5/22/2012
Psychiatric Nursing:
Ready or Not… Recovery
Here We Come
Vanderbilt Psychiatric Hospital
Thursday, May 24, 2012
Mary D Moller, DNP, APRN, PMHCNS-BC, CPRP, FAAN
Associate Professor,
Yale University School of Nursing
Objectives
1. Compare the history of the recovery
movement in psychiatry to the history of
psychiatric nursing
2. Compare the principles and elements of
recovery to definitions of nursing
3. Apply the psychiatric nursing process to the
lived experience of patients who experience
psychosis
2012-Mary D Moller
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What Does Recovery Mean to You?
• Take a few minutes and write down your
personal idea/definition/thoughts about
what recovery is.
• Use any frame of reference— personal,
professional, patient-centered, nursecentered
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2012-Mary D Moller
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Early History of Recovery and
Language
• 1620: patients of the Bethlehem Hospital banded together and sent a
"Petition of the Poor Distracted People in the House of Bedlam" to the
House of Lords.
• 1774: Samuel Bruckshaw published the "iniquitous abuse of private
madhouses“
• 1796: William Belcher wrote his "Address to humanity”,
• Moral treatment originated in part of of French ex-patient turned
hospital-superintendent Jean-Baptiste Pussin and his wife
• 1848: in England, the Alleged Lunatics' Friend Society campaigned for
sweeping reforms to the asylum system and abuses of the moral
approach
• 1851-1860: in the United States, The Opal (1851–1860) was a ten volume
Journal produced by patients of Utica State Lunatic Asylum
• 1868, Elizabeth Packard, founded the Anti-Insane Asylum Society,
published a series of writings describing her experiences in the Illinois
insane asylum in which she was committed by her husband.
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2012-Mary D Moller
Clifford Beers
• 1908-A Mind That Found Itself
• 1909-Created The National Committee for Mental
Hygiene with philosopher William James and
psychiatrist Adolf Meyer
– to improve attitudes toward mental illness and
those with a mental illness;
– to improve services for people with mental
illness ; and
– to work for the prevention of mental illnesses
and promotion of mental health.
• Later became the National Mental Health Association
• Now is Mental Health America
2012-Mary D Moller
Beers: http://www.tradebit.com/usr/ebook-reader/pub/9002/61362370002798822124065Pic.jpg
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Significant Events Effecting Psychiatric
Nursing 1940s, 50s, 60s
•
•
•
•
•
1946-National Mental Health Act/NIMH
1952-Thorazine
1952-Hildegard Peplau
1962-One Flew Over the Cuckoo’s Nest
1963-Community MHC Act
http://www.youtu
be.com/watch?v
=RGRD6JBnHr
U
NIMH: http://www.nimh.nih.gov/images/banner_nimh_logo.png
Beers: http://www.tradebit.com/usr/ebook-reader/pub/9002/61362370002798822124065Pic.jpg
Peplau: http://books.google.com/books?id=jKSKPQAACAAJ&printsec=frontcover&img=1&zoom=1
Cuckoo’s Nest: http://kkcchallenge.files.wordpress.com/2011/03/one-flew-over-the-cuckoos-nest.jpg
Kennedy: http://www.museumofdisability.org/siteimages/newyork/timeline/1960_13.jpg
2012-Mary D Moller
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Thorazine: http://www.mnddc.org/parallels2/prologue/4-drug_ads/drug5.jpg http://www.dhs.wisconsin.gov/mh_mendota/images/pactpict1.gif
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Peer Recovery Pioneers
Sally Zinman, 1977
Judi Chamberlain, 1978
Pat Deegan, 1988
http://www.youtube.com/
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watch?v=jhK-7DkWaKE
Joe Rogers, 1984
Mary Ellen Copeland, 1992
Esso Leete, 1989
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http://www.recoveryxchange.org/M
aryEllenCopeland.html
Provider Pioneers
(year of publications)
John Strauss, M.D.
1973
William Carpenter,
M.D. 1973
William Anthony, PhD.
1977/1993
Courtney Harding,
PhD.1987
Larry Davidson,
Leroy Spaniol,
Moller 1994
PhD. 1992 2012-Mary DPhD.
Mary Moller, RN
JoAnn Wer, RN, 1989
Nora Jacobsen, PhD8
Dianne Greeley, MSW. 1994
Peer/Provider Pioneers
Fred Frese, PhD, 1993
12 Aspects of Coping With
Schizophrenia
http://www.treatmentadvocacycenter.org/storage/
images/Portrait/fred%20publicity%20photo%20%
20%20apr%202009.jpg
Daniel Fisher, MD, 1994
Health Care Reform
Recovering From Schizophrenia
National Empowerment Center
www.Power2u.org
http://www.recovery4all.org/Speakers.htm
http://www.youtube.com/watch?v=RXmNEEpBXcs
&feature=related
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Peer/Provider Pioneers
Kay Redfield Jamison, PhD
Elizabeth Baxter, MD
1995
http://ecx.images-amazon.com/images/I/41dbHhySWwL._SL160_PIsitb-stickerarrow-dp,TopRight,12,-18_SH30_OU01_AA160_.jpg
Building Recovery of Individual Dreams &
Goals through Education & Support
(BRIDGES) was founded in 1995.
http://jama.ama-assn.org/content/289/23/3071/embed/graphic-1.jpg
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•
•
•
•
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Modern Recovery Stories
Carol Kivler-MA-depression
Eric Arauz-MA-bipolar, substance abuse, PTSD
Gayle Bluebird, RN
Mary E. Jensen, MA, RN, CRSS
Eric: http://www.youtube.com/watch?v=9sQNx9zxXYE&feature=player_embedded#!
Carol: http://www.youtube.com/watch?v=J-psYeKTUMo
2012-Mary D Moller
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Original Consumer Definition
Pat
Deegan, 1993
To me recovery means I try to stay in the driver’s seat of
my life. I don’t let my illness run me. Over the years I
have worked hard to become an expert in my own selfcare. Being in recovery means I don’t just take
medications, rather I use medications as part of my
recovery process. Over the years I have learned different
ways of helping myself. Sometimes I use medications,
therapy, self-help and mutual support groups, friends, my
relationship with God, work, exercise, spending time in
nature—all these measures help me remain whole and
healthy, even though I have a disability (p. 10).
Deegan, P.E. (1993).
Recovering 2012-Mary
our sense
of value after being labeled mentally ill.
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D Moller
Journal of Psychosocial Nursing and Mental Health Services. 31, 4, p. 7–11.
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Original Provider DefinitionWilliam Anthony, 1993
Recovery is
– a deeply personal, unique process of changing one’s
attitudes, values, feelings, goals, skills and/or roles.
– a way of living a satisfying, hopeful, and contributing
life even with limitations caused by the illness.
– involves the development of new meaning and
purpose in one’s life as one grows beyond the
catastrophic effects of mental illness.
Anthony, W. A. (1993). Recovery from mental illness: The guiding vision of the mental health
service system in the 1990’s. Psychosocial Rehabilitation Journal, 16(4), 11-23.
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Leroy Spaniol/Martin Koehler-1994
“Recovery is a process by which people with psychiatric
disabilities rebuild and further develop important personal,
social, environmental, and spiritual connections, and
confront the devastating effects of discrimination through a
process of empowerment”.
Spaniol, L. & Koehler, M. (1994). The experience of recovery. Boston: Boston University Center for
Psychiatric Rehabilitation.
http://www.bu.edu/cpr/training/distance/seminars/images/leroys3.jpg
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2012-Mary D Moller
Nora Jacobson/Dianne Greeley-2001
• Internal and external conditions in
understanding recovery.
– Internal: hope, healing, empowerment,
connection
– External: human rights, positive culture
of healing, recovery-oriented services
Jacobson, N. & Greeley, D. (2001). What is recovery? A conceptual model and
explication. Psychiatric Services, 52: 482-485.
Nora Jacobson-U of Toronto- http://www.communitybasedresearch.ca/takingcultureseriouslyCURA/node/88.html
Dianne Greeley-U of Wisconsin
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2012-Mary D Moller
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Robert P Lieberman, MD Alex
Kopelowicz, MD 2002
Operational criteria and factors related to recovery in
schizophrenia
1. Symptom remission: score of 4 or less on positive
and negative symptom items of BPRS for 2
consecutive years
2. Vocational functioning: at least ½ time successful
employment in a job in the competitive sector or
successful attendance in a school for at least ½ time
over two consecutive years. If over 60 participating
actively in recreational, family, or volunteer activities
Lieberman, R.P, Kopelowicz, A., Ventura, J. & Gutkind, D. (2002). Operational criteria and
factors related to recovery in schizophrenia. In, International Review of Psychiatry,
London: Taylor and Francis, LTD.
http://www.psychrehab.com/images/liberman-prc.jpg
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http://dornsife.usc.edu/latino-mental-health/images/ak_photo.jpg
Robert P Lieberman, MD and
Alex Kopelowicz, MD
4 Operational criteria and factors related to recovery in
schizophrenia
3. Independent living: living on one’s own without day to day
supervision for money management, shopping, laundry,
food preparation, personal hygiene, or need for structured
recreational or avocational activities. Able to initiate own
activities and schedule one’s time without reminders from
family or other caregivers
4. Peer (Interpersonal-not other consumers)relationships: at
least once per week having a meeting, social event, meal,
recreational activity, phone conversation, or other joint
interaction with a peer outside of the family
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2012-Mary D Moller
President’s New Freedom Commission-2003
• “We envision:
– a future when everyone with mental illness will recover,
– a future when mental illnesses can be prevented or cured,
– a future when mental illnesses are detected early, and
– a future when anyone with a mental illness at any stage of life
has access to effective treatment and support…
• the essentials for living, working, learning, and participating
fully in the community.” Page 9
• http://govinfo.library.unt.edu/mentalhealthcommission/index.htm
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2012-Mary D Moller
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Larry Davidson, et al, 2003
Recovery elements from the consumer view
– Renewing hope and commitment
– Redefining self
– Incorporating illness
– Being involved in meaningful activities
– Overcoming stigma
– Assuming control
– Becoming empowered and exercising citizenship
– Managing symptoms
– Being supported by others
http://www.psychologytoday.com/experts/larry-davidson-phd
Davidson L, O’Connell MJ, Sells, D. & Staeheli MR. (2003). Is there an outside to mental illness?
In. Living Outside19Mental Illness. Qualitative
Studies
2012-Mary
D Mollerof recovery in Schizophrenia. New York: New
York University Press.
SAMHSA, 2004
“Mental health recovery is a journey of healing
and transformation enabling a person with a
mental health problem to live a meaningful life in
a community of his or her choice while striving to
achieve his or her full potential”
National Consensus Statement on Mental Health Recovery. (2004). United States
Department of Health and Human Services, Substance abuse and Mental Health
Services Administration. Rockville, MD.
www.samhsa.gov/recovery
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SAMHSA and Recovery:
10 Components, 2004
1. Self-direction
2. Individualized and
person-centered
3. Empowerment
4. Holistic
5. Nonlinear
6. Strengths-based
7. Peer support
8. Respect
9. Responsibility
10. Hope
National Consensus Statement on Mental Health Recovery. (2004). United States
Department of Health and Human Services, Substance abuse and Mental Health
Services Administration. Rockville, MD.
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Larry Davidson/
David Roe, 2007
Two complimentary meanings:
– Clinical improvement over time
• Grounded in the medical model-recovery FROM
mental illness
– Person’s right to self-determination and
inclusion in community life
• Grounded in the consumer-survivor movementrecovery IN mental illness
http://www.omicsonline.org/editorialboardJPPT.php
Davidson, L. & Roe, D. (2007). Recovery from versus recovery in mental illness: one strategy for
lessening the confusion
Journal of Mental Health, 16: 459-470.
22 plaguing recovery.
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•
•
•
•
•
Robert Whitley and Robert Drake-2010
Recovery: A Dimensional Approach
Clinical: symptoms, medical care,
psychotropic medications, talking and
behavioral therapies
Existential: religion and spirituality, agency
and self-efficacy, personal empowerment
Functional: employment, education,
housing
Physical: diet, exercise, smoking,
substance abuse
Social: family, friends, peers, community
social activity
Robert Drake- http://dartmed.dartmouth.edu/summer09/html/vs_media_mentions.php
Robert Whitley- http://www.douglas.qc.ca/page/recovery-research
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Whitley, R. & Drake, R. (2010). Recovery a dimensional approach, Psychiatric Services, 61, 1248-1259
SAMHSA-2011
• A process of change through which
individuals improve their health and
wellness, live a self-directed life, and strive
to reach their full potential.
• 4 Dimensions
– Health
– Home
– Purpose
– Community
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Nursing Is…..
caring
an art
a science
patient-centered
holistic
http://www.plu.edu/~aaronnr/img/nursing-process.gif
adaptive
concerned with health promotion, health maintenance,
and health restoration
a helping profession
We’ve always ‘done recovery’ we just
didn’t name it!!!
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Florence Nightingale
• It may seem a strange principle to enunciate as
the very first requirement in a Hospital that it
should do the sick no harm. [1859]
• From Notes on Nursing [1860]
– “What nursing has to do is to put the patient in
the best condition for nature to act upon him.”
– “Nursing ought to signify the proper use of
fresh air, light, warmth, cleanliness, quiet, and
the proper selection of administration of diet-all at the expense of vital power of the
patient.”
– “Nursing creates the environment most
conducive to body's reparative processes.”
2012-Mary D Moller
http://images.suite101.com/3559572_com_florence_nightingale_headshot.png
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Virginia Henderson1966
"The unique function of the nurse is to assist the
individual, sick or well, in the performance of those
activities contributing to health or its recovery (or to
peaceful death) that he would perform unaided if he
had the necessary strength, will or knowledge.
And to do this in such a way as to help him gain
independence as rapidly as possible" (Henderson,
1966).
http://www.nursingworld.org/ClientResources/Images/Hall%20of%20Fame/HENDERS.JPG
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Virginia Henderson
• Emphasized the importance of increasing
the patient’s independence so that progress
after hospitalization would not be delayed
(Henderson,1991)
• Described the nurse's role as substitutive
(doing for the person), supplementary
(helping the person), complementary
(working with the person), with the goal of
helping the person become as independent
as possible.
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Henderson’s 14 Bio-Psycho-SocialSpiritual Components of Nursing
1.
2.
3.
4.
5.
6.
7.
8.
Breathe normally.
Eat and drink adequately.
9.
Eliminate body wastes.
Move and maintain desirable
10.
postures.
Sleep and rest.
Select suitable clothes-dress and11.
undress.
12.
Maintain body temperature
within normal range by adjusting
13.
clothing and modifying
environment
Keep the body clean and well
groomed and protect the
integument
Avoid dangers in the environment
and avoid injuring others.
Communicate with others in
expressing emotions, needs, fears,
or opinions.
Worship according to one’s faith.
Work in such a way that there is a
sense of accomplishment.
Play or participate in various forms
of recreation.
14. Learn, discover, or satisfy the
curiosity that leads to normal
development and health and use
the available health facilities.
http://www.nursingworld.org/ClientResources/Images/Hall%20of%20Fame/HENDERS.JPG
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Hildegard Peplau-1952
• Mother of Psychiatric Nursing
• …Nursing is an educative
instrument, a maturing force, that
aims to promote forward movement
of personality in the direction of
creative, constructive, productive,
personal, and community living.
(Peplau, 1952)
http://www.nursingtimes.net/pictures/182xAny/4/3/0/1213430_Hildegard_Peplau.jpg
http://images.betterworldbooks.com/082/Interpersonal-Relations-in-Nursing-Peplau-Hildegard-9780826179111.jpg
2012-Mary
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Phases and Changing Role in NursePatient Relationship-p. 52
Nurse
Stranger
Patient Stranger
Phase
Unconditional Mother
Surrogate
Infant
Child
Counselor
ResourcePerson
Leadership
Surrogate:
Mother
Sibling
Adolescent
Adult Person
Adult Person
Orientation-------------------Identification--------------Exploitation-----------------------------------------------------------------Resolution
2012-Mary D Moller
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American Nurses Association
• Nursing is…
– the protection, promotion, and optimization of
health and abilities,
– prevention of illness and injury,
– alleviation of suffering through the diagnosis and
treatment of human response,
– advocacy in the care of individuals, families,
communities, and populations.
http://www.nursingworld.org/EspeciallyForYou/What-is-Nursing
2012-Mary D Moller
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Working Definition of Recovery for
Psychiatric Nurses
• Assisting patients to re-emerge from the onset
of mental illness and re-establish a social
identity through creating a new self-identity
and developing a future orientation that will
help maintain a stable level of functioning in
all domains of life.
Moller, M.D. (2006). Psychophenomenology of the lived experience of persons with
schizophrenia in the post-psychotic phase of adjustment of psychosis. Doctoral
thesis, Case Western Reserve University.
2012-Mary D Moller
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The Lived Experience of the Nurse Caring
for a Person With a Mental Illness
• Perceptions, thoughts, feelings about the person/family
coming for care
• Individual nurse experience on the inpatient unit
– Vicarious traumatization
– Direct traumatization
– Henderson’s substitutive, supplementary, complementary
• Reflective exercise
– What has been your most positive experience as a psychiatric
nurse on your unit?
– What has been your most negative experience as a
psychiatric nurse on your unit?
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The Lived Experience of the Person
with a Mental Illness
• Life before illness
• Loss of choices, hopes, dreams
• Entering inpatient care–treatment as trauma
– forensic admission?
– involuntary admission?
•
•
•
•
Effects of previous trauma on course of treatment
Cultural aspects of meaning of symptoms
Support systems-family, employer?
Psychological adjustment milestones
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Adjustment
• The process of coming to terms with life changes
resulting from the psychotic episode and
subsequent diagnosis that include coping with loss,
confusion, and stigma; altering life expectations;
• Creating a new sense of life meaning;
• Learning new skills based on the new intellectual and
emotional reality post-diagnosis in order to respond
to the social environment.
2012-Mary D Moller
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Post-Psychotic Adjustment Process
• Phase One: Cognitive dissonance (couch)
– Extends from onset of symptoms to 6-12 months after
medication efficacy
– The phase the person is during hospitalization
– Sets the stage for success in the community
• Phase Two: Insight (bus depot)
– 6-12 months
• Phase Three: Cognitive Constancy (mall)
– 1-2 years
• Phase Four: Ordinariness (work)
– 2+ years
Moller, M.D. & Zauszniewski, J.A. (2011). Psychophenomenology of the postpsychotic adjustment process. Archives of
Psychiatric Nursing, 25, 253-268.
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Emotional Component
Cognitive
Dissonance
Embarrassment
Insight
Learning how
to cope with
life now
Cognitive Constancy
Ordinariness
Importance of having a
positive initial hospital
experience
Be able to
think about the
future
Fear
Dependable support system
Accomplish
life goals
Frustration
Something to do with my time
Inability to
handle stress
Reassurance/
encouragement
Lost selfconfidence
Treatment environment that
feels safe
Have my own
place to live
Not having too much quiet
time
Being around people
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Having
hope
2012-Mary
D Moller
Cognitive Component
Cognitive
Dissonance
Insight
Cognitive Constancy
Ordinariness
Confusion
Trying to figure out
own thoughts
Something to distract
from the symptoms
Manage
symptoms
Fear of saying
something
wrong
Conducting own
reality checks
Accepting the need for
treatment
Finish education
Getting control of
symptoms
Learning I’m not the
only one with
schizophrenia
Become
employed
Recognize
limitations
Getting back to what I
used to do
Getting used to it
Think positive
Being given choices
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Interpersonal Component
Cognitive
Dissonance
Hard to go out in
public
Insight
Cognitive Constancy
Ordinariness
Communicate
with others
Have someone listen
to me/understand me
Do what other
people do
Hard to be around
people
Someone to talk to
about me
Confidence in the
counselor/therapist
People need to be
honest with reality
Having people explain
things
Someone to talk to
about general things
Having help available
when first get sick
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2012-Mary D Moller
Physiological Component
Cognitive
Dissonance
Used drugs and
alcohol
Required too
much energy
Insight
Cognitive
Constancy
Ordinariness
Length of time to Right medication
stabilize from the
first episode
Taking care of
the body
Having a routine
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2012-Mary D Moller
Perceived Barriers to Recovery
• Not enough time/we can’t take the time
• Competing priorities-administrative versus
direct care
• Staffing inconsistencies
• Too hard to change from the ‘way we’ve always
done it’
• Not another ‘program’ for us to implement
• Can’t add more paperwork
• We have to learn another vocabulary?
• Any others??????
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A Recovery Culture Overcomes
Perceived Barriers
• Develop a unit Philosophy of Recovery where every encounter
is a recovery encounter
• Meet each person where they are in the process using personfirst language and principles of dialogue
– http://www.youtube.com/watch?v=e995pidZQW4&feature=relat
ed
• Introduce recovery components based on person’s readinessbeginning with instillation of hope and promotion of safety
• Be mindful of trauma and implement Trauma-Informed Care as
universal precautions
• Be mindful of the internal psychological, emotional, cognitive,
physical, and spiritual states a person is experiencing
2012-Mary D Moller
Non-Recovery Culture
43
Recovery Culture
Low expectations
Hopeful with high expectations
Stability/maintenance is the goal
Recovery is the goal
No clearly defined exit
Clear exits; graduates return/share
Little or no access to information
Easy access to information
Compliance is valued
Self-determination, critical thinking, and
independence are valued
Coercion is used to achieve compliance
People become the experts in their own care
People protected from trial/error learning
People take risks and have the “right to fail”
One size fits all treatment approach
Wide range of programs and non-program
options
Patients live in ‘treatment centers’
Opportunities for community integration
with choices
Patients are judged by their level of
motivation
Restoring hope creates new choices
Medication is the primary tool
Medication is one of several tools
Emphasis is on treatment
Peer support and self-help are valued
Ashcraft, L., Johnson, E., Zeeb, M (2004). Peer employment training workbook
44
Recovery is Bipartisan: The Nurse
and the Patient
• Assessment: Patient: phases and milestones of post-psychotic
•
•
•
•
•
•
•
psychological adjustment: 1: Cognitive dissonance 2: Insight 3: Cognitive
Constancy 4: Ordinariness
Assessment: The Nurse, the Nursing Unit , the patient
Diagnosis: Patient: use milestones checklist to identify unmet
physiological, interpersonal, psychological, cognitive milestones
Diagnosis: Nursing: what needs to change in the environment? Positive
and negative attitudes. Language? Awareness of post-psychotic
adjustment process
Planning: Patient: Develop interventions to meet unmet milestones and
achieve maximum wellness;
Planning: Nursing: Initiate person-first language; initiate trauma-informed
care; embrace peer support staff; focus on bio-psycho-social-spiritualcultural wellness
Evaluation: Patient: meeting post-psychotic adjustment milestones
Evaluation:Nursing: environmental modification to promote recovery;
attitudinal modification to promote recovery; integration of adjustment
milestones into patient care plan
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Small Group Work
• Pick one milestone to develop a goal and
intervention based on everything we’ve
discussed so far!
– Consumer need to connect with another human
– Awareness of trauma
– Person-first language
– Recovery principles and elements
– Principles of dialogue
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