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GABRIEL BARRINGTON-MOSS, LECTURE CLASS 5 MENTAL HEALTH NURS 272...

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Ch. 6, 13 & 36 Ch. 6: Psychiatric Mental Health Nursing in Community Settings The Evolution of Psychiatric Care in the Community  Between 1960 and 1980, patients began to leave psychiatric hospitals due to: o Financial pressures on the provincially funded psychiatric hospitals o Changing societal values o New mental health treatment philosophies 

Many hospitals were overcrowded and patients’ rights were often disregarded o Since hospitals mainly focused on a more custodial approach to care it left many patients with little incentive for growth or participation in their own care. This phenomenon is referred to as “institutionalization.”

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In 1963 the Canadian Mental Health Association (CMHA) published More for the mind. o Suggested general hospital units become the center of community based care for mental illness. o While general hospitals started to open psychiatric units, psychiatric hospitals started closing beds. This was called the trans-institutionalization

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Policymakers felt that it would be more humane as well as cheaper than hospital care if the patients were living in their own homes The introduction of psychotropic drugs (starting with chlorpromazine) made this a more realistic option. The CMHA and other similar organizations opened up housing and support services for people living with mental illness in the community. All across Canada provinces started deinstitutionalizing psychiatric services. With the move to a community based approach, problems regarding care for more serious cases of mental illness arose. Funding was too limited to provide housing and case management support and patients outnumbered the resources available. Many people with mental illness were discharged to inadequate supports which led to increased homelessness and criminalization. Through the 1990s, advocacy by CMHA and others persisted and increased pressure on the government to redesign the mental health system in Canada. In 2007 the Mental Health Commission of Canada was formed and in 2009 it issued a mental health strategy for Canada surrounding recovery. Recovery is described as the ability of the individual to work, live and participate in the community

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Community Psychiatric Mental Health Nursing  Biopsychosocial Assessment: This model guides the nursing assessment and interventions towards a holistic manner, taking a comprehensive view of clients

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Including their biology, social environment and psychological characteristics. If any problems are found in the following areas, then immediate attention is required because they can seriously impair the success of other treatment goals: o o

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Housing adequacy and stability: a patient who faces daily fears of homelessness will not be able to focus on the treatment Income and source of income: A patient must have a basic income- whether from a relative or other sources- to obtain necessary medication and meet daily needs for food and clothing. Family and support systems: the presence of a family member, friend, or neighbor supports the patient’s recovery and gives the nurse a contact person. Substance abuse history and current use: Often hidden or minimized during hospitalization, substance abuse can be a destructive force, undermining medication effectiveness and interfering with relationships, safety, community acceptance, and procurement of housing. Physical well-being: Factors that increase health risks and decrease life span for people with mental illness include decreased physical activity, smoking, adverse effects of medication, and absence of routine health exams

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Treatment goals and interventions o Treatment goals and interventions are negotiated rather than imposed. o To meet the broad range of patient needs, interventions must be flexible. o Integrating case management into the professional role yields more positive results  Case management refers to assessing patient’s needs, developing a plan for services, linking the patient with necessary services, monitoring the effectiveness of services, and advocating for the patient as needed

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Interprofessional team member: o Psychiatrists, nurses, social workers, psychologists, addictions specialists, recreational therapists, occupational therapists, and mental health workers o Nurses hold a position to link the biopsychosocial and spiritual components relevant to mental health care. o Nurses also are expected to manage and administer psychotropic medications as one of their more significant tasks.

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Promoting continuation of treatment: Nurses are in a position to help the patients manage medication, recognize adverse effects, and become aware of interactions among drugs prescribed for physical illness and mental illness. Among these, nurses are also in a position to educate the patient and family about the illness coping strategies which has been shown to show significant increase in adherence of the patient to the medication regimen. Nurses are now providing mental health care at therapeutic day care centers, schools, partial hospitalization programs, and shelters.

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Mobile mental health units have been developing in some areas.

Ch. 13: Anxiety, Obsessive-Compulsive, and related Disorders Anxiety  “It can be defined as a feeling of apprehension, uneasiness, uncertainty, or dread resulting from a real or perceived threat.”  For most people it happens every day in life, but doesn’t control the situation. o For some the symptoms come severe and interfere with normal functioning.  Anxiety is a vague sense of dread to something unspecific but fear is towards a specific danger. The body physiologically reacts the same to the two even though they affect you much differently.  Normal Anxiety: is healthy as it motivates you and allows you to stride to achieve goals eg) studying for an exam  Levels of Anxiety: Table 13-1. o Mild anxiety: is a normal experience in everyday life. Physical symptoms; restlessness, discomfort, irritability, tension relieving behaviors (nail biting, foot or finger tapping, fidgeting). o Moderate Anxiety: you see, hear and grasp less information. Inattention only certain things are noticed in the environment unless pointed out. Physical symptoms: Heart pounding, pulse increase and same with respiratory rate, voice tremors, may be shaky, mild somatic (headache, urgency to pee). o Panic: most extreme level. Unable to process what is going on around them. Physical hallucinations, pacing, running, shouting, withdrawal, impulsive behaviors. Panic Disorders (PD): Recurring severe panic attacks. Behavioral change could last at least a month. Panic attack is sudden onset of extreme fear that suspends normal function. People may believe they are losing their minds or having a heart attack during a panic attack. Physical symptoms: troubles breathing, chest pain, hot flashes chills, nausea. This can be out of the blue. Agoraphobia: anxiety about people in places where escape is difficult or will be embarrassing Specific phobia: high levels of anxiety to one specific thing or situation. Eg) spiders, water, heights, storms. SOCIAL phobia: also known as social anxiety disorder (SAD) this is a fear provoked by social or performance situations Obsessive Compulsive Disorder (OCD) and related disorders:  Obsessions: thoughts, impulses or images that persist or recur and you can’t get rid of them  Compulsions: Ritualistic behaviors or thoughts one feels they need to complete in order to reduce anxiety o Severe OCD consumes one’s life and time and uses most of their mental process meaning cognitive tasks may be impaired.

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Generalized Anxiety Disorder (GAD): persistent and exaggerated fear to everyday things. Symptoms: restlessness, fatigue, poor concentration, irritability, tension, sleep disturbance

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Post-Traumatic Stress Disorder (PTSD): Acute emotional response to traumatic event involving severe environmental stress. Relives the traumatic event persistently. Normally happen 3 months after the event. May experience flashbacks and avoid stimuli. o Persistent numbing, difficulty sleeping, irritability, difficulty concentrating. Relationships become a problem and abuse may be involved

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Acute Distress Disorder: occurs within one month of traumatic event, only lasts 4 weeks. Substance Induced Anxiety Disorder: symptoms of anxiety, panic attacks, obsessions and compulsions that develop with a use of a substance.

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Anxiety Disorder Not Otherwise Specified: when they have phobia avoidance or anxiety but do not fully meet the diagnostic criteria for a specific disorder

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Attention Deficit Hyperactivity Disorder (ADHD): People that present with procrastination, disorganization, lack of motivation, insomnia, rage attacks, or liable moods.

Epidemiology  Anxiety disorders are the most common form of psychiatric disorder. CO-Morbidity:  Anxiety disorders frequently co-occur with other psychiatric disorders. Biological Factors:  Genetic: anxiety disorders cluster in families, twins have a component to both panic disorder and COD, OCD has higher rate if they have biological family members 

Neurobiological: GABA benzodiazepine theory; Benzodiazepine are linked to a receptor that inhibits the activity of GABA. GABA induces calming.

Psychological Factors: Harry Sullivan believed anxiety is linked to stress caused when early needs go unmet or disapproved. Sociocultural Factors: Some cultures show symptoms in physicals ways while other cultures the cognitive symptoms predominate. Hamilton Rating Scale for Anxiety: High scores may indicate GAD or PD high levels of anxiety may be symptom of major depressive disorder so be careful.

Yale-Brown Obsessive- Compulsive scale (YBOCS): This is not a diagnostic test this is just a test to show severity of OCD. Self-Assessment: As the nurse you may feel uncomfortable in situations with patients that have anxiety disorders.  Using therapeutic communication techniques have shown to be ineffective with these patients  Behavioral change is often very slow  Patience, ability to provide clear structure and empathy are important for patients with anxiety disorders Ways to reduce Anxiety:  Counselling: help enhance coping and communication skills  Milieu Therapy: helps reduce anxiety of the unknown, Including patient in their own care.  Promotion of self-care Activities: o Nutritional and fluid intake: weighing patients frequently is useful in order to tell if nutritional level is being met. o personal hygiene and grooming: encourage pts to express thoughts and feelings about self-care. o Elimination: OCD rituals may stop pts from using the restroom causing constipation or UTIs create a regular schedule for pts to go to the bathroom. o Sleep: teach ways to promote sleep and monitor sleep through a sleep record are good interventions 

Pharmacological Interventions Antidepressants o Antianxiety drugs o

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Integrative therapy: Herbal and complementary therapies Health teaching Advanced Interventions o Cognitive therapy: therapists helps patient (1) Identify automatic negative beliefs that cause anxiety (2) explore the basis for these thoughts (3) reevaluate situation (4) Replace negative self-talk with supportive ideas. o Behavioral therapy:  Relaxation training: aim to relax breathing and muscle groups  Modelling: someone acts a role model and how to act in fearful situation and patient imitates.  Systematic Desensitization: gradually introduced to fear through a series of steps.  Flooding: exposes patient to large amount undesirable stimulus at once, patient learns through long exposure that they can survive the situation.

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Response Prevention: patient with compulsive behavior are not allowed to perform their ritual, patient then realizes anxiety will go away without the ritual Thought stopping: when a negative thought or belief pops in their head they stop it, they can yell stop out loud of snap a rubber band that is on their wrist.

Cognitive-Behavioral therapy: combines cognitive theory with a specific behavioral therapy.

Evaluation: Is the Patient experiencing reduced anxiety? Is patient able to use newly learned skills to reduce anxiety?

Ch. 36: Family Interventions 

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Canadian families are experiencing rapid change and growing diversity in family configurations. They may also differ in composition (parental genders, parental numbers, and blended families). The parent-child relationships are significant and emotionally charged like most family relationships, but it is one of the most important in Canadian society. Parents are expected to raise their children and provide for them until they are adults. Dysfunctional families may result in discord among family members or the family may become trapped in behaviours that do not benefit it or its members. Children growing up in families in which there is mental illness may have emotional problems both in childhood and in their adult lives. Some families may need psychotherapeutic intervention during the early childhood development to assist the child and family and to correct maladaptive patterns. This can minimize psychological impairment and build strengths in the family. Family is a positive force in assisting its members through crises and the life cycle. Families are self-defined meaning it is made up of people the patient identifies as family and this can include neighbors and other significant people in the community.

The Vanier Institute of the Family (2013) identifies the functions of a Canadian family:  Provision of love and nurturance  Socialization of children  Social control of members  Production and consumption of goods and services  Addition of new family members through birth or adoption  Physical care and maintenance of family members  Families play a significant role as caregivers. Family and Mental Illness  Historically, when mental illness occurred, health care providers often cast blame on the family. This blame was predominant in the mental illness of children, especially those with autism, eating disorders, or schizophrenia.  Nurses need to be aware of this history as it may still exist in some patient scenarios today.  An important component of nursing practice is to advise family members of appropriate support groups. Family Therapy  Boundaries: the distinctions made between individuals in the family. They may be: o Clear boundaries: boundaries that are well understood by the members of the family and give the family a sense of “i-ness” and “we-ness”. It helps identify the roles of each family member.

Enmeshed/diffused boundaries: boundaries that result in the blending together of roles, thoughts, and feelings of the individual family members so that clear distinctions fail to emerge. Families with this boundary are prone to psychosocial and psychosomatic symptoms. o Rigid/disengaged boundaries: Boundaries in which the rules and roles are consistently adhered to no matter what; thus these prevent family members from trying out new roles, or sometimes from taking on mature functions as time goes on o When boundaries function properly, family members work out arrangements by compromise based on understanding of appropriate roles.

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Issues associated with Family Therapies  Communication → individuals must have a sense that the self is respected and loved. Avoid dysfunctional communication: manipulating, distracting, generalizing, blaming, placating.  Emotional Support  Socialization Working With the Family  The identified patient→ the individual in the family whom everyone regard as “the problem”. This is the “family symptom bearer”; the focus of the family’s anxiety.  When working with family, it is important to consider the individual developmental stage of each person (Erikson’s developmental stages) o Family Triangles→ When the tension between a close twosome builds, a third person (child, friend, parent) may be brought in to help lower the tension.  Here, the nurse should constantly be doing self-assessments in order to maintain emotional stability in the face of a chaotic family situation. Personal reactions may interfere, and the nurse may become “triangled” into the family system. o The Nuclear Family Emotional System→ the flow of emotional processes within the nuclear family. Nuclear Family refers to parents and the children under the parent’s care. This concept views symptoms as belonging to the nuclear family emotional system rather than to the individual. Family Therapy Theory  Family systems theory: a theory that downplays problem resolution, focusing instead on the long-term differentiation of individual family members.  Differentiation→ describes the ability of an individual to make autonomous choices while separating out feelings and cognitions.  The aims of this is to decrease emotional reactivity and encourage differentiation among individual family members.  Strategic model of family therapy assumes that change in any single element in the family system will bring about change in the entire system. Aims to change the patterns, rules, and meaning of family interactions.

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Structural model of family therapy explains family problems from the perspective of dysfunctional boundary and role structure. The problems become evident when the family is exposed to a stressor or transition point and is unable to adapt to the changes.

Assessment  The Calgary Family Assessment Model (CFAM) has focuses including: o Family system o Family subsystems o Individual members of the family o Sociocultural context of family o Past medical and mental health illness o Family interactions and communication styles o Stressors within the family system 

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Doane and Varcoe indentified some issues that should be assessed in family therapy: Phases of the family life cycle Sociocultural context, beliefs Multigenerational issues, inclusive of historical oppression Relational practice.

Intergenerational Issues  family is composed of the entire emotional system of at least three, and sometimes four generations.  Various patterns of behaviour (e.g. involving geographical distance between members, suicide, divorce, addiction, affairs, grief, triangles, historical colonization, loss) may impact successive generations. Genograms  Help to provide a clinical summary of information and relationships among generations of a family. Goals/ Outcomes of Family Therapy:  Reduce dysfunctional behaviour  Resolve or reduce intra-family relationship conflicts  Mobilize family resources and encourage adaptive family problem-solving behaviours  Strengthen family’s ability to cope with major life stressors and traumatic events  Improve integration of the family system into the societal system  To promote appropriate individual psychosocial development of each family membe  Learning to accept family member’s illness  Learning to deal effectively with an ill member’s symptoms  Understanding the role of medications and when to seek medical advice  Learning about community resources  Feeling less anxiety and regaining control and balance in family.

Planning  The immediate and long-term needs of the family should be determined  A careful analysis of assessment data helps the nurse and other health care team members identify the most appropriate family interventions Implementation  Counselling and communication techniques  Family therapy o Traditional Family therapy o Psychoeducation Family Therapy o Self-Help Groups  Case Management  Pharmacological Interventions o Prescribed medications Evaluation  Has the family improved? Resolved conflicts? Improved communication? Strengthened coping skills?...