Concepts of Mental
Health
Objectives
• At the end of this lesson, the SPN will be able to:
• 1. discuss concepts of mental wellness
• 2. define and give examples of various coping mechanisms
• 3. discuss the legal issues associated with mental health; e.g. consent,
restraints, etc.
• 4. define and discuss what a therapeutic milieu is
• 5. Discuss the different types of crisis, the phases of a crisis, and interventions
for patients in crisis
• 6. Discuss suicide; including risk factors, warning signs, and prevention.
Mental Wellness Concepts
• The World Health Organization (WHO) defines health as:
• …a state of complete physical, mental and social well-being and not merely
the absence of disease or infirmity.
• Mental health is clearly an integral part of this definition
• Mental Health is described by WHO as:
• …a state of well-being in which the individual realizes his or her own
abilities, can cope with the normal stresses of life, can work productively
and fruitfully, and is able to make a contribution to his or her community
• Mental health is the foundation for well-being and effective
functioning for an individual and for a community
Mental Wellness Concepts
• Mental Health is determined by socioeconomic and environmental
factors
• Mental Health is linked to behavior
• Mental Health can be enhanced by effective public health
interventions. Examples include: housing, education, and child care
• A climate that respects and protects basic civil, political, economic,
social and cultural rights is fundamental to the promotion of mental
health
Mental Wellness Concepts
• Mental health can be improved through the collective action of
society. Improving mental health requires policies and programs in
government and business sectors including education, labor, justice,
transport, environment, housing and welfare, as well as specific
activities in the health field relating to the prevention and treatment
of ill-health.
• Mental health is everyone’s business
Strategies for Good Mental Health Wellness
Meditation and relaxation techniques
Time to yourself
Physical Activity
Reading
Friendship
Humor
Hobbies
Spirituality
Pets
Sleeping
Nutrition
Stress
• Stress is defined as the condition that results when a threat or
challenge to one’s well-being requires the person to adjust or adapt
to the environment.
• Acute stress constitutes the reaction to an immediate threat,
commonly called the “fight or flight” response when there is a surge
of the adrenal hormone epinephrine or adrenalin into the
bloodstream
• Chronic stress occurs when the situation is ongoing of continuous,
such as chronic illness of a family member or job-related
responsibilities.
Stressors
• External stressors are those aspects of the environment that may be
adverse, such as an abusive relationship or poverty- level living
conditions
• Internal stressors can be physical, such as chronic illness or a terminal
condition, or psychological, as in continued worry about financial
burdens or a disaster that may never happen
Coping with Stress
• In most situations, the sense of control an individual feels over a
particular stressor determines how he or she thinks about or
perceives it
• The first step in coping with a threatening situation is to assess if it
really is what it seems to be
• Once this has been determined, options can be reviewed to resolve
the problem
Coping Strategies
• A person’s successful management of stress or anxiety is referred to
as adaptation
• When a person uses a rational and productive way of resolving a
problem to reduce anxiety, it is said to be adaptive coping.
• If a solution temporarily relieves the anxiety but the problem still
exists and must be dealt with again at a later time, the strategy is
known as palliative coping.
• If unsuccessful attempts are made to decrease the anxiety without
attempting to solve the problem, the strategies are described as
maladaptive coping and the anxiety remains
Defense Mechanisms
• Defense mechanisms are coping strategies used to reduce stress and
to protect ourselves
• We all use these strategies when we are in challenging situations
• These strategies can be adaptive or maladaptive and are often
unconscious responses
• Let us look at the following defense mechanisms more closely.
Defense mechanisms
• 1. Sublimation- a socially acceptable behavior replaces one that is not
acceptable or attainable.
• 2. Intellectualization- Person uses reasoning and facts or logic to block
unconscious conflict that creates stress and uncomfortable emotions
• 3. Suppression- Voluntary exclusion from conscious awareness anxietyproducing feelings , thoughts, or situations.
• 4. Humor- temporary reprieve of laughter to ease an anxiety-producing
situation or stressor
• 5. Denial- Conscious act of rejecting reality or refusal to recognize facts of a
situation. The truth causes too much pain
Defense Mechanisms Con’t.
• 6. Displacement-Transfer of hostility or other strong feelings from the
original cause of the feelings to another person or object.
• 7. Repression- Involuntary distancing of events or thoughts that are
too painful or unacceptable to one’s ego into the unconscious level.
These feelings can continue to influence behavior into adult years if
unresolved.
• 8. Regression-Personality returns to an earlier more comfortable and
less stressful stage of behavior
Defense Mechanisms Con’t.
• 9. Projection- Emotionally unacceptable traits, feelings, or attitudes
are attributed or blamed on something or someone else. The person
refuses to admit own weakness or accept responsibility for own
actions.
• 10. Compensation- Emphasizing capabilities or strengths to make up
for a lack or loss in personal character
• 11. Introjection- Unconsciously integrating ideas, values, and
attitudes of another into own mannerisms and actions
• 12. Reaction Formation- A conscious attempt to make up for feelings
or attitudes that are unacceptable to the ego by replacing them with
the opposite feelings or beliefs
Defense mechanisms Con’t.
• 13. Conversion- Transfer of emotional conflicts into physical
symptoms.
• 14. Undoing- A positive action is initiated to conceal a negative action
or to neutralize a previously unacceptable action or wish
• 15. Rationalization- Substituting false reasoning or justification for
behavior that is unacceptable or threatening to the ego. This ignores
the real reason for the behavior with falsehoods and avoids
responsibility for the behavior.
Legal and Ethical Considerations in Mental
Health Care
• Ethics- refers to a set of principles or values that provides dignity and
respect to clients.
• Like any other aspect of the health system, the care of clients with
mental disorders involves a certain standard of principles and values.
This set of beliefs also provides a guiding philosophy for the nursing
profession and protects clients from unreasonable treatment
Legal Issues Con’t.-Client Rights
• All clients entering a treatment facility have certain rights that have
been documented in the Patient Bill of Rights. Those rights that apply
to the clients with mental illness were declared in the Mental Health
Systems Act Bill of Rights passed by the U.S. Congress in 1980.
• Clients are given the opportunity to read these rights at the time of
admission for treatment
Legal Issues Con’t.-Appropriate Care
• An integral part of the nurse’s responsibility is to ensure that the client
receives appropriate care.
• All clients are entitled to receive care based on a current and individualized
treatment plan that includes a description of the services that are available
and those that are offered upon discharge.
• Included in the Bill of Rights are the rights to:
• Quality care
Explanation of treatment
• Trained professional providers Understand med effects
• Refuse to be in an experiment Confidentiality
• Be treated in a least restrictive Refuse treatment
setting
Be involved in the plan of care
Legal Issues- Informed Consent
• Informed consent is the client’s grant of permission to undergo a
specific procedure or treatment after being informed about the
procedure, risks, and benefits
• The agency providing the services is protected by getting a signed
statement of understanding from the client.
• At the same time, the client has the right to refuse any aspect of
treatment and may elect not to sign the consent
Legal Issues- Confidentiality
• Confidentiality refers to the client’s right to prevent written or verbal
communications from being disclosed to outside parties without
authorization
• To facilitate a client’s trust, LPN’s must assure them that all
communication is confidential and will not be communicated to
anyone not participating in their care
• HIPAA laws apply to clients in the mental health setting
Legal Issues- Appeals and Complaints
• Clients have a right to receive information about how to channel
complaints about their care or the professionals providing their
treatment.
• Should the person wish to file a complaint to a professional board,
the person should be advised of the procedure to do so.
Legal Issues- Seclusion and Restraints
• Because some mental health disorders may cause a person to become
extremely agitated or even act violently, seclusion or restraints may
sometimes be necessary if other interventions or therapies are ineffective.
• Seclusion refers to the placement of a client in a controlled environment in
order to treat a clinical emergency in which the client poses an immediate
threat to themselves or to others
• Physical restraint refers to the use of mechanical devices to provide limited
movement by the client. Physical restraints are used to prevent harm to
self or others and require careful monitoring. These may consist of padded
leather or cloth devices for the wrist, ankles, waist, or fingers
Legal Issues- Seclusion and Restraints
• Chemical Restraint- refers to the use of medication to calm a client
and prevent the need for physical restraints. Chemical restraint is less
restrictive and is generally the initial choice unless the situation
warrants otherwise.
• ****Seclusion and restraints are only used when verbal
interventions or less restrictive methods of treatment have failed or
are not available****
Legal issues- Seclusion and Restraints
• Nursing Care• Prior to seclusion or restraint use, nurses should attempt to de-escalate
aggressive behaviors before these measures are necessary
• If the environment has provoked the behavior, remove the client to another
area of the unit and allow the client to regain control without further
intervention
• If restraints or seclusion is used, the client is usually given sedating
medication to provide a calming effect and assist in behavior control
• Continuous monitoring of the client in restraints or seclusion is mandatory
• Seclusion and restraints are discontinued at any time they are seen as
ineffective or at the earliest possible indication that the client has regained
control
Milieu
• A therapeutic milieu is a safe and secure structured environment
that facilitates the therapeutic interaction between clients and
members of the professional team
• The setting could be the client’s individual room or the communal
dayroom.
• Dayrooms often include chairs, tables, games, puzzles, books, air
hockey, or pool tables. These types of activities lend themselves to
fulfill goals of participation in acceptable social behaviors and
communication skills
Milieu Con’t.
• Group activities are scheduled that maximize the functional ability of
each client, and clients are encouraged to be as independent as
possible during treatment
• The nurse is often in a position to maintain the milieu as a place
where dignity and acceptance allow the client to practice skills
without reprisal.
• To establish a safe and structured therapeutic milieu, rules are often
needed
Milieu Con’t
• Rules may vary from facility to facility but usually include topics such as:
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Hours of visitation and client approval for certain persons to visit
Types and times for therapy sessions
Personal free time
Mealtimes and bedtime
Caffeine restrictions, available food or snack restrictions
Shaving or cosmetic items
Sharp items, cords, belts
Violent or threatening behaviors
Medication schedule
Activities
Telephone privileges
Milieu Con’t.
• Close supervision is necessary to maintain compliance with all unit
rules
• It is important for each member of the mental health team to
maintain consistency in enforcing the rules to establish limits and
boundaries for behavior.
• Clients are encouraged to comply with all the rules and to attend all
activity and therapy sessions
• Client behaviors such as aggression and physical violence are not
tolerated in a therapeutic milieu
Crisis
• A psychological crisis differs from stress and anxiety in that a state of
disorganization and disarray occurs in the individual as usual coping
strategies fail or are not available
• There are 3 primary types of crisis situations. They include:
• 1. Maturational crisis- may occur at a predictable time period in an
individual’s life related to maturational stages and changes.
• 2. Situational crisis- arises from an external rather than an internal source.
Often the crisis is unanticipated.
• 3. Adventitious crisis- (a.k.a. crisis of disaster)-is not a part of everyday life; it
is unplanned and accidental.
Terrorism
• Terrorism differs from a natural disaster and other mass casualties in
that a terrorist attack is meant to harm/maim/kill innocent civilians
• A terrorist attack occurs suddenly and “there is no warning or
explanation , and there are no rules or guidelines for how to prepare
and how to react”
Phases of Crisis
• There are 4 phases of crisis. They include:
• Phase 1- A person confronted by a conflict or problem that threatens
the self-concept responds with increased feelings of anxiety. The
increase in anxiety stimulates the use of problem-solving techniques
and defense mechanisms in an effort to solve the problem and lower
anxiety
• Phase 2- If the usual defensive response fails, and if the threat
persists, anxiety continues to rise and produce feelings of extreme
discomfort. Individual functioning becomes disorganized. Trial and
error attempts at solving the problem and restoring a normal balance
begin.
Phases of Crisis
• Phase 3- If the trial-and-error attempts fail, anxiety can escalate to
severe panic levels, and the person mobilizes automatic relief
behaviors, such as withdrawal and flight. Some form of resolution
(e.g. compromising needs or redefining the situation to reach an
acceptable solution) may be made in this stage.
• Phase 4- If the problem is not solved, and new coping skills are
ineffective, anxiety can overwhelm the person and lead to serious
personality disorganization, depression, confusion, violence against
others, or suicidal behavior
Interventions for Patients in Crisis
INTERVENTION
RATIONALE
1. Assess for any suicidal thoughts or plans
1. Safety is always the first consideration
2. Take initial steps to make patient feel safe and to
lower anxiety
2. When a person feels safe and anxiety decreases,
the individual is able to problem solve solutions with
the nurse
3. Listen carefully (e.g. make eye contact, give
frequent feedback to make sure you understand,
summarize what patient says at the end)
3. When a person believes that someone is really
listening, this can translate into the belief that
someone cares about the person’s situation and that
help may be available. This offers hope.
4. Use directive and creative approaches. Initially, the
nurse may make phone calls (arrange babysitters,
schedule a visiting nurse, find shelter, contact a social
worker)
4. Initially, a person may be so confused and
frightened that performing usual tasks is not possible
at that moment
Interventions for Patients in Crisis
INTERVENTION
RATIONALE
5. Assess patient’s support systems. Rally existing
supports (with patient’s permission) if patient is
overwhelmed
5. People are often overwhelmed and nurses need to
take an active role
6. Identify needed social supports (with patient’s
input) and mobilize the most needed first)
6. Patient’s needs for shelter help with care for
children or elders, medical attention, hospitalization,
food, safe housing, and self-help group are
determined
7. Identify needed coping skills (problem-solving,
relaxation, assertiveness, job training, newborn care,
improving self-esteem)
7. Increasing coping skills and learning new ones can
help with current crisis and assist with minimizing
future crises.
8. Plan with patient interventions acceptable to both
counselor and patient
8. Patient’s sense of control, self-esteem, and
compliance with plan are increased
Intervention for Patients in Crisis
INTERVENTION
RATIONALE
9. Plan regular follow-up to assess patient’s progress
(e.g. phone calls, clinic visits, home visits as
appropriate)
9. Plan is evaluated to see what works and what does
not work.
Suicide
• People of all ages, races, and socioeconomic status commit suicide
• Firearms, suffocation, and poisoning tend to be the most common
methods used
• Risk of suicide increases when depression, other mental disorders, or
substance-related disorders are involved. It is estimated that more
than 90% of those who succeed in ending their life by suicide have
one of these problems
Suicide-Terms
• Suicidal erosion- the long-term accumulation of negative experiences
throughout a person’s lifetime can lead to suicidal thoughts.
• Suicidal ideation-a verbalized thought or idea that indicates the
person’s desire to do self-harm or destruction.
• Suicidal threat-a statement of intent that is accompanied by behavior
changes that indicate the person has defined their plan
• Suicidal gesture-action that indicates the person may be about ready
to carry out the plan.
• Suicide attempt- the person carries out the plan and is a last
desperate cry for help
Suicide Risk Factors
• Neurobiological- Scientists have identified a strong association
between suicide and serotonin. People who attempted suicide have
lower serotonin functioning; however, those who have completed
suicide have the lowest levels.
• Genetic- Suicide has long been shown to cluster in some families;
therefore family history is important.
• Societal- Lack of social supports, negative life events, severe life
stress. People who are impoverished, recently divorced, separated,
bereaved, childless, homeless, live alone, unemployed
Suicide Risk Factors
• Psychological-People who are psychotic; especially those who
experience command hallucinations telling them to kill themselves or
having delusions that they may die.
• Age-Adolescents and young adults- due to increased rates of ETOH/
drug use in depression. The strongest risk factors for this age group
are substance abuse, aggression, disruptive behaviors, depression,
social isolation. The following other factors are related to youth
suicide:
• Frequently running away
• Frequent expressions of rage
Suicide Risk Factors
• The following other factors are related to youth suicide:
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Frequently running away
Frequent expressions of rage
Family loss or instability
Frequent problems with parents
Withdrawal from family and friends
Expression of suicidal thoughts or talk of death or the afterlife when sad or
bored
• Difficulty dealing with sexual orientation
• Unplanned pregnancy
• Perception of school, work, or social failure
Suicide Risk Factors
• Age- Older adults(age 65-75)- due to social isolation, solitary living
arrangements, widowhood, lack of financial resources, poor health,
and feelings of hopelessness.
Suicide Warning Signs
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Talks about suicide
Difficulty eating or sleeping
Increased substance abuse
Social withdrawal
Loss of interest in school, work or pleasure activities
Giving away possessions
Previous suicide attempt
Unnecessary risk taking
Recent major loss
Preoccupation with death and dying
Lack of attention to personal hygiene
Suicide Prevention
• Individuals who indicate that they are thinking about or wanting to
kill themselves need help.
• It is imperative to listen and find support for the person. The
following are suicide prevention strategies:
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1. Do not leave the person alone
2.Try to get the person immediate medical help
3. Call 911
4. Eliminate access to firearms or other potential suicide tools
5. Remove any unsupervised access to prescription or OTC drugs
6. Follow institutional protocol
Suicide Prevention
• Keep accurate and thorough records of patient’s behaviors- both
verbal and physical- as well as all nursing and physician actions
• Keep accurate and timely records and document patient’s activityusually every 15 minutes
• Encourage patient to talk about their feelings and problem-solving
alternatives
• Put patient on a suicide precaution-(one-on-one monitoring at arm’s
length away) or suicidal observation (15-minutevisual check of mood,
behavior and verbatim statements)