Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
 What is mental health?
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No single definition of mental health exists
o Is NOT separate from physical health.
o Very Subjective because everyone has different symptoms, and it is different for everyone.
Clinical manifestations are different for everyone.
o Comprehensive nursing care—holistic nursing
Deinstitutionalization
o 1963 Deliberate shift from state hospitals to community-based facilities.
o Community movement
o Income for disabled—social security (SSDI, SSI)
o Revolving door effect—take care of symptoms and discharge and send back into community
only to have patient come back to facility. Does not have support at home and find support
within the facility. Typically, this is the homeless population d/t lack of home, resources, food,
income, availability to medications. AKA: Frequent Flyer, their disorder does NOT define them.
Reaching staff—NRS follows patient after discharge and ensure they are adhering to their
regimen and continue to follow until they are stable within the community.
Challenges
o Stigma
 Most wait 10-12 years for depression before seeking treatment. Wait 3-5 years before
reaching out for anxiety help.
 Do not judge anyone when they seek care, avoid stereotypes and making them feel
judged.
o COST
 Managed care—designed to control balance between the quality of care provided and
the cost of that care. Receive care based on need.
 Managed care organizations—control expenditure of insurance funds by requiring
providers to seek approval before the delivery of care.
 Case management—case by case basis, represented an effort to provide necessary
services while containing cost.
 Average admits for 3-5 days for inpatient hospitalization for mental health issues.
Average cost is 25-30,000 per 3-5 day stay.
 We fix/stabilize their symptoms. Brief interventions and then sent home. They do
not learn how to cope/live with symptoms/diagnosis.
o SPECIAL POPULATION
 Homelessness, psychiatric boarding, arrest, incarceration (75-80% can be diagnosed
with at least ONE psych condition), veterans, victimization, suicidality, familial violence,
danger to others.
o WORK FORCE
 Not enough NRSG staff available to fully staff psych facilities.
Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
 Current theories and therapy
o Combo of chapter 3, 4, & 5 most important topics
o Ch 2 NOT on exam!!!
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Outline
o Introduction
Freud's psychoanalysis
 Freud is the father of psychoanalysis
 Developed theories in late 19th and early 20th centuries
 Body of knowledge has been used for developing other theories
 Psycho analytic theory supports the notion that all human behavior is caused and can
be explained
 Personality components (pg 41): ID, Superego, Ego.
 Id: Reflects basic or innate desires such as pleasure-seeking
behavior, aggression, and sexual impulses. ALL ABOUT ME, selfseeking.
 Has no regard for rules or social convention/norms
 Superego: Reflects moral and ethical values
 Behavior is within social expectations. It’s about others, NOT
you.
 Ego: Balancing or mediating force between id and superego. This
helps you make sound decisions. AKA: Defense mechanisms
Defense Mechanisms (pg 42-43) -help protect our ego so that we are not stressed out or being
emotionally vulnerable.
o Aggression-behavior
o Compensation- overachievement in one area to cover deficiencies in another area. Ex:
overachievement in one area to offset real deficiencies in another area.
o Conversion- Expression of emotional conflict through development of physical symptom.
o Denial- failure to acknowledge unbearable condition; failure to admit the reality of a situation or
how one enables the problem to continue. Ex: diabetic person eating chocolate candy. **MOST
COMMONLY USED DEFENSE MECHANISM**
o Displacement-being angry/upset with someone other than who caused those feelings. Ex:
Person who is mad at the boss and yells at their spouse.
o Dissociation- Dealing with emotional conflict by temporary alteration in consciousness or
identity.
o Fixation- Immobilization of portion of the personality resulting from unsuccessful completion of
tasks in a developmental stage.
o Identification- Modeling actions and opinions of influential others while searching for identity or
aspiring to reach a person, social, or occupational goal.
o Intellectualization- Separation of emotions of a painful event or situation from the facts
involved, acknowledging the facts but not the emotions.
o Introjection- Accepting another person’s attitudes, beliefs, and values as one’s own.
o Projection- Unconscious blaming of unacceptable inclinations or thoughts on an external
object.
o Rationalization- Requires intentional thinking to figure out some of the root cause analysis. Ex:
Student blames failure on teacher being mean.
o Reaction formation-acting opposite of what one thinks/feels. Ex: women who never wanted to
have children becomes supermom.
Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
o Regression- Moving back to a previous development stage to feel safer for have needs met.
Ex: 5-year-old asks for a bottle when new baby bro is being fed.
o Repression- Excluding emotionally painful or anxiety provoking thought and feeling from
conscious awareness. Brain automatically does this for you.
o Resistance- Overt or convert antagonism toward remembering or processing anxiety-producing
information.
o Sublimation- Substituting a socially acceptable for an impulse that is unacceptable.
o Substitution- Replacing desired gratification with one that is more readily available.
o Suppression- Conscious exclusion of unacceptable thoughts and feelings from conscious
awareness. Ex: student decides not to think about a parent’s illness to study for a test.
o Undoing- Exhibiting acceptable behavior to make up for or negate unacceptable behavior.
 Erickson stages of development (pg 44-45)
 Foundation for psychosocial assessment
o Infancy stage-birth to 12 months Trust vs Mistrust
 Want to view world as safe and reliable and nurturing and dependable.
 Virtue: Hope
o Toddler stage-Autonomy vs shame & doubt
 Achieve sense of control and free will. Give
2 options to pick from.
 Virtue: Will (sense & freewill)
o Preschool stage-Initiative vs guilt. (Shame and
doubt)
 Beginning development of conscience,
learning to manage conflict and anxiety
 Virtue: Purpose
o School age-Industry vs inferiority
 Emerging confidence in own abilities, taking pleasure in accomplishments
 Virtue: Competence
o Adolescence-Identity vs role confusion
 Formulating sense of self and belonging (act like the ones they want to be like)
 Virtue: Fidelity
o Young adult-Intimacy vs isolation
 Forming adult, loving, long lasting relationships, and meaningful attachment to others
 Virtue: Love
o Middle adult-Generativity vs stagnation
 Being creative and productive, establishing next generation
 Virtue: Care
o Maturity-Ego integrity vs despair (regret their choices—depression)
 Accepting responsibility for oneself and life. Has been through different experiences.
 Virtue: Wisdom
Know interventions and most likely possibly outcome. Will be given scenarios based on stage and
determine the best/most appropriate option. Focus mostly on highlighted ones.
 Milieu (pg 46)
 Persona’s social environment basically. Involved clients’ interpersonal relationship skills,
giving one another feedback about behavior, and working cooperatively as a group to
solve day-to-day problems.
 A person's social environment
 Developed by Sullivan (1892-1949)
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Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
 involved clients’ interactions with one another
 Practicing interpersonal relationship skills
 Giving one another feedback about behavior
 Working cooperatively as a group to solve day today problems
Peplau’s Nurse patient relationship (pg 47)
o Nurse theorist. Think about today’s class.
o Orientation-introduction, expectations,
syllabus, assignements. Explained
expectations, reviewed
suggestions/questions, addressed
corrections will be made (orientation
phase)
o Working phase is working together.
Tylenol vs Ibuprofen. 200 vs 500 which
would you like. What would you rate your
pain at 9/10, give higher dose of medication.
o Resoluation-terminate relationship. Understanding of what needs to happen after discharge
(why we give discharge summary). Want client educated upon discharge.
Maslow’s hierarchy (pg 49)
o Physiological needs supersedes psychological needs.
 Physical needs first then psychological needs
o Physiological Needs—food, water, sleep, shelter, sexual
expression, freedom from pain.
o Safety & Security Needs—include protection, security,
freedom from harm or threatened deprivation.
o Love & Belonging Needs-intimacy, friendship, acceptance.
Empathy vs sympathy
o Empathy—understanding. Trying to put yourself in their
shoes to understand. (Feeling)
o Sympathy—saying I feel bad or sorry for you. “I am here
for you; we will figure this out together”
Group therapy (pg 54)
o 2 different types of groups
o Open groups
 Anyone can walk in. There is NO criteria about anything with this group. Ex: AA
meetings. Informal and no specific leader only identified leader. No training or
certification needed.
 No limitations on # of individuals involved in group
 Sitting in circle facing one another. (No showing back to others in group)
o Closed groups
 Only for certain individuals. They start group at same time and finish the curriculum at
the same time (usually 8-12 weeks).
 Specific appointed leader for the group. Leads the session. MUST be trained for certified
to do this type of group. Needs credentials.
 May require specific time of clothing, hide tattoos, avoid any triggers for anyone else
involved in that specific group session.
 Keep it 5-15 individuals involved.
 May be like classroom settings.
Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
Chapter 1 Foundations of psychiatric mental health nursing
 Mental Health
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o Difficult to define-neurochemical imbalance.
No single, universal definition
Many components influenced by factors
Dynamic, ever-changing state
Influencing factors:
o Individual (personal)—Way you were raised, growth & development, age, maturity—age &
maturity level should match ideally, support level/system, socioeconomic status, genetics
(HUGE),
 Anxiety is most common diagnosis
 Kids are concrete thinkers, must be direct and black/white. Neuron pathways developed
by age:25.
o Interpersonal (relationship)—Intimate zone (spouse, family, parents), work or school
relationships (incivility)
o Social/cultural (environmental)—Homelessness, sense of community, access to resources,
intolerance of violence, support of diversity among people, and mastery of environment.
Includes disorders that affect:
o Mood
o Behavior
o Thinking
These often indicate signs of distress and/or impaired functioning.
General criteria for diagnosis:
o Dissatisfaction with characteristics, abilities, accomplishments
o Ineffective or unsatisfying relationships
o Dissatisfaction with one’s place in the world
o Ineffective coping with life events
o Lack of personal growth
Diagnostic and Statistical Manual of Mental Disorders
DSM-5: Taxonomy published by the American Psychiatric Association
Purposes:
o Standardize nomenclature, language
o Identify defining characteristics or symptoms
o Assist in identifying underlying causes
DSM Classification
Allows the practitioner to identify all factors that relate to a patient’s condition:
o Major psychiatric disorders
o Medical conditions
o Psychosocial and environmental problems
Question Is the following statement true or false?
The definition of mental health is standardized and universally accepted.
Answer: False
o Rationale: There is no single universal definition of mental health, which has many components
and is influenced by myriad factors.
Historical Perspectives
Ancient times
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Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
o Sickness as displeasure of gods; punishment for sins; viewed as demonic or divine
o Aristotle and imbalances of the four humors (blood, water, yellow and black bile); balance
restoration via bloodletting, starving, and purging
o Early Christians’ view as possession by demons
Period of enlightenment (1790s)
o Creation of asylums; moral treatment
o Dorothea Dix
Sigmund Freud: scientific study, treatment of mental illness
Psychopharmacology (1950s): development of psychotropic drugs
Community mental health movement
o Deinstitutionalization
o Legislation for disability income
o Changes in commitment laws
Mental Illness and the 21st Century
Current state
o More than 18.6% of Americans aged 18 years and older have diagnosable mental disorder
(NIMH, 2008), 20.7 million have a substance use disorder, and 8.4 million of this population
have a dual diagnosis.
o 15 million adults and 4 million children and adolescents with impaired daily activities
o Economic burden exceeds that of all types of cancer.
o Leading cause of disability in the United States and Canada for those 15 to 44 years of age
o Increasing number of both adults and children/adolescents are being treated for mental illness;
yet only 1 in 4 adults and 1 in 5 children are treated.
o Treatment still lagging in homeless and those with substance abuse problems
Issues and concerns:
o “Revolving-door” effect due to deinstitutionalization
Often “boarded” in EDs while awaiting inpatient beds
o Shorter hospital stays, decompensation, rehospitalization, dual diagnoses
o Homelessness (42% estimated to have serious mental illness associated with substance abuse)
o 33% have associated physical illness comorbidities.
o Lack of adequate community resources
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.
Answer: Mental health-care costs exceed the costs for cancer care.
o Rationale: The economic burden of mental illness exceeds that for all types of cancer care.
o Only 1 in 4 adults and 1 in 5 children receive 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 2020 objectives:
o Increase the number of people identified, diagnosed, treated, helped to live healthier lives
o Decrease rates of suicide, homelessness
o Increase employment for those with serious mental illness
o Provide more services for incarcerated persons with mental health problems
Community-Based Care
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Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
Lack of appropriate number of community mental health centers to provide services
Development of community support programs
o Availability, quality of services highly variable
o Inaccurate anticipation of extent of people’s needs
o Despite flaws, positive aspects make 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.)
Mental health-care management through privately owned behavioral health-care firms
o 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 (see Chapter 7)
Changes in family structure
Question: Is the following statement true or false?
Community-based programs are preferable for treating many people with mental illness.
Answer True
o Rationale: 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.)
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.)
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
Psychiatric–Mental Health Nursing Phenomena of Concern (see Box 1.2)
Psychiatric Nursing Practice (cont.)
Basic-level functions
o Counseling
o Milieu therapy
o Self-care activities
o Psychobiologic interventions
o Health teaching
o Case management
o Health promotion, maintenance
Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
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Advanced-level functions
o Psychotherapy
o Prescriptive authority for drugs
o Consultation, liaison
o Evaluation
Student Concerns and Psychiatric–Mental Health Clinical Experience
Saying the wrong thing
Knowing what to do
Being rejected or not talking to the student
Asking personal questions
Handling bizarre, inappropriate, or sexually aggressive behavior
Handling feeling unsafe
Student Concerns and Psychiatric–Mental Health Clinical Experience (cont.)
Seeing someone known on the unit
Dealing with similar problems or backgrounds
Question: Is the following statement 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
o Rationale: 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 has unique or different values, ideas, and 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
Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
Chapter 2 Neurobiological theories and psychopharmacology
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Central Nervous System
Brain (See Figures 2.1 and 2.2)
o Cerebrum
o Cerebellum
o Brain stem
o Limbic system
Spinal cord
Nerves that control voluntary acts (neurotransmitters)
Cerebrum
Two hemispheres
Four lobes:
o Frontal lobe (thought, body movement, memories, emotions, moral behavior)
o Parietal lobe (taste, touch, spatial orientation)
o Temporal lobe (smell, hearing, memory, emotional expression)
o Occipital lobe (language, visual interpretation)
Cerebellum
Below cerebrum
Center for coordination of movements, postural adjustments
Reception, integration of information from all body areas to coordinate movement, posture
Brain Stem
Midbrain: reticular activating system (motor activity, sleep, consciousness, awareness) and
extrapyramidal system
Pons: primary motor pathway
Medulla oblongata: vital centers for cardiac, respiratory function
Nuclei for cranial nerves III through XII
Locus ceruleus: norepinephrine-producing neurons (stress, anxiety, impulsive behavior)
Limbic System
Above brain stem
o Thalamus (activity, sensation, emotion)
o Hypothalamus (temperature regulation, appetite control, endocrine function, sexual drive,
impulsive behavior)
o Hippocampus (emotional arousal, memory)
o Amygdala (emotional arousal, memory)
Neurotransmitters
Chemical substances to facilitate neurotransmission (see Figure 2.3)
Important in right proportions to relay messages (see Figure 2.4)
Play role in psychiatric illness and psychotropic medications, including their actions and side effects.
Neurotransmitters (cont.)
Excitatory or inhibitory (see Table 2.1)
o Excitatory
Dopamine: complex movements, motivation, cognition, regulation of emotional response
Norepinephrine: attention, learning, memory, sleep, wakefulness, mood regulation
Epinephrine: flight-or-fight response
Glutamate: major neurotoxic effects at high levels
Neurotransmitters (cont.)
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Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
Excitatory or inhibitory (see Table 2.1) (cont.)
o Inhibitory
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Serotonin: food intake, sleep, wakefulness, temperature regulation, pain
control, sexual behaviors, regulation of emotions
GABA: modulation of other neurotransmitters
o Excitatory or inhibitory
Acetylcholine: sleep-and-wakefulness cycle; signals muscles to become alert
Histamine: neuromodulator
Question
Is the following statement true or false?
The cerebellum consists of four lobes.
Answer
False
Rationale: The cerebrum consists of four lobes. The cerebellum is located below the cerebrum.
Brain Imaging Techniques
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Positron emission tomography (PET)
Single photon emission computed tomography (SPECT)
Limitations
o Use of radioactive substances; expense of equipment; client’s inability to tolerate technique
o Changes nondetectable with current techniques
Neurobiologic Causes
Genetics and heredity: play role but not solely genetic
o Twin, adoption, and family studies are used.
Psychoimmunology: compromised immune system possibly contributing, especially in at-risk
populations
Infections: particularly viruses during fetal development, possibly play role
Nurse’s Role in Research and Education
Ensure all clients, families are well informed.
Help distinguish between facts and hypotheses.
Explain if or how new research may affect client’s treatment or prognosis.
Question
Is the following statement true or false?
Single photon emission computed tomography is considered the best type of brain imaging technique
to diagnose disease.
Answer
False
Rationale: Single photon emission computed tomography (SPECT) is not considered the major type of
brain imaging used to diagnose disease. In fact, many of the changes in the brain are not currently
detectable with any of the current techniques.
Psychopharmacology
Psychotropic drugs
Efficacy (maximum therapeutic effect)
Potency (amount of drug needed for maximum effect)
Half-life
Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
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Approved use
Psychopharmacology (cont.)
Off-label use (effective for disease different from one involved in original testing)
Black box warning (serious or life-threatening side effects)
Principles of Psychopharmacology
Antipsychotic Drugs
Antipsychotic agents—neuroleptics (see Table 2.3)
o Conventional (e.g., chlorpromazine, fluphenazine, thioridazine, haloperidol, loxapine)
o Second generation (e.g., clozapine, risperidone, olanzapine)
o Third generation (dopamine system stabilizers; e.g., aripiprazole)
Antipsychotic Drugs (cont.)
Use: treatment of psychotic symptoms
Mechanism of action: block dopamine receptors
Antipsychotics: Side Effects
Extrapyramidal syndrome (EPS):
o Acute dystonia
Torticollis, opisthotonus, oculogyric crisis
Treatment: anticholinergic drugs or diphenhydramine (see Table 2.4)
o Pseudoparkinsonism (stooped posture, mask-like faces, shuffling gait)
o Akathisia (restlessness, anxiety, agitation)
Antipsychotics: Side Effects (cont.)
Neuroleptic malignant syndrome (NMS)
Tardive dyskinesia (irreversible involuntary movements)
Anticholinergic effects (dry mouth, constipation, urinary hesitancy or retention)
Antipsychotics: Side Effects (cont.)
Other side effects:
o Increased prolactin levels
o Weight gain (second-generation agents, except ziprasidone)
o Prolonged QT interval (thioridazine, droperidol, mesoridazine)
o Agranulocytosis (clozapine)
Antipsychotics: Client Teaching
Adherence to regimen
Side effects, management
o Thirst/dry mouth (sugar-free candy, liquids)
o Constipation (dietary fiber, stool softeners)
o Sedation (safety measures)
Actions for missed dose (dose if within 4 hours of usual time)
CBC, ANC with clozapine
Question
Which of the following drugs would be classified as a conventional antipsychotic?
Clozapine
Risperidone
Fluphenazine
Aripiprazole
Answer
Fluphenazine
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Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
o •
Rationale: Fluphenazine is classified as a conventionalantipsychotic.
o Clozapine and risperidone are considered second-generation antipsychotics. Aripiprazole is
considered a third-generation antipsychotic.
Antidepressants
Use: major depressive illness, anxiety disorders, depressed phase of bipolar disorder, psychotic
depression
Antidepressants (cont.)
Four groups (see Table 2.5):
o Tricyclic and related cycle antidepressants (TCAs)
o Selective serotonin reuptake inhibitors (SSRIs)
o MAO inhibitors (MAOIs)
o Others (venlafaxine, bupropion, duloxetine, trazodone, nefazodone)
Antidepressants (cont.)
Mechanism of action: interact with monoamine neurotransmitter systems, especially norepinephrine
and serotonin
Preferred drugs for clients at high risk for suicide
Antidepressants: Side Effects
SSRIs
o Anxiety, agitation, akathisia, nausea, insomnia, sexual dysfunction
o Weight gain
TCAs
o Anticholinergic effects
o Orthostatic hypotension, sedation, weight gain, tachycardia
o Sexual dysfunction
Antidepressants: Side Effects (cont.)
MAOIs
o Daytime sedation, insomnia, weight gain, dry mouth, orthostatic hypotension, sexual dysfunction
o Hypertensive crisis (with foods containing tyramine)
Antidepressants: Side Effects (cont.)
Other agents
o Sedation, headache (nefazodone, trazodone)
o Loss of appetite, nausea, agitation, insomnia (bupropion, venlafaxine)
o Priapism (trazodone)
Antidepressants: Drug Interactions
Serotonin syndrome
o MAOI + SSRI
o Agitation, sweating, fever, tachycardia, hypotension, rigidity, hyperreflexia
o Coma, death (extreme reactions)
Antidepressants: Client Teaching
Time of dosage
o SSRI first thing in morning
o TCAs at night
Actions for missed dose
o SSRI up to 8 hours after missed dose
o TCAs within 3 hours of missed dose
Safety measures
Dietary restrictions if taking MAOI (see Box 2.1)
Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
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Mood-Stabilizing Drugs
Lithium, some anticonvulsants (carbamazepine, valproic acid; gabapentin, topiramate, oxcarbazepine,
and lamotrigine)
Use: treatment of bipolar disorders
Mood-Stabilizing Drugs (cont.)
Mechanism of action
o Normalize reuptake of certain neurotransmitters (lithium)
o Increase levels of GABA (valproic acid, topiramate)
o Kindling process (valproic acid, carbamazepine)
Mood-Stabilizing Drugs: Side Effects
Lithium
o Nausea, diarrhea, anorexia, fine hand tremor, polydipsia, polyuria, metallic taste, fatigue,
lethargy; weight gain, acne (later in therapy)
o Toxicity: severe diarrhea, vomiting, drowsiness, muscle weakness, lack of coordination
Carbamazepine and valproic acid: drowsiness, sedation, dry mouth, blurred vision
Mood-Stabilizing Drugs: Side Effects (cont.)
Carbamazepine: rash, orthostatic hypotension
Valproic acid: weight gain, alopecia, hand tremor
Topiramate: dizziness, sedation, weight loss
Mood-Stabilizing Drugs: Client Teaching
Periodic monitoring of blood levels
o 12 hours after last dose taken
Drug with meals
Safety measures
Question
Is the following statement true or false?
A client who takes an SSRI with an MAOI is at risk for a hypertensive crisis.
Answer
False
Rationale: A client who takes an SSRI with an MAOI is at risk for serotonin syndrome.
o Hypertensive crisis occurs if the client is taking MAOI and ingests foods containing tyramine.
Antianxiety Drugs
Use: treatment of anxiety and anxiety disorders, insomnia, OCD, depression, posttraumatic stress
disorder, alcohol withdrawal
Benzodiazepines, buspirone (see Table 2.6)
Mechanism of action
o Mediation of GABA (benzodiazepines)
o Partial agonist activity at serotonin receptors (buspirone)
Antianxiety Drugs: Side Effects
Benzodiazepines
o Physical, psychological dependence
o CNS depression
o Hangover effect
o Tolerance
Buspirone
o Dizziness, sedation, nausea, headache
Antianxiety Drugs: Client Teaching
Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
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Safety measures
Avoidance of alcohol
Avoidance of abrupt discontinuation
Stimulants
Amphetamines (methylphenidate amphetamine, dextroamphetamine)
Use: treatment of ADHD in children and adolescents, residual attention-deficit disorder in adults,
narcolepsy
Stimulants (cont.)
Mechanism of action
o Cause release of norepinephrine, dopamine, serotonin presynaptically
o Direct agonist effects postsynaptically
o Block reuptake of neurotransmitters
Stimulants: Side Effects and Client Teaching
Side effects
o Anorexia, weight loss, nausea, irritability
o Growth and weight suppression
Client teaching
o Dose after meals
o Avoidance of caffeine, sugar, chocolate
o Proper storage out of reach of children
Disulfiram
Use: aversion therapy for alcoholism
Mechanism of action: inhibition of enzyme involved with alcohol metabolism
o Adverse reaction with alcohol ingestion
Side effects: fatigue, drowsiness, halitosis, tremor, impotence
Disulfiram (cont.)
Drug interactions with phenytoin, isoniazid, warfarin, barbiturates, long-acting benzodiazepines
Client teaching: avoidance of alcohol, including common products that may contain it
o Shaving cream, deodorant, OTC cough preparations
Question
Which of the following drugs would the nurse expect to administer to a client with ADHD?
Disulfiram
Methylphenidate
Buspirone
Lithium
Answer
Methylphenidate
Rationale: Methylphenidate is a stimulant used to treat ADHD.
o Disulfiram is used to treat alcoholism. Buspirone is used to treat depression. Lithium is used to
treat bipolar disorder.
Cultural Considerations
More rapid response to antipsychotics, TCAs for African Americans than whites
o Greater risk of side effects
Slower metabolism of antipsychotics, TCAs for Asians
o Lower doses to produce the same effects
Cultural Considerations (cont.)
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Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
Lower doses of antidepressants for Hispanics than whites to achieve desired effects
Lower doses of lithium for Asians and African Americans than whites to produce desired effects
Cultural Considerations (cont.)
Increased frequency of herbal medicine use
o St. John’s wort
o Kava
o Valerian
o Ginkgo biloba
Increased risk for interactions
Common Barriers to Maintaining Medication Management
Long-term, chronic illness requires ongoing treatment.
Symptoms of poor insight and confusion
“Faulty” thinking
Major side effects/interactions of meds
Stereotyping and discrimination against mental illness
Self-Awareness Issues
View chronic mental illness as having remissions and exacerbations, just as chronic physical illnesses
do.
Remain open to new ideas that may lead to future breakthroughs.
Understand that medication noncompliance is often part of the illness, not willful misbehavior.
Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
Chapter 3 Psychosocial theories & therapies
Psychosocial Theories
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Psychoanalytic (Freud)
Developmental (Erikson, Piaget)
Interpersonal (Sullivan, Peplau)
Humanistic (Maslow, Rogers)
Behavioral (Pavlov, Skinner)
Existential (Beck, Ellis, Frankl, Perls, Glasser)
Psychoanalytic Theories: Sigmund Freud
All human behavior is caused, explainable
Repressed sexual impulses, desires as motivation for behavior
Personality components
o Id
o Ego
o Superego
Behavior motivation due to subconscious thoughts, feelings
o Conscious, preconscious, unconscious
o Subconscious
Ego defense mechanisms (see Table 3.1)
Psychosexual stages of development
o Oral
o Anal
o Phallic/oedipal
o Latency
o Genital (see Table 3.2)
Transference, countertransference
Current Psychoanalytic Practice
Psychoanalysis
o Focus on discovering causes of patient’s unconscious, repressed thoughts, feelings, conflicts
related to anxiety
o Free association, dream analysis, behavior interpretation used to gain insight into and resolve
these conflicts, anxieties
Lengthy, expensive, practiced on limited basis today
Freud’s defense mechanisms still current
Question: Is the following statement true or false? Freud identified three stages of psychosexual
development.
Answer: False
o Rationale: Freud identified five stages of psychosexual development: oral, anal, phallic/oedipal,
latency, and genital.
Developmental Theories
Erik Erikson
o Eight stages of psychosocial development (see Table 3.3)
o Achievement of life’s virtues
Jean Piaget
o Cognitive, intellectual development
o Four stages: sensorimotor, preoperational, concrete operations, formal operations
Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
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Interpersonal Theories: Sullivan
Five life stages: infancy, childhood, juvenile, preadolescence, adolescence (see Table 3.4)
Three developmental cognitive modes
o Prototaxic (infancy, childhood)
o Parataxic (early childhood)
o Syntaxic (school-aged children; more predominant in preadolescence)
Significance of interpersonal relationships
Therapeutic milieu or community
Interpersonal Theories: Peplau
Therapeutic nurse–patient relationship
Four phases: orientation, identification, exploitation, resolution (see Table 3.5)
Nurse’s roles to meet patient’s needs: stranger, resource person, teacher, leader, surrogate, counselor
Four levels of anxiety: mild, moderate, severe, panic (see Table 3.6)
Humanistic Theories
Abraham Maslow
o Hierarchy of needs
o Basic physiologic, safety and security, love and belonging, esteem, self-actualization
Carl Rogers
o Client-centered therapy (focus on client’s role)
o Unconditional positive regard, genuineness, empathetic understanding
Behavioral Theories
Behaviorism: focus on behaviors and behavior changes, not how mind works
Ivan Pavlov: classical conditioning
B. F. Skinner: operant conditioning
o All behavior learned
o Behavior with consequences (reward or punishment)
o Recurrence of rewarded behavior
o Positive reinforcement: increased frequency of behavior
o Removal of negative reinforcers: increased frequency of behavior
o Continuous reinforcement: fastest way to increase behavior; random intermittent reinforcement
increasing behavior more slowly but with a longer-lasting effect
Treatment modalities: behavior modification, token economy, systematic desensitization
Question: Is the following statement true or false? Abraham Maslow was the first theorist to focus on
the client’s role.
Answer: False
o Rationale: Carl Rogers was the first to focus on the client’s role in his client-centered therapy.
Existential Theories
Overall belief: deviations occur when person is out of touch with self or environment
o Goal: to return person to authentic sense of self
Cognitive therapy
o Focus on immediate thought processing
o Use by most existential therapists
Rational emotive therapy (Albert Ellis)
o 11 “irrational beliefs” leading to unhappiness
o “Automatic thoughts”; use of ABC technique
Logotherapy (Viktor Frankl): life with meaning; therapy as search for that meaning
Gestalt therapy (Frederick “Fritz” Perls)
Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
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o Emphasis on self-awareness
o Identification of thoughts, feelings in the here and now
Reality therapy (William Glasser)
o Focus on person’s behavior and how that behavior keeps a person from achieving life goals
Crisis Intervention
Four stages of crisis
o Exposure to stressor
o Increased anxiety when usual coping ineffective
o Increased efforts to cope
o Disequilibrium, significant distress
Categories of crises
o Maturational
o Situational
o Adventitious
Crisis Intervention (cont.)
Duration: usually 4 to 6 weeks
Outcome: resolution to functioning at precrisis level, higher level, or lower level
Crisis intervention techniques
o Directive interventions: assess health status, promote problem solving
o Supportive interventions: deal with person’s needs for empathetic understanding
Question
Which of the following includes the concept of automatic thoughts?
Cognitive therapy
Rational emotive therapy
Logotherapy
Gestalt therapy
Answer
B. Rational emotive therapy
Rationale: Rational emotive therapy focuses on 11 irrational beliefs and automatic thoughts.
o Cognitive therapy focuses on immediate through processing. Logotherapy involves therapy as a
search for life with meaning. Gestalt therapy emphasizes self-awareness.
Cultural Considerations
Major psychosocial theorists were
o White
o Born in Europe or United States
o Seldom treated outside their cultural populations
Assumptions of normal or typical may not apply equally well to different racial, ethnic, or cultural
backgrounds.
Treatment Modalities
Community mental health treatment (primary mode of treatment)
o Clients continue to work and are able to stay connected with family, friends, and other support
systems.
o Personality or behavior patterns gradually develop; unable to be changed in a relatively short
inpatient course of treatment
o Peer counseling, advocacy, and mentoring are showing positive results.
Treatment Modalities (cont.)
Hospital (inpatient) treatment (often last mode of treatment)
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Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
o Indications: severe depression/suicidal; severe psychosis; alcohol or drug withdrawal; behaviors
requiring close supervision in a safe, supportive environment
Individual Psychotherapy
Bringing about change in a person by exploring his or her feelings, attitudes, thinking, behavior
One-to-one relationship between the therapist and the patient
o Progression through stages
o Relationship as key to success
Therapist’s theoretical beliefs strongly influence style of therapy
Groups and Group Therapy
Therapist or leader and group of clients sharing common purpose
Members contribute to group with expectations of benefiting from it.
Stages of group development:
o Pregroup stage
o Beginning or initial stage
o Working stage
o Termination
Groups and Group Therapy (cont.)
Group leadership
o Formal leader usually for therapy groups and education groups; informal leader usually for
support groups and self-help groups
o Focus on group process, group content to be effective
Groups and Group Therapy (cont.)
Group roles
o Growth producing: information seeker, opinion seeker, information giver, energizer, coordinator,
harmonizer, encourager, elaborator
o Growth inhibiting: monopolizer, aggressor, dominator, critic, recognition seeker, passive follower
Groups and Group Therapy (cont.)
Therapeutic results (Yalom, 1995):
o New information or learning, inspiration or hope
o Interaction with others
o Feelings of acceptance, belonging
o Awareness of not being alone; others share same problems
o Insight into problems, behaviors, and effects on others
o Altruism
Types of Therapy Groups
Psychotherapy groups
Family therapy
Family education
Education groups
Support groups
Self-help groups
Question
Is the following statement true or false?
Self-help groups tend to have an informal or no definitive leader.
Answer
True
Rationale: Support groups and self-help groups tend to have an informal leader or no leader at all.
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Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
o Therapy and education groups typically have a formal leader.
Complementary and Alternative Therapies
Alternative medical systems (homeopathy, traditional Chinese medicine)
Mind–body interventions (meditation, art, music therapy)
Biologically based therapies (herbs, foods, vitamins)
Complementary and Alternative Therapies (cont.)
Manipulative and body-based therapies (therapeutic massage, chiropractic manipulation)
Energy therapies (therapeutic touch, qi gong, pulsed fields, magnetic fields)
Psychiatric Rehabilitation
Services to patients with persistent, severe mental illness in the community
Also known as community support services or programs
Focus on patient’s strengths
Activities involving medication management, transportation, shopping, food preparation, hygiene,
finances, social support, vocational referral
Psychosocial Interventions
Nursing activities that enhance patient’s social and psychological functioning and promote social skills,
interpersonal relationships, communication
Skills used in mental health, other practice areas
Self-Awareness Issues
No one theory or treatment approach is effective for all patients.
Using a variety of psychosocial approaches increases nurse’s effectiveness.
Patient’s feelings, perceptions most influential in determining his or her response
Current theories and therapy
Outline
Introduction
Freud's psychoanalysis
Defense Mechanisms
Erickson stages of development
Milieu
Peplau’s Nurse patient relationship
Maslows hierarchy
Group therapy
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Defense mechanism
What is Milieu?
A person's social environment
Developed by Sullivan ( 1892-1949)
involved clients interactions with one another
Practicing interpersonal relationship skills
Giving one another feedback about behavior
Working cooperatively as a group to solve day today problems
Groups
Reference
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Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
 Chapter 4 Treatments settings & therapeutic programs
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Treatment Settings
Inpatient hospital treatment
o Rapid assessment, stabilization of symptoms, discharge planning
Client-centered multidisciplinary approach to brief stay
o Short inpatient stays
Treatment Settings (cont.)
Inpatient hospital treatment
o Long-stay clients (severe, persistent mental illness requiring acute care services)
o Case management
o Discharge planning
Partial hospitalization programs
o Day treatment programs
o Eight broad categories of goals (see Box 4.1)
Treatment Settings (cont.)
Residential settings
o Vary in structure, level of supervision, services provided
Group homes
Supervised apartments
Board, care homes
Adult foster care
Crisis resolution/respite care
Treatment Settings (cont.)
Residential settings (cont.)
o Evolving consumer household
Group-living situation
Residents make transition from group home to residence where they fulfill own responsibilities and
function without onsite supervision.
Transitional care
o Peer support
o Bridging staff
Question
Is the following statement true or false?
Board and care homes are an example of a partial hospitalization program.
Answer
False
Rationale: A board and care home is an example of a residential treatment setting.
o A day treatment program is an example of a partial hospitalization program.
Psychiatric Rehabilitation and Recovery Programs
Services to promote recovery process (see Box 4.3)
o Emphasis on recovery, going beyond symptom control and medication management; includes
personal growth
o Reintegration into community
o Empowerment, increased independence
o Improved quality of life
Psychiatric Rehabilitation Programs (cont.)
Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
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Clubhouse model
o Four guaranteed rights of members
A place to come to
Meaningful work
Meaningful relationships
A place to return to (lifetime membership)
o Physician–client relationship as key
o Focus on health, not illness
Psychiatric Rehabilitation Programs (cont.)
Assertive community treatment (ACT)
o One of the most effective approaches (see Box 4.5)
o Problem-solving orientation
No problem is too small
o Direct provision of service rather than referral
o Services intense; no time constraints
Psychiatric Recovery Programs
Recovery goes beyond symptom control and medication management
Includes personal growth, reintegration into the community, empowerment, increased independence,
and improved quality of life as the beginning of the recovery process.
Higher-level goals and expectations characterize later stages of recovery (see Box 4.4).
Creates and manages the change this requires, both for individual staff and throughout the
organization.
Question
Is the following statement true or false?
In the clubhouse model, the relationship between clients is most important.
Answer
False
Rationale: With the clubhouse model, the physician–client relationship is the most important.
Special Populations: Homeless Mentally Ill
In comparison to homeless, not mentally ill:
o Spend more time in jail
o Are homeless longer
o Spend more time in shelters
o Have less family contact
o Face greater barriers to employment
PATH program
ACCESS demonstration project
Special Populations: Prisoners
The rate of mental illness among the incarcerated is 5 times higher than the general population.
Factors for placement in criminal justice system
o Deinstitutionalization
o More rigid criteria for civil commitment
o Lack of adequate community support
o Economization of treatment for mental illness
o Attitudes of police, society
Special Populations: Prisoners (cont.)
Criminalization of mental illness
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Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
Barriers to successful community reintegration
o Poverty
o Homelessness
o Substance use
o Violence
o Victimization, rape, trauma
o Self-harm
Special Populations: Active Military and Veterans
The prevalence of PTSD and major depression is greater than their civilian counterparts.
Increased rates of:
o Suicide
o Homicide
o Injury
o Physical illness
o Sleep disorders
o Substance abuse
o Marital and family dysfunction
Special Populations: Active Military and Veterans (cont.)
Reluctance to seek treatment
Treatment may not be readily available
Stigmatizing
Sexual traumas widespread for both males and females
Interdisciplinary Team
Pharmacist (see Box 4.6)
Psychiatrist
Psychologist
Psychiatric nurse
Psychiatric social worker
Occupational therapist
Recreation therapist
Vocational rehabilitation specialist
Interdisciplinary Team (cont.)
Core skills
o Interpersonal skills (tolerance, patience)
o Humanity (warmth, acceptance, empathy)
o Knowledge base
o Communication skills
o Personal qualities (consistency, assertiveness, problem solving)
o Teamwork skills
o Risk assessment, risk management
Question
Which of the following disciplines most likely would be included as part of the interdisciplinary team?
Physician’s assistant
Physical therapist
Pharmacist
Dietician
Answer
Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
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Pharmacist
Rationale: The pharmacist would be a member of the interdisciplinary team when medication,
management of side effects, and/or interactions with nonpsychiatric medications are complex.
o A physician’s assistant, physical therapist, and dietician are not typically involved as members
of the psychiatric interdisciplinary team.
Psychosocial Nursing in Public Health and Home Care
Primary prevention: stress management education
Secondary prevention: early identification of mental health problems
Tertiary prevention: monitoring, coordinating psychiatric rehabilitation services
Clinical practice issues such as substance abuse, domestic violence, child abuse, grief, depression,
and many others
Self-Awareness Issues
Evolution of care away from inpatient settings into community
Nontraditional settings such as jails or homeless shelters
Empowering clients to make their own decisions
Frustration of working with clients having persistent and severe mental illness
Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
 Chapter 5 Therapeutic Relationships
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Therapeutic Relationship
Components of Therapeutic Relationship
Trust
o Behaviors such as caring, interest, understanding, consistency, honesty, promise keeping,
listening (see Box 5.1)
o Congruence is essential.
Genuine interest
o Self-comfort, self-awareness of strengths and limitations, clear focus
Components of Therapeutic Relationship (cont.)
Empathy
o Putting oneself in client’s shoes
Client and nurse giving “gift of self”
o Different from sympathy (feelings of concern or compassion; focus shifting to nurse’s feelings)
Acceptance (no judgments; set boundaries)
Positive regard (unconditional nonjudgmental attitude)
Self-Awareness
Know self
o Values (sense of right and wrong, code of conduct for living)
Values clarification
Choosing
Prizing
Acting
o Beliefs
o Attitudes (see Boxes 5.2 and 5.3)
Question
Is the following statement true or false?
A nurse displays empathy by showing feelings of concern and compassion.
Answer
False
Rationale: Empathy is putting oneself into the client’s shoes.
o Sympathy is showing feelings of concern and compassion.
Therapeutic Use of Self
Use of aspects of personality, experience, values, feelings, intelligence, needs, coping skills,
perceptions to establish relationships beneficial to clients
o Concept developed by H. Peplau
Therapeutic Use of Self (cont.)
Johari window: tool to learn about oneself
o 4 quadrants: open/public self; blind/unaware self; hidden/private self; unknown
o Goal: move qualities from quadrants 2, 3, 4 into quadrant 1
Therapeutic Use of Self (cont.)
Patterns of Knowing
Ways of observing, understanding client interactions
Four patterns (Carper, 1978; see Table 5.1)
o Empirical (derived from nursing science)
o Personal (from life experiences)
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Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
o Ethical (from moral nursing knowledge)
o Aesthetic (from art of nursing)
Patterns of Knowing (cont.)
Fifth pattern : unknowing (Munhall, 1993)
o Nurse admits lack of knowledge of client or understanding of client’s subjective world
Types of Relationships
Social
o Purpose of friendship, socialization, companionship, or task accomplishment
o Superficial communication; shifting roles; outcomes rarely assessed
Intimate
o Emotional commitment of two persons
o Individual needs met; assistance with helping each other meet needs
Types of Relationships (cont.)
Therapeutic
o Focus on needs, experiences, feelings, ideas of client only
o Use of communication skills, personal strengths, understanding of human behavior by nurse
o Joint agreement on areas to work on; outcome evaluation
Question
Is the following statement true or false?
A social relationship involves superficial communication for the purposes of friendship or task
accomplishment.
Answer
True
Rationale: A social relationship occurs for friendship, socialization, companionship, or task
achievement. It involves superficial communication with shifting roles.
Establishing a Therapeutic Relationship
Peplau’s model of three phases
o Orientation
o Working
o Termination (see Table 5.3)
Overlapping, interlocking of phases
Establishing a Therapeutic Relationship: Orientation Phase
Meeting nurse, client
Establishment of roles
Discussion of purposes, parameters of future meetings
Clarification of expectations
Identification of client’s problems
Nurse–client contracts/confidentiality, duty to warn/self-disclosure
Establishing a Therapeutic Relationship: Working Phase
Problem identification: issues or concerns identified by client; examination of client’s feelings and
responses
Exploitation: examination of feelings and responses; development of better coping skills, more positive
self-image, behavior change, independence
Possible transference/countertransference
Establishing a Therapeutic Relationship: Termination Phase
Begins when client’s problems are resolved
Ends when relationship is ended
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Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
Deals with feelings of anger or abandonment that may occur; client may feel termination as impending
loss.
Behaviors Diminishing Therapeutic Relationships
Inappropriate boundaries (relationship becomes social or intimate)
Feelings of sympathy, encouraging client dependency
Nonacceptance of client, avoidance (see Box 5.4)
Question
During the working phase of a nurse–client relationship, which of the following would occur?
Expectations are clarified.
Nurse–client contracts are established.
Feelings of loss are addressed.
Client’s feelings are examined.
Answer
Client’s feelings are examined.
Rationale: During the working phase, the client identifies issues or concerns and his or her feelings and
responses are examined.
o Expectations are clarified and contracts are established during the orientation phase. Feelings
of loss are addressed during the termination phase.
Therapeutic Roles of the Nurse in a Relationship
Teacher (coping, problem solving, medication regimen, community resources)
Caregiver (therapeutic relationship, physical care)
Advocate (ensuring privacy and dignity, informed consent, access to services, safety from abuse and
exploitation)
Parent surrogate (see Box 5.5)
Self-Awareness Issues
Nurse’s self-awareness: crucial to developing therapeutic relationships
Helpful activities: values clarification, journaling, group discussions, reading
Development of self-awareness: continual, ongoing process
Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
 Chapter 6 Therapeutic Communication
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Communication
Exchange of information
Verbal
o Content: literal words spoken
o Context: environment, circumstances, situation in which communication occurs
Nonverbal
o Process: all messages used to give meaning, context to message
o Congruent or incongruent message
Therapeutic Communication
Interpersonal interactions; focus on patient’s needs
Need for privacy
Encompasses goals that facilitate the nursing process
Needed to effectively meet the standards of client care
Therapeutic Communication (cont.)
Goals of therapeutic communication
o Establish therapeutic relationship
o Identify patient’s most important concerns; assess patient’s perceptions
o Facilitate patient’s expression of emotions
o Teach patient, family necessary self-care skills
o Recognize patient’s needs; implement interventions to address patient’s needs
o Guide patient toward acceptable solutions
Therapeutic Communication (cont.)
Respect for boundaries
o Distance zones
Intimate (0 to 18 inches)
Personal (18 to 36 inches)
Social (4 to 12 feet)
Public (12 to 25 feet)
o Therapeutic communication: most comfortable when nurse and patient are 3 to 6 feet apart
Therapeutic Communication (cont.)
Touch
o Five types: functional/professional; social–polite; friendship–warmth; love–intimacy; sexual–
arousal
o Comforting and supportive; also possible invasion of intimate and personal space
o The nurse must evaluate use of touch based on the client’s preferences, history, and needs.
For example, clients with a history of abuse
Question
Is the following statement true or false?
A distance of 2 feet between the nurse and patient is adequate for promoting comfortable therapeutic
communication.
Answer
False
Rationale: For effective therapeutic communication, a distance of 3 to 6 feet between the nurse and
patient would be most appropriate.
Therapeutic Communication (cont.)
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Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
Active listening (concentrating exclusively on what patient says)
Active observation (watching nonverbal actions as speaker communicates)
o Recognize the most important issue
o Know what questions to ask
o Use of therapeutic communication techniques
o Prevents jumping to conclusions
o Objectively respond to message
Verbal Communication Skills
Need for concrete, not abstract, messages
Techniques (see Table 6.1)
o Exploring, focusing, restating, reflecting promotes discussion of feelings or concerns in more
depth
o Other techniques useful in focusing or clarifying what is being said
o Feedback via making an observation or presenting reality
Verbal Communication Skills (cont.)
Avoidance of nontherapeutic techniques (see Table 6.2)
o Advising, belittling, challenging, probing, reassuring
Interpretation of signals or cues
o Overt
o Covert (themes, metaphors, proverbs, clichés)
Nonverbal Communication Skills
Facial expression
o Expressive
o Impassive
o Confusing
Body language
o Open body position
o Closed body position
Nonverbal Communication Skills (cont.)
Vocal cues
Eye contact
Silence
Question
Is the following statement true or false?
Nonverbal communication is often less accurate than verbal communication.
Answer
False
Nonverbal communication is often more accurate than verbal communication when the two are
incongruent. People can readily change what they say, but are less likely to be able to control
nonverbal communication.
Understanding Meaning, Context, and Spirituality of Communication
Meaning: usually more meaning than just spoken word
Context
o Validation with client of verbal, nonverbal information
o Who, what, when, how, why
Understanding Meaning, Context, and Spirituality of Communication (cont.)
Spirituality
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Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
o Self-awareness of own spiritual beliefs
o Need for objectivity and nonjudgmental attitude about patient’s beliefs
Cultural Considerations
Need for awareness of cultural differences
o Speech patterns, habits
o Styles of speech, expression
o Eye contact
o Touch
o Concept of time
o Health, health care
Question
Which of the following would be a nontherapeutic communication technique?
Reassuring
Reflecting
Focusing
Exploring
Answer
Reassuring
Rationale: Reassuring is a nontherapeutic technique because it attempts to dispel the patient’s
feelings.
o Reflecting, focusing, and exploring are examples of therapeutic communication techniques.
Therapeutic Communication Session
Goals
o Establishing rapport
o Identifying issues of concern
o Being empathetic, genuine, caring, unconditionally accepting of the person
o Understanding patient’s perception
o Exploring patient’s thoughts, feelings
o Developing problem-solving skills
o Promoting patient’s evaluation of solutions
Therapeutic Communication Session (cont.)
Initiation of session
o Introduction
o Establishment of contract for relationship
o Identification of major concern
Nondirective role (broad-opening, open-ended questions)
Directive role (direct yes/no questions; usually for patients with suicidal thoughts, in crisis, or who are
out of touch with reality)
Therapeutic Communication Session (cont.)
Proper phrasing of questions
o Clarification
o Identification of patient’s avoidance of anxiety-producing topic
Guidance in problem-solving, empowerment to change
Assertive Communication
Expression of positive and negative feelings/ideas in open, honest, direct way
o Calm, specific factual statements
o Focus on “I” statements
Mental Health Exam 1 Outline Ch 1, 2, 3, 4, 5, 6 & ATI Ch 3, 7, 8, 9
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Possible responses
o Aggressive
o Passive–aggressive
o Passive
o Assertive
Community-Based Care
Nurses increasingly caring for high-risk patients in homes; families becoming more responsible for
primary prevention
Therapeutic communication techniques and skills are essential for caring for patients in the community.
Increased self-awareness, knowledge needed about cultural differences; sensitivity to beliefs,
behaviors, feelings of others
Collaboration with patient and family as well as other health-care providers
Question
Is the following statement true or false?
Assertive communication focuses on identifying negative feelings.
Answer
False
Rationale: Assertive communication focuses on the expression of positive and negative feelings or
ideas in an open, honest, direct manner.
Self-Awareness Issues
Nonverbal communication: as important as verbal
Therapeutic communication influential in effectiveness of interventions
Awareness of own communication is first step in improving communication
o Ask for feedback from colleagues
o Examine own communication skills