COMMUNITY

MENTAL HEALTH
NURSING

Presented by:
Merin solomon
M.Sc.Nursing 1st yr
 INTRODUCTION
• The methods of treating mental illness have
changed dramatically in the past century.
• The overall goal of community mental health as
outlined by Mrs. Indira Gandhi in may 1981 while
addressing the world health assembly is as :

“In India, we would like to go homes

instead of large numbers gravitating towards
centralized hospitals. Services must begin where
people are and where problems arise.”
 Community mental health-
psychiatric nursing

DEFINITION

Community mental health- psychiatric nursing is

the application of specialized knowledge to
populations and communities to promote and
maintain mental health, and to rehabilitate
populations at risk that continue to have residual
effects of mental illness.
 Community mental health-
psychiatric nursing
• Psychiatric nursing in the community setting differs
markedly from its hospital counterpart.

• The community setting requires that the psychiatric

nurse possess knowledge about the community
resources.

• She should be flexible in approaching problems

related to individual psychiatric symptoms, family
and support systems and basic living needs such as
housing and financial support.
 HISTORY
• Before 1840, there was no known treatment for
individuals who were mentally ill because mental
illness was perceived as incurable.

• The intervention was thought to be removing these

ill persons from the community to a place where
they would do no harm to themselves or others.

• With establishment of the National Mental Health

Act of 1946, the U.S. government awarded grants
to the states to develop mental health programs
outside of state hospitals.
 HISTORY
• Outpatient clinics and psychiatric units in general
hospitals were inaugurated.

• In 1949, National Mental Health (NIMH) was

established.

• Deinstitutionalization movement started as the

care of the client in the hospital became cost
prohibitive whereas care for client in community
is cost effective.
 HISTORY
• Deinstitutionalization means closing of state mental
hospitals and discharging of mentally ill individuals.

• Provision of outpatient mental health services not

only is the wave of the future but also has become
a necessity today.

• Provision of health promotion, early intervention,

and to ensure rehabilitation or prevention of long-
term disability.
PRINCIPLES OF
COMMUNITY
MENTAL HEALTH
 PRINCIPLES OF COMMUNITY
MENTAL HEALTH
(A) General principles:

• The home and community environment help

clients sustain social, family, and self - care
functions. Keeping clients in their usual
environments is preferred, as long as it is
medically, socially and economically feasible to do.

• A health problem is a manifestation of several

related problems and issues, residual or ongoing,
in various aspects of life. A holistic approach is
necessary.
 Principles Cont…
• Cost- effectiveness can be achieved only through
well coordinated and integrated services & close
monitoring.

• Home health care is delivered in a client’s place of

residence. When entering a client’s home, the nurse
is in that person’s cultural surroundings and must
respect them, as well as integrate cultural
preferences and expectations into services.

• High quality client care is an indisputable goal,

regardless of changes in policy and regulation of
home care services.
 Principles Cont…
(B) Specific principles

• Each person has an unique psychological makeup.

Nurses must tailor an individualized care plan to
the person’s particular circumstances and consider
his or her home and community surroundings.

• Goals for improving health status and developing

personal resources must be realistic based on the
client’s condition.
 Principles Cont…
• A client’s or family’s reaction to an alteration in
mental health status, mental disability or mental
illness is often influenced by whether the condition
is permanent, temporary, or degenerative.

• Empathy for emotional reactions from clients and

families to various mental illnesses can help
establish a positive therapeutic relationship.

• Nurses base client care on the therapeutic

relationship. Therapeutic rapport is the
foundation for providing appropriate psychiatric
home care nursing services.
 THE PUBLIC
HEALTH MODEL
 THE PUBLIC HEALTH MODEL

• The model of public health is based largely on

the concepts set forth by Gerald Caplan (1964)
during the initial community mental health
movement.
• Concepts include:

1. Primary prevention
2. Secondary prevention
3. Tertiary prevention
 PRIMARY PREVENTION
• Services aim at reducing the incidence of mental
disorders within the population. Primary
prevention targets both individuals and the
environment. Emphasis is twofold:

• 1. Assisting the individuals to increase their ability

to cope effectively with stress.

• 2. Targeting and diminishing harmful forces

(stressors) within the environment.
 Nursing Interventions in
primary prevention
• Focused on the targeting of groups at risk and the
provision of educational programmes.
Examples include:

1. Teaching parenting skills and child development

to prospective new parents.

2. Teaching physical and psychosocial effects of

alcohol/drugs to elementary school students.
 Nursing Interventions in
primary prevention

3. Teaching techniques of stress management to

virtually anyone who desires to learn.

4. Teaching groups of individuals’ ways to cope with

the changes associated with various maturational
stages.

5. Teaching concepts of mental health to various

groups within the community.
 Nursing Interventions in
primary prevention
6. Providing education and support to unemployed
or homeless individuals.

7. Providing education and support to other

individuals to various transitional periods (e.g.
Widows and widowers, new retirees, and women
entering the work force in middle life.)

8. Antenatal care to the mother and educating her

regarding the adverse effects of irradiation,
certain drugs and pre-maturity.
 Nursing Interventions in
primary prevention
9. Ensuring timely, efficient, obstetrical assistance to
guard against the ill effects of anoxia and injury to
new born at birth.

10. Providing dietary corrections to those infants

suffering from metabolic disorders.

11. Correction of endocrinal disorders.

12. Training programs for mentally and physically

handicapped children like blind, deaf and mute.
 Nursing Interventions in
primary prevention
13. Rendering crisis counseling to the parents of
physically and mentally handicapped children.

14. Identifying the problems of scholastic

performance and emotional disturbances among
school going children and giving timely
intervention.

15. Ensuring harmonious relationship among the

members of the family, and teaching healthy
adaptive techniques at the time of stress producing
events.
 Nursing Interventions in
primary prevention

• These services can be offered in a variety of

settings that are convenient for the public (e.g.
churches, schools, colleges, community centres,
YMCAs and YWCAs, work place of employee
organizations, meetings of women’s group, or civic
or social organizations such as PTA’s health fairs,
and community shelters.
 SECONDARY PREVENTION

• Services aimed at reducing the prevalence of

psychiatric illness by shortening the course
(duration) of the illness. (Sadock & Sadock, 2003)

• Secondary prevention is accomplished through

early identification of problems and prompt
initiation of effective treatment.
 Nursing in secondary prevention
Focuses on recognition of symptoms and provision
of, or referral for, treatment.

• Examples include:

1. Ongoing assessment of individuals at high risk for

illness exacerbation (e.g. during home visits, at
day care, in community health centres, or in any
setting where screening of high- risk individuals
might occur.)
 Nursing in secondary prevention
2. Provision of care for individuals in whom illness
symptoms have been assessed.

Example:

Individual or group counseling, medication

administration, education and support during
period of increased stress( crisis intervention),
staffing rape crisis centres, suicide hotlines,
homeless shelters, shelters for abused women, or
mobile mental health units.
 Nursing in secondary prevention
3. Referral for treatment of individuals in whom
illness symptoms have been assessed.

Referrals may come from support groups,

community mental health centres, emergency
services, psychiatrists or psychologists, and day or
partial hospitalization.
• The salient features of secondary prevention
include:

1. Early diagnosis and case finding

2. Early referral
3. Screening programmes
4. Early and effective treatment for patient and, if
necessary, to relevant family members.
5. Mental health education
6. Crisis intervention
7. Consultation services.
 TERTIARY PREVENTION
• Services aimed at reducing the residual defects
that are associated with severe or chronic mental
illness.

• Tertiary prevention is accomplished in two ways:

1. Preventing the complication of the illness.

2. Promoting rehabilitation that is directed toward
achievement of each individual’s maximum level
of functioning.
 Nursing Interventions in
tertiary prevention
Focuses on helping clients learn or relearn socially
appropriate behaviors so that they may achieve a
satisfying role within the community.

Examples include:

1. Consideration of the rehabilitation process at the

time of initial diagnosis and treatment planning.
2. Teaching the client daily living skills and
encouraging independence to his or her maximum
ability.
 Nursing Interventions in
tertiary prevention
3. Referring clients for various after-care services
like support groups, day treatment programs,
psycho social rehabilitation programs.

4. Monitoring effectiveness of after-care services

through home health visits or follow-up

5. Making referrals for support services when

required.
 Nursing Interventions in
tertiary prevention
Nursing care at the tertiary level of prevention can
be administered on an individual or group basis and
in a variety of settings such as :

• inpatient hospitalization
• day or partial hospitalization
• group home or halfway house
• shelters, home health-care & nursing homes
• community mental health centers.
THE COMMUNITY AS
CLIENT
 PRIMARY
&
SECONDARY
PREVENTION
 Lancaster (1980) states:

• The term community refers to a group of

people living in close proximity and having
some dependency on each other.

• Community encompasses the place where

people live, work, raise children, and in
general carry on the activities necessary for
daily living.
 Lancaster (1980) states:
• A given community is composed of
individuals who are engaged in some degree
of social interaction within a defined
geographic area and who have one or more
common ties.

• The community is the social environment in

which hazards are experienced and
supports are provided.
 PRIMARY PREVENTION
• Primary prevention within communities
encompasses the twofold emphasis, i.e.:

• Identifying stressful life events that

precipitate crisis and targeting the relevant
populations high risk.
• Intervening with these high-risk
populations to prevent or minimize
harmful consequences.
 POPUATION AT RISK

1. Adolescence

2. Marriage

3. Midlife

4. Retirement
 {1}. ADOLESCENTS
• It is a transition into young adulthood and is a
volatile time in most families.
• Commonly there is conflict over issues of control.
• It seems that the adolescent is 25 yrs old one day
and 5 yrs old the next.
• An often –quoted definition of an adolescent, by
an anonymous author, is “A toddler with
hormones and wheels”.
• Most frequent precipitant to adolescent suicide is
loss, or threat of loss, or abandonment by parents
or closest peer relationship.
 PRIMARY LEVEL
• It focused on providing support and accurate
information to ease the difficult transition
they are undergoing.

• Educational offerings can be presented in

schools, churches, youth centers, or any
location in which group of teenagers gather.

• Programmes that inform about and validate

bodily changes and emotional feelings about
which they may be some concerns.
 NURSING
INTERVENTIONS
 NURSING INTERVENTIONS AT
PRIMARY LEVEL
• Educational programmes that inform about
sexuality, pregnancy, contraception and
sexually transmitted diseases.

• Educational programmes that inform about

the use and abuse of alcohol and other
drugs.

• Educational programmes that inform about

the nutritional needs specific for this age
group.
 NURSING INTERVENTIONS AT
SECONDARY LEVEL
• The need for intervention occurs when disruptive
and age-inappropriate behaviors become the
norm, and the family can no longer cope
adaptively with the situation.

• All levels of dysfunction are considered, from

dysfunctional family coping to the need for
hospitalization of the adolescent.

• Do interventions at community mental health

centers, physician’s offices, schools, public health
departments, and crisis intervention centers.
 NURSING INTERVENTIONS AT
SECONDARY LEVEL
• Work with families to problem solve and
improve coping and communication skills

• Or they may work on a one-to-one basis

with the adolescent in an attempt to modify
behavior patterns.

• Focus on problem identification and

stabilizing a crisis situation.
 {2}. MARRIAGE
• No two people can possibly coordinate all
their developmental crises.

• Additional conflicts sometimes also arise

when the marriage is influenced by
crossovers in religion, ethnicity, social
status, or race, although these types of
differences have become more individually
and societal acceptably than once were.
 PRIMARY LEVEL
• It involves education regarding what to expect
at carious stages in the marriage.

• Nurses could offer courses in marriage and

family living in community through role-play.

• Encouraging honest communication.

• Determining what each person expects from

the relationship.
 NURSING
INTERVENTIONS
 NURSING INTERVENTIONS AT
PRIMARY LEVEL
• Ascertaining whether or not each individual
can accept compromise.

• Can be done effective in individual or couple

therapy or in support/educational groups of
couples experiencing similar circumstances.

• Parenthood causes developmental crisis

precipitated by the birth of a child.
 NURSING INTERVENTIONS AT
PRIMARY LEVEL
• Anticipatory guidance is the term used to describe
the interventions used to help new parents to know
what they might expect.

Information is given about :

• parent-infant bonding
• changing husband-wife relationships,
• clothing and equipment
• feeding and other expectations,
• prepared childbirth classes
• stages of growth and development.
 NURSING INTERVENTIONS AT
SECONDARY LEVEL

• Nursing interventions at this level with

individuals encountering marriage problems
may include one or more of the following:

• Counseling with the couple or with one of the

spouses on a one-to-one basis.

• Referral to a couples’ support group.

 NURSING INTERVENTIONS AT
SECONDARY LEVEL

Identification of the problem and definite

solutions. Support and guidance as changes
are undertaken.

• Referral to a sex therapist.

• Referral to a financial advisor.
• Referral to parent effectiveness.
 NURSING INTERVENTIONS AT
SECONDARY LEVEL
• PARENTHOOD: nurse should be able to
recognize the following problems of parents &
signs of abuse:

1. Physical, emotional or sexual abuse of a child.

2. Birth of an imperfect child.
3. Physical or emotional neglect of a child.
4. Diagnosis of a terminal illness in a child.
5. Death of a child.
 NURSING INTERVENTIONS AT
SECONDARY LEVEL
• Teaching effective methods of disciplining
children, aside from physical punishment.

• Positive reinforcement.

• Committed to consistent use of the adapted

behavior.
 {3}. MIDLIFE
The occurrence of middle crisis is not
defined by a specific number. This is very
individual but classified as:

• An altercation in perception of self.

• An altercation in perception of others.
• An altercation in perception of time.
 NURSING
INTERVENTIONS
 NURSING INTERVENTIONS
AT PRIMARY LEVEL
• Providing accurate information regarding changes
occurring during this time of life and support for
adapting to these changes effectively.

• Nutrition classes to avoid obesity, exercise and

good nutrition.

• Assistance with ways to improve health. E.g. quit

smoking, cease or reduce alcohol consumption,
reduce fat intake.
 NURSING INTERVENTIONS
AT PRIMARY LEVEL
• Regular physical examinations.

• Classes on menopause.

• Support and information R/T physical

changes occurring in body in this time.

• Support and information related to care of

ageing parents
 SECONDARY LEVEL
• Nursing care becomes necessary when the
individual is unable to integrate all the changes.
• An inability to accept the physical and biological
changes;
• Changes in relationships between themselves and
their adult children and ageing parents;
• The loss of the perception of youth
– may result in depression for which the
individual may require help to resolve.
 {4}. RETIREMENT
• Retirement is regarded as an achievement
in principle but is dreaded as a crisis when
it actually occurs.

• Retirement can result in depression and

lowered self-esteem.

• It involves providing information and

support to individuals who have retired or
are considering retirement.
 NURSING INTERVENTION AT
PRIMARY LEVEL
• Support can be one-to-one basis to assist to
sort out their feelings regarding retirement.

• Group support of individuals undergoing

same experiences.

• Information about Medicare, social security,

and Medicaid; information regarding ways
to use newly acquired free time
constructively.
 NURSING INTERVENTION AT
SECONDARY LEVEL
• Inpatient and outpatient settings both.
Close observation
• Medicine supervision.
• Activity scheduling.
• Exploring about suicidal plan
if severe depression.
• Providing information about medicine, side-
effects and compliance.
 TERTIARY
PREVENTION
 NURSING INTERVENTIONS AT
TERTIARY LEVEL

• In 1955, more than half a million individuals

resided in public mental hospitals.

• Deinstitutionalization of chronically mentally

ill persons began in the 1960s as national
policy change and with a strong belief in the
individual’s right to freedom.
BARRIERS IN PROVIDING HEALTH
SERVICES IN COMMUNITY
• Community – based mental health system is
not working for the chronically mentally ill
because of the following barriers:

• Public attitudes
• Fragmented systems
• Poverty and race
• Private insurance
• Public findings.
 ESSENTAIL SERVICES
REQUIRED
• Primary care mental health services

• Universal access to a basic mental health

package (both OPD & inpatient).

• Long-term care

• Managed care
HEALTH SERVICES AVAILABLE
AT COMMUNITY LEVEL
• Group homes
• Half-way homes
• Boarding homes
• Mobile outreach clinics: outreach
programmes literally reach out to the
homeless individuals in their own
environment in an effort to provide health
care.
HEALTH SERVICES AVAILABLE
AT COMMUNITY LEVEL
• Store-front clinics: these operate under poor
working conditions under budgetary
constraints with inadequate staffing,
supplies & equipments. Administering
medicines, vital signs, screening for
communicable diseases, health education &
supportive counseling.
• Foster homes
• Day care centers
HEALTH SERVICES AVAILABLE
AT COMMUNITY LEVEL
• Sheltered care facilities: provide a safe and
supportive environment

• Transitional housing

• Independent living programmes

• Social-rehabilitation centers
 POPULATION REQUIRING
TERTIARY PREVENTION

• The elderly

• The chronically mentally ill

• Homeless mentally ill

• Those with acute mental health problems.

 CONCLUSION
• Mental health care within the community
targets primary prevention (reducing the
incidence of mental disorders within the
population), the secondary prevention
(reducing the prevalence of psychiatric illness
by shortening the course of illness), and
tertiary prevention (reducing the residual
defects that are associated with severe or
chronic mental illness)
 REFERENCES
• 1. Lalitha K. Mental health and psychiatric
nursing. (First edn). Gajanana book publishers
and distributors. Bangalore; 2006.

• 2. Shives L. R. Basic concepts of psychiatric

mental health nursing. (7th edn) Lippincott
Williams and Wilkins.

• 3. Mohr W K. Psychiatric mental health nursing.

(6th edn). Lippincott Williams and Wilkins.
Philadelphia.
 CONCLUSION
• Nurses are unique in their ability to bridge the
gap between the hospital and the community,
between the psychiatrist and the community
care given, and between the public and other
health care providers.
• Therefore, nurse’s role in community support
service is primary.
 REFERENCES
• 4. http./www.googles.com
• 5. Benjamin J. Sadock, Virginia A. Sadock, Menas
S. Gregory; comprehensive textbook of
psychiatry, 8th edition.
• 6. Merry C. Townsend, psychiatry mental health
nursing, 5th edition, jaypee publications, page no
76-88.
• 7. Steuart W.Gail; Laraia T Michele, principles of
psychiatry nursing, 8th edition, Mosby
publication, page no 140-168.