Chapter 1: Foundations of Psychiatric-Mental Health Nursing

No single, universal definition Many components influenced by factors Mental Health Difficult to define No single, universal definition Many components influenced by factors Dynamic, ever-changing state Influencing factors: Individual (personal) Interpersonal (relationship) Social/cultural (environmental)

Mental Illness Mental disorder: behavioral or psychological syndrome or pattern (clinically significant) Association with present distress or disability or increased risk of death, pain, disability or important loss of freedom

Mental Illness (cont’d) General criteria for diagnosis Dissatisfaction with characteristics, abilities, accomplishments Ineffective or unsatisfying relationships Dissatisfaction with one’s place in the world Ineffective coping with life events Lack of personal growth

Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR: taxonomy of American Psychiatric Association Purposes: Standardize nomenclature, language Identify defining characteristics or symptoms Assist in identifying underlying causes

DSM-IV-TR Classification Axis I: major psychiatric disorders except mental retardation, personality disorders Axis II: mental retardation, personality disorders Axis III: current medical conditions potentially relevant Axis IV: psychosocial, environmental problems Axis V: Global Assessment of Functioning

Question Tell whether the following statement is true or false: The definition of mental health is standardized and universally accepted.

Answer False There is no single universal definition of mental health, which has many components and is influenced by myriad factors.

Historical Perspectives Ancient times Sickness as displeasure of gods; punishment for sins; view as demonic or divine Aristotle and imbalances of the four humors (blood, water, yellow and black bile); balance restoration via bloodletting, starving, purging Early Christians’ view as possession by demons

Historical Perspectives (cont’d) Period of Enlightenment (1790s) Creation of asylums; moral treatment Dorothea Dix Sigmund Freud: scientific study, treatment of mental illness

Historical Perspectives (cont’d) Psychopharmacology (1950s): development of psychotropic drugs Community mental health movement Deinstitutionalization Legislation for disability income Changes in commitment laws

Mental Illness and the 21st Century Current state More than 26% of Americans 18 and older have diagnosable mental disorder (NIMH, 2008) 15 million adults, 4 million children and adolescents with impaired daily activities Economic burden exceeds that by all types of cancer

Mental Illness and the 21st Century (cont’d) Current state Leading cause of disability in United States Canada for those 15-44 years of age 1 in 4 adults and 1 in 5 children and adolescents getting care needed

Mental Illness and the 21st Century (cont’d) Issues and concerns: “Revolving-door” effect due to deinstitutionalization Shorter hospital stays, decompensation, rehospitalization, dual diagnoses

Mental Illness and the 21st Century (cont’d) Issues and concerns: Homelessness (⅓ estimated to have serious mental illness; over ½ with substance abuse problems) Lack of adequate community resources ACCESS to address needs of full- or part- time homeless persons with mental illness

Question Which statement best reflects the current state of mental health and mental illness? Mental health care costs exceed the costs for cancer care. Most adults and children receive adequate mental health care. Community resources for the homeless with mental illness are adequate. Deinstitutionalization has reduced the revolving door effect.

Mental health care costs exceed the costs for cancer care. Answer Mental health care costs exceed the costs for cancer care. The economic burden of mental illness exceeds that for all types of cancer care. Only 1 in 4 adults and 1 in 5 children received the necessary mental health care. Community resources for homeless clients with mental illness are inadequate. Deinstitutionalization has led to the “revolving-door” effect.

Objectives for the Future Healthy People 2010 objectives Increase number of people identified, diagnosed, treated, helped to live healthier lives Decrease rates of suicide, homelessness Increase employment for those with serious mental illness Provide more services for incarcerated persons with mental health problems

Development of community support programs Community-Based Care Lack of appropriate number of community mental health centers to provide services Development of community support programs Availability, quality of services highly variable Inaccurate anticipation of extent of people’s needs Despite flaws, positive aspects making them preferable for treatment

Cost Containment and Managed Care Managed care movement (early 1970s) Development of utilization review firms/managed care organizations (1990s); case management Separation of mental health care from physical care for insurance coverage

Cost Containment and Managed Care (cont’d) Mental health care management through privately owned behavioral health care firms If no private insurance, reliance on counties of residence for payment HCFA: Medicare, Medicaid Mental health parity, insurance coverage

Cultural Considerations Culturally diverse population Cultural differences influencing mental health, treatment of mental illness Changes in family structure

Question Tell whether the following statement is true or false: Community-based programs are preferable for treating many people with mental illness.

Answer True Although there are flaws in the system, community-based programs have positive aspects that make them preferable for treating many people with mental illness.

Psychiatric Nursing Practice Linda Richards: first American psychiatric nurse McLean Hospital, Belmont MA: site of first training for nurses to work with persons with mental illness Expansion of role with development of somatic therapies

Psychiatric Nursing Practice (cont’d) First psychiatric nursing textbook (Nursing Mental Diseases) published in 1920 Johns Hopkins: first school of nursing to include psychiatric nursing course (1913) National League for Nursing (1950) requiring schools to include psychiatric nursing experience

Psychiatric Nursing Practice (cont’d) H. Peplau: therapeutic nurse-client relationship; interpersonal dimension (foundation for current practice) J. Mellow: focus on client’s psychosocial needs, strengths American Nurses Association and Standards of Care (see Box 1.3) Psychiatric-Mental Health Nursing Phenomena of Concern (see Box 1.2)

Psychiatric Nursing Practice (cont’d) Basic-level functions Counseling Milieu therapy Self-care activities Psychobiologic interventions Health teaching Case management Health promotion, maintenance Advanced-level functions Psychotherapy Prescriptive authority for drugs Consultation, liaison Evaluation

Student Concerns and Psychiatric-Mental Health Clinical Experience Saying the wrong thing Knowing what to do Being rejected or not talking to student Asking personal questions Handling bizarre, inappropriate, or sexually aggressive behavior Handling feeling unsafe

Student Concerns and Psychiatric-Mental Health Clinical Experience Seeing someone known on the unit Dealing with similar problems or backgrounds

Question Tell whether the following statement is true or false: The National League for Nursing required schools to include a psychiatric nursing experience before the first nursing school included a psychiatric nursing course in its curriculum.

Answer False Johns Hopkins was the first school of nursing to include a course in psychiatric nursing in its curriculum; this was done in 1913. It was not until 1950 that the National League for Nursing required schools to include an experience in psychiatric nursing.

Self-Awareness Issues Everyone with unique or different values, ideas, beliefs Possible conflict between personal values/beliefs, those of client Need to accept differences, view each client as worthwhile regardless of opinions or lifestyle Self-awareness through reflection