Mental Health Nursing

Mental Health
• Successful adaptation to internal & external stressors
– age appropriate thoughts, feelings & behaviors

• Adaptive Coping Mechanisms

– + Self-Esteem
– + Relationships
– Reality oriented
– Effective Problem Solver
– Communicate effectively
– Control emotions
– Reason Logically
– Risk Taker
– Dynamic and adjust PRN
Mental Illness

• Clinically significant behavioral pattern or

psychological syndrome
• Associated with distress or disability
• ↑↑ Risk of suffering causing;
– Loss of freedom
– Isolation
– Pain
– Death
Mental Health-Illness Continuum

Health ↔ Illness
Reality Oriented Hallucinations
Meaningful Work Disengaged
Resilient Anhedonia
 DSM IV-TR
Diagnostic & Statistical Manual of Mental
Disorders 4th ed, Text Revision
• Taxonomy used to describe mental disorders
according to specific criteria.
• Multi-axial (Axis I-V) classification system
Axis I - Clinical Disorders
Axis II - Personality Disorders & Mental
Retardation
Axis III - General Medical Conditions
Axis IV - Psychosocial & Environmental Problems
Axis V - Global Assessment Functioning (GAF)
[Psychological, social & occupational]
Psychological Theories
• Psychoanalytic Model- Freud
– Basic character formed by age 5.
– Psychosexual stages of development.
• Oral, Anal, Phallic, Latency & Genital
– Behavior motivated by subconscious thoughts
& feelings.
– Ego defense mechanisms.
– Neurotic symptoms are attempts to control
anxiety.
– Change is a process of insight.
• Uncover the repressed feelings to resolve conflicts.
Psychoanalytic Model- Freud cont.
• Personality Components:
– Id: Pleasure Principle
– Ego: Reality Principle
– Superego: Perfection Principle

• Conscious-Aware of present
Here & Now

• Subconscious - Not aware

– Repressed feelings, thoughts
Psychoanalytic Model- Freud cont.

• Transference
– Feelings and attitudes patient had originally
experienced in other relationships, now
displaces onto the therapist.

• Countertransference
– Therapist displaces onto the patient attitudes
or feelings from his past.
Developmental Model-Erikson
• Social processes affect specific tasks for each stage and
emotional growth.
• Incorporates:
Problem Solving, Decision Making, Coping & Communication

• 8 Continuous and evolutionary stages

– Trust vs. Mistrust

– Autonomy vs. Shame/Doubt
– Initiative vs. Guilt
– Industry vs. Inferiority
– Identity vs. Role Diffusion
– Intimacy vs. Isolation
– Generativity vs. Self-Absorption
– Ego Integrity vs. Despair
Interpersonal Model - Sullivan

• Behavior and personality development are direct

result of interpersonal relationships.
• Basic fear is rejection = ↑ anxiety

• Therapeutic Milieu
– Community environment which facilitates client
interaction
– Practice interpersonal skills
– Work cooperatively to solve problems.
Humanistic Model- Maslow
• Hierarchy of basic human needs
1. Physical
2. Safety/Security
3. Love & Belonging
4. Self-Esteem
5. Self-Actualization

• Focus on client’s strength and potential to

change
• Present/Future oriented
Humanistic Model-Rogers

• Client-centered therapy
• Unconditioned positive regard for the
client
• Genuineness & empathetic understanding
• Importance of learning
– ↑ Potential
– ↑ Personal Growth
 Behavioral Model- Skinner & Pavlov
Behaviorism
• Focuses on behaviors and changes, not the
mind’s effect.
• All behavior is learned.
• Behavior has consequences
– Reward or Punishment
• Reconditioning
– Unlearning maladaptive behavior

• Treatment Modalities
– Behavior Modification
– Token Economy
– Systematic Desensitization
 Behavioral Model- cont.
Reinforcement
• ↑ Frequency of behavior
• (+) Reinforcement uses a stimulus
– Praise for completed work
• (-) Reinforcement removes the stimulus
– No attention for interrupting
• Continuous Reinforcement
– Fastest way to ↑ behavior
• Intermittent Reinforcement
– Slower, but longer lasting way to ↑ behavior
Punishment
• ↓ Frequency of behavior
• (+) Punishment = Scolding for inappropriate behavior
• (-) Punishment = No contact with “wrong” crowd (↓ cursing)
Medical Model- Kraeplin
• Disease Entity
– Signs & Symptoms
• Physiological ▲s and possibly viruses, altered immune
system
• PET scans √ brain metabolism
• CT scans √ lesions, tumors
– Classify illness via DSM-IV TR
• Biochemical
– ▲s in Neurotransmitters
– ↑ DA = hallucinations & delusions
– Drug therapy is effective
• Genetic
– Specific genes predispose to ↑ risk of illness
– Chromosome # 5 & 6 ↑ risk of schizophrenia
– Twins 50-75% risk
 Cerebrum = 2 Hemispheres & 4 Lobes
• L Hemisphere → controls R side of body
– Logical reasoning, reading, writing, math
• R Hemisphere → controls L side of body
– Creative thinking, intuition, artistic abilities
• Frontal Lobe
– Thought, emotions, memories, movement & moral
behavior
• Parietal Lobe
– Taste, touch , spatial orientation
• Temporal Lobe
– Smell, hearing, memory & emotional expression
• Occipital Lobe
– Language & visual interpretation
Brain Stem

• Midbrain, Pons & Medulla Oblongata

• Reticular Activating System (RAS)

– Motor activity, sleep, consciousness &
awareness

• Extrapyramidal System (EPS)

– Movement & coordination
 Limbic System = Emotional Brain
• Thalamus
– Activity, sensation & emotion

• Hypothalamus
– Temp regulation, appetite control, sexual drive,
& impulsive behavior (anger, rage, excitement)

• Amygdala & Hippocampus

– Emotional arousal & memory
Neurotransmitters
• Dopamine (DA) Excites
– Complex movements, motivation, cognition,
– Emotional responses
– ↑ DA – Schizophrenia

• Norepinephrine (NE) Excites

– Mood regulation, attention, learning, memory,
– sleep, wakefulness
– ↓ NE – depression

• Epinephrine (E) Excites

– Perception = Flight or Fight response
Neurotransmitters
• Serotonin (5-HT) Inhibits
– Appetite, sleep, arousal, pain perception,
– Libido, regulation of emotions
– ↓ 5-HT –Schizophrenia, Aggression & suicide
• Gamma Aminobutyric Acid (GABA) Inhibits
– Slows down other neurotransmitters
– ↑ GABA - ↓ DA, G, NE, E, ACh
• Glutamate (G) Excites
• Acetylcholine (ACh) Excites/Inhibits
– Sleep & arousal, pain perception & movement
– ↓ ACh = confusion
• Histamine (H)
– Alertness, allergic response, gastric secretions,↑↑ wt.
Nursing Theory -Peplau
• Interpersonal Therapeutic Model
– Nurse-Patient Relationship (1:1)
– Collaborative process
– Nurse’s Role
• Resource person, teacher, leader, surrogate,
counselor
Therapeutic Relationship Criteria
• Patient initiated
• Pt accepted unconditionally
• Create environment of trust
• RN conveys genuineness & empathy
• Explore feelings, thoughts, behaviors &
experiences
• Identify alternate methods for problem
solving
 Therapeutic Relationship
4 Distinct Phases
1. Orientation
• Orientation/Introduction
– Establish trust and rapport
– Identify purpose, roles and
responsibilities
– Assess client’s needs
– Form contract
Working (Identification & Exploitation)

2. Identification
• RN facilitates expression of feelings
• Pt participates to identify problems
• Pt responds and trusts RN
3. Exploitation
• Promote Pt insights & perception of reality
• Overcome resistant behaviors
• Pt tests alternate problem solving & coping
skills
• Initiate action plan & new goals
• ▲ from dependent → independent behavior
• ↑ skills in interpersonal relationships
4. Resolution/Termination

• Summarize work & growth accomplished

• Review discharge plan & actions to deal with
potential stressors
• Referrals to community resources
• Acknowledge feelings RT ending relationship
Therapeutic Communication
• Active Listening
– Be attentive to verbal & non-verbal messages.
– Assess congruency of message

• RN Non-Verbal Skills
S - Sit squarely facing Pt
O - Observe an open posture
L - Lean forward toward the Pt.
E - Establish eye contact
R – Relax!
Non-Verbal Assessment
• Physical Assessment
– Clothing & Hygiene
• Body Movement/Posture
– Reflects self-esteem & status
• Touch
– Ellict both (+ & -) responses
– Cultural interpretation
• Facial Expression
– Reflects affect
• Eye Movement
– “Windows of the soul”
– ↑ Direct contact = personal interest

• Vocal Cues
– How a message is verbalized
– Pitch, tone, loudness, rate of speaking
Communication Techniques
• Acceptance
– Non-judgmental attitude
– Convey respect
• Offering Self
– Sense of presence
– Being available
• Open-ended Questions
– Broad openings allow Pt to select the topics
• Validation
– Confirming what the patient has said
Communication Techniques
• Reflection
– Content & feeling is referred back to Pt
– Pt recognition & acceptance
• Restatement
– Paraphrase main content or emotion
• Focus
– Direct conversation to a single concept
• Clarification
– Enhance understanding vague or confused
message
Communication Techniques
• Convey Information
– Supply data via statement
• Provide Feedback
– Specific constructive information
• State Observations
– Verbalize what is witnessed or perceived
• Connect Information
– Identify relationships, similarities or
differences to clarify behavior/ thoughts
Communication Techniques
• Confrontation
– Identify discrepancies between what the
Pt says & does
• Summarize
– Highlight the main themes of content &
feelings discussed
• Present Reality
– Orient to the present
– Clarify misperceptions
• Silence
– Interaction without words
Blocks to Communication
• False Reassurance
– May discourage Pt from disclosing feelings
• Rejecting
– Refusing to consider the Pt’s ideas or behaviors
• Giving Approval
– Passing judgment or Pt “right or wrong”
• Giving Advice
– Implies RN knows what is best for the Pt.
• Probe
– Pushing for answers the Pt does not want to
discuss
Blocks to Communication
• Defend
– Implies Pt has no right to express his own
ideas
• Belittle
– Minimizing Pt. distress → Pt. unimportant
• Change the Subject
– RN takes over the direction of the conversation
• Denial
– Blocks further discussion

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