 74

TABLE OF CONTENTS  v
6.4 Stages of Psychosexual Development 76

Summary 77
Key Terms 78
References 79
Topic 7 Understanding Substance Use and Abuse in the Context of 80

Mental Health Care
7.1 Terminologies 81
7.2 Substance Use, Abuse and Dependence in the 84
Malaysian Context
7.2.1 Scope of the Problem 85
7.2.2 Commonly Abused Substances 86
7.3 Treatment for Substance Abuse and Dependence 87
7.3.1 Detoxification 87
7.3.2 Medical Management of Alcohol Withdrawal 88
7.3.3 Medical Management of Heroin Withdrawal 89
7.3.4 Structured Psychosocial Interventions 90
7.4 Challenges for Healthcare Personnel 92
7.4.1 Acute Physical Withdrawal Phase 92
7.4.2 Keeping the Patient Engaged with the Service after 93
Detoxification
Summary 93
Key Terms 94
References 95
Topic 8 Prevention and Management of Aggression and Violence in 96

Mental Health Care
8.1 Aggression and Violence in Everyday Social Relationships 98
8.2 Strategy for Reducing the Risk of Violence 98
8.3 Factors that Indicate Increased Risk of Violence 99
8.3.1 The Assault Cycle 101
8.4 Interventions in Managing Aggression and Violence 103
8.4.1 Awareness of Warning Signs 103
8.4.2 Physical Interventions 104
8.4.3 Control and Restraint (C&R) 105
Summary 108
Key Terms 108
References 109

COURSE GUIDE

COURSE GUIDE  ix
COURSE GUIDE DESCRIPTION

You must read this Course Guide carefully from the beginning to the end. It tells
you briefly what the course is about and how you can work your way through the
course material. It also suggests the amount of time you are likely to spend in order
to complete the course successfully. Please refer to the Course Guide from time to
time as you go through the course material as it will help you to clarify important
study components or points that you might miss or overlook.
INTRODUCTION
NBMH3913 Mental Health Care is one of the courses offered at Open University
Malaysia (OUM). This course is worth 3 credit hours and should be covered over
8 to 15 weeks. The course will provide you with insights about caring for mental
health patients.
COURSE AUDIENCE
The Malaysian Qualification Agency (MQA) stipulated this course as compulsory
for all learners undertaking the Bachelor of Medical Health Sciences (Honours)
programme at OUM.
As an open and distance learner, you should be acquainted with learning

independently and being able to optimise the learning modes and environment
available to you. Before you begin this course, please ensure that you have the
right course material, and understand the course requirements as well as how the
course is conducted.
STUDY SCHEDULE
It is a standard OUM practice that learners accumulate 40 study hours for every
credit hour. As such, for a three-credit hour course, you are expected to spend
120 study hours. Table 1 gives an estimation of how the 120 study hours could be
accumulated.

x  COURSE GUIDE
Table 1: Estimation of Time Accumulation of Study Hours
Study
Study Activities
Hours
Briefly go through the course content and participate in initial discussion 10
Study the module and completing assignments 50
Attend 5 face-to-face tutorial sessions 10
Online participation 20
Revision and self-tests 22
Examination(s) 8
TOTAL STUDY HOURS ACCUMULATED 120
COURSE LEARNING OUTCOMES

By the end of this course, you should be able to:
1. Describe the principles of psychiatric and mental health nursing;
2. Discuss the treatment modalities in managing patients with mental illness;
3. Discuss the collaboration of care significance to community psychiatric care;

and
4. Discuss psychosocial assessment in psychiatric and mental health nursing.

COURSE GUIDE  xi
COURSE SYNOPSIS
This course is divided into eight topics. The synopsis for each topic is as follows:
Topic 1 introduces a number of common concepts in mental health, clarifies these

concepts and explains the role of the health care personnel in the context of caring
for patients with mental illness.
Topic 2 discusses assessment in mental health care and the skills needed to carry
out a thorough and effective assessment. The topic also considers the nature of
therapeutic relationship.
Topic 3 emphasises the importance of understanding emotions and explores the

dynamic relationships between cognition, emotion and behaviour that underpin
the experience of anxiety. It explains the concept of healthy emotions, unhealthy
or negative emotions and provides an overview of anxiety-related mental
disorders as well as their treatment methods.
Topic 4 covers major affective disorders, namely depression (sometimes regarded

as the common cold of psychological disorders) and bipolar disorder. The topic
highlights a range of interventions, including psychosocial interventions and
traditional psychiatric treatment.
Topic 5 looks at schizophrenia (a severe form of mental disorder) and discusses its
symptomatology, both positive and negative, diagnostic categories or types and
treatment modalities, including psychosocial interventions.
Topic 6 reviews two theories that have had the greatest influence on our
understanding of mental health, behaviour and behaviour modification as well as
learning in general. They are classical and operant conditioning, and Freudian
psychodynamic theory. You will be introduced to the basic concepts and
applications of these theories.
Topic 7 examines the challenges of caring for people in the mental health services
who have drug and alcohol problems. Some individuals may be in mental health
care because of their dependency problem while others may be mentally ill and
also have a substance abuse problem (dual diagnosis). We will discuss these issues
in the local context, and cover a range of medical and psychosocial approaches to
managing alcohol and opioids addiction.
Topic 8 concludes this module with an overview of the prevention and management
of aggression and violence in mental health care settings. We will examine the risk
factors and triggers of violence, and get familiarised with the assault cycle. Though
emphasis must always be on prevention, it is likely that some individuals may not
xii  COURSE GUIDE
respond to efforts at de-escalation. Therefore, we will also discuss control and

restraint (C&R), and rapid tranquilisation as means of gaining control of the
situation and ensuring the safety of the patient, staff and others.
TEXT ARRANGEMENT GUIDE

Before you go through this module, it is important that you note the text
arrangement. Understanding the text arrangement will help you to organise your
study of this course in a more objective and effective way. Generally, the text
arrangement for each topic is as follows:
Learning Outcomes: This section refers to what you should achieve after you have
completely covered a topic. As you go through each topic, you should frequently
refer to these learning outcomes. By doing this, you can continuously gauge your
understanding of the topic.
Self-Check: This component of the module is inserted at strategic locations

throughout the module. It may be inserted after one subtopic or a few subtopics.
It usually comes in the form of a question. When you come across this component,
try to reflect on what you have already learnt thus far. By attempting to answer
the question, you should be able to gauge how well you have understood the topic.
Most of the time, the answers to the questions can be found directly from the
module itself.
Activity: Like Self-Check, the Activity component is also placed at various

locations or junctures throughout the module. This component may require you
to solve questions, explore short case studies, or conduct an observation or
research. It may even require you to evaluate a given scenario. When you come
across an Activity, you should try to reflect on what you have gathered from the
module and apply it to real situations. You should, at the same time, engage
yourself in higher order thinking where you might be required to analyse,
synthesise and evaluate instead of only having to recall and define.
Summary: You will find this component at the end of each topic. This component
helps you to recap the whole topic. By going through the Summary, you should
be able to gauge your knowledge retention level. Should you find points in the
Summary that you do not fully understand, it would be a good idea for you to
revisit the details in the module.

COURSE GUIDE  xiii
Key Terms: This component can be found at the end of each topic. You should go
through this component to remind yourself of important terms or jargon used
throughout the module. Should you find terms here that you are not able to
explain, you should look for the terms in the module.
References: The References section is where a list of relevant and useful textbooks,
journals, articles, electronic contents or sources can be found. The list can appear
in a few locations such as in the Course Guide (at the References section), at the
end of every topic or at the back of the module. You are encouraged to read or
refer to the suggested sources to obtain the additional information needed and to
enhance your overall understanding of the course.
PRIOR KNOWLEDGE
This course does not require prior knowledge of the subject matter.
ASSESSMENT METHOD
Please refer to myINSPIRE.
REFERENCES
Main Reference
Fortinash, K., & Holoday-Worret, P. (2012). Psychiatric: Mental health nursing

(5th ed.). Elsevier.
Additional Readings
American Psychological Association. (2019). Publication manual of the American

Psychological Association (7th ed.).
Antai-Otong, D. (2008). Psychiatric nursing: Biological & behavioural concepts

(2nd ed.). Thomas Delmar Learning.
Clarke, L. (2007). Reading mental health nursing: Education, research, ethnicity &
power. Churchill Livingstone.

xiv  COURSE GUIDE
Meyer, J. S., & Quenzer, L. F. (2013). Psychopharmacology: Drugs, the brain, and
behavior. Sinauer Associates/Lippincott.
Videbeck, S. L. (2014). Psychiatric mental health nursing (6th ed.). Lippincott

Williams & Wilkins.
TAN SRI DR ABDULLAH SANUSI (TSDAS) DIGITAL

LIBRARY
The TSDAS Digital Library has a wide range of print and online resources for the
use of OUM learners. This comprehensive digital library, which is accessible
through the OUM portal, provides access to more than 30 online databases
comprising e-journals, e-theses, e-books and more. Examples of databases
available are EBSCOhost, ProQuest, SpringerLink, Books24×7, InfoSci Books,
Emerald Management Plus and Ebrary Electronic Books. As an OUM learner, you
are encouraged to make full use of the resources available through this library.

Topic  Introduction
to Mental
1 Health
LEARNING OUTCOMES
By the end of this topic, you should be able to:
1. Define mental health;
2. Discuss the characteristics of mental health and illness;
3. Outline three areas where mental health problems can arise from;
4. Discuss the role of the mental health personnel; and
5. State concerns pertaining to working with mentally ill people.
 INTRODUCTION
Mental health problem is one of the major contributors to disease burden
worldwide. It also has an impact on economic burden. Mental health illness is a
major community health concern whereby depression and anxiety are the two
most common mental illness. Furthermore, depression is a leading cause of
disability worldwide. Mental illness can affect anyone regardless of the age,
income, social status, race ethnicity, religion/spirituality, background or other
aspects of culture (Mohd Faizul Hassan, Naffisah Mohd Hassan, Erne Suzila
Kassim & Muhammad Iskandar Hamzah, 2018).

2  TOPIC 1 INTRODUCTION TO MENTAL HEALTH
Psychiatrists have a central role in treating these patients. Healthcare personnel

assist psychiatrists in administering medication as well as in containing and
controlling the patients. As the nature of understanding mental illness changes
over time, and with better training, healthcare personnel are able to shape a more
therapeutic role for the patients (we will discuss this later). In addition, the
recognition and involvement of other professionals such as psychologists, social
workers and occupational therapists as well as art and drama therapists in the care
of the mentally ill patients led to the development of a broader multidisciplinary
team approach where the psychiatrist is important but decision-making is a much
more shared process within the team.
In Europe and the United States, this process of change was expedited by the
movement to close large psychiatric hospitals. Instead, the hospitals were replaced
by small units attached to local general hospitals and supported by community
teams. During this process, the term „mental health service‰ or „community
mental health team‰ began to be used to reflect the multi-professional nature of
the service. The healthcare personnel working in this new arrangement usually see
themselves as mental health nurses. The change in the use of language is also
viewed as more neutral and less stigmatising for the patients. However, you will
still find textbooks, especially those written for nurses, with titles such as
„psychiatric and mental health nursing‰ to be inclusive of all readership.
1.1 WHAT IS MENTAL HEALTH?

You may be wondering what is mental health. There are no simple answers.
When we talk about mental health, we normally refer to an individualÊs
performance of a number of important functions. Primarily, this refers to the
successful performance of mental functions especially in relation to oneÊs
productive activities at work, in the home and in leisure activities. The nature of
oneÊs relationship with other people has a direct influence on oneÊs mental
health; the more satisfying and fulfilling the relationships, the more positive the
mental health status.

TOPIC 1 INTRODUCTION TO MENTAL HEALTH  3
Mental health also refers to oneÊs ability to adapt to changing circumstances and
cope with everyday challenges. It would not be an overstatement if it is said that
from early childhood until late life, mental health is the basis for thinking, learning,
communicating, emotional and spiritual growth and adaptability, among others.
Take a look at the following definition of mental health by the World Health
Organization (WHO) and see if you notice the important elements emphasised:
A state of well-being in which the individual realises his own abilities, can cope
with the normal stresses of life, can work productively and fruitfully, and is able
to make a contribution to his community.
World Health Organization (2018)
Now that you have an idea of what mental health means, let us briefly explore
what we mean by mental illness or mental disorder. These terms are generally
used to mean more or less the same thing and are used interchangeably. Illness is
the feeling of being unwell or the discomfort one complains of when suffering from
a disease such as cancer or malaria, where there is a clear and demonstrable
pathology for the illness. However, this is not always the case. There will be times
when one may have a disease but not feel ill and hence will not even be aware of
the disease.
In mental health, it is more common for people to complain of feeling ill or distressed
in some way but with no demonstrable physical cause that may explain the feeling
of being ill – it may lead you to wonder if it could be due to the disturbance of a
more psychological or spiritual nature. You may sometimes hear people use the
phrase „functional illness‰, suggesting that the problem has to do with a personÊs
functioning (or behaviour) as opposed to organic or more biological cause as in the
case with dementia and epilepsy. The term „mental disorder‰ is sometimes used by
medical and legal professionals to refer to a severe mental health problem. Although
not specific, this term usually implies there is a pathology.

ACTIVITY 1.1
Look up the historical development of psychiatry and mental health.
Most textbooks on mental health will carry a reasonable account.
Research on the Internet as well. This can be a fascinating read. Discuss
your findings with your coursemates in the myINSPIRE online
learning forum.
1.2 MENTAL HEALTH PROBLEMS

Let us explore a range of factors that are considered important in the development
of mental illness (in other words, its aetiology). The factors are grouped in the
following manner:
(a) Factors Located Within the Individual
(i) Biological
Structural defects in the brain, genetics, biochemical processes in the
brain, for example, neurotransmitters, particularly serotonin,
dopamine and glutamate gamma-aminobutyric acid (GABA); and
(ii) Psychosocial
Self-concept, especially poor self-perception or low opinion of oneself
(low self-worth) and traumatic experiences (including childhood abuse
and neglect). Individuals with poor social skills, especially
interpersonal and problem-solving skills, faulty reasoning and
unrealistic expectations of self and others will be more likely to develop
mental health problems.
(b) Factors Located in the Interpersonal Domain

The saying „no man is an island‰ is probably appropriate in this context. We
are all healthily interdependent and develop numerous networks of
relationships through family, work and leisure activities. However, being
overly dependent or overly private and withdrawn from social contact, due
largely to poor communication, may lead to a lack of sense of belonging,
social support and emotional well-being.

(c) Factors Located in the Sociocultural Domain

Societal problems such as poverty, homelessness, violence, drug addiction,
lack of resources, stigma, discrimination, sexism and racism, among others,
will shape a negative view of oneself and the world. This will in turn generate
negative emotions. In a relative sense, health and illnesses are largely
culturally constructed phenomena.
1.2.1 Fears and Concerns of Mental Health Personnel

– Talk About It
It is not uncommon for mental health personnel to worry about working with
psychiatric patients especially if it is a new experience. Most of us worry about
things that we do not know or understand. You may have personal issues or a
family member may have had treatment for a mental health problem. Your
experience will influence your perception. You may have many questions in your
mind. You may even feel uncomfortable. The best way to deal with it is to talk
about it.
The following are thoughts and experiences of some students before their mental
health posting:
(a) Disturbed sleep;
(b) Doubts regarding the ability to cope;
(c) Fear of not being accepted (Will people talk to me?);
(d) Anxiety over personal safety (this is due to the stereotyping of mentally ill
people as being violent);
(e) Lack of belief in the ability to help (I have my own problems, how can I help
others?); and
(f) Self-doubt (Am I mentally ill? What I am reading seems to describe me.)
Most of these concerns appear to resolve themselves by the second day of working
in the ward. You can also prepare yourself by making an informal visit to the ward
a few days before your posting, if possible. This helps to remove some of the
worries. Do not forget to use your meetings with your tutor to discuss your
concerns.

ACTIVITY 1.2
Activity for Tutorial Session: Fear in a Hat
Write one concern you have on a piece of paper. Fold and place it in a
basket or box. Mix it together with other pieces of paper belonging to
other group members. Then pick one piece of paper each and read it out
for general discussion. This activity will help you to air concerns without
personalising the issues.
1.2.2 Role of Mental Health Personnel

You may wonder what mental health personnel actually do. This is a simple
enough question. However, the answer is not so straightforward. The role of
mental health personnel has evolved over the years from a narrow custodial role
to include a more task-oriented medical role. The mental health personnelÊs role is
dependent on the nature and culture of the service. There will also be other
activities such as admissions, discharges and attending medical rounds.
Although this picture is true of most wards, the mental health personnel role has
expanded considerably in recent years to include a more therapeutic role and
function, offering a range of expertise depending on the mental health personnelÊs
experience and seniority but subscribing to the same goals. Some of the major roles
of mental health nurses are outlined in the following.
Major Roles of Mental Health Personnel
(a) Caregiver
Assessment of need and delivery of care:
(i) The mental health personnel will assess the patient to identify physical,
social, emotional and psychological needs, whilst encouraging patient
independence. The nurse will plan and coordinate the delivery of care
and monitor progress.
(ii) Medication management – checking for understanding, safe use and
compliance.
(b) Patient Advocate

Key worker: In a multidisciplinary team, it is likely that mental health
personnel will liaise with other professionals and agencies to coordinate
mental health personnel care. Mental health personnel have to make sure
that their patientsÊ interest is protected. It is important for patients and carers

to be included in the delivery of care. Where available, independent

advocates and other groups may make important contributions to support
patients.
(c) Therapeutic Agent

Psychosocial interventions:
(i) Social Skills Training

This covers areas such as life and self-care skills, relationship skills,
assertiveness and problem-solving skills. In some patients, defects in
social abilities not only contribute to their mental health problems but
also impede their recovery and rehabilitation.
(ii) Counselling
The mental health personnel work is mainly one-to-one individual
work, requiring a satisfactory level of basic counselling skills. Many
mental health personnel have undertaken professional counselling
courses and are proficient in humanistic, psychodynamic and cognitive
behavioural counselling.
(iii) Group Work

In addition to individual work, mental health personnel are also
involved in facilitating therapeutic change through groups. Group
facilitation skill is an important part of mental health personnelÊs core
skills. Patient groups can be wide ranging and focus on problems such
as anxiety, hearing voices, drug withdrawal, assertiveness and the like.
(iv) Milieu (Therapeutic Environment)

The ward environment is generally influenced by the mental health
personnel team with a wide range of therapeutic activities. The rest of
the multidisciplinary team members do contribute towards the
atmosphere but after they finish work and leave the ward, the
environment changes. Patients and nurses become more relaxed. It is
as if the focus is not on the patientsÊ problems but more towards the
social environment. Friendliness, warmth, respect, social support,
safety, time and personal space are all important for patientsÊ sense of
well-being and recovery.

(d) Patient Safety or Custodial

Assessment and management of risks:
(i) In creating a place of safety for the patients, mental health personnel
should be acutely aware of the potential for suicide and self-harm. The
mental health personnel role in assessing risk and taking appropriate
measures to prevent self-harm and suicide is instrumental in saving
lives.
(ii) Managing aggression and violence – Providing a safe environment
means that patients (and staff) will not come to any harm whilst in the
ward. This means assessing patients for risk of violence and ensuring
the safety of others including the general public. Patients who are
potentially violent cannot be discharged and are usually detained
against their will according to regulation in the mental health act.
Hence, the mental health personnel custodial role is to contain and
control potentially violent patients.
(e) Mental Health Promotion or Psychoeducation

Patients need to understand the nature of their illness before they can
develop a realistic and shared understanding of their problems and the
potential solutions together with the mental health personnel and actively
participate in their care. This psychoeducation and health promoting role of
mental health personnel not only help manage the patientsÊ immediate
problems with better patient insights but will also help in patient
rehabilitation and prevention of relapse in the future.
(f) Clinical Leadership

In addition to their managerial and supervisory role, mental health personnel
lead by example when it comes to clinical leadership, ensuring that good
standards of clinical practice are maintained.
Other advanced roles include prescribing nurse, psychotherapist, researcher

and educator.

• Mental health and mental illnesses are broad concepts which primarily refer to
the successful performance or otherwise of:
– Mental function;
– Productive activities at work, in the home and in leisure activities;
– Relationship with other people whereby the more satisfying and fulfilling
the relationship, the more positive the mental health status; and
– OneÊs ability to adapt to changing circumstances and cope with everyday
challenges.
• Mental health problems can be viewed as originating from three areas - within
the individual, interpersonal and sociocultural.
• The role of mental health personnel includes the following:

– Caregiver – Assess, plan, implement and evaluate care;
– Patient advocate – Encourage user and carer participation;
– Therapeutic worker – Provide psychosocial interventions;
– Patient safety or custodial – Assess and manage risk;
– Provider of mental health promotion or psychoeducation; and
– Provider of clinical leadership.

Assessment of risk Patient advocate

Biological Psychoeducation
Carer Psychosocial
Interpersonal Self-harm
Mental health Social skills
Mental illness Suicide
Milieu
Mohd Faizul Hassan, Naffisah Mohd Hassan, Erne Suzila Kassim, & Muhammad
Iskandar Hamzah. (2018). Issues and challenges of mental health in Malaysia.
International Journal of Academic Research in Business & Social Sciences, 8
(12), 1685–1696. https://dx.doi.org/10.6007/IJARBSS/v8-i12/5288
World Health Organization. (2018, March 30). Mental health: Strengthening our
response. https://www.who.int/news-room/fact-sheets/detail/mental-
health-strengthening-our-response

Topic  Psychosocial
Assessment in
2 Mental Health
LEARNING OUTCOMES
1. Outline the nature of healthcare personnel-patient relationship;
2. Discuss the concept of therapeutic relationship;
3. Identify factors that influence assessment in mental health;
4. Demonstrate skills in the management of assessment and questioning
skills; and
5. Discuss the content of a psychosocial assessment.
 INTRODUCTION
As with all problem-solving models including the healthcare process, assessment
is where you start to address the problem. You are probably quite familiar with
what assessment is, therefore, this part will be dealt with briefly. Instead, we can
explore the process, skills and content of assessment in more detail.
To put it simply, assessment is the process of gathering data about a problem,

organising it and making judgement about its relevance. The importance of
thorough and accurate assessment cannot be overstated. It is what you are going to
base your care on. In mental healthcare, assessment is mainly psychosocial in nature.

12  TOPIC 2 PSYCHOSOCIAL ASSESSMENT IN MENTAL HEALTH
In order to conduct a satisfactory assessment, you need to be aware of some

important issues. Firstly, you need a good relationship with your patient.
Therefore, it is important to establish a reasonable understanding with your
patient. Let your patient get to know you and learn to trust you. Do not forget your
patientÊs relatives. You need a good working relationship with them as well. In
mental health, you cannot conduct a thorough assessment without contributions
from the family.
In reality, assessment is not a one-way process of gathering information about your

patient and his circumstance. Your patient and his relatives will want to talk. They
will want information, clarification and reassurance. They may also to air their
complaints. How well you handle this will determine how well they are likely to
work with you. We will discuss about establishing and maintaining the
relationship with patients later in the topic.
Let us briefly consider what else will be important in the assessment of mental
health. You need to be aware of the factors that may get in the way of your
assessment. This can be a long list; we will look at some of the factors. You will
also need to know how to conduct an assessment, what the necessary skills are and
what to assess. We will explore these in greater detail later on in the topic.
The following is a reminder of the important issues in the assessment process:

(a) Your relationship with your patient (nurse-patient relationship)
(b) What can influence the assessment?
(c) How to conduct the assessment?
(d) What to assess?
2.1 NATURE OF YOUR RELATIONSHIP WITH

YOUR PATIENT
You already know that the relationship with patients is important regardless of
where you work. However, in the care of people with mental health problems, the
relationship is given special prominence as the communication within it forms the
basis for the nursing intervention and the desired outcomes. We normally use the
phrase „therapeutic relationship‰ to differentiate this form of relationship from
other types of relationships such as social or intimate relationships.

TOPIC 2 PSYCHOSOCIAL ASSESSMENT IN MENTAL HEALTH  13
You may worry about whether you can you handle this therapeutic relationship.
Well, do not worry. Your posting is about gaining insight into mental health
personnel and your learning outcomes will reflect this. Therefore, observe and
learn from experienced nurses. Patients usually expect student nurses to be
friendly and sociable.
In a social relationship, there is little structure or formal goal and usually there
is no evaluation involved. It is about meeting the need for friendship,
companionship and attending to tasks at hand. Communication usually includes
topical and neutral exchanges of experiences and ideas, and most of the time
these exchanges are superficial in nature. Sometimes, you will be entertained by
the patients.
Unlike a social relationship, an intimate relationship involves an emotional bond

and commitment to one another, usually with shared goals and with each otherÊs
needs being met. This level of familiarity may include sexual intimacy. If it does,
then it is inappropriate. Sexual intimacy has no place in a professional nursing
relationship.
2.2 THERAPEUTIC RELATIONSHIP

In a therapeutic relationship, the healthcare personnel is there for the patient. The
carer is trained to use her interpersonal skills and knowledge in human behaviour
for the benefit of the patient.
2.2.1 What is Therapeutic Relationship?

Therapeutic relationship focuses exclusively on the patientÊs needs – experiences,
beliefs and feelings. Problems are negotiated and goals agreed upon. Interventions
and outcomes are reviewed. It is not about the mental health personnel, therefore
it is necessary for the carer to have a certain level of self-awareness in order to
appreciate oneÊs own needs and limitations. It is usual for a nurse to discuss her
needs with her supervisor. There is a clear boundary or limit in this relationship.
It is necessary to know the important components that create the quality of

experience in a therapeutic relationship. You may have heard of some of these.
Most textbooks for mental health nurses will provide an outline of what is known
in the world of counselling as „core conditions.‰ These are adopted from Rogerian
(or humanistic) counselling. They are empathetic understanding, genuineness and
unconditional positive regard. Other qualities include warmth, trust and the like.

The challenge is how to create and convey these experiences in our interactions.
There was this incident whereby a psychiatrist was giving a talk to a group of
former patients and he mentioned that his relationship with patients was based on
trust and understanding. One former patient muttered under his breath, „Yes, you
donÊt understand us and we donÊt trust you.‰ As professionals, we need to work
very hard to earn the patientÊs trust.
2.2.2 Therapeutic Relationship Ideals

To effectively help patients through therapeutic relationship, the carer should
aspire to the ideals encapsulated by the following words:
(a) Trust
Mental health personnel use the word „trust‰ very frequently in mental
health. Make a mental list of other peopleÊs behaviours which encourages
you to trust them. These are some that comes to mind – keeping promises,
being reliable, honest and willing to listen. Can you add to this list?
(b) Empathetic Understanding

Think of the times when you sobbed while watching a movie. ThatÊs
empathy. You felt for the lead character because you had been seeing and
following events from his point of view and you understand his experience
– that is empathetic understanding.
(c) Genuineness
This is about a way of being with your patient. When you are with your
patient, you are there for your patient and not distracted by other issues. In
addition, a good degree of what is referred to as congruence is also needed.
When what you feel and what you say matches, your patient perceives you
as genuine or authentic. It is not uncommon for nurses to say things to
patients that they do not really mean. It is similar to when a teacher asks the
students if they understand what he has said. They may say yes but their
nonverbal signals indicate something different. A teacher can usually sense
this. Likewise, patients can see through when nurses are not being genuine.
(d) Unconditional Positive Regard

Humanistic counsellors view this as the primary change agent whereby the
patientÊs need for positive regard is met. The patient experiences
unconditional acceptance and regard. People become disturbed partly
because they internalise conditional self-values learnt from parents and
others around them. It is not uncommon to hear depressed people say they
„hate‰ themselves for having failed an exam or in a relationship. As a result,
they tell themselves that they are „no good‰, unworthy or undeserving as a
human being. To these individuals, their self-worth is conditional – usually

it requires approval from others. Therefore, a negative experience like failing
an exam or ending a relationship can cause them to „beat‰ themselves up
afterwards (or put themselves down) and make themselves even more
unhappy. The healthcare personnel will convey to the person that he is
worthy and deserving regardless of his behaviour, that is, his apparent lack
of success. You accept the person even as you disapprove of his bad
behaviour.
2.3 FACTORS THAT INFLUENCE ASSESSMENT

Certain factors can get in the way of your assessment. The following is a short list
of the factors. Can you add to the list?
(a) Located Within the Patient

(i) Too ill to give information, distracted by his „voices‰, pain or other
conditions;
(ii) Previous experience influences present behaviour;
(iii) Level of comprehension; and
(iv) Insight into the problem and willingness to participate.
(b) Located Within the Healthcare Personnel

(i) Level of interpersonal skills and knowledge;
(ii) Attitude towards the patient; and
(iii) Distracted by other problems or priorities.
(c) Other Possible Major Dislocations

(i) Language;
(ii) Social class; and/or
(iii) Poor nurse-patient relationship.

2.3.1 How to Conduct the Assessment

Remember that assessment is not about making judgements or giving advice. It is
important to create the right physical and psychological environment for your
patient to talk. It is not really different from your classroom learning experience.
What conditions would encourage you to relax and talk freely? What would help
you to feel the psychological freedom to express your thoughts and feelings? You
may wish to add to the list in Table 2.1 and remember to include the physical
conditions.
Table 2.1: Conditions for Freedom of Thoughts and Feelings

Condition
No fear of punishment
Safe and secure
Not being judged
Free to express
Accepted for who you are
You would want the same for your patients. Create the right conditions and your
patient will talk freely.
2.3.2 Subjective and Objective Data

The information provided by your patient will be mainly subjective information.
It is important to have it verified by others, usually by family members and friends.
Social workers and police, if involved, may be useful in corroborating your
patientÊs account. As you will soon discover, most mental health problems revolve
around relationship difficulties. Therefore, we should not be surprised to hear
different accounts from family members. Some people will blame their parents for
all their problems. Then when their own children grow up, they will blame their
children for their unhappiness.
Subjective data includes the patientÊs account of history, his view of his present
situation, his thoughts and feelings.
Objective data is what is collected by the nurse through observations or provided

by other professionals from their assessment. Objective data includes physical
examination, medical history, social relationships, religious and cultural practices.

2.3.3 Questioning Skills

Questioning is an important component of your assessment skill. It shows that you
have the ability to understand your patientÊs real needs. You are probably aware
of open-ended questions and close-ended questions. Your choice of the type of
question will depend on your intention and the type of information you are
looking for.
(a) Open-ended Questions

This type of question is very useful especially at the beginning of your
assessment where your intention is to encourage your client to talk in order
for you to get more information. Open-ended means exactly that. Your
patientÊs scope of response is wide and the choice is his. It does not encourage
a „yes‰ or „no‰ answer. Examples of open-ended questions are as follows:
(i) How can I help you this morning?
(ii) Tell me what is troubling you.
(iii) What would you like to discuss?
(b) Close-ended Questions

Such questions limit your patientÊs options to respond. They are often
answered with a „yes‰ or „no‰, or with a direct specific answer. Close-ended
questions are a quick and efficient way to gather biodata. Examples as follows:
(i) What is your name?
(ii) Do you like fried rice?
(iii) Would you like to talk to a doctor about your problem?
(iv) Do you want to go for a walk?
(v) How much do you get paid?
(c) Probing Questions

Use probing questions when your open-ended question gives only part of
the information you are looking for, a follow-up probing question will help
you develop a fuller picture. It is essentially another open-ended question
with a narrower focus. Examples as follows:
(i) What concerns you most?
(ii) Tell me more about what was said to you.
(iii) What is worrying you about your new job?

(d) Leading Questions

Leading questions are rarely helpful in the context of an assessment. We are
essentially asking the patient to give the answers we want. If used
excessively, the relationship will be nurse-centred instead of being patient-
centred. These will be good questions if you are a salesperson. Examples of
leading questions are as follows:
(i) You are with me on this one, arenÊt you?
(ii) You understand what IÊm saying, donÊt you?
(iii) This is a good idea, isnÊt it?
Keep your questions simple, clear and direct. Avoid asking multiple questions
such as „Are you sleeping enough, what medications are you taking?‰
2.3.4 What to Assess

You need to know what information to gather before the assessment. After you
have gathered the information, organise it according to appropriate categories. In
order to be thorough and systematic, you need an organising framework.
Although there is no standard or one right way of doing this, most assessment
tools will have similar categories. For our purpose, Videbeck (2008) has suggested
a few categories for the assessment tools, which are:
(a) History;
(b) General appearance and motor behaviour;
(c) Mood and affect;
(d) Thought process and content;
(e) Sensory and intellectual process;
(f) Judgement and insight;
(g) Self-concept;
(h) Roles and relationships; and
(i) Physiological and self-care concerns.

It is always helpful to create the right conditions by attending to the patientÊs need
first. For example, if your patient is anxious or overly depressed, talk about what
concerns him first. If he does not feel like answering the questions, agree to do it
another time. Attending to your patientÊs priority first will encourage him to
respond to your priority. There will be circumstances where the nurse will dictate
the priority. These are exceptional and involve life-threatening situations.
Make sure you have a private and conducive environment to assess your patient.
If family members are present, ask your patient if it is okay with him for them to
be present. At every stage of the process, explain and give some indication of how
long it will take. Sometimes, it is necessary to have short breaks. In the interest of
good practice, seek your patientÊs permission to talk to other family members.
(a) History
(i) Personal details – name, age, address, marital status.
(ii) Educational background, work history.
(iii) Family history, history of mental illness.
(b) General Appearance and Motor Behaviour

(i) Grooming and hygiene, dress, eye contact, posture.
(ii) Motor activity (pacing, slow, rigid, restless, bizarre).
(iii) Speech pattern – slurring, volume, speed, dysphasia.
(c) Mood and Affect

(i) Facial expression, intensity, duration.
(ii) Sad, anxious, euphoric, labile, irritable.
(iii) Blunted affect, flat affect, labile (rapid mood swings from depressed to
euphoria and to crying).
(d) Thought Process and Content

Your patientÊs speech will give a good indication of the content of his
thoughts. Assess how the content is organised, its appropriateness, whether
it is logical and whether it makes sense. Examples of some thought disorders
to look out for are as follows:
(i) Delusional Thoughts

Fixed false beliefs, not shared by others.

(ii) Flight of Ideas

Pressure of speech, ideas are unrelated and unrealistic.
(iii) Looseness of Association

Expression of a string of vaguely related or unrelated ideas reflecting a
disorganised thought process.
(iv) Thought Block

Sudden interruption of speech, unable to continue with his sentence
because he cannot remember what he was talking about.
(v) Thought Broadcasting

Belief that others can hear his thoughts.
(vi) Ideas of Reference

Patient draws personal significance from general events, for example,
stating that the newscaster on television is talking about him.
(vii) Thought Insertion

Denies his ideas belong to him and claims they have been put there by
others.
(viii) Confabulation
Patient makes up stories to fill in the gaps in memory; this is usually
associated with alcohol abuse (Korsakoff syndrome).
(e) Other Sensory and Intellectual Processes
(i) Orientation
Person, place and time. Knowing who and where he is. Awareness of
day, date, month and year.
(ii) Memory
Ask only verifiable questions such as: Who is the current Prime
Minister? What is the capital of this country?
(iii) Ability to Concentrate

For example, repeat the days of the week in reverse. Or can you do
„serial sevens‰ like subtract sevens starting with one hundred?

(iv) Abstract Thinking

Assesses your patientÊs intellectual ability to interpret and make
reasonable associations in relation to the situation. You can use
common proverbs such as crying over spilt milk, raining cats and dogs
and donÊt count your chickens before they are hatched.
Where there is intellectual impairment, the patient is likely to
repeatedly give the concrete meaning for the different proverbs and
will not grasp the abstract meaning.
(f) Judgement and Insight

Judgement is essentially oneÊs ability to assess and interpret environmental
cues accurately so as to be able to make adaptive responses and meet oneÊs
need with relative ease. Mentally ill people sometimes display poor
judgement as they describe their relationships, decisions about jobs, finance
and others. As an example, ask the patient what he will do if he found a
wallet with a lot of money in it.
Insight is oneÊs accurate understanding of his present social realities and a

clear acceptance of some responsibilities for the problems. You will find both
extremes where some patients will deny they have a problem and claim that
they are in the ward because of other people. Whilst others will display a
similar lack of insight into their problems, they will complain a lot and blame
themselves and even unrealistically take responsibility for othersÊ behaviour.
(g) Self-concept
This relates to the subjective understanding that we have about ourselves as
an individual. It includes our physical appearance, values, beliefs, family, job
and other roles we may play. Essentially, our understanding of ourselves is
largely a reflection of how we think others view us. Self-concept is made up
of the following:
(i) Self-image
• How you think others view you and how you view yourself.
• What you think you look like and how much you like yourself or
how much you think others like you. The numerous roles you play
in life. Your status in the community.

(ii) Self-esteem
• The way you feel about yourself.
• Your self-esteem depends on how you evaluate your own

performance and othersÊ responses. Hence, the idea of how you
value yourself, self-worth, pride and dignity.
(iii) Body Image
• Closely linked to self-esteem, body image is about how you feel

about your physical appearance. Most people have something that
they wanted to change in their physical appearance.
• Ask around and see what your group members say. In mental
health care, there will be some individuals whose perception of
their body will be distorted to the extreme. This is known as body
dysmorphic disorder.
(iv) Ideal-self
This is what you wish or think you should be. It is not real and is a
standard you cannot reach.
(v) Actual or Real Self

This is how you see yourself as being at the present moment. The gap
between real and ideal-self is called incongruity; the bigger the gap, the
greater the possibility of distress.
(h) Roles and Relationships

This is an important area to assess. Throughout our lives, we play numerous
roles. You will also have other role relationships such as daughter, mother,
father, brother, sister and many others. Your school life, work life, married life,
family life and social relationships contribute to your understanding of
yourself and your psychological and emotional health. The individuals you
will meet in the wards are likely to have limited role relationships. As a result,
they lack social support and develop a negative self-concept. You will also
notice that the different areas you assess are related to and affect one another.
(i) Physiological and Self-care Concerns

You would be familiar with activities of daily living, so this will not be
discussed here. It is important though, not to neglect this aspect of mental
health care. We will need to have a clear idea of the patientÊs ability to
perform or meet their self-care needs.

ACTIVITY 2.1
Carry out the following activity during a group tutorial session:

Time: 45 minutes
Aim: To develop awareness of social attitudes that can influence
assessment.
Scenario: Life on Planet Earth is coming to an end. Planet Earth is being
evacuated. You have to fill the last five spaces in your
spacecraft. But you have eight people on your list. You have
to decide who gets to go and who remains behind.
Your passenger list:

(a) Second year medical student
(b) Lesbian computer expert
(c) An alcoholic plumber
(d) 70-year-old clergyman
(e) Policeman
(f) Philosophy lecturer
(g) Motorcycle stunt rider (Mat rempit)
(h) Vegetarian environmentalist
Your task:
1. Make a list (without discussing with others) of the people you
would take with you, justifying your reasons. Also note your
reasons for the individuals whom you are leaving behind.
2. In a group of five, please share individual lists and arrive at your
groupÊs list. Again, note your groupÊs reason for taking and
leaving the various people behind.
3. In your big group, try to arrive at one list for the whole class.
4. Note what the major discussion points are. Evaluate the exercise.

ACTIVITY 2.2
Carry out the following activity during a group tutorial session.
Time: 45 minutes
Aim: Develop questioning skills
Your task:
In groups of three, take turns to play the following roles:
(a) Mental health personnel
(b) Patient
(c) Observer
The mental health personnel will pick any two areas from the list of
psychosocial assessment to assess the patient for no more than five
minutes. The observer will give feedback on the type of questions used
and their appropriateness.
Discuss your experience in your large group. Evaluate the exercise.
• Assessment is a complex process and there are many factors that can influence
the assessment process.
• The management of the assessment process and questioning skills will

determine the assessment effectiveness.
• The areas to cover in the assessment include:

– History;
– General appearance and motor behaviour;
– Mood and affect;
– Thought process and content;
– Sensory and intellectual process;
– Judgement and insight;

– Self-concept;
– Roles and relationships; and
– Physiological and self-care concerns.
Affect Psycho-social
Assessment Questioning skills
Empathetic understanding Self-concept
Genuineness Therapeutic relationship
Judgement and insight Thought process
Nurse-patient relationship Unconditional positive regard
Perceptions
Barker, P. (Ed) (2003). Psychiatric and mental health nursing: The craft of caring.
Arnold.
Videbeck, S. L. (2008). Psychiatric-mental health nursing (4th ed.). Wolters Kluwer

Health/Lippincott Williams & Wilkins.

Topic  Caring for
People with
3 Mental Health
Problems:
Anxiety
Disorder
LEARNING OUTCOMES
1. Define anxiety disorder;
2. Identify cognitive, behavioural and physiological features of anxiety;
3. Differentiate the various anxiety-related disorders;
4. Discuss the care and behavioural treatment for anxiety; and
5. Discuss the role of drugs in the treatment of anxiety.
 INTRODUCTION
This topic will provide an overview of the commonly presented severe mental
health problems, namely anxiety, depression and schizophrenia. (Depression and
schizophrenia will be discussed in Topics 4 and 5.) The key concepts and major
manifestations of the distress as well as the mental health care of the patients will
be discussed. You are advised to do some further reading to get a more complete
picture of the disorder. As mental health personnel, we need to keep in mind that
our prime concern is caring for the person who is in distress or suffering in some
TOPIC 3 CARING FOR PEOPLE WITH MENTAL HEALTH PROBLEMS:  27
ANXIETY DISORDER
ways. We will not be able to do this unless we have develop a good relationship
and, to a certain degree, have empathetic understanding of the person and his
situation. We have discussed the nurse-patient relationship in Topic 2.
Emotions such as anxiety and depression are powerful yet unhealthy negative
emotions that can be devastating for the individual as well as the family. Hence,
an important challenge for the healthcare personnel will be to provide support for
the patient and the family in a timely and sensitive manner.
3.1 THE DYNAMIC RELATIONSHIP BETWEEN

COGNITION, BEHAVIOUR AND EMOTION
At this point, we should briefly discuss the relation between our thoughts
(cognition), actions (behaviour) and feelings (emotion). It is important for you to
recognise that these three domains interact with and influence each other. For
instance, if thoughts about our life and what is happening in our lives are unduly
pessimistic or negative over a period of time, it will most likely lead us towards
feeling down or depressed. Our depressed feeling will in turn influence our
thinking, creating more negative thoughts. The negative feelings will also
influence our behaviour. We may not feel like doing the things that we normally
do such as spending time with friends, shopping, going to work and so forth. We
can become withdrawn and feel isolated. Our withdrawn and isolating behaviour
will in turn distort our thinking further and remain in our depressed condition for
a longer time.
In order to understand a certain emotion, you need to learn to recognise the

specific sets of behaviour that are usually associated with a given emotion. We will
discuss this further when we consider anxiety and depression.
Figure 3.1: Relation between cognition, behaviour and emotions

28  TOPIC 3 CARING FOR PEOPLE WITH MENTAL HEALTH PROBLEMS:
ANXIETY DISORDER
3.2 UNDERSTANDING ANXIETY

It is usual for people to talk about anxiety as a common problem. Anxiety is part
of everyday life. From a professional point of view, it is important to understand
the difference between the everyday stresses or „arousal‰ which motivates us to
confront and deal with everyday challenges and anxiety which can be harmful and
incapacitating in situations where there is a real threat to your physical self. For
example, let us say that whilst you were out for a walk, you were confronted by a
large unfriendly dog. Even before you start to think that the dog is going to attack
you, your body has already responded to the threat. Fortunately for you, the dogÊs
owner suddenly appeared and placed the dog under his control. The threat was
over and your arousal level gradually returned to normal. Most likely, you can
think of many other situations where there was an actual or real physical threat.
There are other circumstances where our body respond in a similar way, even
when there is no physical threat. For instance, being asked to give a presentation
or a speech, realising that there is less money in your bank account than you
expected, losing your wallet containing your money and credit cards or being late
for an important interview. These are examples of actual situations.
There are also situations that are not actual, in other words, inferred situations,
whereby your body becomes aroused. For instance, thoughts such as „What if he
turns me down?‰, „What if I canÊt get along with people in my new job?‰, „Why
do these bad things happen to me?‰ or „I must get to know others like me.‰ In
our modern life, arousals that are related to such negative thoughts (related to
need for approval) are perhaps more common than arousals related to actual
physical threat.

ANXIETY DISORDER
ACTIVITY 3.1
Carry out the following activity at a group tutorial session:
Time: 30 minutes
In small groups (4 to 6 students), share one of your personal „being

anxious‰ experiences.
(a) Identify the physiological, behavioural and cognitive features of
your responses.
(b) Work out whether each of the experience described was „being
concerned‰ or anxiety.
(If appropriate, share the highlights of your discussion with the whole
class.)
3.3 PHYSIOLOGY OF AROUSAL

In any emotional response, the physical component of the response would
comprise the behavioural, autonomic and hormonal systems. The behavioural
response will be specific to the situation that elicits it. In the earlier example, in
which you were confronted with a fierce dog, your physical action involving your
muscles would most likely be to fend off the dog, protect yourself or to run away.
Your autonomic nervous system responds in support of your behaviour, ensuring

energy is available quickly for energetic action. As you would have guessed, the
activity of your sympathetic system increases whilst the parasympathetic system
decreases. This will account for your increased heart rate, increased air intake and
diversion of your blood supply from the digestive organs to the muscles.
The hormonal response adds further support to the sympathetic responses. The
hormones epinephrine and norepinephrine released by the adrenal medulla also
increase blood supply to the muscles while nutrients in the muscles and glycogen
stored in the liver are converted into glucose for food. Steroid hormones secreted
by adrenal cortex also make glucose available to the muscles (Carlson, 2007).
As the threat passes, the activity of the parasympathetic system will increase whilst
the sympathetic system will decrease. Arousal is over and the body returns to
normal.

ANXIETY DISORDER
3.4 ANXIETY AS UNHEALTHY NEGATIVE

EMOTION
What is anxiety? The everyday arousal that we experience as described earlier is
not anxiety and usually does not lead to anxiety. Most people do not suffer from
anxiety. All of us would have been concerned or may even have been profoundly
concerned about one thing or another given the negative events that can and do
happen in our lives but do not suffer from anxiety. Some authors call this mild or
moderate anxiety and say that it can be motivating and helpful. It is actually a state
of being concerned, not anxious.
On the other hand, anxiety is neither normal nor healthy. This broad use of the
word „anxiety‰ can be unhelpful. Anxiety is an unhealthy negative emotion,
which can be debilitating to the sufferer, with its characteristic physiological,
cognitive and behavioural features (Halgin & Whitbourne, 2008).
(a) Physiological Features

Muscle tension, restlessness, headache, dry mouth, diaphoresis (excessive
sweating), trembling, paleness, tachycardia, chest pain, nausea, vomiting and
diarrhoea, among others.
(b) Cognitive Features

Inability to concentrate, focus on irrelevant activity, distorted perception
and/or narrowed perceptual field. Cannot solve problems or learn effectively.
Patient usually anticipates and complains of impending doom or dread and
powerlessness to change the situation. It is also usual for the anxious person
to exaggerate a perceived threat or the actual difficulty whilst minimising
personal ability to cope.
(c) Behavioural Features

The main feature will be avoidance or withdrawal from the feared situation
or object and the tendency to want to make oneself small and hide.
Behaviour is directed at relieving anxiety; this can become ritualised but is
usually ineffective.

ANXIETY DISORDER
3.5 ANXIETY-RELATED DISORDERS

There are a number of specific disorders which are clearly fuelled by anxiety or
have anxiety as the predominant feature. Here are some relatively common
examples:
(a) Generalised Anxiety Disorder

(i) People with this disorder are social worriers.
(ii) They are distressed for at least six months and this is accompanied by
persistent and excessive worrying.
(iii) Some of the symptoms include restlessness, muscle tension,
nervousness and apprehension.
(iv) They get tired easily and experience sleeping difficulties.
(b) Obsessive Compulsive Disorder (OCD)

(i) Persistent and intrusive negative automatic thoughts (may also be
images or impulses) that cause considerable anxiety.
(ii) These individuals tend to have an exaggerated sense of responsibility
and want to be 100% sure that they would not be the cause of something
terrible happening. Hence, they will check or clean over and over again.
(iii) Compulsive (repetitive) behaviours and mental acts are usually
attempts at reducing anxiety, although usually ineffective. For
example, excessive or ritualised hand washing, showering, brushing
teeth or grooming.
(c) Phobia
(i) A phobia is an irrational and extreme fear of specific social situations
or objects, resulting in severe distress and disruption of normal
functioning.
(ii) Most people with phobias manage to avoid the fearful situation or
object without too much difficulty and continue to function pretty
much normally. However, some may develop anticipatory anxiety, that
is, even the thought of going out and encountering the fearful situation
or object will generate considerable anxiety. Even if they avoid the
situation or object, they are not free from the anxiety.

ANXIETY DISORDER
(iii) Phobias are generally grouped in three types, namely agoraphobia,

specific phobia and social phobia.
• Agoraphobia
This is essentially fear of open spaces or of being in crowded, public
places like markets, as such they will avoid these places. Your
patient will usually be fearful of having a panic attack in public
places and, wherever possible, will avoid situations or places from
which escape may not be easy. In time, some will begin to fear
leaving a safe place like home.
• Specific Phobia
This is an irrational fear of a specific situation or object. For
example, fear of heights, getting into lifts, flying in an aeroplane;
fear of objects like needles, knives, spiders, cats, dogs, germs, etc.
• Social Phobia
This is essentially worrying about what others think of us. It is the
fear of being evaluated negatively in social situations, for example,
making a presentation, attending a meeting at work, introducing
oneself to the class, etc. To people suffering from social phobia,
any social contact can become a problem and is therefore avoided.
(d) Panic Disorder

Patients with agoraphobia sometimes also complain of panic attacks. Panic
disorder is characterised by a sudden overwhelming anxiety attack, which
comes on quickly and lasts for about 30 minutes. The patient often thinks that
he is going to die because of chest pain or discomfort. Physiological
symptoms include palpitation, sweating, tremor, nausea, difficulty
breathing, cold or hot flashes and stomach upset. The patient will associate
the attack with the place where it occurred and will be very afraid that it will
occur again. This leads to avoidance of the place, for example, supermarkets.
Hence, the development of agoraphobia symptoms.
(e) Post-traumatic Stress Disorder (PTSD)

This condition is characterised by the re-living or re-experiencing of a
traumatic experience. Soldiers, police officers and paramedics are trained to
cope with very difficult situations. Despite this, there will be circumstances
so extreme that they may be affected by their experiences. Likewise,
survivors of physical assault, rape, serious accidents, major natural disasters
and so forth can be traumatised by their experience. To be diagnosed with
PTSD, the symptoms must be present for more than a month and the
disturbance is sufficiently distressing to interfere with oneÊs everyday

ANXIETY DISORDER
functioning. Symptoms include persistent re-experiencing of the event,

intrusive images of horror, intense fear, helplessness, nightmares, persistent
increased autonomic arousal.
You are also likely to find patients talking about their guilt feeling for having
survived whilst others did not. As you now know, with regard to anxiety,
avoidance can be unhelpful and affects interpersonal relationships, leading
to marriage break-up, loss of job and others.
3.6 CARE AND TREATMENT OF PEOPLE

SUFFERING FROM ANXIETY DISORDERS
All treatment and care must be tailored to individual needs after a careful and
thorough assessment. A range of interventions will be discussed here in general
terms without specifying the anxiety disorder. Earlier, we discussed the
importance of your relationship with your patient. People suffering from anxiety
or anxiety-related disorders will generally want help and will collaborate well
with the nurse, so encourage them to participate in the assessment and planning
of their care as you build a good rapport with your patient (Videbeck, 2008).
Remember that:
(a) For the anxious patient, the presence of a supportive and understanding
nurse can have a reassuring and calming effect;
(b) Anxious patients cannot process complex information, therefore, keep your
language and the message simple and calm; and
(c) Anxious patients are likely to misinterpret cues, therefore, it will be helpful
to keep minimal environmental stimuli.
Some individuals would want to be allowed some space whilst others would seek
constant reassurance and want to be close to the nurse. Use your judgement of the
patient to determine your use of eye contact, touch and so forth.

ANXIETY DISORDER
3.6.1 Behavioural Intervention

Behavioural intervention usually begins with the patient learning what anxiety is,
and becoming aware of how he responds physically, behaviourally and
cognitively when experiencing anxiety. Set goals and work out strategies to
achieve those goals. The following are well-established behavioural interventions:
(a) Exposure Therapy

In exposure therapy for anxiety disorder, the patient is helped to confront his
fears in a safe, controlled environment. It would be useful for the patient to
master a relaxation technique before undertaking the exposure therapy.
There are two options in exposure therapy:
(i) Systematic Desensitisation
Gradual and repeated exposures (from least to most anxiety
provoking) either through imagination or in reality to the feared object
or situation. Only when the patient demonstrates success at one stage
(he manages to relax and remain calm) is the patient moved to the next
stage. In the final stage, the patient actually handles the feared object
or remains in the formerly feared situation without experiencing
anxiety.
(ii) Flooding (or Implosion)
This is a quicker process but needs to be handled by an experienced
therapist following careful preparation of the patient. This technique
involves maximum exposure of the patient to the source of anxiety,
initially through imagination and subsequently in reality. The idea is
to increase the anxiety to a high level. Because the patient is not able to
avoid the feared object or situation, he learns that there is no actual
harm. In time, the object or situation stops producing anxiety in the
patient.
(b) Cognitive Behavioural Therapy

This approach combines both proven behavioural techniques and cognitive
strategies that focus on unhelpful thoughts. Cognitive behavioural therapy
helps the patient to identify and challenge the negative thinking patterns and
irrational beliefs that are associated with the patientÊs anxiety.

ANXIETY DISORDER
(c) Relaxation Techniques

Patients are usually taught relaxation techniques to be used in conjunction
with behavioural interventions. The concept of „reciprocal inhibition‰ is
important, that is, one cannot be relaxed and anxious at the same time.
(i) Progressive Muscle Relaxation

For the anxious person, progressive muscle relaxation releases muscle
tension and gives the patient a break from worrying. The technique
involves progressive tensing and then releasing different muscle
groups in the body.
(ii) Deep Breathing Exercises

Anxious people tend to breathe fast and shallow. This causes dizziness,
breathlessness and light-headedness, which may further fuel the
anxiety and panic. Deep breathing will help to minimise the symptoms
and reduce anxiety.
(d) Biofeedback
Patients learn to manage their anxiety faster when there is biofeedback that
they can respond to. Sensors that measure galvanic skin response, heart rate,
breathing and muscle tension can help the patient to learn to control the
bodyÊs response to anxiety using relaxation techniques.
(e) Exercise
This is the best stress buster and anxiety reliever there is. Regular exercise –
30 minutes, three to five times a week – can make a huge difference to oneÊs
sense of well-being.
(f) Assertiveness Training

Many anxious people worry because they have a need for approval from
others as well as to know what others think of them. Hence, they become
very concerned about upsetting others and become unable to reasonably and
appropriately assert themselves in relationships. Assertiveness training
helps to minimise anxiety by developing the patientÊs understanding of his
rights, self-acceptance and confidence when relating with others.

ANXIETY DISORDER
3.6.2 Drug Treatment

A large number of drugs are available to treat anxiety disorders. They are quite
freely prescribed in general practice. It is important for the nurse to make sure that
the patient knows how the drug should be used and understands its unwanted
effects. They reduce the physiological response, thus providing good relief for the
patient from anxiety but they do not educate the patient in any way. The healthcare
personnel team can help through psychoeducation, making sure the patient is
aware of the range of options available in managing anxiety-related problems.
Table 3.1 lists some common drugs used to treat anxiety-related disorders.
Table 3.1: Common Drugs Used to Treat Anxiety
Drug Mental Disorder
Diazepam (Valium) • Anxiety and panic disorder
Fluoxetine (Prozac) • Anxiety, OCD and panic disorder
Alprazolam (Xanax) • Anxiety, agoraphobia, panic disorder, OCD and social

phobia
Clomipramine (Anafranil) • OCD
Imipramine (Tofranil) • Anxiety, agoraphobia and panic disorder
ACTIVITY 3.2
Carry out the following activity during group tutorial session:
Time: 30 minutes
In small groups (4 to 6 students), develop a psychoeducation plan for a

patient (and his family) who is recovering from anxiety.
(If appropriate, present your plan to the whole class.)

ANXIETY DISORDER
• A wide range of issues is involved when working with and caring for people
who suffer from anxiety.
• Anxiety is an unhelpful and unhealthy emotional response to negative life

situations where the patient perceives a threat of some sort – actual or
imagined.
• The patientÊs treatment and recovery often starts with an awareness of his
physiological, behavioural and cognitive response when anxious.
• A range of interventions and helpful strategies are available for people who
suffer from anxiety-related disorders, including drugs.
Anxiety Flooding
Arousal Generalised anxiety disorder
Assertiveness Healthy negative emotion
Behaviour Obsessive compulsive disorder
(OCD)
Biofeedback
Phobias
Cognition
Progressive muscle relaxation
Cognitive behavioural therapy
Post-traumatic stress disorder (PTSD)
Concern
Systematic desensitisation
Emotion
Unhealthy negative emotion

ANXIETY DISORDER
Carlson, N. R. (2007). Physiology of behaviour (9th ed.). Allyn and Bacon.
Halgin, R. P., Whitbourne, S. K. (2008). Abnormal psychology: Clinical

perspectives on psychological disorders (5th ed.). Mc Graw-Hill.
Videbeck, S. L. (2008). Psychiatric-mental health nursing (4th ed.). Wolters Kluwer

Health/ Lippincott: Williams & Wilkins.

4 People with
Mental Health
Problems:
Depression
and Bipolar
Disorder
LEARNING OUTCOMES
1. Outline the differences between healthy and unhealthy negative
emotions;
2. State the major clinical features of depression;
3. Discuss psychosocial assessment and interventions for depression;
4. Identify four groups of drugs used in the treatment of depression;
and
5. Discuss bipolar disorder and state the major clinical features of
mania.

DEPRESSION AND BIPOLAR DISORDER
 INTRODUCTION
In the previous topic, you learnt that anxiety is an unhealthy emotional response
to an actual or imagined adverse situation, together with its characteristic
cognitive and behavioural features. In this topic, you will explore the nature of
depression, its characteristics, treatment and outcome. Depression is the most
common mental health problem presented by patients in the wards. You will see
a wide range of social problems presented by depressed people and the extent of
your interaction with these individuals will be largely influenced by the severity
of their depression. The more severe the depression, the harder you may have to
work to engage the patient because he will be withdrawn, lacking in energy and
interest. The problem of depression is so common that it is sometimes referred to
as the „common cold of psychological disorders‰.
You will come across mental health nursing textbooks with chapter headings like
„mood disorders‰, „affective disorders‰ or „emotional disorders‰ – they all mean
the same thing. Depression is mainly to do with „feeling‰ or oneÊs emotions. As
we discussed in earlier topics, all emotions have characteristic cognitive and
behavioural features. Now you will learn to recognise what thoughts and
behaviours normally go with a given emotion. In this topic, we will consider the
thoughts and behaviours that go with depression.
The word „depressed‰ or „depressing‰ is sometimes used in everyday

conversation without implying a clinically significant condition. In this module,
the word „depressed‰ is used to refer to the unhealthy negative emotion. The use
of the word „sad‰ or „sadness‰ is preferable as a healthy negative emotion as
opposed to depression or feeling depressed. Now you might be clear that it is not
normal or natural to experience „depression‰, which is an unhealthy negative
emotion. For instance, given a negative or adverse situation, for example, failing
an exam or death of a loved one, it is normal and healthy to experience a healthy
negative feeling, that is, sadness or even profound sadness. However, it would be
unhealthy and abnormal if one were to feel depressed about the negative situation.
To state it simply, it is okay to feel sad but not depressed.
ACTIVITY 4.1
List the differences between these two emotions – sadness and
depression. Share and compare your list with your coursemates on the
myINSPIRE online learning platform.

4.1 TRADITIONAL PSYCHIATRIC APPROACH

TO AFFECTIVE DISORDERS
It is common practice in Malaysia for psychiatrists to refer to DSM IV (Diagnostic
and Statistical Manual of Mental Disorders 4th Edition, American Psychiatric
Association), which will be reflected in our discussion on psychiatric conditions.
Prominent affective disorders are major depressive disorder and manic-depressive
illness (more commonly referred to currently as bipolar disorder). Other affective
disorders include dysthymic disorder, cyclothymic disorder, substance-induced
affective disorder, mood disorder related to a general medical condition, seasonal
affective disorder (SAD), postpartum depression and postpartum psychosis.
Firstly, an outline of the diagnosis, clinical features and treatment of major

depression and bipolar disorder will be provided. This is followed by a brief
description of dysthymic disorder and cyclothymic disorder. You are unlikely to
see patients with the other conditions in the ward. You certainly would not see
anyone diagnosed with seasonal affective disorder in Malaysia because our
weather is not seasonal, moreover, we have nicer weather here.
4.2 DIAGNOSIS OF MAJOR DEPRESSION

For someone to be diagnosed as suffering from major depressive disorder, the
person must have been depressed for at least two weeks and during this period
experienced a loss of pleasure in almost all activities (anhedonia). Other additional
symptoms must include at least four of the following:
(a) Changes in appetite or weight;
(b) Changes in sleep pattern;
(c) Psychomotor activity;
(d) Decreased energy;
(e) Feeling of worthlessness or guilt;
(f) Difficulty in thinking, concentrating or making decisions; and
(g) Persistent suicidal thoughts, plans or attempts.
For diagnostic purposes, it is expected that these symptoms will be present every
day for two weeks and cause the patient sufficient distress to affect his work, social
life and other important areas of functioning.

It is important to bear in mind that people are unique and are likely to present a
wide range of symptoms. Most are likely to complain about a limited range of
symptoms but will be preoccupied with their everyday social realities. The patient
may develop a negative view of self, self-blame, feelings of guilt and extreme
dejection and loss of interest in normally pleasurable activities. It is also worth
noting that when a patient is severely depressed, it is likely, though uncommon,
for psychotic symptoms such as delusions, hallucination, disorientation and
derealisation to be present.
SELF-CHECK 4.1
There are many explanations for the cause of depression. Outline three
major causes of depression.
4.3 TREATMENT OF DEPRESSION

There are numerous treatment options available for people suffering from
depression. We use psychopharmacology (drug treatment) as the main treatment
option, as practised in most developed countries. But unlike in the other countries,
the broader psychosocial options are not as readily available for patients in this
country, even though it has long been recognised that a combination of drugs and
psychosocial interventions produce better outcomes for patients (Rush, 2005). The
discussion of treatment will be confined to what you are likely to see in the wards.
However, you may wish to consider why psychosocial interventions are poorly
developed in this country.
4.3.1 Psychopharmacology
The following are the five major categories of antidepressants that you will see in
the wards. It will be helpful for you to familiarise yourself with the commonly
used antidepressants, the categories they belong to and their side effects. They are
as follows:
(a) Tricyclic antidepressants – e.g., Amitriptyline, Imipramine and Doxepin;
(b) Monoamine oxidase inhibitor (MAOI) – e.g., Phenelzine and
Tranylcypromine;
(c) Selective serotonin reuptake inhibitor (SSRI) – e.g., Fluoxetine, Sertraline and
Paroxetine;

(d) Atypical antidepressants – e.g., Mianserin and Mirtazapine; and

(e) Selective norepinephrine reuptake inhibitor (SNRI) – e.g., Venlafaxine.
4.3.2 Electroconvulsive Therapy (ECT)

Psychiatrists still use ECT for depressed patients whom they think are not
responding well to antidepressant drugs. This is mostly used as a last resort. ECT
remains controversial but has support from a relatively small group of
psychiatrists working in in-patient areas. ECT is the application of modified
electrical stimulation to the brain via electrodes placed on both sides of the
patientÊs forehead. Short acting anaesthetic is used to render the patient
unconscious during the treatment and a muscle relaxant is used to keep the
convulsion to a minimum.
The nurseÊs role in the preparation and post-ECT recovery and care is important.
The preparation is much like your outpatient minor surgical procedure, involving
both psychological and physical preparation. Your patient must be clear as to what
to expect before, during and after the procedure. The healthcare personnel will
check for the patientÊs understanding and offer appropriate support. Because of
the anaesthetic, it is important your patient understands that he must not take in
any food or drinks from midnight onwards, remove nail varnish, dentures and so
forth. It is common for patients to experience some memory loss (confusion and
disorientation) and headache after the treatment. The nurse, by being with the
patient, could offer some reassurance.
4.3.3 Psychosocial Assessment

It is important that the nurse responds to the patientÊs immediate concerns and
develops a working relationship with the patient. The nurse will make an
assessment in the following areas:
(a) History;
(b) General appearance and motor behaviour;
(c) Mood and affect;
(d) Thought process and content;
(e) Sensory and intellectual process;
(f) Judgement and insight;
(g) Self-concept;

(h) Roles and relationships; and

(i) Physiologic and self-care concerns.
In addition to the psychosocial assessment, tools such as the Beck Depression

Inventory and the Zung Self-rating Depression Scale may be routinely used. Some
of the areas of concern identified from the nursesÊ assessments include the
following:
(a) Risk of suicide;
(b) Self-neglect – inadequate nutritional intake, poor personal hygiene;
(c) Hopelessness;
(d) Negative self-regard and low self-worth;
(e) Fatigue;
(f) Difficulty sleeping;
(g) Agitation;
(h) Financial and relationship problems; and
(i) Guilt and anxiety.
4.3.4 Psychosocial Intervention

It will not be possible to address all of the patientsÊ problems at the same time. In
the interest of working in a client-centred manner, it is important to negotiate
which problems are perceived by the patient as his priority and agree on clear
goals for each problem. Unless the patient is highly suicidal or likely to harm
himself or others, under those circumstances the healthcare personnelÊs priority
will be imposed, whilst still responding to the patientÊs other immediate needs.
Let us look at some of the aspects to be considered when establishing a comfortable

relationship with the patients:
(a) Therapeutic Use of Self

Through interactions with the patient and others, the healthcare personnel
models the appropriate interpersonal relationship skills, teaches the patient
to value himself and conveys unconditional acceptance of the patient.

(b) Patient Safety

The healthcare personnel will ensure a safe environment for the patient, both
physically (self-harm or exploitation by others) and psychologically
(freedom to express his views and emotions without being censured or
judged.)
(c) High Risk of Suicide When People are Depressed (Sudak, 2005)
Any talk of suicide, threats of self-harm or behaviours that are secretive
(such as hoarding of tablets, hidden razor blade and the like) must be taken
seriously and communicated to the team. As students, you are likely to
become aware of these behaviours first. Some patients become more actively
suicidal when they are recovering and the risk of suicide is also high in the
first few weeks following discharge (Rihmer, 2007).
(d) Self-care Need

The healthcare personnel will focus on identified self-care deficits and assess
the level of intervention and support needed to ensure that basic self-care
needs are met. A depressed patient with pronounced psychomotor
retardation will feel overwhelmed even by a request for simple self-care
activity such as „Would you like to have a shower and a change of clothes?‰
As such, the patient must be encouraged to do as much as possible.
Therefore, be patient and persist, and try not to rush in to do things for the
patient. Patients will, in due time, get to their normal level of functioning.
ACTIVITY 4.2
What would you do to encourage a depressed patient with poor
appetite to eat? Discuss with a coursemate and share your
conclusion with the others in the myINSPIRE forum.
(e) One-to-one Session

The healthcare personnel may arrange to have a fixed time for the patient to
talk and to explore personal issues. This also gives the healthcare personnel
an opportunity to check the patientÊs experience in the ward and to monitor
his progress. Experienced healthcare personnel could also undertake
psychoeducation and relapse-prevention work.

(f) Occupational Therapy

Interacting and doing things with people outside the ward environment can
be very helpful in focusing the patientÊs thoughts on things other than his
personal problems. Activities such as art and craft, cooking and playing
games will provide valuable information about the patientÊs mental and
emotional state as well as the level of social and problem-solving skills.
Other interventions such as group therapy, family therapy, individual

psychotherapy (humanistic, cognitive, behavioural and psychodynamic) can
help patients overcome longstanding, unresolved issues and improve their
quality of life.
4.4 BIPOLAR DISORDER

Some of you may not be familiar with bipolar disorder as you may have been with
depression. Bipolar disorder is not as common as depression. Individuals who
become depressed will also experience emotions at the other end of the spectrum
where they will feel high or manic (hence, bipolar – two poles). In the old
diagnostic system, it used to be called manic-depressive disorder or commonly
called manic depression. Today this extreme mood swing is diagnosed as bipolar
disorder. As a matter of fact, one does not have to experience a depressive episode
to be diagnosed as having bipolar disorder. During the manic phase, the patient is
likely to be elated, outgoing, energetic, sleepless and grandiose.
Because of the high level of energy, the patientÊs thoughts and speech will be rapid,
jumping from one idea to another (also known as „flight of ideas‰) or from activity
to activity, very distractible and usually display poor judgement. If you were to
ask the patient how he felt, the response will most likely be „on top of the world‰.
During the depression phase, the patientÊs the moods, thoughts and behaviour are
the same as those in major depression. Whilst a major depressive episode develops
slowly and will subside gradually, a manic episode can appear rapidly and end
just as suddenly. Symptoms can appear in a matter of days and last from a few
weeks to a few months.
To be considered as having a manic episode, the patient must experience a period

of abnormally and persistently elevated or irritable mood lasting at least one week.
During this period, three of the following features must be present, four if the
mood is only irritable:
(a) Inflated self-esteem or grandiosity;
(b) Decreased need for sleep;

(c) Increased talkativeness;

(d) Flight of ideas or racing thoughts;
(e) Distractibility;
(f) Increase in goal-directed activity or psychomotor agitation; and
(g) Excessive involvement in pleasurable activities with potentially painful
consequences.
It is important to exclude symptoms that are not a result of a medical condition or

substance use. The symptoms are severe enough to cause significant distress or
impairment, or necessitate hospitalisation to prevent harm to self or others.
There is a related condition called hypomanic episode. In hypomania, there are

no psychotic features and the episode is not severe enough to cause much
disruption to the patientÊs life or the need for hospitalisation. To be diagnosed as
hypomanic, a patient must have experienced a period of persistently elevated or
irritable mood lasting at least four days, which should be different from the
patientÊs normal mood and is observable by others. During this period, three or
more of the symptoms listed for mania above must be present; four if the mood
was only irritable. And, of course, the symptoms are not attributable to a medical
condition or the effects of a substance. To put it simply, hypomania is a mild
version of mania.
Just as a matter of interest, DSM-IV recognises a variation in the manifestation of

bipolar disorder. When an individual experiences one or more manic episodes and
one or more depressive episodes (although this is not necessary), this clinical
course is diagnosed as bipolar I disorder. In contrast, when an individual has one
or more major depressive episodes and at least one hypomanic episode, it is
considered as bipolar II disorder. Therefore, it is not necessary for one to
experience mania in order to be diagnosed as having bipolar disorder.
4.4.1 Treatment of Bipolar Disorder

Medical treatment for bipolar disorder mainly involves the use of lithium
carbonate as mood stabiliser. It prevents the highs and lows, which are features of
bipolar disorder, specifically in treating acute manic episodes. For a small group
of patients who cannot tolerate lithium, a number of anticonvulsant drugs may be
used as mood stabilisers, for example, carbamazapine (Tegretol) and valproic acid
(Depakote). Antidepressant drugs are used during the severe depressive phase. In
addition, antipsychotic drugs are used to treat the psychotic symptoms.

4.4.2 Healthcare Interventions

This is largely dependent on the individual and the severity of the illness. When
the patient is in the depression phase, the care will be the same as with major
depression. Nevertheless, caring for the patient during a manic episode can be
challenging. When a patient is elated and is full of ideas about how he is going to
change the world, taking the patientÊs history for assessment purpose is no easy
task. The healthcare personnel may resort to doing it in several short sessions and
refer to family and friends in order to gather further information. Providing for the
patientÊs safety and adequate nutritional intake will be major concerns for the
healthcare personnel.
Some of the common problems from the assessment are likely to include the
following:
(a) Risk of violence largely due to frustration. Any restriction imposed will be
an irritant to the patient;
(b) Nutritional status – The patient will go without food and drink but would
not realise that he is hungry or tired;
(c) Disrupts and interferes with other patients;
(d) Compliant problem;
(e) Difficulty sleeping; and
(f) Unable to recognise and meet self-care needs.
The following is a brief account of some of the problems presented by patients

during a manic episode. It is recommended that you read further to get a better
understanding of the behaviours presented by manic patients.
(a) Dysthymic Disorder

Some individuals suffer from a milder form of depression, not as deep or
as intense but enough to make oneÊs life miserable. A person with
dysthymic disorder suffers similar symptoms as major depression such
as sleeping difficulty, poor appetite, fatigue, problem concentrating,
difficulty in making decisions and feeling hopeless. Though the
symptoms are not as many or as severe as in major depression, the
patientÊs quality of life will suffer, particularly when he feels inadequate
and unable to experience pleasure in everyday activities. This would last
for two years or more. It is the chronic nature of this condition that
distinguishes it from a major depression. Some patients will try unwisely,
though understandably, to get rid of their depressive and hopeless
feelings by consuming alcohol or taking drugs. Usually, these individuals

would not need to be admitted unless they become severely depressed or
suicidal.
(b) Cyclothymic Disorder

This is a chronic condition whereby the individualÊs mood fluctuates in a
recurrent and dramatic fashion. It is similar to bipolar disorder but not as
intense. When the patient feels high or hypomanic, it is not severe enough
to be diagnosed as mania. When he feels down, it is not severe enough to
be diagnosed as a depressive episode. Nevertheless, the condition can be
distressing and sufficiently disruptive to the patientÊs life. Although some
individuals welcome the periods of high energy and creativity, their work
and relationships can suffer because of the mood disorder as others may
come to regard them as moody, unpredictable and unreliable. They may
also experience a high risk of full-blown bipolar illness.
ACTIVITY 4.3
Discuss the following with your coursemates in the myINSPIRE

online forum:
(a) What is meant by hypomanic episode? List four clinical
features.
(b) State three features of depression for each of the following
domains: cognitive, affective and behavioural.
(c) Explain the difference between bipolar I and bipolar II
disorders.

• Affective disorders or mood disorders refer to the disturbance in an

individualÊs emotional state.
• This can involve a range of disturbances in the form of extreme depression to

mania or a combination of these emotional states as in bipolar, dysthymic and
cyclothymic disorders.
• Major depressive disorder is an acute, time-limited episode when severe

depressive symptoms are present. The depressive feeling will generate
negative thoughts about self, life situation and future. In addition, the
behaviour is one that is withdrawn and isolating, which is usually unhelpful
or self-defeating.
• Assessment in mental health is holistic in nature as it includes the intrapsychic

(within the individual) and psychosocial aspects of life. The risk of self-harm
and suicide is high when people are depressed. Therefore, knowing what to
look for, communicating with the rest of the team and documenting important
information will be an integral part of caring for such a patient.
Bipolar disorder Psychomotor agitation

Cyclothymic Psychotherapy
Depression Selective norepinephrine reuptake
inhibitors (SNRI)
Dysthymic
Selective serotonin reuptake inhibitor
Electroconvulsive therapy (ECT) (SSRI)
Hypomania Substance abuse
Lithium carbonate Suicide and psychosocial assessment
Mania Tricyclic antidepressants

Rihmer, Z. (2007). Suicide risk in mood disorders. Current Opinion in Psychiatry,

20(1), 17–22.
Rush, A. J. (2005). Mood disorders: Treatment of depression. In Sadock, B. J.,

Sadock & V. A. (Eds.). Comprehensive textbook of psychiatry Volume I
(8th ed.). (pp. 1652–1661). Lippincott Williams & Wilkins.
Sudak, H. S. (2005). Suicide. In Sadock, B. J., Sadock., & V. A. (Eds.),

Comprehensive textbook of psychiatry Volume I (8th ed.). (pp. 1652–1661).
Lippincott Williams & Wilkins.

People with
5 Mental Health
Problems:
Schizophrenia
LEARNING OUTCOMES
1. Define psychosis;
2. Discuss the positive and negative symptoms of schizophrenia;
3. Identify the five subtypes of schizophrenia;
4. Differentiate between first generation and second generation
antipsychotic drugs; and
5. Discuss the benefits of psychosocial interventions for patients
suffering from schizophrenia.
 INTRODUCTION
Public prejudice against people with mental illness is usually conjured up by
mental images of crazy, psychotic or mad people, who are unpredictable and
dangerous. Have you come across people in the street who keeps muttering and
walking at a fast pace or talking loudly to someone invisible, with hands waving
in the air and fingers pointing? You may have also come across several people who
would stop to stare at the passer-by but chose not engage with the person. What
would you have done if you were in that situation? Most likely and quite

SCHIZOPHRENIA
understandably, you would have crossed the road and walked on the opposite
side to avoid him. You may wonder what was the matter with the person and why
was he displaying such strange behaviour.
The personÊs behaviour could have been caused by a host of factors such as
infection, drugs or alcohol abuse. He could also be suffering from a severe form of
mental illness known as schizophrenia. This is an illness that is grouped under
psychosis (it comes from the Greek word psyche, which means mind or soul and
osis for abnormal condition; in other words, it means abnormal condition of the
mind). One of the central features of psychosis is the distortion in a personÊs
perception of reality (the way he sees himself and the external world). The phrase
„loss of contact with reality‰ is often used to describe this experience. The
individualÊs thoughts and speech will be jumbled and will not make sense. He may
also suffer from hallucinations and delusions. This is a very distressing and
frightening experience for the patient. It is also difficult for others to understand
and their responses may further alienate the patient.
5.1 SCHIZOPHRENIA
Over the years, schizophrenia has remained a contentious diagnosis. There is no
construct validity, meaning there is still no way of demonstrating that this
condition exists. This is because no x-ray, scan, blood test or post-mortem
findings are available to confirm the condition. The diagnosis is made exclusively
on the basis of the observed behaviour. Do read the history of schizophrenia, it
will surely hold your attention. Then find out what is the difference between
psychosis and neurosis.
It is generally accepted that about one per cent of the population suffers from this
disorder (American Psychiatric Association, 2000). It is usually noticed and
diagnosed in late adolescence and early adulthood, with a slight variation with
regard to the peak incidence of onset for men and women. The incidence of onset
peaks around the ages of 15 to 25 years for men and 25 to 35 years for women.
5.1.1 Characteristics of Schizophrenia

Schizophrenia is not a simple disorder, it is complex and can take many forms. Let
us look at some of the major features or symptoms highlighted in the following
before we discuss the diagnostic criteria. Some of these symptoms also appear in
other conditions such as mania and severe depression.

SCHIZOPHRENIA
(a) Hallucination
Sensory experience (or false perception) without an external stimulus. All the
senses can be affected but the most common is auditory, with the person
„hearing voices‰. Visual hallucination, with the patient seeing things, is the
next most common. Tactile, where the skin misperceives such as sensing
something crawling on the skin without a stimulus. Olfactory (smell) and
gustatory (taste) can also be affected. In other words, hallucination is false
perception without a stimulus.
(b) Illusion
Misinterpretation of a stimulus. For example, a piece of rope is mistaken for
a snake.
(c) Delusion
A fixed false belief that is not shared by others and is so deeply held that it
cannot be shifted through reasoning or evidence. It indicates a severe
disturbance in the thinking process, particularly the content of thought.
Some examples are shown in Table 5.1.
Table 5.1: Examples of Delusions
Delusion Example
Delusion of persecution „The CIA has decided to eliminate me, they track me
using satellites.‰
Delusion of grandeur „I can help all of you, I am the chosen one who will
save the planet.‰
Idea of reference „The newscaster on TV is talking about me.‰
Thought insertion „The thoughts in my head are not mine, they have
been put there.‰
Nihilistic delusion „The food I eat is falling into a vacuum because I donÊt
have a stomach.‰
Thought broadcasting „Other people can hear my evil thoughts; the police
will be around to arrest me anytime.‰
(d) Loosening of Association

Ideas are fragmented and unrelated but strung together in a sentence. For
example, when asked what he had for lunch, a patient responded with
„Chicken and the floor was wet got to go to town now.‰

SCHIZOPHRENIA
There are many other concepts that you will come across in the course of this
discussion. Explanations will be provided where appropriate. The symptoms of
schizophrenia are usually thought of as belonging to two major groupings, namely
positive symptoms and negative symptoms.
(a) Positive symptoms are exaggerations or distortions of normal thoughts,

emotions and behaviour, for example, hallucinations, delusions,
disorganised thinking, speech and behaviour.
(b) Negative symptoms are characterised by behavioural deficits (absence) or

functioning below what is normal. The following are some examples of
negative symptoms:
(i) Avolition
Lack of energy and inability to persist in routine activities;
(ii) Alogia (poverty of speech)

Reduction in amount or content of speech;
(iii) Anhedonia
Inability to experience pleasure;
(iv) Asociality
Severe impairment in social relationships;
(v) Flat Affect

Lack of facial or bodily response that indicate emotion or mood; and
(vi) Catatonia
A psychological state in which the patient is immobile as though in
trance; can also become excited and agitated.
ACTIVITY 5.1
Carry out the following activity during a group tutorial session:
In groups of three, take turns to role play the experience of „hearing

voices‰. One person tells a story, another listens and the third person,
who is supposed to be invisible will whisper into the ear of the listener
from behind, insisting he should be listened to. Discuss the experience in
your larger group.

SCHIZOPHRENIA
5.1.2 Types of Schizophrenia

To be diagnosed with schizophrenia, a patient would have experienced the
disturbance for at least six months and at least two of the following symptoms for
one month: delusion, hallucination, disorganised speech, disturbed or catatonic
behaviour and negative symptoms such as flat affect or severe lack of motivation.
The symptoms must also disrupt the patientÊs work, relationship or self-care. It
will be important to exclude symptoms that are due to another disorder, a medical
condition or substance use.
In acknowledgement of the complexity of this disorder, DSM-IV (American

Psychiatric Association, 2000) classifies schizophrenia into five sub-groups:
(a) Disorganised Type

Characterised by symptoms such as flat or inappropriate affect, disorganised
speech, incoherent, loosening of association and disorganised behaviour.
(b) Paranoid Type

Characterised by preoccupation with one or two bizarre delusions or have
auditory hallucination of being harassed or victimised. Although their
cognitive functioning and affect can be quite normal, they will experience
a lot of relationship problems because of their suspicious and
argumentative nature.
(c) Catatonic Type

This type is marked by disturbance in motor behaviours. Either motionless
or excessive motor activity, apparently purposeless. Patients can adopt
strange motionless physical postures referred to as catalepsy (waxy
flexibility). On the other hand, they may engage in excessive purposeless
activity or movements that do not have external stimulation. Other features
may include extreme negativism or mutism, echopraxia (repletion of othersÊ
actions) and echolalia (persistent repetition of words or phrases) and odd
mannerisms or grimacing.
(d) Schizophrenia, Undifferentiated Type

Some patients may present a mixture of symptoms that are clearly related to
schizophrenia but cannot be neatly placed in any of the other categories.
(e) Schizophrenia, Residual Type

The patients had a previous diagnosis of schizophrenia but show no active
psychotic symptoms such as hallucination or delusion. However, negative
symptoms persist such as emotional dullness, social withdrawal, eccentric
behaviour and some loosening of association.

SCHIZOPHRENIA
Other psychotic disorders include brief psychotic disorder, schizophrenic form

disorder, schizoaffective disorder, delusional disorder and shared psychotic
disorder.
5.1.3 Treatment of Schizophrenia

Psychopharmacology
Drugs used in the treatment of schizophrenia are usually called neuroleptics
or antipsychotic medication. The most notable of these is chlorpromazine
(Thorazine), which was developed in 1952. Examples of other early antipsychotic
drugs are thioridazine (Melleril) and trifluoperazine (Stelazine). These
antipsychotic drugs are used for their sedative effects and to generally control the
positive symptoms of schizophrenia such as hallucination, delusion and
disordered thinking. They do not have much of an effect on the negative
symptoms. These conventional drugs are sometimes referred to as first generation
antipsychotics (FGAs). They are mainly dopamine antagonists, which means they
block dopamine receptor sites.
Other more recent drugs referred to as atypical or second generation

antipsychotics (SGAs) are weak blockers of dopamine receptor sites, which are
said to produce fewer side effects (Daniel, Copeland & Tamminga, 2006). In
addition, the SGAs are said to improve the negative symptoms (Davis, Chan &
Glick, 2003) because they also block the reuptake of serotonin. Examples of SGAs
or atypical antipsychotics are clozapine (Clozaril), risperidone (Risperdal) and
olanzapine (Zyprexa).
It is important to bear in mind that these drugs do not cure schizophrenia. They
just control and offer some relief from distressing symptoms. This symptom
control comes at a price, a trade-off between the symptoms and side effects of the
drugs. Some of the side effects of the antipsychotic drugs can be quite distressing.
The conventional antipsychotics or FGAs produce a range of side effects including:
(a) Extrapyramidal Side Effects

Also known as extrapyramidal symptoms (EPS). Examples are:
(i) Dystonia
Muscle rigidity, difficulty swallowing due to stiff or thick tongue;
(ii) Akathisia
Restlessness, anxiety and agitation. Rigid gait and lack of spontaneity;

SCHIZOPHRENIA
(iii) Pseudoparkinsonism (Drug Induced)

Stiff stooped posture, mask-like face, small shuffling steps, tremor,
drooling and bradycardia;
(iv) Tardive Dyskinesia

Involves permanent (irreversible) involuntary movement of the
tongue, facial and neck muscles. Blinking, tongue protruding and
grimacing;
(v) Neuroleptic Malignant Syndrome (NMS)

A potentially fatal reaction in which the patient will be confused and
mute, involve muscle rigidity, high fever, unstable blood pressure,
excessive sweating, pallor and delirium; and
(vi) Anticholinergic Side Effects

Dry mouth, constipation, urinary retention, hypotension, blurred
vision, dry eyes and photosensitivity.
(b) Other Side Effects

Increased blood prolactin level causing enlarged and sensitive breasts in both
men and women. Patients also suffer from diminished libido, erectile
dysfunction, menstrual irregularities and increased risk of breast cancer.
(c) Weight gain is a problem with all antipsychotics but particularly so with the
atypical antipsychotics (for example, clozapine and olanzapine). Given the
nature and extent of the side effects of the antipsychotic drugs, patients need
to be well informed, carefully monitored and managed in order to maintain
compliance. Non-compliance is usually the result of a combination of the
patient being unhappy with the side effects of the medication, lack of
knowledge, poor relationship with staff and lack of monitoring.
5.2 PSYCHOSOCIAL INTERVENTIONS (PSI)

PSIs are an integral part of the mental health nurseÊs skills. Patients suffering from
severe and long-term mental illness tend to suffer from loss of self-confidence and
deterioration in much of the basic self-care and social skills. Patients also have to
overcome the dehumanising and stigmatising effects of long-term hospitalisation;
for many recovering patients, this can be a major challenge. It would require a
multidisciplinary team effort to assess and plan the care to meet the patientsÊ
complex needs. Care must be taken to avoid overly stressful interventions as these
may exacerbate the symptoms. The intention here is for you to be aware of what

SCHIZOPHRENIA
mental health nursing teams can do to minimise the negative effects of

schizophrenia and enhance the quality of a patientÊs life. Your presence, interest
and attention can make a difference to the patientÊs experience.
There is a good range of PSIs that could benefit those suffering from schizophrenia.
The most notable being individual and group therapy. In addition to being
supportive, it provides opportunity for social contact and the development of
meaningful relationships in an accepting environment. These sessions can be
therapeutic. Patients sharing their experience of their symptoms can have the effect
of lessening their burden and providing an opportunity to reflect. Patients learn
and benefit from the experience of others especially experiences such as hearing
voices, severe depression and medication management (Pfammatter, Junghan &
Brenner, 2006). It is that much more credible and effective when a recovering
patient offers reassurance to new patients.
The patient education process can be undertaken either individually or in groups.

Involvement of the family and carers as early as possible in the learning process
cannot be overstated (Birchwood, 1992). Improvement in the knowledge of
schizophrenia and its course helps achieve better compliance and satisfaction with
the care provided. Family involvement minimises the negative effects of
schizophrenia and prevents relapse (Penn, 2005). This is particularly so in families
with „high expressed emotion‰ as a result of much criticisms, hostility and over-
involvement.
Group work can specifically target the patientÊs social competence through social
skills training. Complex tasks are broken down into smaller manageable steps and
taught through role-play and simulation with the view to applying the new
learning in the community or in an actual situation. Such groups can address the
need for assertiveness, development of interpersonal and problem-solving skills,
handling money, shopping, using the launderette and many others.
There is an expectation that patients diagnosed with schizophrenia will have

complex needs, require long-term support and have numerous admissions. A
properly planned long-term support in the community can help prevent relapses
and readmissions. Currently, our resources are centred around hospitals.
Community resource for people with mental health problems appear somewhat
underdeveloped. Community services such as community mental health teams,
assertive outreach teams, crisis intervention teams and voluntary groups will be
required to provide sustained long-term care in the community.
There are numerous other therapies or interventions that can be helpful for
patients such as cognitive behavioural therapy (CBT), case management, assertive
outreach programmes and compliance therapy.

SCHIZOPHRENIA
ACTIVITY 5.2
Imagine that you woke up one morning and started hearing voices. The
voices are not very clear but you know they are critical of you and appear
to be laughing at you.
What would your immediate response be? What would you think, feel
and do?
(a) Make a list of your responses.
(b) Discuss your responses with a coursemate and compare your lists.
(c) Compare your responses against the signs and symptoms of
schizophrenia.
Combine your lists and share it in the myINSPIRE forum together with
the conclusions of your discussion.
SELF-CHECK 5.1
1. List four positive and four negative symptoms of schizophrenia.
2. State the five types of schizophrenia and provide a brief

description of each.
3. Discuss the effects of the following on a patient:

(a) Stigma
(b) Long-term hospitalisation

SCHIZOPHRENIA
• The concepts of psychosis and schizophrenia overlap considerably, with some

treating them as one and the same.
• Some individuals only have one psychotic episode without the full blown
experience of schizophrenia.
• The general symptoms of schizophrenia are categorised into positive and

negative symptoms. The positive symptoms are exaggerations or distortions
of oneÊs thought process, expression of emotion and behaviour. The negative
symptoms reflect insufficiency in functioning, for example, lacking in
motivation, poverty of speech, flat affect and social withdrawal.
• DSM-IV categorises schizophrenia into five main diagnostic groups or

types, namely disorganised type, paranoid type, catatonic type, schizophrenia,
undifferentiated type and schizophrenia, residual type.
• The treatment of schizophrenia is largely dominated by the use of

antipsychotic drugs.
• The drugs that are used today are either conventional (first generation
antipsychotics) or atypical (second generation antipsychotics).
• Conventional drugs tend to have more sedative effect whilst atypical drugs
control the positive and negative symptoms with less sedative effect.
• Their extrapyramidal and anticholinergic side effects can be sufficiently

troublesome to the extent that some patients would want to discontinue them.
• There are severe side effects of using the drugs, some of which can be
distressing, irreversible or even fatal.
• Psychosocial interventions are usually carried out by a mental health nurse. It

is an important part of the nurseÊs role. The nurseÊs therapeutic relationship
with the patient, family and carer will be a factor in the patientÊs management
and recovery.
• Family and carer involvement in patient care and education about the illness
and the cause of the illness not only reduce the negative effect of schizophrenia
but also increase their satisfaction with the care given.

SCHIZOPHRENIA
Affect Hearing voices

Atypical antipsychotic Loosening of association
Clozapine Neuroleptic malignant syndrome
Conventional antipsychotic Paranoia, catatonic
Delusion Psychosocial interventions
Dopamine Schizophrenia
Extrapyramidal side effects Therapeutic relationship emotion
Hallucination
American Psychiatric Association. (2000). Diagnostic and statistical manual

of mental disorders (4th ed.). American Psychiatric Association.
Birchwood, M., Smith, J., & Cochrane, R. (1992). Specific and non-specific effects
of educational intervention for families living with schizophrenia. A
comparison of three methods. Br J Psychiatry, 160: 806–14.
Daniel, D. G., Copeland, I. F., & Tamminga, C. (2006). Ziprasidone. In Schatzberg,

A. F., Nemeroff, C. B. (Eds), Essentials of clinical pharmacology (2nd ed.).
(pp. 297–305). American Publishing.
Davis, J. M., Chan, N., & Glick, I. D. (2003). A meta-analysis of the efficacy
of second generation antipsychotics. Archives of general psychiatry, 60,
553–564.
Penn, D. L., Wldheter, E. J., Perkins, D. O., Mueser, K.T., & Lieberman, J. A. (2005).
Psychosocial treatments for first episode psychosis. A research update.
American Jr. Of Psychiatry, 162(12), 2220–2232.
Pfammatter, M., Junghan, U. M., & Brenner, H. D. (2006). Efficacy of psychological

therapy in schizophrenia: Conclusions from meta-analysis. Schizophrenia
Bulletin, 32(1), 564–580.

Topic  Behavioural
6 and Freudian
Ideas in
Mental Health
Care
LEARNING OUTCOMES
1. Describe classical and operant conditioning;
2. Discuss the concept of reinforcement and the consequences that
encourage learning;
3. Apply behavioural principles in explaining explain phobias;
4. Outline the Freudian structure of the mind; and
5. Discuss psychological defence mechanisms.
 INTRODUCTION
Mental health personnel practice is underpinned by a range of philosophical and
theoretical perspectives, though on the face of it, this may not be readily apparent
to you. In this topic, we will review and discuss some of the major theoretical
perspectives that have contributed to mental health nursing. You may wonder
why it is important to understand these theories. After all, those working in the
wards seem to do fine without them. It may be useful to remind ourselves that
none of us function in a theoretical vacuum. Even as an untrained mental health
personnel, you will inevitably perceive your patientsÊ problems through your lens.

64  TOPIC 6 BEHAVIOURAL AND FREUDIAN IDEAS IN MENTAL HEALTH CARE
You have to remember that your cultural background, experiences and beliefs will
influence how you interpret, relate and work with your patients. That is how you
„see‰ the situation and the problems. For instance, it is likely that you will be
familiar with some knowledge in psychiatry. Concepts such as schizophrenia,
bipolar and depression will inevitably influence your interpretation of your
patientsÊ behaviour in the ward as emanating from their psychiatric disorder. Why
else would they be in the ward if not for their illness, right? In time, your
knowledge will increase and your perspective will change. You will become better
able to discriminate between behaviours and to see the problems from your
patientÊs perspective.
In a psychiatric setting, there is total surveillance of the patientÊs behaviour – there

is no privacy or personal space. All your patientsÊ actions are observed, interpreted
and documented. How do we know what to look for and what to record? Hence,
if we are not careful, normal behaviour could easily be interpreted as being part of
the patientÊs mental disorder, especially if the patient refuses to cooperate,
becomes angry or turns aggressive. Similar behaviour elsewhere, for instance, in
the casualty department, will not normally be interpreted as being due to the
personÊs „mental disorder‰. It is important in mental health practice to be aware
of the lens that we look through, in other words, to reflect on our actions and
develop an awareness of the implications of our knowledge and actions.
In addition to the medical psychiatric perspective, it would be helpful to be

familiar with the behavioural, psychodynamic, interactionist and humanistic
perspectives in understanding human behaviour. This topic will provide a review
of the core principles and concepts of behavioural and Freudian (psychodynamic)
perspectives. It is strongly recommended that you read and make some notes
regarding the interactionist (George H Mead) and humanistic (Carl Rogers)
perspectives.
6.1 PRINCIPLES OF BEHAVIOURAL THEORY

In terms of the development of mental health care, the importance of the
contribution of behavioural theories and associated intervention techniques
cannot be overstated. Behavioural theory was one of the early theories that helped
mental health personnel develop a therapeutic role.
Behavioural theory suggests that all behaviours, including abnormal or illness

behaviour, are learnt in the same way. The principles involved in the learning can
also be used to unlearn or learn new behaviours. Our focus will inevitably be on
behaviours that are deemed to be abnormal or distressing in some way. For
instance, it would not be helpful if a health personnel were to faint at the sight of

TOPIC 6 BEHAVIOURAL AND FREUDIAN IDEAS IN MENTAL HEALTH CARE  65
needles or for a salesman to be afraid of crowded places and avoid getting into
lifts. Likewise, it cannot be easy for a lecturer who is distressed because of a
pronounced stammer.
6.1.1 Classical Conditioning

If you have undertaken a psychology module, you might remember this theory as
„Pavlov and his dog‰. Pavlov, a Russian neurologist, was studying salivary
secretion using dogs. The dogs were restrained in a harness in a standing position,
with their salivary duct extruded into a test tube. The researchers used food to
stimulate the salivary secretion. They noticed that the dogs were salivating in
anticipation even at the sight of researchers in white coats entering the laboratory.
They initially called this „psychic secretions‰ as the dogs somehow knew that they
were going to be fed. Their curiosity to understanding this phenomenon led to the
development of the basic principles of classical conditioning.
The principles of classical conditioning are relatively simple. There are three
categories of stimuli and responses that you need to be clear about in order to
understand the conditioning process – unconditioned, neutral and conditioned.
(a) Unconditioned Stimulus (UCS) such as food elicits the unconditioned
response (UCR) of salivation. Another example is when you shine a bright
light into someoneÊs eyes, you will see the pupils constrict as a response. The
light is the UCS and the constriction of the pupil is the UCR. Another
example is when someone quietly sneaks up behind you and makes a sudden
loud noise. You will be startled. These behaviours are natural and built-in;
you did not learn them.
Food (UCS) Salivation

(b) Neutral Stimulus (NS) is a stimulus that does not elicit any particular
response although it will draw your attention. Most stimuli in our
surrounding are neutral. For instance, you notice a dog barking in the
background, a bell ringing, a tiny spider crawling on the table, an aeroplane
flying in the distance, a pigeon feather on the floor and many others.
Although we attend to these stimuli, they do not elicit any strong emotional
or behavioural response.
(c) Conditioned Stimulus (CS) is essentially a neutral stimulus that has been
paired or associated with an unconditioned stimulus (UCS). This then elicits
a new and specific emotional and behavioural response, which is known as
conditioned response (CR) and the neutral stimulus is now a conditioned
stimulus (CS).

It would perhaps be better to use an example to illustrate the conditioning process.

For instance, the sound of a bell (NS) would not normally elicit any particular
response. However, after a number of pairings of the bell with an UCS such as
food, the bell will elicit the response of salivation. It is important that for the
conditioning process to work, the food (UCS) is presented immediately after the
bell.
Bell (NS)
+
Food (UCS) Salivation (UCR)
Bell (CS) Salivation (CR)
The dogÊs response of salivation to the sound of the bell is a new learned
behaviour, a conditioned response to the bell, which is now a conditioned
stimulus. Figure 6.1 illustrates the conditioning process.
Figure 6.1: Conditioning process

Source: https://oshepsyche.wordpress.com/2015/10/07/classically-conditioned/
It is thought that in our everyday natural setting, sometimes one strong pairing is
all that is necessary for new learning to take place.

6.1.2 Operant Conditioning

PavlovÊs work encouraged other researchers to investigate behavioural learning
principles. Most notable of them was B. F. Skinner, who called his work „operant
conditioning‰. The focus of his work was on the relationship between behaviour
and the consequences of the behaviour. Sometimes, the word „contingency‰ was
used to denote the relationship between the behaviour and its consequences.
Skinner did most of his work in a laboratory, mostly with rats and pigeons. He
created a box which he used to study the behaviour of rats and pigeons. It was
known as the „Skinner box‰. This box consisted essentially of a bar or lever (to
press), food dispenser, small light and a loud speaker. There were variations in
some boxes with additional bar-press or coloured lights. Figure 6.1 shows the
Skinner box.
Figure 6.2: Skinner box

Source: https://www.simplypsychology.org/operant-conditioning.html
A hungry rat in the box wandered around and accidentally touched the bar-press.
A food pellet dropped in the food dispenser for the rat to eat. After several
experiences of accidentally touching the bar-press and getting food, the rat actively
pressed on the bar-press for food. It has now learnt to associate the bar pressing
behaviour with the delivery of food pellets. When the reinforcement (the food
pellets) was stopped, the bar-pressing behaviour decreased to the point of
extinction. Spontaneous recovery took place when the rat was put back in the box
after a period of being let out.
The use of the light teaches the rat to discriminate when to press the bar. For
instance, the food was delivered only when the bar was pressed and when the light
was on. The rat soon learnt to pressed the bar only when the light was on.

6.1.3 Reinforcement
Reinforcement is one of the important aspects of the behavioural principle. In
reality, the reinforcement does not always have to be a fixed ratio of one to one
(continuous reinforcement). In other words, one bar-pressing action equals to one
food pellet (1:1). The reinforcement can be varied, for instance, fixed at five bar-
pressing actions to one food pellet (5:1) (partial reinforcement). Alternatively, it
can be a variable ratio of average five bar presses to one (average 5:1). Interval ratio
is used when the delivery of reinforcement is dependent on time. For instance, in
the fixed interval ratio, it can be reinforced or delivered four seconds after the last
bar-press action (4 seconds: 1) or it can be a variable interval of average five
seconds since the last bar press.
ACTIVITY 6.1
Which schedule of reinforcement is used to motivate a gambler to keep
on playing – continuous or partial reinforcement? Discuss in the
myINSPIRE forum.
The example of a gambling addict playing the slot machine (Figure 6.3) is quite
useful. It allows us to consider the reinforcements that will maintain his gambling
behaviour. The variable reinforcements built into the machines will give him some
wins. This will keep him engaged and expecting the jackpot anytime but he will
soon run out of money.
Figure 6.3: Gambler seated at the slot machines
Another example is when a child throws a temper tantrum, demanding something.

Can you work out how his behaviour is reinforced?

A reinforcement is anything that makes the behaviour more likely to occur. In

other words, when we experience the consequences of an action as rewarding or
pleasing, we will do more of it. It is similar to you asking a question in class and
the teacher responds approvingly with praise. Consequently, you are more likely
to ask questions. If the teacher responds in a critical and disapproving manner,
you are less likely to ask questions in the future. Operant conditioning places the
emphasis for learning on the consequences.
The reinforcement must be carefully selected and delivered immediately (or as

close as possible) after the behaviour in order to be effective. It is important to bear
in mind that what is considered as a reinforcement for one person may not be a
reinforcement for another.
There are many types of consequences or reinforces that encourage learning. They
are outlined as follows, in a way that may help you remember:
(a) Primary Positive Reinforcers

Examples are food, drink, warmth and air. These reinforcers are useful with
children, particularly those with learning disabilities who have to learn basic
skills like getting dressed in the morning. A reinforcer such as a sip of fruit
juice through a straw from a small carton every time the child performs a
task like getting one arm into a shirt sleeve can be very motivating for the
child.
(b) Secondary Positive Reinforcers

Examples are touch, eye contact, smile, proximity and praise. You know
these can be useful reinforcers but how have they acquire the power to
reinforce?
(c) Generalised Positive Reinforcers

One example is token. There will be circumstances when it may be
convenient and more immediate to use tokens, which can be exchanged for
other benefits later. The tokens are not too dissimilar to the tokens people
receive at the end of every month in the form of money.
(d) Negative Reinforcers

This involves the removal of noxious or unpleasant stimulus. For instance, if
a child is unhappy and anxious in school, staying away from school will
reduce his anxious feeling. That reduction in anxiety will reinforce his school
avoidance behaviour. In the Skinner box, the floor is mildly electrified but
sufficiently uncomfortable for the birds. Any of the birdsÊ action that manage

to remove the discomfort will be repeated. The birdsÊ newly learned

behaviour is negatively reinforced. Skinner used this technique to teach
pigeons complex behaviours (see shaping).
(e) Punishment
This is the application of corporal punishment such as caning and smacking.
What are your views about corporal punishment? Do you think it works?
Consider for a moment the following domestic scenario. A woman living in

a high-rise apartment with her husband and two boys, five and seven years
of age, loses her temper with the boys for misbehaving one morning. She says
their father will deal with them when he returns after work. In the evening,
the boys are doing their homework when their father returns. When he hears
what had happened in the morning, he promptly gets angry and smacks the
boys.
Which behaviour do you think will suffer – the behaviour in the morning or
the behaviour immediately preceding the delivery of punishment?
ACTIVITY 6.2
Think of appropriate reinforcers to be used in the context of a classroom.

List them down, share and compare your list with your coursemates in
the myINSPIRE forum.
(f) Shaping
This is a technique where new behaviour is taught through the use of
reinforcement until the target behaviour is achieved. It is not always possible
to wait for the final or finished behaviour to reinforce. You are likely to come
across the reinforcement of the phrase „successive approximation to the
target behaviour.‰ For instance, a lecturer may wish to shape the behaviour
of a very quiet student in class to increase her verbal contribution and
interaction, and to perform at a higher level during class. The lecturer may
first reinforce her for attending class. Subsequently, she has to attend class
and answer questions directed at her for the same reinforcement (she does
not have to be correct with her answers). The lecturer may then add other
behaviours such as cooperating and contributing in small group work as part
of reinforcement for her. Ultimately, the aim is that the student will be
volunteering answers, asking questions and initiating discussions.

(g) Chaining
In chaining, a complex task or behaviour is broken down into
smaller discreet units. Each unit must be learnt and mastered successfully
with appropriate reinforcement or feedback. Upon successful mastery of all
the units, the task is performed as a whole in the right sequence. For example,
a procedure like administering an injection could be broken down and learnt
in smaller units.
(h) Reverse Chaining

The learner is encouraged to finish the end part of a procedure – the easy,
clean and pleasurable part. For instance, when dressing a wound, the new
learner is asked to administer the final stage of covering the wound with
clean dressing and subsequently performing the more difficult part like
wound cleaning.
(i) Token Economy

Tokens are used as reinforcers in carefully designed behaviour modification
programmes to encourage desirable behaviours in patients. The tokens are
exchanged for privileges such as going to the cinema and taking a walk with
staff.
ACTIVITY 6.3
During your group tutorial session, discuss one of the following and
present using a flip chart to other groups.
(a) Explain how one may learn to become afraid of tiny harmless
spiders. Discuss the conditioning process and consider how the
behaviour is maintained.
(b) An eight-year-old schoolboy has been anxious about going to
school and has started to refuse to go to school in recent days. As a
behaviourist, how would you explain this learned behaviour and
how would you help the child feel better about school again?
(c) A five-year-old displays persistent and prolonged temper
tantrums. Using behavioural principles, explain how this child may
have learnt to behave in this manner.

6.2 PSYCHODYNAMIC PERSPECTIVE IN

MENTAL HEALTH CARE
Sigmund Freud (1856–1939) was an influential thinker of his time. He profoundly
influenced every aspect of European thinking and theorising about human
nature and behaviour. Without a doubt, his theories has dominated
psychological and psychiatric thinking for a long time. Inevitably, mental health
nursing was also influenced by Freudian views. Freud used his own life
experiences – his childhood development, family relationships and case studies
of his patients – to develop his theories.
Although his influence is still felt today, our interest is more focused in the
historical importance of his theories. An overview of some of his major and
relevant theories will be provided, particularly his ideas about personality and the
structure of personality, psychosexual development and defence mechanisms.
When we talk about personality of the individual, we are essentially talking about
the enduring aspects or established patterns of behaviour, which are related to our
thoughts, feelings and actions. Perhaps Freud was one of the early people to argue
that childhood experiences had a bearing on the development of personality and
general adult behaviour.
6.2.1 Levels of Consciousness

The suggestion here is that all the things that we are aware of, including our own
thoughts and feelings and our general environment, are in the conscious area.
Beyond this is an area called the preconscious in which we have only limited
access. The preconscious in turn continues into the unconscious. In the innermost
unconscious, there are thoughts or wishes, feelings and even memories that we are
not aware of. Level of consciousness always relates to the iceberg metaphor
introduced by Dr Sigmund Freud (see Figure 6.4).

Figure 6.4: Structure of the mind as an iceberg
The idea of the unconscious being below the surface of awareness encouraged the
comparison to an iceberg. Our consciousness is the tip of the iceberg and what is
submerged deep beneath the surface is what Freud tried to work out. He theorised
that it is important to understand the inaccessible, unconscious part of the
personality because it influences our behaviour.
6.2.2 Id, Ego and Superego

The deep unconscious part is Id. The Id is simply the bundle of instincts that we
were born with – the urge for pleasure. The only rule being the pleasure principle
(gratification, satisfying its need for pleasure) is here and now. Time, as we
understand, does not apply. Incompatible wishes and desires will co-exist in a
timeless manner. Id is the source of all our energy.
Ego is the part of Id that stretches outwards and faces the reality. In other words,
the conscious, which is the aware part that deals with external reality through its
senses, large parts of it is in the preconscious and unconscious. Ego draws its
energy from Id. Ego is there to serve Id and to meet IdÊs demand for immediate
gratification as well as to ensure survival. Ego is essentially ruled by the reality
principle. As such, more often than not, Ego will have to defer or put off the
immediate demand for gratification. As you can see, Ego also has to serve another

master, namely reality. Ego uses up a lot of its energy in devising ways to cope
with the demands of Id (we will look at how this is done later). However, there is
a third master that Ego has to serve, namely the Superego.
Superego is an important constituent of personality. Superego is developed

through socialisation. As a child begins to become aware of his environment and
develops curiosity to explore, parents or carers will act as an external agency that
controls and imposes rules. They will state what is right and what is wrong, what
is allowed and what is not. When rules are broken, the child will be punished.
These rules are not just about physical safety. They also extend to moral doÊs and
donÊts, forming a basis for judgements. As the child becomes more independent
and broadens his circle of socialisation e.g. attends school, the parental rules are
internalised and continue to influence the childÊs behaviour. Depending on the
rigidity of the moral upbringing, any breach of the rules will be severely punished.
The Ego has three masters to serve – Id, Reality and Superego. The demands of Id
have to be held back to account for reality and the ever-watchful moral police
within. The conflict between Ego and Id results in neurotic anxiety while the
conflict between Ego and Superego results in moral anxiety, and the conflict
between Ego and Reality results in realistic anxiety. Hence, Freudians view anxiety
as a product of unresolved internal conflicts.
6.3 PSYCHOLOGICAL DEFENCE MECHANISMS

One of the ways in which the Ego copes with the demands of Id is to deploy what
is referred to as psychological defence mechanisms. These are processes that take
place in the unconscious and the individual has little awareness of what is
happening. There are numerous defence mechanisms; however, we will only
consider some of the notable ones here.
(a) Repression
This is an important process in Freudian theory. The Ego uses considerable
energy to keep a lid on unacceptable wishes or desires even before they get
anywhere near consciousness or oneÊs awareness. The more the repression,
the greater the energy used to keep the desires repressed. However, when
one sleeps, the level of consciousness is lowered and the Ego is able to
withdraw some energy to conserve. It is a bit like the sea coast. When the tide
is in (high tide), the water looks simmering as it should be. As the tide
gradually recedes, it reveals objects that perhaps should not be dumped
there.

The Ego is also able to take advantage of the lowered consciousness and
present to Id, through dreams, that its wish has been fulfilled. When we wake
up, we are none the wiser because we could not make head or tail of the
dream. The true message is sufficiently disguised through symbolism and
dream censorship. How many times have you woken up and thought, „What
was that about?‰
(b) Reaction Formation

Unacceptable wishes or impulses are made to look the opposite. For instance,
someone who is angered by cruelty to animals may publicly campaign very
hard against cruelty to animals.
(c) Regression
Backward move to a more comfortable psychological stage of development
as a way of coping with anxiety. For example, a teenager may act in an
infantile manner when faced with everyday demands.
(d) Projection
We have our own „ego ideal‰ and when we subconsciously notice our own
unacceptable attributes and impulses, we will see more of it in others. We
will be critical and even condemn others for it. Presumably, paranoid or
antisocial individuals rely heavily on the defence mechanism of projection.
(e) Rationalisation
A behaviour or event may be explained in a self-justifying manner to avoid
pain or threat, usually by using a more intellectual explanation, which is
logical and rational. The expression „sour grapes‰ describes this defence
mechanism well. For example, if you do not get a job you want, you may say,
„It wasnÊt a well-paying job‰.
(f) Displacement
Let us say you had a bad day at work and when you arrived home, you kick
your cat. This is called redirecting aggressive impulses towards a more
acceptable or weaker person or object.
There are many other defence mechanisms that you will come across in the
course of your reading. They are carried out at the unconscious level and
deployed by the Ego. Defence mechanisms are almost always used to
minimise pain, avoid conflict and maintain social acceptability.

6.4 STAGES OF PSYCHOSEXUAL

DEVELOPMENT
You will find this part of FreudÊs theory more straightforward. He theorised that
a child goes through stages of development where the sensation of bodily pleasure
is progressively experienced in different parts of the body, which he called
erogenous zones. A baby has to successfully complete each stage. Each stage
basically has three components, namely physical focus, psychological theme and
adult character type. An outline of each stage and its implications for adulthood is
as follows:
(a) Oral Stage (0–18 Months)

The physical focus is around the mouth - deriving pleasure through sucking,
chewing, biting and exploring the world through the mouth. Babies are
dependent on others to meet their needs. There will be psychological
implications when babies are overly indulged or when their needs go unmet.
Overindulged babies tend to trust others easily and can be quite gullible.
They experience difficulty in comprehending when their demands are not
met. On the other hand, babies whose needs go unmet, become distrustful of
others. Freudians believe that if a child has unresolved issues at this stage or
becomes fixated at this stage, he will become an „oral character‰ in his
adulthood. He will become highly dependent on other people to fulfil his
needs.
(b) Anal Stage (18–36 Months)

The physical focus is on the anus. Freudians believe this is the stage of
development of control over the anus and the focus of pleasurable sensation
is centred on the anus. Retention and expulsion of bowel motion is not only
pleasurable but also about the sense of control over carers. The psychological
concern is about the balance between control and obedience, the problem
being excessive control or insufficient control by carers. Fixation during this
stage will lead to „anally retentive‰ characters. They are rigid, give
importance to procedures and rules, and are compliant to higher authorities
(they are the perfect bureaucrats). They could also become „anally expulsive‰
characters, who show little self-control, are disorganised and are even
hostile.
(c) Phallic (3–6 Years)

The physical focus is on the genitals. During this stage, there is heightened
awareness of the genitals and the sensation of pleasure is centred on the
genitals. The potential for conflict is at its maximum. From a psychological
point of view, the rigid moral environment (you may recall the Superego)

will make any exploration highly risky and a sense of severe guilt as
punishment for any breaking of the moral rules. Other issues will revolve
around anxiety that is related to identity and relationship with parents. In
fact, Freudians describe a number of conflicts during this stage such as the
Oedipus complex in boys, the Electra complex in girls, castration anxiety and
penis envy. You may want to read further to explore the nature of the theory.
How these conflicts are resolved may have a bearing on oneÊs attitude
towards sexuality in adulthood – ranging from asexual and puritanical to the
opposite extreme of amoral and promiscuous behaviour.
(d) Latency Stage (6 Years to Puberty)

This is a relatively peaceful period compared to the preceding stages. Sexual
urges and conflicts subside, allowing the child to focus on school and social
activities.
(e) Genital (Puberty Onwards)

The focus is on the genitals, subject to earlier stages being successfully
resolved. It produces a balanced individual with a mature adult sexual
interest, long-term intimate relationship, family and achieving a balance
between work and love.
The theory and a range of associated techniques involving a dialogue between the
patient and the therapist such as free association, anamnesis (making sense of
personal events), interpretations of Freudian slips, dreams and symbols have come
to be known as psychoanalysis.
ACTIVITY 6.4
Think of a recurrent dream that you have had and your interpretation
of it. Then follow up with a group exploration of alternative
explanations. Make use of the myINSPIRE online learning platform for
this activity.
• Behavioural and psychodynamic theories have been of immeasurable value to

mental health personnel.
• Classical conditioning involves the pairing of an initially neutral stimulus such

as bell and spider with an unconditioned stimulus. In time, the neutral
stimulus will elicit the same response as the unconditioned stimulus.

• In operant conditioning, the emphasis is on the consequences of an action.

Skinner demonstrated the principles of reinforcement using the Skinner box.
• Reinforcers are any consequences of a behaviour that makes the specific

behaviour more likely to occur. Types of reinforcers range from primary
positive reinforcers, secondary positive reinforcers, generalised positive
reinforcers, negative reinforcers and punishment.
• FreudÊs work was more focused on the unconscious and psychological

development of the individual, especially the psychosexual development of
the child and the structure of the personality.
• In FreudÊs theory, the dynamic relationships between Id, Ego and the Superego
exist. Psychological defence mechanisms are deployed by the Ego to cope with
the demands of Id, Reality and Superego, with repression being the most
significant of the defence mechanisms.
• FreudÊs stages of psychosexual development have a physical focus,

psychological theme and implications for adult behaviour. The stages of
psychosexual development are oral, anal, phallic, latency and genital.
Behaviour Psychosexual development

Classical conditioning Psychological defence mechanisms
Consequences Punishment
Negative reinforcement Reinforcement
Operant conditioning Repression
Psychodynamic Unconscious

Prochaska, J. O., & Norcross, J. C. (2007). Systems of psychotherapy: A

transtheoretical analysis. Thomson Brooks/Cole.
Videbeck, S. L. (2008). Psychiatric – Mental health nursing (4th ed.). Wolters

Kluwer/Lippincott: Williams & Wilkin.

Topic  Understanding
Substance Use
7 and Abuse in
the Context of
Mental Health
Care
LEARNING OUTCOMES
1. List five groups of psychotropic drugs and their effects;
2. Define substance use, abuse and dependency;
3. Discuss substance dependency and its treatment in Malaysia;
4. Discuss drug withdrawal programme for alcohol and heroin; and
5. Critically discuss the psychosocial interventions in the treatment of
substance abuse and dependency.
 INTRODUCTION
Our mental health services are often expected to cope with societal problems that
are not related to the usual understanding of mental health problems. Substance
abuse is a problem that is essentially social in nature but mental health services has
to pick up the pieces. Although most people who use and abuse substances may
not be mentally ill, there are some who may have developed diagnosable mental

TOPIC 7 UNDERSTANDING SUBSTANCE USE AND ABUSE IN THE  81
CONTEXT OF MENTAL HEALTH CARE
illness. For some, the mental illness may predate their substance abuse behaviour,
which developed as a result of their lifestyle and social realities. Yet, there are
others whose mental illness may be induced by the use and abuse of the substance.
Cannabis, for instance, is known to trigger a psychotic breakdown in some
individuals. The phrase „dual diagnosis‰ refers to patients who have a
diagnosable mental illness as well as a drug problem.
From the healthcare point of view, the presence of individuals who use and abuse
substances in the ward will present some additional unwelcome challenges. The
substance abuserÊs addictive and dependency behaviour can be a disruptive
influence in the ward. Other vulnerable patients may be manipulated to provide
money and other forms of assistance to support the substance abuserÊs habits.
Ward staff needs to be alert to substances being brought into the ward by visitors,
usually „friends‰ whom the patient hardly knows. Careful control and supervision
of such visitors will be necessary to stop the ward from being used by the drug
pushers and to deny them access to vulnerable patients.
Having briefly mentioned about the potential negative impact on the ward
environment when caring for a substance abuser, our main focus for this topic
must be to try and understand and care for persons struggling with the problem
of substance dependency. What is meant by substance use, abuse and
dependence? What are the substances involved? Each of these questions will be
clarified before we explore the treatment and care for such patients. Perhaps it will
be useful to note at this juncture that our concern is not so much with the
diagnostic criteria for these labels but with our understanding of the concepts.
7.1 TERMINOLOGIES
The following comprises terms and definitions generally used in the field of
psychiatry to describe and explain substance use and abuse:
(a) Substance Use

Substance use in a general sense includes the use of caffeine, nicotine and
alcohol; you may also consider the ingredients especially spices that are used
in cooking as „substance use‰. We use them because they stimulate our
system or help change the way we feel. You have a cup of coffee in the
morning to wake yourself up. Most likely, you have seen individuals who
smoke a cigarette to relax or reduce tension, or those who have a few
alcoholic drinks at the end of a dayÊs work. There are even those who
routinely consume wine together with their meals. As you can see, we all use
substances in one form or another. The word „psychoactive‰ is sometimes
used to describe these substances. This is because they can change our mood

82  TOPIC 7 UNDERSTANDING SUBSTANCE USE AND ABUSE IN THE
and behaviour. When these substances are consumed in moderation, there

are no noticeable ill effects. There are also those who use illegal substances
such as cannabis, amphetamine and the like, albeit occasionally.
(b) Substance Abuse

Substance abuse usually refers to excessive use. But more importantly, it
refers to the effects of the substance on oneÊs functioning. It is very likely that
different people respond differently to the substance consumed. Therefore,
it may seem more appropriate to focus on the effects of the substance on a
person in order to determine substance abuse as opposed to the amount
consumed. As such, it was generally accepted (American Psychiatric
Association, 2000) that the label „substance abuse‰ denotes the severity of
the effects of the substance abused. I other words, the extent in which the
substance consumed interferes with oneÊs normal functioning in the areas of
work, education, family and other relationships. Putting oneself at risk whilst
under the influence such as drunk driving and other problems with the law
would be considered as drug/alcohol abuse.
(c) Substance Dependence

Saying that someone has a substance dependence problem is the same as
saying he is addicted. Both terms, „substance dependence‰ and „addiction‰,
are usually used interchangeably, although in recent years more authors
appear to have dropped the use of addiction in preference for substance
dependence. The concept of substance dependence is quite complex and
includes both physiological and psychological dependence.
(d) Physiological Dependence

Physiological dependence refers to both tolerance and withdrawal.
(e) Tolerance
Tolerance occurs when more and more of the abused substance is needed to
experience the same „high‰ or „rush‰. To put it another way, the continued
use of the same amount of the substance produces less and less of the desired
effect. There may be a number of reasons for this. It could be due to the
increased production of enzymes that break down the substance in the liver.
Hence, more of the substance is needed to achieve the same effect (metabolic
tolerance). The other reason could be that the receptors in the brain adjust to
the excessive amount of the substance by reducing the receptors or by
becoming less sensitive to the substance. This is known as pharmacodynamic
tolerance (Oltmanns and Emery, 2009).

(f) Withdrawal
Withdrawal is another important phenomenon associated with dependence.
This is the unpleasant physical response of the body that one experiences
when one stops taking the psychoactive substance. Sometimes, Malaysians
who have gone overseas for a short period say how much they missed the
food that they have been used to. If you are used to consuming a lot of
caffeine through coffee, tea and soft drinks, in about 12 hours you will notice
the withdrawal symptoms such as irritability, restlessness, muscle stiffness,
headache and difficulty concentrating.
(g) Psychological Dependence

This usually refers to the strong craving that one experiences, resulting in
what is sometimes described as drug-seeking behaviour. It is generally about
the fear and avoidance of the anticipated withdrawal symptoms.
Characteristically, the substance dependent person will go to great lengths
to make sure that there is no interruption in the supply of the substance. The
amount of time spent in planning to consume the drug will give a good
indication of the extent of dependence. Borrowing money, deceiving others
(such as lying and stealing) are also related to psychological dependence.
(h) Substance Intoxication

This refers to the high or drunkenness state that is experienced as the effect
of the consumed psychoactive substances. As you would expect, motor
coordination will be affected and standing straight will be difficult, let alone
walking a straight line. Altered mood and impaired judgement are the other
main effects.
(i) Psychoactive Substances

Psychoactive substances are generally categorised into five convenient
groups:
(i) Depressants
These substances have a sedative and relaxing effect. Examples include
alcohol, barbiturates and benzodiazepines.
(ii) Stimulants
These are substances that stimulate the central nervous system, causing
one to stay alert, active and feeling euphoric. Included in this group are
substances such as nicotine, caffeine, amphetamine, cocaine and
methamphetamine (syabu).

(iii) Opiates
These substances create a sense of well-being and euphoria. The
analgesic effects cause the numb pain. Included in this group are
substances such as heroin, opium, codeine, morphine and methadone.
(iv) Hallucinogens
These substances have a profound effect of enhancing sensory
perception. Hallucination-like experiences are common. Substances
include LSD, MDMA (ecstasy) and Phencyclidine (PCP or angel dust).
(v) Cannabinoids
Derived from the hemp plant, marijuana and hashish, these substances
can induce a feeling of „getting high‰, a pleasant feeling of well-being.
7.2 SUBSTANCE USE, ABUSE AND

DEPENDENCE IN THE MALAYSIAN
CONTEXT
The problem of psychoactive substance abuse is a worldwide problem. Most of the
psychoactive drugs used by people in developed countries are prescribed legally
by general practitioners and psychiatrists in the form of antidepressants and
anxiolytics (anti-anxiety drugs). These drugs can be abused (and they do get
abused), resulting in all the attendant problems of dependency. Usually, general
practitioners in these countries are supported by well-developed mental health
services and yet, there is significant problems of abuse and dependency.
Consider for a moment a country like Malaysia, with its underdeveloped mental
health services where the prescribing is mostly by doctors operating privately on
the high street, neither accountable nor responsible for the patient, with no
obligation to monitor or follow up. It would be difficult to estimate the extent of
the problem because this is done privately and not talked about. In addition, there
are also others who self-medicate, those whom we also know very little of. Clearly,
in countries like Malaysia, there is widespread use of general drugs, namely
lifestyle drugs, herbal medicines, vitamins, nutritional supplements, antioxidants,
medicines for coughs and colds, and the like. In fact, it would not be surprising if
most households were likely to be well stocked with their own mini pharmacy.

7.2.1 Scope of the Problem

The problem of illegal substance abuse by young people is relatively small
compared to the use and abuse of legally prescribed psychoactive substances.
However, we should not underestimate the potential harm of the abuse of illegal
substances on individuals, families and the wider community.
The National Anti-Drugs Agency (NADA) has about 300,000 registered „addicts‰.
There is a general view that the problem is escalating over time and the actual
numbers may be two to three times higher. The Malaysian government policy has
been, until recently, to criminalise the abusers of illegal drugs and to place
emphasis on the custodial approach to treatment and rehabilitation (Mazlan,
Schottenfeld & Chawarski, 2006). As a consequence, our prison population is
heavily represented by people who are dependent on drugs and/or committed
drug-related offences.
There are about 29 drug treatment centres throughout the country, treating a
maximum of about 10,000 people. These facilities are insufficient even for the
number of registered drug abusers. According to the law, all confirmed substance
abusers, even those who voluntarily admit themselves, will be required to undergo
a two-year treatment and rehabilitation at a drug rehabilitation centre (Pusat
Serenti). The success rate of this form of custodial approach is thought to be only
about 20 per cent. With more effective treatment and management of substance
abusers especially with the use of substitute medication, the gradual development
of more community-oriented treatment programmes appears to be more promising.
Even though it is still a crime to be in possession of or use illegal substances, there

has been a shift in emphasis towards greater involvement of health services in
providing medical treatment and other harm reduction approaches such as health
promotion, psychoeducation and needle exchange, among others. These are much
more enlightened strategies in dealing with the problem of drug dependence and
other drug-related problems. Close to 80 per cent of our HIV/AIDS sufferers
acquired the disease as a result of their drug habit, particularly by sharing needles.

ACTIVITY 7.1
During the group tutorial session, discuss the contributions of the
following factors in the development of alcohol dependence.
(a) Cultural and social attitudes, peer influence, law and cost
(b) Psychological factors
(c) Biological factors
7.2.2 Commonly Abused Substances

You may not be old enough to have experienced the lifestyle of the 1960s and
1970s. In those days, middle-aged and elderly men sat at the doorway of their
village houses, smoking opium to get a high. Crime and other associated social ills
were not so apparent in those days. The scene today is very much different with
many younger people being involved in substance abuse. A significant proportion
of them are women. Heroin, morphine (processed derivative of opium) and
marijuana (ganja) are very popular. Other relatively common substances abused
are opium, LSD and cocaine (hallucinogens), ecstasy (amphetamine) and of course,
the cheap option of inhalants especially glue.
It may be noteworthy that the use of cigarettes, alcohol and cannabis appears
to precede heroin abuse and dependence. Even while they were dependent
on heroin, the use of these substances continued. In addition, the use of
benzodiazepines (especially flunitrazepam) by heroin users is also relatively
common. Its use appears primarily to enhance and extend the experience of
euphoria, though some may also use it to cope with withdrawal symptoms.
SELF-CHECK 7.1
List the pros and cons for the following treatment modalities for
substance abusers:
(a) Institutional treatment and rehabilitation
(b) Community-based treatment programmes

7.3 TREATMENT FOR SUBSTANCE ABUSE

AND DEPENDENCE
The general approach or model for drug treatment seems to reflect the approach
used in the treatment for alcohol dependence.
7.3.1 Detoxification
The first stage of treatment is usually detoxification and helping the client to
manage withdrawal symptoms. Detoxification describes the safe manner in which
the substance will be withdrawn from the body. Do not make the mistake of
thinking that it is the treatment; it is only the first stage of the treatment. In a
moment, we will discuss some of the interventions necessary to help a person stay
off the substance.
Psychoactive substances have some similarities and differences in their effects and
withdrawal symptoms. The effects and withdrawal symptoms of some of the
commonly abused substances such as alcohol, nicotine, heroin and amphetamines
are outlined in Table 7.1. Most textbooks will provide you with a list of the effects
of a wide range of abused substances.
Table 7.1: Commonly Abused Substances
Substance Effects Withdrawal Symptoms

Alcohol • Depressant – Initially reduces • Coarse hand tremors,
inhibition and leads to sweating, nausea and
feeling of well-being and vomiting.
outgoing behaviour. • Anxiety, insomnia, agitation,
• Continued drinking affects high pulse and blood
other brain functions, pressure.
coordination, speech, • In severe cases, especially if
judgement, etc. untreated – delirium tremens
• Disinhibited behaviours - (DTs) transient hallucinations
sexually and aggression. and body tremors. Can be life
• May experience blackout. threatening.
Nicotine • Psychoactive substance, CNS • Insomnia, irritability,

stimulant, improves mood difficulty in concentrating,
and helps with stress. depressed mood, anxiety,
• Causes high blood pressure, increased appetite and weight
increased risk of heart gain.
disease and cancer.

Heroin • Pain reliever (analgesic), • Intense craving for the drug.

induces a sense of well-being, Excessive yawning, dysphoria,
euphoria, drowsiness and restlessness, insomnia, aches
slowed breathing. High doses and pain in the muscles and
can suppress breathing. joints. Abdominal cramps.
• Vomiting and diarrhoea.
Sweating and chills. Dilated
pupils.
Amphetamine • CNS stimulant – induces a • Dysphoria, fatigue, insomnia
feeling of „high‰ and vigour. or hypersomnia, vivid
• Helps to stay awake, reduce unpleasant dreams, increased
fatigue. Appetite appetite, psychomotor
suppressant. retardation or agitation.
• Depression and suicidal
ideation.
We have discussed the idea of negative reinforcement earlier. Consider for a

moment how it can be used to explain drug dependency behaviour.
Drug-consuming behaviour is about the desire to avoid the pain and discomfort
associated with the withdrawal of the drug. Drug-seeking behaviour and
continued consumption of the drug is negatively reinforced by the removal of
the pain and discomfort, providing a powerful motivation for the continued use
of the drug.
7.3.2 Medical Management of Alcohol Withdrawal

Because of the risk to life, it is important to bear in mind that all alcohol
detoxification must be conducted under medical supervision. Withdrawal can be
safely achieved at home if the withdrawal symptoms are moderately severe and
the client is able to stay clear of alcohol. It is not uncommon for clients to be
admitted for a short period if the withdrawal symptoms are severe or if they could
not stay off alcohol during this period. Some mental health units offer this facility.
Alcohol withdrawal symptoms are usually managed medically by using a

benzodiazepine (such as diazepam, lorazepam or chlordiazepoxite). As you would
expect, nutritional deficiency is also a common health problem with alcoholics;
hence, the prescription of thiamine and folate. Anticonvulsants may also be
prescribed for patients who may be at risk for seizures. Antihypertensive drugs
may be prescribed for patients with sustained hypertension.

7.3.3 Medical Management of Heroin Withdrawal

Heroin withdrawal can be unpleasant and distressing. Because of this, many
abusers feel compelled to continue using heroin. Withdrawal symptoms will take
effect as early as six hours and at the outside 24 hours. Symptoms will peak around
the third day and will gradually weaken and diminish by the seventh day. A major
strategy used in the management of heroin withdrawal is agonist substitution.
This simply means substituting another safe substance with a similar chemical
effect (agonist) as heroin. The most commonly used heroin agonist is methadone,
a synthetic narcotic. Methadone is prescribed to help the patient give up on heroin
without suffering too much of the heroin withdrawal symptoms. Methadone,
however, is not the magic solution to heroin dependency. Methadone has its own
problem of creating tolerance and dependency. Except that whilst on methadone,
the patientÊs drug-seeking behaviour and other high-risk behaviours are greatly
reduced as methadone can be obtained legally on prescription. For instance, the
sharing and multiple use of injection needles dramatically increases the risk of
infection at injection site, AIDS and HIV, hepatitis B and so forth.
Other drugs that are used in heroin withdrawal are buprenorphine and naltrexone.
Buprenorphine is similar to methadone and provides an alternative substitute to
the use of methadone. Naltrexone (an opiate antagonist) is used to block the effects
of heroin and bring about heroin withdrawal symptoms. Naltrexone is also used
in a similar way with alcoholics. It is perhaps worth mentioning that heroin
withdrawal symptoms can be complex in nature with a strong psychological
overtone to the experience of withdrawal. Some have even suggested that heroin
withdrawal is not life threatening (unlike alcohol withdrawal) and does not
require a great deal of expensive medical management during withdrawal.
ACTIVITY 7.2
Many drug-dependent individuals are reluctant to seek any kind of
treatment. Why do you think this is so?
Discuss with a coursemate and share your conclusion with the others in
the myINSPIRE online learning forum.
In summary, let us review the medical approaches in the treatment of drug abuse
and dependency:
(a) The Use of Agonist Substitution

Using another drug that is similar in make-up and effect to the abused
substance. For example, the use of methadone or buprenorphine in the case
of heroin dependency.
(b) The Use of Antagonist Drugs

These are used to block receptor sites of the abused substance. For instance,
naltrexone may be used to block heroin and alcohol receptor sites.
(c) Aversive Treatment

This treatment involves the use of drugs to create unpleasant consequences
for the abused substance. As you know, people abuse substances to
experience a pleasant feeling or „high‰. The reasoning here is that by
inducing unpleasant consequences every time the abused substance is
consumed, the substance will lose its original appeal. This approach is
sometimes used with people who are dependent on alcohol. Disulfiram
(Antabuse) is used to induce nausea when alcohol is consumed. Silver nitrate
lozenges or gum is used on smokers to create a bad taste in the mouth
(Oltmanns & Emery, 2009).
Other medical drugs may be used symptomatically, particularly to prevent

seizures, deal with high blood pressure and others.
7.3.4 Structured Psychosocial Interventions

As you are already aware, drug-related behaviours have a strong social and
psychological influence. Because of that, no medical treatment alone will be
successful in preventing people from continuing to abuse substances. In this
subtopic, we will consider briefly a range of psychosocial interventions that have
been found to be helpful in the management of drug-dependent behaviours.
(a) Inpatient Care

A period of inpatient care may be helpful for some individuals especially if
the problem is severe (may have a diagnosis of mental illness) and there is
inadequate social support. A structured environment with appropriate
medical treatment, psychoeducation and social support will provide a good
start for the rehabilitation process.
(b) Relapsed Prevention Model

In this approach, relapses are not viewed as inevitably leading to drug use
but as aspects of dependency behaviour. The emphasis is on the individualÊs
cognitive and behavioural coping skills. Relapse, according to this model,
essentially means deficit or failure in these coping skills, hence relapses are
situations that can be recovered. For instance, the individual may become
unsure (ambivalent) about getting rid of the substance. Reviewing his beliefs
about positive aspects of the drug and the negative implications of its use
will help the person deal with his ambivalence and recommit to therapy. It
is important to identify environmental cues and triggers that can lead to
unhelpful thoughts and feelings, and develop strategies and skills to cope
with them. The individual is encouraged to view the relapse as a temporary
state or a consequence of stress, and it can be managed.
(c) Alcoholic Anonymous (AA)

A popular non-medical model of treatment that views alcohol dependency
as a disease and addiction as more powerful than the individual.
Acknowledgement of this dependency and the negative effects of alcohol is
a necessary first step of the treatment process. The AA popularised the
system of 12 steps to recovery from alcohol. An integral part of the process
is total abstinence, a belief in God and reliance on prayer. Social support is in
the form of group meetings and the facility to call someone when in need.
(d) Controlled Use of Substance

Unlike the total abstinence required by the AA, this approach recognises that
some people can be taught to return to social use of substances such as
tobacco and alcohol without returning to abusing the substances. Hence, the
teaching of controlled drinking is central to this approach.
(e) Conditioning (for Example, Aversion Therapy)

You have already encountered the idea of classical conditioning. This
principle is used to associate the drug with an unpleasant consequence. For
instance, the use of Antabuse to induce nausea as a consequence of drinking
alcohol. The unpleasant feeling of nausea and feeling ill will be associated
with the consumption of alcohol. Covert sensitisation is a technique that uses
the same principle except that the patient is taught to imagine the usual scene
of substance use and just before the substance is used to visualise the painful
negative consequences.
(f) Contingency Management

This is a straightforward operant conditioning process where you negotiate
target behaviours and use appropriate reinforcements to maintain the
desired behaviours.
(g) Community Reinforcement Approach

In this approach, drug abuse is viewed as a multifaceted problem, that is, all
the significant factors that have a bearing on the patientÊs substance use
behaviour will be assessed and problems identified. Relationship building
through the use of a non- substance by family or friend will be the initial
starting point to help develop relationship with others. The patient will be
taught to recognise and handle antecedents or triggers to substance use such
as situations, people or internal states such as feeling depressed, worry and
the like. This model also emphasises the need for help with education or

training, finance, work, housing and others. New leisure activities to replace
the patientÊs substance use behaviour and avoid boredom will also be
necessary.
7.4 CHALLENGES FOR HEALTHCARE

PERSONNEL
The patients whom we care for have unique experiences and presentation of their
problems. People who are substance abusers are really no different, except that
many of their behaviours may be related to and are a consequence of their
dependence on the substance. The healthcare personnelÊs assessment will be no
different from the psychosocial assessment that you are now familiar with.
7.4.1 Acute Physical Withdrawal Phase

This is a difficult period for the patient and it is important for the healthcare
personnel to be with the patient and to empathise with the patientÊs pain. Your
patient is likely to experience symptoms such as nausea, vomiting, stomach
cramps, chill, sweat, chest pain and diarrhoea. This is an opportunity for the
healthcare personnel to work on developing a meaningful and trusting
relationship with the patient. It will also be useful to always maintain a
professional attitude and self-composure. Drug-dependent people come to expect
a certain negative attitude from others. It is necessary for the healthcare personnel
to convey a non-judgemental and accepting attitude towards the patient.
Your listening skills will be valuable in encouraging the patient to talk about his
relationship and drug-related behaviour. It is very likely that your patient has
developed a very negative perception of himself, has low self-worth and
denigrates himself. This negative self-perception will lead to depression and
anxiety. Your unconditional acceptance of him will not only be therapeutic but will
also model the appropriate way to view and relate to himself. It is important that
the patient is given the responsibility to choose and make decisions at every stage
of his treatment as a way to encourage control and autonomy.

7.4.2 Keeping the Patient Engaged with the Service

after Detoxification
It is likely that given your good relationship with your patient, he will use you
as a resource or support during times of difficulty. A broader psychosocial
intervention package should be in place along the lines discussed earlier, which
includes the patientÊs family members.
The encouragement of realistic patient expectations about the prospect of recovery

and rehabilitation is important in how the patient will view and handle any future
relapse that may occur.
SELF-CHECK 7.2
Describe the impact of drug-dependency behaviours on the family.
• Psychoactive substances are generally categorised into five groups, namely

depressants, stimulants, opiates, hallucinogens and cannabinoids.
• Related key concepts include substance use, substance abuse, dependency,

substance withdrawal and intoxication.
• Approach to drug abuse and dependency in Malaysia has indicated a gradual

shift in recent years, from a custodial and punitive approach to a more
community-oriented medical treatment programme.
• Due largely to the high rates of HIV/AIDS among heroin-dependent people,

the treatment of heroin dependency with agonist substitution (methadone and
buprenorphine) has been allowed in Malaysia in recent years. Harm reduction
measures such as needle exchange have also been introduced.
• Treatments for substance abuse include the medical management of alcohol

and heroin withdrawal, and the use of agonist substitution and antagonist
drugs.

• The following are a range of psychosocial interventions that have been deemed
to be useful in the treatment of substance-dependent individuals:
– Inpatient care;
– Relapse prevention;
– Alcoholic Anonymous (AA) – 12 steps to recovery from alcohol abuse;
– Controlled use of substance such as controlled drinking;
– Conditioning such as aversion therapy;
– Contingency management such as the use of rewards; and
– Community reinforcement approach – A holistic approach targeting every
aspect of the individualÊs life.
• Challenges faced by the healthcare personnel in handling substance abuse

patients include a professional, non-judgemental and accepting attitude
towards the patient.
Agonist substitution Craving

Alcoholic Anonymous (AA) Detoxification
Amphetamine Drug withdrawal
Antagonist drugs Methamphetamine
Aversion therapy Methadone
Buprenorphine Nicotine
Caffeine Psychoactive substance
Cocaine Relapse prevention
Conditioning Substance abuse
Contingency management Substance dependency
Controlled drinking Tolerance

American Psychiatric Association. (2000). Diagnostic and statistical manual of

mental disorders (4th ed. text rev.).
Mazlan, M., Schottenfeld, R. S., & Chawarski, M. C. (2006). New challenges and
opportunities in managing substance abuse in Malaysia. Drug Alcohol
Review, 25(5), 473–478.
Oltmanns, T. F., & Emery, R. E. (2009). Abnormal Psychology (5th ed.). Pearson
Prentice Hall.
Videbeck, S. L. (2008). Psychiatric – Mental Health Nursing (4th ed.). Wolters

Kluwer/Lippincott Williams & Wilkin.

Topic  Prevention and
Management
8 of Aggression
and Violence
in Mental
Health Care
LEARNING OUTCOMES
1. Discuss triggers and risk factors for aggression and violence in
mental health care;
2. Outline the five phases of the assault cycle;
3. Discuss interventions to de-escalate an escalating situation;
4. Critique the use of control and restraint (C&R) in mental health care;
and
5. Discuss the role of rapid tranquillisation in mental health care.
 INTRODUCTION
In this mental health module, we have explored a wide range of experiences and
behaviours presented by people receiving care in mental health settings. We
considered emotional disturbances (such as depression, anxiety and mania),

TOPIC 8 PREVENTION AND MANAGEMENT OF AGGRESSION AND  97
VIOLENCE IN MENTAL HEALTH CARE
cognitive disturbances (such as delusions and hallucinations) and strange

behavioural problems (such as withdrawn, mute and catatonia). After your clinical
posting, you may feel quite confident in handling challenging behaviours
presented by patients in other areas of nursing.
In this final topic, we will explore an area that is considered challenging for most
nurses but is only mentioned in passing. In fact, in the Topic 1 when you did the
„fears in a hat‰ exercise, you may recall the stereotyping of mentally-ill people as
violent people. We now have the opportunity to address the issue head on and in
some detail. This topic will help you to develop a realistic view of the nature and
extent of risk of violence in mental health care and how it is managed.
The methods involved in managing aggression and violence among people with
mental health problem have evolved over the years. With improved knowledge
and understanding of potential causes and risk factors for aggression and violence
in clinical practice, mental health teams have developed policies and strategies
wherever possible to prevent the occurrence in the first place and when it occurs,
to control and manage it effectively. You should know that mental health
professionals clearly take the problem of aggression and violence very seriously.
However, as a learner, you are not expected to play a significant role in the care of
such challenging behaviours since qualified staff will be on hand to handle
situation. Maintain your supportive role, communicate whatever observations or
information you may have to the qualified staff and document them, whenever
appropriate. You only get involved in the care of these individuals under the direct
supervision of qualified staff. However, by the time you complete your clinical
posting, you should have a good understanding of the issues involved in caring
for people who may at times become aggressive and violent.
The definitions of aggression and violence are not as straightforward as they might
appear. In psychological literature, the term „aggression‰ is related to a wide range
of behaviours. Coie and Dodge (2000) used it to simply mean any behaviour
intended to harm another individual who is motivated to avoid being harmed.
Krug et al. (2002) defined the term „violence‰ as the „intentional use of physical
force or power, threatened or actual, against oneself, another person or against a
group or community, that either results in or has a high likelihood of resulting in
injury, death, psychological harm, maldevelopment or deprivation.‰ For our
purposes, the differences between the two concepts are too subtle and there is
sufficient overlap in the concepts for us to use them interchangeably.

98  TOPIC 8 PREVENTION AND MANAGEMENT OF AGGRESSION AND
8.1 AGGRESSION AND VIOLENCE IN

EVERYDAY SOCIAL RELATIONSHIPS
Aggression and violence may appear as part and parcel of human relationships.
People get angry and sometimes become abusive and violent. You may have been
brought up by parents who used physical punishment or taught by teachers who
used physical punishment to control students. You may have also seen violence in
courting and marital relationships (domestic violence). Undoubtedly, there is
plenty of violence depicted in the media such as the newspapers, television
programmes and movies. For some, aggression and violence may be part of their
everyday social reality and they have come to accept it as such. We hope that with
better education and personal development, no one accepts violence as part of
their relationship.
In working with the mentally ill, you would expect to handle a higher level of risk
of aggression and violence. This is a fact that all mental health professionals are
acutely aware of. Over the years, they have tried where possible to minimise this
potential risk through careful assessment of risk for aggression and violence. You
will probably not witness any serious incidence of violence during your clinical
posting. However, it is more likely that you may witness angry patients,
sometimes hostile and even aggressive individuals. However, these are usually
minor instances. You must listen carefully to the staff in the ward and work closely
with them. Most patients whom you will be working with will pose no risk of
violence.
8.2 STRATEGY FOR REDUCING THE RISK OF

VIOLENCE
This will involve a multidisciplinary team assessment of clinical and
environmental risks and a review of past behaviour relating to violence and
warning signs.
Develop a plan of care specifically designed to prevent and/or reduce the

possibility of incidents occurring. The plan should be regularly reviewed.

8.3 FACTORS THAT INDICATE INCREASED

RISK OF VIOLENCE
Certain factors or variables suggest an increased risk of violent behaviours.
Aspects usually considered important to assess for risk of aggression and violence
are shown in Figure 8.1 and described in detail thereafter.
Figure 8.1: Important variables in the assessment of risk of violence
(a) Personal History

This will include, first and foremost, the patientÊs history of disturbed and/or
assaultive behaviour. Nature of assault, known triggers, frequency, use of
weapons, extent of injury caused, victim profile and the like.
A thorough assessment will highlight the following:

(i) A full account of substance and/or alcohol abuse;
(ii) Reports by others, especially carers, of expressions of anger and threats
of violence – intentions to harm others;
(iii) Social restlessness – drifting, no fixed address and unable to hold on to
jobs;
(iv) Previous dangerous impulsive acts;
(v) Denial of previous established dangerous acts;

(vi) Evidence of recent severe stress especially loss or threat of loss; and
(vii) Cruelty to animals, reckless driving and so forth.
(b) Clinical Variables

(i) Abuse of substances and/or alcohol;
(ii) Drug effects – restlessness and disinhibition;
(iii) Positive symptoms such as hallucinations (especially command
hallucination) and delusions, particularly if related to specific
individuals;
(iv) Obsession with violent fantasy, control and so forth;
(v) Excitable, impulsive, overt hostility and paranoia; and
(vi) Poor treatment compliance.
(c) Situational Variables (The immediate environment)

(i) Availability of social support;
(ii) Potential weapons in the immediate vicinity;
(iii) Relationship problems (especially with potential victim) and access
to this person; and
(iv) Compliance with ward routine and rules – limit setting, staff attitude
and so forth.
SELF-CHECK 8.1
List the warning signs that a person may be escalating towards physical
violence.
(Focus on emotional, behavioural and cognitive changes.)
ACTIVITY 8.1
During a group tutorial session, discuss the healthcare personnelÊs

attitude which may provoke aggressive behaviour.

Clearly, a number of elements must come together for violent incidents to occur.
Attention to each of the following elements may go a long way towards
minimising the risk of the situation escalating into violence:
(a) A trigger is always present, usually in the form of an event or circumstance
that the person reacts or responds to;
(b) It is common for a high level of arousal to accompany aggression and
violence;
(c) A weapon – this can be anything including a fist, knife or cup; and
(d) A target.
8.3.1 The Assault Cycle

Once the individual has reached the point of being aggressive or violent, he has
entered the assault cycle (Kaplan & Wheeler, 1983). There are five phases in this
model of violent incident as shown in Figure 8.2.
Figure 8.2: The assault cycle

(a) Trigger Phase

We all have a baseline or normal behaviour, which is usually non-aggressive.
You are now aware of a range of possible triggers. Depending on how well
we know the patient, the triggers are often missed. A trigger moves emotion
and behaviour away from the baseline (psychological discomfort) into the
escalation phase.
(b) Escalation Phase

Emotion in the form of anger increases and the potential for violence is
present. It is important for the healthcare personnel to recognise the need to
improve the situation and take appropriate actions.
This phase is also related to a situation where there is no support such as

during a home visit; one may decide to leave the situation. A person who is
angry is unlikely to listen to reason or consider other peopleÊs point of view.
Therefore, it is better to validate his anger and listen to what he has to say in
a non-defensive manner. Accept what he has to say without disagreeing or
arguing. Check with him if he would like to discuss his problem, give him
control of the situation and respect. In this way, he may be more willing to
negotiate. More often than not, inappropriate actions and attitude on the part
of the healthcare personnel will escalate the situation into the crisis phase.
(c) Crisis Phase

The crisis point differs from one individual to another. During this phase,
some individuals may simply retreat to their room and slam the door while
others may kick the furniture, refuse to cooperate or complete a task. Yet
there will be some whose crisis point will be to exert intentional violence or
physical assault on others. If communication during this phase becomes very
difficult to handle and unsafe, the healthcare personnel should prioritise the
safety of the patient, self and others. Immediately steer other patients and
visitors away from the surrounding area. Staff in numbers will contain the
situation. We will explore physical interventions to prevent a crisis or to
manage a crisis situation later in the topic.
(d) Recovery Phase

During this phase, the agitation subsides and the patient begins to look calm
– the crisis has ended. However, healthcare personnel should still be vigilant
and not assume that the patient is back at his baseline behaviour. The risk of
further crisis remains high. The patientÊs adrenaline level will take some time
to decrease (about 90 minutes) and the staff who are called to help should
remain to ensure control of the situation. In practice, there have been many
instances where even experienced healthcare personnel were assaulted
during this phase because they intervened therapeutically too soon. Please

remember that it does not take much for the patient who is still highly
aroused to reach crisis stage again. In Figure 8.2, the assault cycle graph
shows the crisis points in the recovery phase.
SELF-CHECK 8.2
1. List five possible triggers for aggression and violence in your
clinical area.
2. List measures that the healthcare personnel may take to improve
the situation.
(e) Depression Phase

This is the post-crisis period where the patientÊs behaviour dips below his
baseline behaviour. He will be fatigued and is likely to be tearful and sad,
ashamed, feeling guilty and even angry towards himself. The patient may be
willing to accept the care designed to relieve feelings of guilt and other
concerns he may have, and also to discuss the incident with a view to
preventing future occurrences. At this point, close observation will be an
integral part of the plan of care.
8.4 INTERVENTIONS IN MANAGING

AGGRESSION AND VIOLENCE
Experienced mental health professionals will be alert to typical signs or changes in
behaviour that precede a potential violent incident. You would agree that
prevention is much better than having to deal with a full-blown incident.
8.4.1 Awareness of Warning Signs

The healthcare personnelÊs knowledge of the patient is important, particularly
knowledge of warning signs from previous incidents. There are patients who are
aware of changes in their mental state and will self-report angry or violent feelings,
thus allowing for appropriate early intervention. Table 8.1 lists some of the
warning signs to be aware of. Are you able to add more warning signs to the list?

Table 8.1: Warning Signs That May Precede a Violent Incident

Warning Signs
Increased restlessness and agitation; pacing
Bodily tension
Increased volume of speech
Tense and/or angry facial expression
Refusal to communicate; withdrawn
Thought processes unclear; poor concentration
Verbal threats or gestures
8.4.2 Physical Interventions

When experienced mental health nurses notice the possibility of an incident
developing, they will do the following:
(a) Assess the situation;
(b) If necessary, telephone for assistance; and
(c) Avoid getting involved until adequate support is available.
An important principle in the management of aggression and violence is the staffÊs

response to be appropriate and proportionate as the patientÊs behaviour escalates.
The nurseÊs intervention should be very less restrictive considering the patientÊs
behaviour and the circumstances. If possible, maintain verbal communication and
offer the patient the opportunity to comply with instructions.
Restraint might be necessary in some circumstances as a last resort for the

following reasons:
(a) Significant physical attacks;
(b) Significant threats or attempts at self-injury;
(c) Prolonged over activity, risk of exhaustion;
(d) Prolonged and serious verbal abuse, threats, disruption in the ward; and
(e) Risk of serious incident to self or others.

In any potentially aggressive or violent situation, it is important that one member

of the staff takes on the role of incident coordinator. This person does not need to
be the person in-charge or a registered nurse. This personÊs role is to take an
overview of the situation in the clinical area especially in relation to availability of
staff support, those who might be at risk and what action is needed to contain the
situation. The coordinator also directs staff in responding to the call for assistance
as to what their roles will be, for example:
(a) Part of the control and restrain (C&R) team;
(b) Care for other patients;
(c) Make the environment safe (clear the area); and
(d) Stand by for further instruction.
There must be sufficient support staff presence before any physical intervention to
control an aggressive patient takes place. The incident coordinator will not
normally be part of the C&R team unless it was a planned change, in which case
someone else will take over the role of the coordinator.
8.4.3 Control and Restraint (C&R)

Should the need to physically restrain a violent patient arises, it must be
undertaken by staff who are trained in team restraint. There are three C&R trained
staff in team restraint who will physically bring the violent patient under control,
with minimal risk of injury to the patient and staff. The primary objective is to
ensure the safety of the patient, staff, other patients and visitors.
The techniques used in control and restraint activity should be in accordance with
current practice – mechanically sound and avoid causing undue stress on limbs
and joints. The patientÊs head must always be supported by one team member and
no pressure should be applied on the patientÊs back, neck or chest. The time that
the patient spends on the floor in a prone position should be kept to an absolute
minimum (no more than three minutes), bringing him to a kneeling, sitting or
standing position as soon as practicable.
The application of flexion on the wrist joint will cause pain, which is used to gain
patient compliance in the process of restraint. However, pain tends to also produce
fear, anger and resentment in the patient and should be avoided if possible. Once
restrained, the patient may be secluded in a seclusion room and/or sedated.

Control and restraint training is a specialised five-day training after which staff are
expected to attend an annual update to keep current. Members of the staff who are
not C&R trained should not get involved in physically restraining patients. The
following are activities conducted during the control and restraint procedure.
(a) Seclusion
Usually, a specially designated room will be used for the purpose of
secluding patients for short periods. Mental health units will have policies
about the use of seclusion, review and medical supervision. There is no real
therapeutic benefit from the use of seclusion.
(b) Rapid Tranquillisation

The aim of using medication at this stage is to rapidly achieve a reduction in
agitation and aggression without necessarily sedating the patient and with
minimal side effect. It is important for the patient to be conscious,
communicating and participating in his care. Rapid tranquillisation should
be conducted under medical supervision, preferably in the presence of a
psychiatrist. Rapid tranquillisation is also conducted when parenteral
medication is given to a patient against his will. This is an intervention of the
last resort, where other measures have been exhausted and there is a high
risk of violence and harm to the patient and others. This is because the patient
is still fighting and threatening to assault others. Rapid tranquillisation as an
intervention is not about treating the patient but more about calming him
and reducing the risk of violence, and consequently harm, to the patient and
others.
It is usual for the following medication to be administered intramuscularly

for the purpose of rapid tranquillisation:
(i) Lorazepam 1–2mg; or
(ii) Olanzapine 10mg; or
(iii) Haloperidol 5mg +/– Lorazepam 1–2mg.
The staff who uses rapid tranquillisation must be familiar with the unit or
hospital policy on the use of rapid tranquillisation and should be trained in
the assessment and management of such patients. There are serious risks
involved in the use of benzodiazepines and antipsychotics. Therefore, the
nurses need to ensure that they maintain the techniques and equipment
needed for cardiopulmonary resuscitation. They must also make sure that
before rapid tranquillisation is done, a set of drugs in injectable form for
side effects (Benzatropine, Procyclidine) and benzodiazepine antagonist
(Flumazenil) are available and at hand.

Nurses should always monitor a patientÊs vital signs to avoid the patient
being over-sedated, causing loss of alertness or even consciousness. There is
also the possibility of respiratory and cardiovascular collapse or other
underlying physical disorders. Adverse drug interaction may be an issue as
the patient is likely to be on prescribed medication; some may use self-
purchased or even illicit drugs. It is likely that an important therapeutic
relationship will be damaged by restraint and rapid tranquillisation,
therefore, everything must be done to rebuild the relationship.
(c) Documentation
A clear documentation on the nursing care delivered to patients is both a
professional and legal requirement. In mental health care, the same applies.
In Malaysia, there is an additional law relating to the care of the mentally ill,
which is the Mental Health Act 2001. When we are treating people against
their will or restraining and rapidly tranquillising them, we would want
some legal protection in doing so. It is important for nurses who work under
these circumstances to understand and work clearly within the law and
institutional policies. Failure to abide by the rules will lead the nurses to face
a host of accusations, violation of human rights, assault, illegal detention or
kidnapping, among others.
Incidents need to be documented clearly and objectively. In addition to date,

time, place, who was involved, what actually happened and the nature of
injury, nurses also need to document clearly what was done as a result, why
and by whom, and what was the outcome.
It is important to avoid interpreting the patientÊs behaviour by using phrases

such as „The patient was angry‰ and „His behaviour was very bad and
threatening.‰ It would be better to document exactly what the patient said
and did. For example, „The patient pointed his fingers at S/N Jones and said,
ÂI will get you, you stupid woman.Ê‰ In the documentation, there must be
clear justification for the use of restraint or rapid tranquillisation and it must
reflect the hospital policy on such interventions.

• Violent incidents may be avoided by understanding and managing the risk

factors – personal history, clinical and situational variables.
• The assault cycle is made up of five phases, namely trigger phase, escalation
phase, crisis phase, recovery phase and depression phase.
• Physical interventions in the prevention and management of aggression and

violence should be considered.
• In using control and restraint (C&R) and the administration of rapid

tranquillisation, care should be taken to make sure that the nurseÊs response is
appropriate and proportionate.
• There should be thorough, accurate and objective documentation of violent

incidents and the nursesÊ interventions with clear justifications for the actions
taken and the outcomes.
Aggression Rapid tranquillisation

Assault cycle Recovery phase
Control and restraint (C&R) Risk assessment
Crisis phase Seclusion
Depression phase Trigger phase
Escalation phase Violence
Physical interventions

Coie, J. D., & Dodge, K. A. (2000). Aggression and antisocial behaviour. In Damon,
W., Eisenberg, N. (Eds), Handbook of child psychology: Vol. 3. Social,
emotional, and personality development (5th ed.). (pp. 779–862). Wiley.
Kaplan, S. G., & Wheeler, E. G. (1983). Survival skills for working with potentially
violent client. Social Casework, 64, 339–45.
Krug, E. G., Mercy, J. A., Dahlberg, L. L., & Zwi, A. B. (2002). The world report on
violence and health. Lancet 360, 1083–88.

MODULE FEEDBACK
MAKLUM BALAS MODUL
If you have any comment or feedback, you are welcome to:
1. E-mail your comment or feedback to modulefeedback@oum.edu.my
OR
2. Fill in the Print Module online evaluation form available on myINSPIRE.
Thank you.
Centre for Instructional Design and Technology

(Pusat Reka Bentuk Pengajaran dan Teknologi )
Tel No.: 03-78012140
Fax No.: 03-78875911 / 03-78875966


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NBMH3913

Mental Health Care

Copyright © Open University Malaysia (OUM)

Copyright © Open University Malaysia (OUM)

Module Writer: Utharas Arumugam

Moderator: Narima Zainal

Enhancer: Mispan Mangon

Developed by: Centre for Instructional Design and Technology

First Edition, April 2020

Copyright © Open University Malaysia (OUM)

Topic 1 Introduction to Mental Health 1

Topic 2 Psychosocial Assessment in Mental Health 11

Topic 3 Caring for People with Mental Health Problems: 26

Copyright © Open University Malaysia (OUM)

3.6.1 Behavioural Intervention 34

Topic 4 Caring for People with Mental Health Problems: Depression 40

Topic 5 Caring for People with Mental Health Problems: Schizophrenia 53

Topic 6 Behavioural and Freudian Ideas in Mental Health Care 63

Copyright © Open University Malaysia (OUM)

6.4 Stages of Psychosexual Development 76

Topic 7 Understanding Substance Use and Abuse in the Context of 80

Topic 8 Prevention and Management of Aggression and Violence in 96

Copyright © Open University Malaysia (OUM)

Copyright © Open University Malaysia (OUM)

COURSE GUIDE DESCRIPTION

As an open and distance learner, you should be acquainted with learning

Copyright © Open University Malaysia (OUM)

Table 1: Estimation of Time Accumulation of Study Hours

Briefly go through the course content and participate in initial discussion 10

Study the module and completing assignments 50

Attend 5 face-to-face tutorial sessions 10

Revision and self-tests 22

TOTAL STUDY HOURS ACCUMULATED 120

COURSE LEARNING OUTCOMES

1. Describe the principles of psychiatric and mental health nursing;

2. Discuss the treatment modalities in managing patients with mental illness;

3. Discuss the collaboration of care significance to community psychiatric care;

4. Discuss psychosocial assessment in psychiatric and mental health nursing.

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Topic 1 introduces a number of common concepts in mental health, clarifies these

Topic 3 emphasises the importance of understanding emotions and explores the

Topic 4 covers major affective disorders, namely depression (sometimes regarded

respond to efforts at de-escalation. Therefore, we will also discuss control and

TEXT ARRANGEMENT GUIDE

Self-Check: This component of the module is inserted at strategic locations

Activity: Like Self-Check, the Activity component is also placed at various

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Fortinash, K., & Holoday-Worret, P. (2012). Psychiatric: Mental health nursing

American Psychological Association. (2019). Publication manual of the American

Antai-Otong, D. (2008). Psychiatric nursing: Biological & behavioural concepts

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Videbeck, S. L. (2014). Psychiatric mental health nursing (6th ed.). Lippincott

TAN SRI DR ABDULLAH SANUSI (TSDAS) DIGITAL

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Psychiatrists have a central role in treating these patients. Healthcare personnel

1.1 WHAT IS MENTAL HEALTH?

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1.2 MENTAL HEALTH PROBLEMS

(a) Factors Located Within the Individual

(b) Factors Located in the Interpersonal Domain

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