MENTAL HEALTH AND MENTAL ILLNESS Mental Health The World Health Organization defines health as a state of complete physical, mental, and social wellness, not merely the absence of disease or infirmity. This definition emphasizes health as a positive state of well-being. People in a state of emotional, physical, and social well-being fulfill life responsibilities, function effectively in daily life, and are satisfied with their interpersonal relationships and themselves. In most cases, mental health is a state of emotional, psychological, and social wellness evidenced by satisfying interpersonal relationships, effective behavior and coping, positive self-concept, and emotional stability Mental health has many components, and a wide variety of factors influence it. These factors interact; thus, a person’s mental health is a dynamic, or ever-changing, state. Factors influencing a person’s mental health can be categorized as individual, interpersonal, and social/cultural. Individual, or personal, factors include a person’s biologic makeup, autonomy and independence, self-esteem, capacity for growth, vitality, ability to find meaning in life, emotional resilience or hardiness, sense of belonging, reality orientation, and coping or stress management abilities. Interpersonal, or relationship, factors include effective communication, ability to help others, intimacy, and a balance of separateness and connectedness. Social/cultural, or environmental, factors include a sense of community, access to adequate resources, intolerance of violence, support of diversity among people, mastery of the environment, and a positive, yet realistic, view of one’s world Mental Illness Mental illness includes disorders that affect mood, behavior, and thinking, such as depression, schizophrenia, anxiety disorders, and addictive disorders. Mental disorders often cause significant distress or impaired functioning or both. Individuals experience dissatisfaction with self, relationships, and ineffective coping. Daily life can seem overwhelming or unbearable. Individuals may believe that their situation is hopeless. Factors contributing to mental illness can also be viewed within individual, interpersonal, and social/cultural categories. Individual factors include biologic makeup, intolerable or unrealistic worries or fears, inability to distinguish reality from fantasy, intolerance of life’s uncertainties, a sense of disharmony in life, and a loss of meaning in one’s life. Interpersonal factors include ineffective communication, excessive dependency on or withdrawal from relationships, no sense of belonging, inadequate social support, and loss of emotional control. Social/cultural factors include lack of resources, violence, homelessness, poverty, an unwarranted negative view of the world, and discrimination such as stigma, racism, classism, ageism, and sexism. ----------------------------------------------------------------------------------------------------------------------------------------------------------HISTORICAL PERSPECTIVES OF THE TREATMENT OF MENTAL ILLNESS Period of Enlightenment and Creation of Mental Institutions Sigmund Freud and Treatment of Mental Disorders Those with mental disorders were viewed as either divine or demonic, depending on their behavior. Individuals seen as divine were worshipped and adored; those seen as demonic were ostracized, punished, and sometimes burned at the stake. Later, Aristotle (382–322 BC) attempted to relate mental disorders to physical disorders and developed his theory that the amounts of blood, water, and yellow and black bile in the body controlled the emotions. These four substances, or humors, corresponded with happiness, calmness, anger, and sadness. Imbalances of the four humors were believed to cause mental disorders; therefore, treatment was aimed at restoring balance through bloodletting, starving, and purging. Possessed by demons In early Christian times (1–1000 AD), primitive beliefs and superstitions were strong. All diseases were again blamed on demons, and the mentally ill were viewed as possessed. Priests performed exorcisms to rid sufferers of evil spirits. When that failed, they used more severe and brutal measures, such as incarceration in dungeons, flogging, and starving. The period of scientific study and treatment of mental disorders began with Sigmund Freud and others, such as Emil Kraepelin and Eugen Bleuler. With these men, the study of psychiatry and the diagnosis and treatment of mental illness started in earnest. Freud challenged society to view human beings objectively. He studied the mind, its disorders, and their treatment as no one had done before. Many other theorists built on Freud’s pioneering work. Kraepelin began classifying mental disorders according to their symptoms, and Bleuler coined the term schizophrenia. Development of Psychopharmacology A great leap in the treatment of mental illness began in about 1950 with the development of psychotropic drugs, or drugs used to treat mental illness. Chlorpromazine (Thorazine), an antipsychotic drug, and lithium, an antimanic agent, were the first drugs to be developed. Over the following 10 years, monoamine oxidase inhibitor antidepressants; haloperidol (Haldol), an antipsychotic; tricyclic antidepressants; and antianxiety agents, called benzodiazepines, were introduced. For the first time, drugs actually reduced agitation, psychotic thinking, and depression. Move toward Community Mental Health Deinstitutionalization, a deliberate shift from institutional care in state hospitals to community facilities, began. Community mental health centers served smaller geographic catchment, or service, areas that provided less restrictive treatment located closer to individuals’ homes, families, and friends. These centers provided emergency care, inpatient care, outpatient services, partial hospitalization, screening services, and education. Thus, deinstitutionalization accomplished the release of individuals from long-term stays in state institutions, the decrease in admissions to hospitals, and the development of community-based ----------------------------------------------------------------------------------------------------------------------------MENTAL ILLNESS IN THE 21ST CENTURY Ancient Times People of ancient times believed that any sickness indicated displeasure of the gods and, in fact, was a punishment for sins and wrongdoing. In the 1790s, formulated the concept of asylum as a safe refuge or haven offering protection at institutions where people had been whipped, beaten, and starved because they were mentally ill (Gollaher, 1995). The period of enlightenment was short-lived. Within 100 years after the establishment of the first asylum, state hospitals were in trouble. Attendants were accused of abusing the residents, the rural locations of hospitals were viewed as isolating patients from their families and homes, and the phrase insane asylum took on a negative connotation. Some believe that deinstitutionalization has had negative as well as positive effects. Although deinstitutionalization reduced the number of public hospital beds by 80%, the number of admissions to those beds correspondingly increased by 90%. Such findings have led to the term revolving door effect. Such findings have led to the term revolving door effect. Although people with severe and persistent mental illness have shorter hospital stays, they are admitted to hospitals more frequently. Revolving Door ------------------------------------------------------------------------------------------------------------------------------------------NEUROBIOLOGIC THEORIES AND PSYCHOPHARMACOLOGY Primary function of the nervous system Coordinates all activities of the body (sending, receiving, and interpreting information) Enables the body to respond and adapt to changes both inside and out. Part of Nervous System Central Nervous System (brain and spinal cord) Peripheral Nervous System Brain – located sa cranium ng skull. Main sections are; cerebrum, cerebellum, diencephalon, midbrain, pons, and medulla oblongata Protected by meninges, dura mater, arachnoid mater, and pia mater The space between the arachnoid mater and pia mater is composed of cerebrospinal fluid The two hemisphere is connected by a nerve tract called corpus callosum Cerebrum – largest part. Consists of four lobes; frontal, parietal, temporal, occipital; Frontal Lobe – reasoning and thought Parietal Lobe – integrating sensory information Temporal Lobe – processing auditory information from the ears Occipital Lobe – processing visual information from the eyes Cerebellum – located below the cerebrum and above the 1st cervical of the neck Responsible for muscle coordination, balance posture, and muscle tone Diencephalon – contains two structures; thalamus and hypothalamus Thalamus behaves like a relay station and direct sensory impulses to the cerebrum Hypothalamus controls and regulates temperature, appetite, water balance, sleep and blood vessel constriction and dilation. Plays control in the emotion such as anger, fear, pleasure, pain and affection Midbrain – located below cerebrum and top of brain stem; responsible for certain eyes and auditory reflexes Pons – located below the midbrain; responsible for certain reflexes such as chewing, tasting, and saliva production Medulla Oblongata – located as the bottom of the brainstem; connects to the spinal cord; aka “The Center for Respiration” Regulates heart and blood vessel function, digestion, respiration, swallowing, coughing, sneezing, blood pressure Spinal cord – is the link between the brain and the nerves in the rest of the body. Protected by the vertebral column. Hollow tube containing cerebral spinal fluid 31 spinal nerves arise from the spinal cord ( transmit information form organs to the brain, and vice versa) 4 regions; cervical, thoracic, lumbar, spinal nerves Afferent spinal nerves – responsible for carrying information from the body to the brain Efferent spinal nerves – responsible for carrying information from the brain to the body Neurotransmitters Approximately 100 billion brain cells form groups of neurons, or nerve cells that are arranged in networks. These neurons communicate information with one another by sending electrochemical messages from neuron to neuron, a process called neurotransmission These electrochemical messages pass from the dendrites (projections from the cell body), through the soma or cell body, down the axon (long extended structures), and across the synapses (gaps between cells) to the dendrites of the next neuron. In the nervous system, the electrochemical messages cross the synapses between neural cells by way of special chemical messengers called neurotransmitters. Neurotransmitters are the chemical substances manufactured in the neuron that aid in the transmission of information throughout the body. They either excite or stimulate an action in the cells (excitatory) or inhibit or stop an action (inhibitory). These neurotransmitters fit into specific receptor cells embedded in the membrane of the dendrite, just like a certain key shape fits into a lock. After neurotransmitters are released into the synapse and relay the message to the receptor cells, they are either transported back from the synapse to the axon to be stored for later use (reuptake) or metabolized and inactivated by enzymes, primarily monoamine oxidase Major Neurotransmitters Type Mechanism of Action Physiologic Effects Dopamine Excitatory Norepinephrine (noradrenaline) Epinephrine (adrenaline) Serotonin Excitatory Controls complex movements, motivation, cognition; regulates emotional response Causes changes in attention, learning and memory, sleep and wakefulness, mood Controls fight or flight response Histamine Neuromodulator Acetylcholine Excitatory or inhibitory Neuropeptides Neuromodulators Glutamate γ-Aminobutyric acid Excitatory Inhibitory Excitatory Inhibitory Controls food intake, sleep and wakefulness, temperature regulation, pain control, sexual behaviors, regulation of emotions Controls alertness, gastric secretions, cardiac stimulation, peripheral allergic responses Controls sleep and wakefulness cycle; signals muscles to become alert Enhance, prolong, inhibit, or limit the effects of principal neurotransmitters Results in neurotoxicity if levels are too high Modulates other neurotransmitters Dopamine - a neurotransmitter located primarily in the brain stem. It is generally excitatory and is synthesized from tyrosine, a dietary amino acid. Dopamine is implicated in schizophrenia and other psychoses as well as in movement disorders such as Parkinson disease. Antipsychotic medications work by blocking dopamine receptors and reducing dopamine activity. Norepinephrine - the most prevalent neurotransmitter in the nervous system, is located primarily in the brain stem and plays a role in changes in attention, learning and memory, sleep and wakefulness, and mood regulation. Excess norepinephrine has been implicated in several anxiety disorders; deficits may contribute to memory loss, social withdrawal, and depression. Some antidepressants block the reuptake of norepinephrine, while others inhibit MAO from metabolizing it. Epinephrine - has limited distribution in the brain but controls the fight or flight response in the peripheral nervous system. Serotonin - is derived from tryptophan, a dietary amino acid. The function of serotonin is mostly inhibitory, and it is involved in the control of food intake, sleep and wakefulness, temperature regulation, pain control, sexual behavior, and regulation of emotions. - Serotonin plays an important role in anxiety, mood disorders, and schizophrenia. It has been found to contribute to the delusions, hallucinations, and withdrawn behavior seen in schizophrenia. Some antidepressants block serotonin reuptake, thus leaving it available longer in the synapse, which results in improved mood. Histamine – The role of histamine in mental illness is under investigation. It is involved in peripheral allergic responses, control of gastric secretions, cardiac stimulation, and alertness. Some psychotropic drugs block histamine, resulting in weight gain, sedation, and hypotension. Acetylcholine - neurotransmitter found in the brain, spinal cord, and peripheral nervous system, particularly at the neuromuscular junction of skeletal muscle. It can be excitatory or inhibitory. - It is synthesized from dietary choline found in red meat and vegetables and has been found to affect the sleep–wake cycle and to signal muscles to become active. Studies have shown that people with Alzheimer disease have decreased acetylcholinesecreting neurons, and people with myasthenia gravis (a muscular disorder in which impulses fail to pass the myoneural junction, which causes muscle weakness) have reduced acetylcholine receptors. Glutamate - an excitatory amino acid that can have major neurotoxic effects at high levels. It has been implicated in the brain damage caused by stroke, hypoglycemia, sustained hypoxia or ischemia, and some degenerative diseases such as Huntington or Alzheimer. Gamma-aminobutyric acid (γ-aminobutyric acid, or GABA), an amino acid, is the major inhibitory neurotransmitter in the brain and has been found to modulate other neurotransmitter systems rather than to provide a direct stimulus. Drugs that increase GABA function, such as benzodiazepines, are used to treat anxiety and to induce sleep. More advanced imaging techniques, such as positron emission tomography (PET) and single-photon emission computed tomography (SPECT), are used to examine the function of the brain. - Neurotransmitters and Related Mental Disorders Neurotransmitter Mental Disorder Dopamine Nonepinephrine Serotonin Acetylcholine GABA - Schizophrenia Depression Depression Alzheimer’s Disease Anxiety - Limitations of Brain Imaging Techniques ----------------------------------------------------------------------------------------------------------------------------------------------------------- At one time, the brain could be studied only through surgery or autopsy. During the past 25 years, however, several brain imaging techniques have been developed that now allow visualization of the brain’s structure and function. These techniques are useful for diagnosing some disorders of the brain and have helped correlate certain areas of the brain with specific functions. Brain imaging techniques are also useful in research to find the causes of mental disorders. Brain Imaging Technology Procedure Computed tomography (CT) Magnetic resonance imaging (MRI) Positron emission tomography (PET) Single-photon computed (SPECT) emission tomography Imaging Method Serial x-rays of brain Radio waves from brain detected from magnet Radioactive tracer injected into bloodstream and monitored as client performs activities Same as PET Although imaging techniques such as PET and SPECT have helped bring about tremendous advances in the study of brain diseases, they have some limitations BRAIN IMAGING TECHNIQUES Duration 20–40 minutes 45 minutes ------------------------------------------------------------------------------------------------------------------------------------------- Functional 2–3 hours Genetics and Heredity Functional 1–2 hours NEUROBIOLOGIC CAUSES OF MENTAL ILLNESS Computed tomography (CT), also called computed axial tomography, is a procedure in which a precise x-ray beam takes crosssectional images (slices) layer by layer. The person undergoing CT must lie motionless on a 65 stretcher-like table for about 20 to 40 minutes as the stretcher passes through a tunnel-like “ring” while the serial x-rays are taken. CT can visualize the brain’s soft tissues, so it is used to diagnose primary tumors, metastases, and effusions and to determine the size of the ventricles of the brain. Some people with schizophrenia have been shown to have enlarged ventricles; this finding is associated with a poorer prognosis and marked negative symptoms Magnetic resonance imaging (MRI), a type of body scan, an energy field is created with a huge magnet and radio waves. The energy field is converted to a visual image or scan. MRI produces more tissue detail and contrast than CT and can show blood flow patterns and tissue changes such as edema. - - The use of radioactive substances in PET and SPECT limits the number of times a person can undergo these tests. There is the risk that the client will have an allergic reaction to the substances. Some clients may find receiving intravenous doses of radioactive material frightening or unacceptable. Imaging equipment is expensive to purchase and maintain, so availability can be limited. A PET camera costs about $2.5 million; a PET scanning facility may take up to $6 million to establish. Some persons cannot tolerate these procedures because of fear or claustrophobia. Researchers are finding that many of the changes in disorders such as schizophrenia are at the molecular and chemical levels and cannot be detected with current imaging techniques Results Structural image Structural image - Radioactive substances are injected into the blood; the flow of those substances in the brain is monitored as the client performs cognitive activities as instructed by the operator. PET uses two photons simultaneously; SPECT uses a single photon. PET provides better resolution with sharper and clearer pictures and takes about 2 to 3 hours; SPECT takes 1 to 2 hours. PET and SPECT are used primarily for research, not for the diagnosis and treatment of clients with mental disorders These scans have shown that clients with Alzheimer disease have decreased glucose metabolism in the brain and decreased cerebral blood flow. Some persons with schizophrenia also demonstrate decreased cerebral blood flow. It can also be used to measure the size and thickness of brain structures; persons with schizophrenia can have as much as 7% reduction in cortical thickness. The person undergoing an MRI must lie in a small, closed chamber and remain motionless during the procedure, which takes about 45 minutes. Those who feel claustrophobic or have increased anxiety may require sedation before the procedure. Clients with pacemakers or metal implants, such as heart valves or orthopedic devices, cannot undergo MRI. To date, one of the most promising discoveries is the identification in 2007 of variations in the gene SORL1 that may be a factor in late-onset Alzheimer disease. Current theories and studies indicate that several mental disorders may be linked to a specific gene or combination of genes but that the source is not solely genetic; non-genetic factors also play important roles. Three types of studies are commonly conducted to investigate the genetic basis of mental illness: 1. Twin studies are used to compare the rates of certain mental illnesses or traits in monozygotic (identical) twins, who have an identical genetic makeup, and dizygotic (fraternal) twins, who have a different genetic makeup. Fraternal twins have the same genetic similarities and differences as nontwin siblings. 2. Adoption studies are used to determine a trait among biologic versus adoptive family members. 3. Family studies are used to compare whether a trait is more common among first-degree relatives (parents, siblings, and children) than among more distant relatives or the general population. Stress and the Immune System (Psychoimmunology) Psychoimmunology, a relatively new field of study, examines the effect of psychosocial stressors on the body’s immune system. A compromised immune system could contribute to the development of a variety of illnesses, particularly in populations already genetically at risk. So far, efforts to link a specific stressor with a specific disease have been unsuccessful. However, the immune system and the brain can influence neurotransmitters. When the inflammatory response is critically involved in illnesses such as multiple sclerosis or lupus erythematosus, mood dysregulation and even depression are common. Infection as a Possible Cause Theories that are being developed and tested include the existence of a virus that has an affinity for tissues of the CNS, the possibility that a virus may actually alter human genes, and maternal exposure to a virus during critical fetal development of the nervous system. Prenatal infections may impact the developing brain of the fetus, giving rise to a proposed theory that inflammation may causally contribute to the pathology of schizophrenia. The conventional, or first-generation, antipsychotic drugs are potent antagonists (blockers) of D2, D3, and D4. This not only makes them effective in treating target symptoms but also produces many extrapyramidal side effects (discussion to follow) because of the blocking of the D2 receptors. -----------------------------------------------------------------------------------------------------------------------------------------------------------PSYCHOPHARMACOLOGY Medication management is a crucial issue that greatly influences the outcomes of treatment for many clients with mental disorders. Efficacy- maximal therapeutic effect that a drug can achieve Potency- Describes the amount of the drug needed to achieve that maximum effect. Low potency drugs require higher dosages to achieve efficacy, while high-potency drugs achieve efficacy at lower dosages. Half-life- is the time it takes for half of the drug to be removed from the bloodstream. Drugs with a shorter half-life may need to be given 3-4 times a day, but drugs with a longer half-life may be given once a day. The U.S. Food and Drug Administration (FDA) is responsible for supervising the testing and marketing of medications for public safety. These activities include clinical drug trials for new drugs and monitoring the effectiveness and side effects of medications. At times, a drug will prove effective for a disease that differs from the one involved in original testing and FDA approval. This is called off-label use. An example is some anticonvulsant drugs (approved to prevent seizures) that are prescribed for their effects in stabilizing the moods of clients with bipolar disorder (off-label use). When a drug is found to have serious or life-threatening side effects, even if such side effects are rare, the FDA may issue a black box warning. This means that package inserts must have a highlighted box, separate from the text, which contains a warning about the serious or life-threatening side effects. Newer, atypical or second-generation antipsychotic drugs, such as clozapine (Clozaril), are relatively weak blockers of D2, which may account for the lower incidence of extrapyramidal side effects. In addition, second-generation antipsychotics inhibit the reuptake of serotonin, as do some of the antidepressants, increasing their effectiveness in treating the depressive aspects of schizophrenia. The third generation of antipsychotics, called dopamine system stabilizers, is being developed. These drugs are thought to stabilize dopamine output; that is, they preserve or enhance dopaminergic transmission when it is too low and reduce it when it is too high. ---------------------------------------------------------------------------------------------------------------------------------------------------------Side effects of Antipsychotic Drugs Extrapyramidal Side Effects. Extrapyramidal symptoms (EPSs), serious neurologic symptoms, are the major side effects of antipsychotic drugs. They include acute dystonia, pseudoparkinsonism, and akathisia. Although often collectively referred to as EPSs, each of these reactions has distinct features. Blockade of D2 receptors in the midbrain region of the brain stem is responsible for the development of EPSs. Firstgeneration antipsychotic drugs cause a greater incidence of EPSs than do second-generation antipsychotic drugs, with ziprasidone (Geodon) rarely causing EPSs Principles that Guide Pharmacologic Treatment Pseudoparkinsonism Stooped posture Shuffling gait Rigidity Bradykinesia Tremors at rest Pill-rolling motion of the hand Akathisia Restless Trouble standing still Paces the floor Feel in constant motion rocking back and forth A medication is selected based on its effect on the client’s target symptoms such as delusional thinking, panic attacks, or hallucinations. The medication’s effectiveness is evaluated largely by its ability to diminish or eliminate the target symptoms. Many psychotropic drugs must be given in adequate dosages for some time before their full effects are realized. For example, tricyclic antidepressants can require 4 to 6 weeks before the client experiences optimal therapeutic benefit. The dosage of medication is often adjusted to the lowest effective dosage for the client. Sometimes a client may need higher dosages to stabilize his or her target symptoms, while lower dosages can be used to sustain those effects over time. As a rule, older adults require lower dosages of medications than do younger clients to experience therapeutic effects. It may also take longer for a drug to achieve its full therapeutic effect in older adults. Psychotropic medications are often decreased gradually (tapering) rather than abruptly. This is because of potential problems with rebound (temporary return of symptoms), recurrence (of the original symptoms), or withdrawal (new symptoms resulting from discontinuation of the drug). Follow-up care is essential to ensure compliance with the medication regimen, to make needed adjustments in dosage, and to manage side effects. Compliance with the medication regimen is often enhanced when the regimen is as simple as possible in terms of both the number of medications prescribed and the number of daily doses. - Antipsychotic Drugs Antipsychotic drugs, formerly known as neuroleptics, are used to treat the symptoms of psychosis, such as the delusions and hallucinations seen in schizophrenia, schizoaffective disorder, and the manic phase of bipolar disorder. Antipsychotic drugs work by blocking receptors of the neurotransmitter dopamine. They have been in clinical use since the 1950s. They are the primary medical treatment for schizophrenia and are also used in psychotic episodes of acute mania, psychotic depression, and drug-induced psychosis. Clients with dementia who have psychotic symptoms sometimes respond to low dosages of conventional antipsychotics. Second-generation antipsychotics can increase mortality rates in elderly clients with dementia-related psychosis. Short-term therapy with antipsychotics may be useful for transient psychotic symptoms such as those seen in some clients with borderline personality disorder. Acute dystonia Facial grimacing Involuntary upward eye movement Muscle spasms of the tongue, face, neck, and back (back muscle spasms cause trunk to arch forward) Laryngeal spasms Tardive dyskinesia (most common in conventional) Protrusion and rolling of the tongue Sucking and smacking movements of the lips Chewing motion Facial dyskinesia Involuntary movement of the body and extremities. Extrapyramidal symptoms associated with atypical antipsychotics; A – Acute D – Dystonia A – Akathisia P – Parkinsonism T – Tardive Dyskinesia Anticholinergic Side Effects. Anticholinergic side effects often occur with the use of antipsychotics and include orthostatic hypotension, dry mouth, constipation, urinary hesitance or retention, blurred near vision, dry eyes, photophobia, nasal congestion, and decreased memory. These side effects usually decrease within 3 to 4 weeks but do not entirely remit. The client taking anticholinergic agents for EPSs may have increased problems with anticholinergic side effects. Using calorie-free beverages or hard candy may alleviate dry mouth, and stool softeners, adequate fluid intake, and the inclusion of grains and fruit in the diet may prevent constipation. Ego Defense Mechanisms. Freud believed that the self, or ego, uses ego defense mechanisms, which are methods of attempting to protect the self and cope with basic drives or emotionally painful thoughts, feelings, or events. Other Side Effects Elevated Prolactin- breast enlargement and tenderness, diminished libido, erectile and orgasmic dysfunction, menstrual irregularities. Increased risk for breast cancer, weight gain. Drugs used to treat extrapyramidal side effects Generic (Trade) Name Amantadine (Symmetrel) Benztropine (Cogentin) Biperiden (Akineton) Diazepam (Valium) Diphenhydramine (Benadryl) Lorazepam (Ativan) Procyclidine (Kemadrin) Propanolol (Inderal) Trihexyphenidyl (Artane) Drug Class Dopaminergic Agonist Anticholinergic Anticholinergic Benzodiazepine Antihistamine Benzodiazepine Anticholinergic Beta-Blocker Anticholinergic Compensation Overachievement in one area to offset real or perceived deficiencies in another area Conversion Expression of an emotional conflict through the development of a physical symptom, usually sensorimotor in nature Denial Failure to acknowledge an unbearable condition; failure to admit the reality of a situation or how one enables the problem to continue Displacement Ventilation of intense feelings toward persons less threatening than the one who aroused those feelings Dissociation Dealing with emotional conflict by a temporary alteration in consciousness or identity Fixation Immobilization of a portion of the personality resulting from unsuccessful completion of tasks in a developmental stage Identification Introjection Modeling actions and opinions of influential others while searching for identity, or aspiring to reach a personal, social, or occupational goal Separation of the emotions of a painful event or situation from the facts involved; acknowledging the facts but not the emotions Accepting another person’s attitudes, beliefs, and values as one’s own Projection Unconscious blaming of unacceptable inclinations or thoughts on an external object Rationalization Excusing own behavior to avoid guilt, responsibility, conflict, anxiety, or loss of self-respect Reaction formation Regression Acting the opposite of what one thinks or feels Repression Excluding emotionally painful or anxiety-provoking thoughts and feelings from conscious awareness Resistance Overt or covert antagonism toward remembering or processing anxiety-producing information Sublimation Substituting a socially acceptable activity for an impulse that is unacceptable Substitution Replacing the desired gratification with one that is more readily available Suppression Conscious exclusion of unacceptable thoughts and feelings from conscious awareness Undoing Exhibiting acceptable behavior to make up for or negate unacceptable behavior Intellectualization Client Teaching • • • Inform clients about the types of side effects that may occur. Encourage client to report such problems to the physician instead of discontinuing the medication. Teach the client methods of managing or avoiding side effects and maintaining the medication regimen. Intervention 1. 2. 3. 4. 5. 6. 7. Drinking sugar free fluids and eating sugar free hard candy ease the dry mouth. To prevent constipation, include exercise and increase water and bulk forming foods in the diet. Avoid driving and performing other potentially dangerous activities until their response times and reflexes seem normal. Use of sunscreen due to photosensitivity. Monitor the amount of sleepiness or drowsiness. If client forgets the medication, he can take the missed dose if its 3 or 4 hours late. More than 4 hours, omit the forgotten dose. Clients who have difficulty remembering should use chart and record doses or use pillbox. Moving back to a previous developmental stage to feel safe or have needs met -----------------------------------------------------------------------------------------------------------------------------------------------------------PSYCHOANALYTIC THEORIES -----------------------------------------------------------------------------------------------------------------------------------------------------Five Stages of Psychosexual Development. Sigmund Freud: The Father of Psychoanalysis Sigmund Freud developed psychoanalytic theory in the late 19th and early 20th centuries in Vienna. Psychoanalytic theory supports the notion that all human behavior is caused and can be explained (deterministic theory). Freud believed that repressed (driven from conscious awareness) sexual impulses and desires motivate much human behavior. Freud based his theory of childhood development on the belief that sexual energy, termed libido, was the driving force of human behavior. Oral Birth to months 18 Personality Components: Id, Ego, and Superego. Anal 18–36 months The id is the part of one’s nature that reflects basic or innate desires such as pleasure-seeking behavior, aggression, and sexual impulses. The id seeks instant gratification, causes impulsive unthinking behavior, and has no regard for rules or social convention. Phallic/oedipal 3–5 years The superego is the part of a person’s nature that reflects moral and ethical concepts, values, and parental and social expectations; therefore, it is in direct opposition to the id. Latency 5–11 years Genital 11–13 years The third component, the ego, is the balancing or mediating force between the id and the superego. The ego represents mature and adaptive behavior that allows a person to function successfully in the world. Freud believed that anxiety resulted from the ego’s attempts to balance the impulsive instincts of the id with the stringent rules of the superego. or 13 Major site of tension and gratification is the mouth, lips, and tongue; includes biting and sucking activities. Id is present at birth. Ego develops gradually from rudimentary structure present at birth. Anus and surrounding area are major source of interest. Voluntary sphincter control (toilet training) is acquired Genital is the focus of interest, stimulation, and excitement. Penis is organ of interest for both sexes. Masturbation is common. Penis envy is seen in girls; oedipal complex (wish to marry opposite-sex parent and be rid of same-sex parent) is seen in boys and girls. Resolution of oedipal complex. Sexual drive channeled into socially appropriate activities such as school work and sports. Formation of the superego. Final stage of psychosexual development Begins with puberty and the biologic capacity for orgasm; involves the capacity for true intimacy. Transference and Countertransference. INTERPERSONAL THEORIES Transference occurs when the client displaces onto the therapist attitudes and feelings that the client originally experienced in other relationships. Transference patterns are automatic and unconscious in the therapeutic relationship. (patient-nurse) Countertransference occurs when the therapist displaces onto the client attitudes or feelings from his or her past. -----------------------------------------------------------------------------------------------------------------------------------------------------------DEVELOPMENTAL THEORIES Harry Stack Sullivan: Interpersonal Relationships and Milieu Therapy Five Life Stages. Sullivan established five life stages of development— infancy, childhood, juvenile, preadolescence, and adolescence, each focusing on various interpersonal relationships. He also described three developmental cognitive modes of experience and believed that mental disorders are related to the persistence of one of the early modes Stage Infancy Age Birth to onset of language Focus Primary need exists for bodily contact and tenderness. Prototaxic mode dominates (no relation between experiences). Primary zones are oral and anal. If needs are met, infant has sense of well-being; unmet needs lead to dread and anxiety. Childhood Language to 5 years Parents are viewed as source of praise and acceptance. Shift to parataxic mode; experiences are connected in sequence to each other. Primary zone is anal. Gratification leads to positive self-esteem. Moderate anxiety leads to uncertainty and insecurity; severe anxiety results in self-defeating patterns of behavior Juvenile 5–8 years Shift to the syntaxic mode begins (thinking about self and others based on analysis of experiences in a variety of situations). Opportunities for approval and acceptance of others. Learn to negotiate own needs. Severe anxiety may result in a need to control or in restrictive, prejudicial attitudes. Preadolescence 8–12 year Move to genuine intimacy with friend of the same sex. Move away from family as source of satisfaction in relationships. Major shift to syntaxic mode occurs. Capacity for attachment, love, and collaboration emerges or fails to develop. Adolescence Puberty to adulthood Lust is added to interpersonal equation. Need for special sharing relationship shifts to the opposite sex. New opportunities for social experimentation lead to the consolidation of selfesteem or self-ridicule. If the self-system is intact, areas of concern expand to include values, ideals, career decisions, and social concerns. Erik Erikson and Psychosocial Stages of Development In each stage, the person must complete a life task that is essential to his or her well-being and mental health. These tasks allow the person to achieve life’s virtues: hope, purpose, fidelity, love, caring, and wisdom Stage Virtue Trust vs. mistrust (infant) Task Hope Viewing the world as safe and reliable; relationships as nurturing, stable, and dependable Will Achieving a sense of control and free will Purpose Beginning development of a conscience; learning to manage conflict and anxiety Industry vs. inferiority (school age) Competence Emerging confidence in own abilities; taking pleasure in accomplishments Identity vs. role confusion (adolescence) Fidelity Formulating a sense of self and belonging Intimacy vs. isolation (young adult) Love Forming adult, loving attachments to others Generativity vs. stagnation (middle adult) Ego integrity vs. despair (maturity) Care Being creative and productive; establishing the next generation Wisdom Accepting responsibility for oneself and life Autonomy vs. shame and (toddler) Initiative vs. guilt (preschool) doubt relationships, and meaningful Jean Piaget and Cognitive Stages of Development Jean Piaget explored how intelligence and cognitive functioning develop in children. He believed that human intelligence progresses through a series of stages based on age, with the child at each successive stage demonstrating a higher level of functioning than at previous stages. In his schema, Piaget strongly believed that biologic changes and maturation were responsible for cognitive development. Therapeutic Community or Milieu. Sullivan envisioned the goal of treatment as the establishment of satisfying interpersonal relationships. The therapist provides a corrective interpersonal relationship for the client. Sullivan coined the term participant observer for the therapist’s role, meaning that the therapist both participates in and observes the progress of the relationship. - Piaget’s four stages of cognitive development are as follows: 1. Sensorimotor—birth to 2 years: The child develops a sense of self as separate from the environment and the concept of object permanence, that is, tangible objects do not cease to exist just because they are out of sight. He or she begins to form mental images. It involved client’s interactions with one another including practicing interpersonal relationships skills, giving one another feedback about behavior, and working cooperatively as a group to solve day-to-day problems. Milieu therapy was one of the primary modes of treatment in the acute hospital setting. In today’s health care environment, however, inpatient hospital stays are often too short for clients to develop meaningful relationships with one another. Therefore, the concept of milieu therapy receives little attention. Management of the milieu, or environment, is still a primary role for the nurse in terms of providing safety and protection for all clients and promoting social interaction. ------------------------------------------------------------------------------------------------------------------------------------------------------------ 2. Preoperational—2 to 6 years: The child develops the ability to express self with language, understands the meaning of symbolic gestures, and begins to classify objects. Hildegard Peplau: Therapeutic Nurse–Patient Relationships 3. Concrete operations—6 to 12 years: The child begins to apply logic to thinking, understands spatiality and reversibility, and is increasingly social and able to apply rules; however, thinking is still concrete. Hildegard Peplau was a nursing theorist and clinician who built on Sullivan’s interpersonal theories and also saw the role of the nurse as a participant observer. Peplau developed the concept of the therapeutic nurse–patient relationship, which includes four phases: orientation, identification, exploitation, and resolution 4. Formal operations—12 to 15 years and beyond: The child learns to think and reason in abstract terms, further develops logical thinking and reasoning, and achieves cognitive maturity. ------------------------------------------------------------------------------------------------------------------------------------------------------------ - During these phases, the client accomplishes certain tasks and makes relationship changes that help the healing process Stage Orientation Identification Tasks The orientation phase is directed by the nurse and involves engaging the client in treatment, providing explanations and information, and answering questions. ------------------------------------------------------------------------------------------------------------------------------------------------------------ Patient’s problems and needs are clarified. Patient asks questions. Hospital routines and expectations are explained. Patient harnesses energy toward meeting problems. Patient’s full participation is elicited Abraham Maslow: Hierarchy of Needs Abraham The identification phase begins when the client works interdependently with the nurse, expresses feelings, and begins to feel stronger. Patient responds to persons he or she perceives as helpful. Patient feels stronger. Patient expresses feelings. Interdependent work with the nurse occurs. Roles of both patient and nurse are clarified HUMANISTIC THEORIES Maslow studied the needs or motivations of the individual. Maslow formulated the hierarchy of needs, in which he used a pyramid to arrange and illustrate the basic drives or needs that motivate people. Exploitation Resolution In the exploitation phase, the client makes full use of the services offered. Patient makes full use of available services. Goals such as going home and returning to work emerge. Patient’s behaviors fluctuate between dependence and independence In the resolution phase, the client no longer needs professional services and gives up dependent behavior. The relationship ends. Patient gives up dependent behavior. Services are no longer needed by patient. Patient assumes power to meet own needs, set new goals, and so forth. The most basic needs—the physiologic needs of food, water, sleep, shelter, sexual expression, and freedom from pain— must be met first. The second level involves safety and security needs, which include protection, security, and freedom from harm or threatened deprivation. The third level is love and belonging needs, which include enduring intimacy, friendship, and acceptance. The fourth level involves esteem needs, which include the need for self-respect and esteem from others. The highest level is self-actualization, the need for beauty, truth, and justice. Maslow used the term self-actualization to describe a person who has achieved all the needs of the hierarchy and has developed his or her fullest potential in life. Few people ever become fully self-actualized. Carl Rogers: Client-Centered Therapy Roles of the Nurses in the Therapeutic Relationship. Peplau also wrote about the roles of the nurses in the therapeutic relationship and how these roles help meet the client’s needs. The primary roles she identified are as follows: Stranger—offering the client the same acceptance and courtesy that the nurse would to any stranger Resource person—providing specific answers to questions within a larger context • Teacher—helping the client learn either formally or informally Leader—offering direction to the client or group Surrogate—serving as a substitute for another, such as a parent or sibling Counselor—promoting experiences leading to health for the client, such as expression of feelings Four Levels of Anxiety. Peplau defined anxiety as the initial response to a psychic threat. She described four levels of anxiety: mild, moderate, severe, and panic Mild Moderate Severe Panic Sharpened senses Increased motivation Alert Enlarged perceptual field Can solve problems Learning is effective Restless Gastrointestinal “butterflies” Sleepless Irritable Hypersensitive to noise Selectively attentive Perceptual field limited to the immediate task Can be redirected Cannot connect thoughts or events independently Muscle tension Diaphoresis Pounding pulse Headache Dry mouth Higher voice pitch Increased rate of speech Gastrointestinal upset Frequent urination Increased automatisms (nervous mannerisms) Perceptual field reduced to one detail or scattered details Cannot complete tasks Cannot solve problems or learn effectively Behavior geared toward anxiety relief and is usually ineffective Feels awe, dread, or horror Doesn’t respond to redirection Severe headache Nausea, vomiting, diarrhea Trembling Rigid stance Vertigo Pale Tachycardia Chest pain Crying Ritualistic (purposeless, repetitive) behavior Perceptual field reduced to focus on self Cannot process environmental stimuli Distorted perceptions Loss of rational thought Personality disorganization Doesn’t recognize danger Possibly suicidal Delusions or hallucination possible Can’t communicate verbally Either cannot sit (may bolt and run) or is totally mute and immobile Carl Rogers focused on the therapeutic relationship and developed a new method of client-centered therapy. Rogers was one of the first to use the term client rather than patient. Client-centered therapy focuses on the role of the client, rather than the therapist, as the key to the healing process. Rogers believed that each person experiences the world differently and knows his or her own experience best (Rogers, 1961). According to Rogers, clients do “the work of healing,” and within a supportive and nurturing client–therapist relationship, clients can cure themselves. Clients are in the best position to know their own experiences and make sense of them, to regain their selfesteem, and to progress toward self-actualization. The therapist takes a person-centered approach, a supportive role, rather than a directive or expert role, because Rogers viewed the client as the expert on his or her life. The therapist must promote the client’s self-esteem as much as possible through three central concepts: • • • Unconditional positive regard—a non-judgmental caring for the client that is not dependent on the client’s behavior Genuineness—realness or congruence between what the therapist feels and what he or she says to the client Empathetic understanding—in which the therapist senses the feelings and personal meaning from the client and communicates this understanding to the client --------------------------------------------------------------------------------------------------------------------------------------------------------Treatment Modalities Individual Psychotherapy - method of bringing about change in a person by exploring his or her feelings, attitudes, thinking, and behavior. It involves a one-to-one relationship between the therapist and the client. Group Therapy- A group is a number of persons who gather in a face-to-face setting to accomplish tasks that require cooperation, collaboration, or working together. It includes family therapy, education groups, support groups, and self-help groups Complementary and Alternative Therapies • • Complementary medicine includes therapies used with conventional medicine practices (the medical model). Alternative medicine includes therapies used in place of conventional treatment. Variety of complementary and alternative therapies • Alternative medical systems - include homeopathic medicine and naturopathic medicine in Western cultures, and traditional Chinese medicine, which includes herbal and nutritional therapy, restorative physical exercises (yoga and tai chi), meditation, acupuncture, and remedial massage. • Mind-Body Interventions - include meditation, prayer, mental healing, and creative therapies that use art, music, or dance. • Biologically based therapies - use substances found in nature, such as herbs, food, and vitamins. Dietary supplements, herbal products, medicinal teas, aromatherapy, and a variety of diets are included • Manipulative and body based therapies - are based on manipulation or movement of one or more parts of the body, such as therapeutic massage and chiropractic or osteopathic manipulation. • Energy therapies - include two types of therapy: biofield therapies, intended to affect energy fields that are believed to surround and penetrate the body, such as therapeutic touch, qi gong, and Reiki, and bioelectric-based therapies involving the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, and alternating current or direct current fields. Qi gong is part of Chinese medicine that combines movement, editation, and regulated breathing to enhance the flow of vital energy and promote healing. Reiki (which in Japanese means “universal life energy”) is based on the belief that when spiritual energy is channeled through a Reiki practitioner, the patient’s spirit and body are healed. Psychiatric Rehabilitation - involves providing services to people with severe and persistent mental illness to help them to live in the community. These programs are often called community support services or community support programs. These programs assist clients with activities of daily living, such as transportation, shopping, food preparation, money management, and hygiene. Social support and interpersonal relationships are recognized as a primary need for successful community living. - ----------------------------------------------------------------------------------------------------------------------------------------------------------- Therapeutic Nurse-Patient Relationship - is defined as a helping relationship that's based on mutual trust and respect, the nurturing of faith and hope, being sensitive to self and others, and assisting with the gratification of your patient's physical, emotional, and spiritual needs through your knowledge and skill. This caring relationship develops when you and your patient come together in the moment, which results in harmony and healing. Components of a Therapeutic Nurse-Patient Relationship Trust Genuine Interest Empathy Acceptance Positive regard Self Awareness and Therapeutic use of Self ----------------------------------------------------------------------------------------------------------------------------------------------------------Types of Relationships Social Relationship- primarily initiated for the purpose of friendship, socialization, companionship or accomplishment of task. Intimate Relationship- involves two people who are committed to each other. Therapeutic Relationship- focuses on the needs, experiences, feelings, and ideas of the client only. ----------------------------------------------------------------------------------------------------------------------------------------------------------Phases of the Nurse-Client Relationship Treatment Settings and Therapeutic Programs Orientation- Nurse and client meet and ends when the client begins to identify problems to examine. Confidentiality Self Disclosure Working Phase - Problem Identification - the client identifies the issues or concerns causing problems. Exploitation- the nurse guides the clients to examine feelings and responses and develop better coping skills and more positive self-image. Termination or Resolution Phase - Begins when the problems are resolved and ends when the relationship is ended. Inpatient Hospital Treatment Short-Stay Clients Long-Stay Clients Case Management Discharge Planning ---------------------------------------------------------------------------------------------------------------------------------------------------------- Partial Hospitalization Programs Communication Residential Settings Group Homes Supervises Apartments Board and Care homes Assisted Living Adult Foster Care Respite/Crisis Housing The process that people use to exchange information • Verbal communication- consists of words a person uses to speak to one or more listeners. • Non-Verbal Communication- behaviour that accompanies verbal content such as body language, eye contact, facial expression, tone of voice, speed and hesitations in speech, grunts and groans, and distance from the listeners. ----------------------------------------------------------------------------------------------------------------------------------------------------------Psychiatric Rehabilitation and Recovery Clubhouse Model Assertive Community Treatment Technology Therapeutic Communication is an interpersonal interaction between the nurse and the client during which the nurse focuses on the client’s specific needs to promote an effective exchange of information. Skilled use of therapeutic communication techniques helps the nurse understand and empathize with the client’s experience. Therapeutic Communication Techniques • Accepting • Broad Openings • Consensual Validation • Encouraging comparison • Encouraging description of perceptions • Encouraging expression • Exploring • • • • • • • • • • • • • • • • • Focusing Formulating a plan of action General leads Giving Information Giving Recognition Making Observations Offering Self Presenting reality Reflecting Restating Seeking Information Silence Silence collaboration Summarizing Translating into feelings Verbalizing the implied Voicing doubt Anger, Hostility, and Aggression Anger Anger results when a person is frustrated, hurt, or afraid. Handled appropriately and expressed assertively, anger can be a positive force that helps a person resolve conflicts, solve problems, and make decisions. Although anger is normal, it is often perceived as a negative feeling. Possible consequences are physical problems such as migraine headaches, ulcers, or coronary artery disease, and emotional problems such as depression and low self-esteem. Anger that is expressed inappropriately can lead to hostility and aggression. Assertive communication uses “I” statements that express feelings and are specific to the situation, for example, “I feel angry when you interrupt me,” or “I am angry that you changed the work schedule without talking to me.” Hostility, also called verbal aggression, is an emotion expressed through verbal abuse, lack of cooperation, violation of rules or norms, or threatening behavior (Schultz & Videbeck, 2013) Physical aggression is behavior in which a person attacks or injures another person or destroys property. --------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------- Nontherapeutic Communication Techniques • Advising • Agreeing • Belittling feelings expressed • Challenging • Defending • Disagreeing • Disapproving • Giving approval • Giving literal responses • Indicating existence of an external source • Interpreting • Introducing an unrelated topic • Making stereotyped comments • Probing • Reassuring • Rejecting • Requesting an explanation • Testing • Using denial Stages in Aggressive Incidents: • Triggering phase (incident or situation that initiates an aggressive response) • Escalation phase • Crisis phase • Recovery phase • Post-crisis phase. -----------------------------------------------------------------------------------------------------------------------------------------------------------Nonverbal Communication Skills • Facial Expression- expressive, impassive, confusing • Eye contact • Silence • Body language- gestures, postures, movements, and body positions Phase Definition Signs, Symptoms, and Behaviors Triggering An event or circumstances in the environment initiates the client’s response, which is often anger or hostility. The client’s responses represent escalating behaviors that indicate movement toward a loss of control. Restlessness, anxiety, irritability, pacing, muscle tension, rapid breathing, perspiration, loud voice, anger Escalation Crisis During an emotional and physical crisis, the client loses control. Recovery The client regains physical and emotional control. The client attempts reconciliation with others and returns to the level of functioning before the aggressive incident and its antecedents. Postcrisis Related Disorders • Paranoid Delusion • Auditory Hallucinations • Dementia • Delirium • Head injuries • Intoxication with alcohol or other drugs • Antisocila and borderline personality disorders • Depression • IED- Intermittent Explosive Disorder Pale or flushed face, yelling, swearing, agitation, threatening, demanding, clenched fists, threatening gestures, hostility, loss of ability to solve the problem or think clearly Loss of emotional and physical control, throwing objects, kicking, hitting, spitting, biting, scratching, shrieking, screaming, inability to communicate clearly Lowering of voice; decreased muscle tension; clearer, more rational communication; physical relaxation Remorse; apologies; crying; quiet, withdrawn behavior Acting out - an immature defense mechanism by which the person deals with emotional conflicts or stressors through actions rather than through reflection or feelings. The person engages in acting-out behavior, such as verbal or physical aggression, to feel temporarily less helpless or powerless. Etiology Neurobiologic Theories - Low serotonin levels increased activity of dopamine and norepinephrine increased activity of dopamine and norepinephrine structural damage to the limbic system and the frontal and temporal lobes Psychosocial Theories - Failure to develop impulse control and ability to delay gratification. Cultural Considerations In certain cultures, anger expression has been seen as rude and disrespectful. Some culture-bound syndromes involve aggressive, agitated, or violent behaviour. Treatments and Medications The treatment of aggressive clients often focuses on treating the underlying or comorbid psychiatric diagnosis • Lithium• Carbamazepine (Tegretol) and valproate (Depakote) • Atypical antipsychotic agents such as clozapine (Clozaril), risperidone (Risperdal), and olanzapine • (Zyprexa) • Benzodiazepines • Haloperidol (Haldol) and lorazepam (Ativan) --------------------------------------------------------------------------------------------------------------------------------------------------------Legal Considerations: Rights of Clients and Related Issues • Involuntary Hospitalization • Release from the Hospital • Mandatory Outpatient Treatment • Conservatorship and Guardianship • Least Restrictive Environment • Confidentiality Nursing Liability • Torts- is a wrongful act that results in injury, loss, or damage. Torts may be either unintentional or intentional. • Unintentional torts- Negligence and malpractice 1. Duty 2. Breach of Duty 3. Injury or damage 4. Causation • Intentional Torts 1. Assault 2. Battery 3. False Imprisonment Prevention of Liability • Practice within the scope of state laws and nurse practice act. • Collaborate with colleagues to determine the best course of action. • Use established practice standards to guide decisions and actions. • Always put the client’s rights and welfare first. • Develop effective interpersonal relationships with clients and families. • Accurately and thoroughly document all assessment data, treatments, interventions, and evaluations of the client’s response to care. Ethical Issues Theories Utilitarianism Deontology Principles of Ethics Autonomy Beneficence Nonmaleficence Justice Seven Principles of Healthcare Ethics Autonomy ( Freedom) Veracity ( Truth) Beneficence ( Do good) Nonmaleficence( Do no harm) Justice (fairness) Confidentiality ( Privacy) Fidelity Ethical Dilemmas in Mental Health Many dilemmas in mental health involve the client’s right to self- determination and independence (autonomy) and concern for the “public good” (utilitarianism). Examples include the following: • • • Are psychotic clients necessarily incompetent, or do they still have the right to refuse hospitalization and medication? Should a client who is loud and intrusive to other clients on a hospital unit be secluded from the others? Should physicians break confidentiality to report clients who drive cars at high speeds and recklessly? Points to Consider When Confronting Ethical Dilemmas • Talk to colleagues or seek professional supervision. Usually, the nurse does not need to resolve an ethical dilemma alone. • Spend time thinking about ethical issues, and determine what your values and beliefs are regarding situations before they occur. • Be willing to discuss ethical concerns with colleagues or managers. Being silent is condoning the behavior.
