Mental Health Nursing Elisa A. Mancuso RNC, MS, FNS Professor

Mental Health Mental Health NursingNursing

Elisa A. Mancuso RNC, MS, FNSElisa A. Mancuso RNC, MS, FNS

ProfessorProfessor

Mental HealthMental Health• Successful adaptation to internal & external Successful adaptation to internal & external

stressors stressors – age appropriate thoughts, feelings & behaviorsage appropriate thoughts, feelings & behaviors

• Adaptive Coping MechanismsAdaptive Coping Mechanisms– + Self-Esteem+ Self-Esteem– + Relationships+ Relationships– Reality oriented Reality oriented – Effective Problem SolverEffective Problem Solver– Communicate effectivelyCommunicate effectively– Control emotionsControl emotions– Reason LogicallyReason Logically– Risk TakerRisk Taker– Dynamic and adjust PRNDynamic and adjust PRN

Mental IllnessMental Illness

• Clinically significant behavioral pattern or Clinically significant behavioral pattern or psychological syndromepsychological syndrome

• Associated with distress or disabilityAssociated with distress or disability

• ↑↑ ↑↑ Risk of suffering causing;Risk of suffering causing;– Loss of freedomLoss of freedom– IsolationIsolation– PainPain– DeathDeath

Mental Health-Illness Mental Health-Illness ContinuumContinuum

Health Health ↔ ↔ IllnessIllness

Reality Oriented Reality Oriented Hallucinations Hallucinations

Meaningful WorkMeaningful Work Disengaged Disengaged

ResilientResilient Anhedonia Anhedonia

DSM IV-TRDSM IV-TRDiagnostic & Statistical Manual of Diagnostic & Statistical Manual of

Mental Disorders 4Mental Disorders 4thth ed, Text Revision ed, Text Revision

• Taxonomy used to describe mental disorders Taxonomy used to describe mental disorders according to specific criteria.according to specific criteria.

• Multi-axial (Axis I-V) classification systemMulti-axial (Axis I-V) classification systemAxis I - Clinical DisordersAxis I - Clinical DisordersAxis II - Personality Disorders & Mental Axis II - Personality Disorders & Mental

Retardation RetardationAxis III - General Medical ConditionsAxis III - General Medical ConditionsAxis IV - Psychosocial & Environmental Axis IV - Psychosocial & Environmental

ProblemsProblemsAxis V - Global Assessment Functioning Axis V - Global Assessment Functioning

(GAF)(GAF) [Psychological, social & occupational][Psychological, social & occupational]

Psychological TheoriesPsychological Theories• Psychoanalytic Model- FreudPsychoanalytic Model- Freud

– Basic character formed by age 5.Basic character formed by age 5.– Psychosexual stages of development.Psychosexual stages of development.

• Oral, Anal, Phallic, Latency & GenitalOral, Anal, Phallic, Latency & Genital

– Behavior motivated by subconscious Behavior motivated by subconscious thoughts & feelings.thoughts & feelings.

– Ego defense mechanisms.Ego defense mechanisms.– Neurotic symptoms are attempts to Neurotic symptoms are attempts to

control anxiety.control anxiety.– Change is a process of insight.Change is a process of insight.

• Uncover the repressed feelings to resolve Uncover the repressed feelings to resolve conflicts.conflicts.

Psychoanalytic Model- Freud Psychoanalytic Model- Freud cont.cont.• Personality Components:Personality Components:

– Id: Pleasure PrincipleId: Pleasure Principle– Ego: Reality PrincipleEgo: Reality Principle– Superego: Perfection PrincipleSuperego: Perfection Principle

• Conscious-Aware of present Conscious-Aware of present Here & NowHere & Now

• Subconscious - Not aware Subconscious - Not aware – Repressed feelings, thoughtsRepressed feelings, thoughts

Psychoanalytic Model- Freud Psychoanalytic Model- Freud cont.cont.

• TransferenceTransference– Feelings and attitudes patient had Feelings and attitudes patient had

originally experienced in other originally experienced in other relationships, now displaces onto the relationships, now displaces onto the therapist.therapist.

• CountertransferenceCountertransference– Therapist displaces onto the patient Therapist displaces onto the patient

attitudes or feelings from his past.attitudes or feelings from his past.

Developmental Model-Developmental Model-EriksonErikson• Social processes affect specific tasks for each stage Social processes affect specific tasks for each stage

and emotional growth.and emotional growth.• Incorporates:Incorporates:

Problem Solving, Decision Making, Coping & Problem Solving, Decision Making, Coping & CommunicationCommunication

• 8 Continuous and evolutionary stages8 Continuous and evolutionary stages

– Trust vs. MistrustTrust vs. Mistrust– Autonomy vs. Shame/DoubtAutonomy vs. Shame/Doubt– Initiative vs. GuiltInitiative vs. Guilt– Industry vs. InferiorityIndustry vs. Inferiority– Identity vs. Role DiffusionIdentity vs. Role Diffusion– Intimacy vs. IsolationIntimacy vs. Isolation– Generativity vs. Self-AbsorptionGenerativity vs. Self-Absorption– Ego Integrity vs. DespairEgo Integrity vs. Despair

Interpersonal Model - Interpersonal Model - SullivanSullivan

• Behavior and personality development are Behavior and personality development are direct result of interpersonal relationships.direct result of interpersonal relationships.

• Basic fear is rejection = Basic fear is rejection = ↑ ↑ anxietyanxiety

• Therapeutic MilieuTherapeutic Milieu– Community environment which facilitates Community environment which facilitates

client interactionclient interaction– Practice interpersonal skillsPractice interpersonal skills– Work cooperatively to solve problems.Work cooperatively to solve problems.

Humanistic Model- MaslowHumanistic Model- Maslow

• Hierarchy of basic human needsHierarchy of basic human needs1.1. PhysicalPhysical2.2. Safety/SecuritySafety/Security3.3. Love & BelongingLove & Belonging4.4. Self-EsteemSelf-Esteem5.5. Self-ActualizationSelf-Actualization

• Focus on client’s strength and potential Focus on client’s strength and potential to changeto change

• Present/Future orientedPresent/Future oriented

Humanistic Model-RogersHumanistic Model-Rogers

• Client-centered therapyClient-centered therapy

• Unconditioned positive regard for the Unconditioned positive regard for the clientclient

• Genuineness & empathetic Genuineness & empathetic understandingunderstanding

• Importance of learning Importance of learning – ↑ ↑ PotentialPotential– ↑ ↑ Personal GrowthPersonal Growth

Behavioral Model- Skinner & Behavioral Model- Skinner & PavlovPavlov

BehaviorismBehaviorism• Focuses on behaviors and changes, not Focuses on behaviors and changes, not

the mind’s effect.the mind’s effect.• All behavior is learned.All behavior is learned.• Behavior has consequencesBehavior has consequences

– Reward or PunishmentReward or Punishment• ReconditioningReconditioning

– Unlearning maladaptive behaviorUnlearning maladaptive behavior

• Treatment ModalitiesTreatment Modalities– Behavior ModificationBehavior Modification– Token EconomyToken Economy– Systematic DesensitizationSystematic Desensitization

Behavioral Model- cont.Behavioral Model- cont.ReinforcementReinforcement

• ↑ ↑ Frequency of behaviorFrequency of behavior

• (+) Reinforcement uses a stimulus(+) Reinforcement uses a stimulus– Praise for completed workPraise for completed work

• (-) Reinforcement removes the stimulus(-) Reinforcement removes the stimulus– No attention for interruptingNo attention for interrupting

• Continuous ReinforcementContinuous Reinforcement– Fastest way to ↑ behaviorFastest way to ↑ behavior

• Intermittent ReinforcementIntermittent Reinforcement– Slower, but longer lasting way to ↑ behaviorSlower, but longer lasting way to ↑ behavior

PunishmentPunishment• ↓ ↓ Frequency of behaviorFrequency of behavior

• (+) Punishment = Scolding for inappropriate behavior(+) Punishment = Scolding for inappropriate behavior

• (-) Punishment = No contact with “wrong” crowd (↓ (-) Punishment = No contact with “wrong” crowd (↓ cursing)cursing)

Medical Model- KraeplinMedical Model- Kraeplin• Disease EntityDisease Entity

– Signs & SymptomsSigns & Symptoms• Physiological Physiological ▲s and possibly viruses, altered ▲s and possibly viruses, altered

immune system immune system • PET scans √ brain metabolism PET scans √ brain metabolism • CT scans √ lesions, tumorsCT scans √ lesions, tumors

– Classify illness via DSM-IV TRClassify illness via DSM-IV TR

• BiochemicalBiochemical– ▲▲s in Neurotransmitterss in Neurotransmitters– ↑ ↑ DA = hallucinations & delusionsDA = hallucinations & delusions– Drug therapy is effectiveDrug therapy is effective

• GeneticGenetic– Specific genes predispose to Specific genes predispose to ↑ risk of illness↑ risk of illness– Chromosome # 5 & 6 ↑ risk of schizophreniaChromosome # 5 & 6 ↑ risk of schizophrenia– Twins 50-75% riskTwins 50-75% risk

Cerebrum = Cerebrum = 2 Hemispheres & 4 2 Hemispheres & 4 LobesLobes

• L HemisphereL Hemisphere → → controls R side of bodycontrols R side of body– Logical reasoning, reading, writing, mathLogical reasoning, reading, writing, math

• R HemisphereR Hemisphere → → controls L side of bodycontrols L side of body– Creative thinking, intuition, artistic abilitiesCreative thinking, intuition, artistic abilities

• Frontal LobeFrontal Lobe– Thought, emotions, memories, movement & Thought, emotions, memories, movement &

moral behaviormoral behavior

• Parietal LobeParietal Lobe– Taste, touch , spatial orientationTaste, touch , spatial orientation

• Temporal LobeTemporal Lobe– Smell, hearing, memory & emotional expressionSmell, hearing, memory & emotional expression

• Occipital LobeOccipital Lobe– Language & visual interpretationLanguage & visual interpretation

Brain StemBrain Stem

• Midbrain, Pons & Medulla OblongataMidbrain, Pons & Medulla Oblongata

• Reticular Activating System Reticular Activating System (RAS)(RAS)– Motor activity, sleep, consciousness & Motor activity, sleep, consciousness &

awarenessawareness

• Extrapyramidal System (EPS)Extrapyramidal System (EPS)– Movement & coordinationMovement & coordination

Limbic System = Emotional Limbic System = Emotional BrainBrain

• ThalamusThalamus– Activity, sensation & emotionActivity, sensation & emotion

• HypothalamusHypothalamus– Temp regulation, appetite control, sexual Temp regulation, appetite control, sexual

drive, & impulsive behavior (anger, rage, drive, & impulsive behavior (anger, rage, excitement)excitement)

• Amygdala & HippocampusAmygdala & Hippocampus– Emotional arousal & memoryEmotional arousal & memory

NeurotransmittersNeurotransmitters• DopamineDopamine (DA) Excites (DA) Excites

– Complex movements, motivation, cognition,Complex movements, motivation, cognition,– Emotional responsesEmotional responses– ↑ ↑ DA – SchizophreniaDA – Schizophrenia

• NorepinephrineNorepinephrine (NE) Excites (NE) Excites– Mood regulation, attention, learning, Mood regulation, attention, learning,

memory,memory,– sleep, wakefulnesssleep, wakefulness– ↓ ↓ NE – depressionNE – depression

• EpinephrineEpinephrine (E) Excites (E) Excites– Perception = Flight or Fight responsePerception = Flight or Fight response

NeurotransmittersNeurotransmitters• SerotoninSerotonin (5-HT) Inhibits (5-HT) Inhibits

– Appetite, sleep, arousal, pain perception,Appetite, sleep, arousal, pain perception,– Libido, regulation of emotionsLibido, regulation of emotions– ↓ ↓ 5-HT –Schizophrenia, Aggression & suicide5-HT –Schizophrenia, Aggression & suicide

• Gamma Aminobutyric AcidGamma Aminobutyric Acid (GABA) Inhibits (GABA) Inhibits– Slows down other neurotransmittersSlows down other neurotransmitters– ↑ ↑ GABA - ↓ DA, G, NE, E, AChGABA - ↓ DA, G, NE, E, ACh

• GlutamateGlutamate (G) Excites (G) Excites• AcetylcholineAcetylcholine (ACh) Excites/Inhibits (ACh) Excites/Inhibits

– Sleep & arousal, pain perception & movementSleep & arousal, pain perception & movement– ↓ ↓ ACh = confusionACh = confusion

• HistamineHistamine (H) (H) – Alertness, allergic response, gastric secretions,Alertness, allergic response, gastric secretions,↑↑ ↑↑

wt.wt.

Nursing Theory -PeplauNursing Theory -Peplau• Interpersonal Therapeutic ModelInterpersonal Therapeutic Model

– Nurse-Patient Relationship (1:1)Nurse-Patient Relationship (1:1)– Collaborative processCollaborative process– Nurse’s RoleNurse’s Role

•Resource person, teacher, leader, Resource person, teacher, leader, surrogate, counselorsurrogate, counselor

Therapeutic Relationship CriteriaTherapeutic Relationship Criteria•Patient initiatedPatient initiated•Pt accepted unconditionallyPt accepted unconditionally•Create environment of trustCreate environment of trust•RN conveys genuineness & empathyRN conveys genuineness & empathy•Explore feelings, thoughts, behaviors & Explore feelings, thoughts, behaviors &

experiencesexperiences•Identify alternate methods for problem Identify alternate methods for problem

solvingsolving

Therapeutic RelationshipTherapeutic Relationship

4 Distinct Phases4 Distinct Phases1. Orientation1. Orientation• Orientation/IntroductionOrientation/Introduction

– Establish trust and rapportEstablish trust and rapport– Identify purpose, roles and Identify purpose, roles and

responsibilitiesresponsibilities– Assess client’s needsAssess client’s needs– Form contractForm contract

Working (Identification & Exploitation)Working (Identification & Exploitation)

2. Identification2. Identification

• RN facilitates expression of feelingsRN facilitates expression of feelings

• Pt participates to identify problemsPt participates to identify problems

• Pt responds and trusts RNPt responds and trusts RN

3. Exploitation3. Exploitation

• Promote Pt insights & perception of Promote Pt insights & perception of realityreality

• Overcome resistant behaviorsOvercome resistant behaviors

• Pt tests alternate problem solving & Pt tests alternate problem solving & coping skillscoping skills

• Initiate action plan & new goalsInitiate action plan & new goals• ▲ ▲ from dependentfrom dependent → independent behavior→ independent behavior

• ↑ ↑ skills in interpersonal relationshipsskills in interpersonal relationships

4. Resolution/Termination4. Resolution/Termination

• Summarize work & growth Summarize work & growth accomplishedaccomplished

• Review discharge plan & actions to Review discharge plan & actions to deal with potential stressorsdeal with potential stressors

• Referrals to community resourcesReferrals to community resources• Acknowledge feelings RT ending Acknowledge feelings RT ending

relationshiprelationship

Therapeutic CommunicationTherapeutic Communication

• Active ListeningActive Listening– Be attentive to verbal & non-verbal messages.Be attentive to verbal & non-verbal messages.– Assess congruency of messageAssess congruency of message

• RN Non-Verbal SkillsRN Non-Verbal SkillsSS - Sit squarely facing Pt - Sit squarely facing Pt

OO - Observe an open posture - Observe an open posture

LL - Lean forward toward the Pt. - Lean forward toward the Pt.

EE - Establish eye contact - Establish eye contact

RR – Relax! – Relax!

Non-Verbal AssessmentNon-Verbal Assessment• Physical AssessmentPhysical Assessment

– Clothing & HygieneClothing & Hygiene

• Body Movement/PostureBody Movement/Posture– Reflects self-esteem & statusReflects self-esteem & status

• TouchTouch– Ellict both (+ & -) responsesEllict both (+ & -) responses– Cultural interpretationCultural interpretation

• Facial ExpressionFacial Expression– Reflects affectReflects affect

• Eye MovementEye Movement– ““Windows of the soul” Windows of the soul” – ↑ ↑ Direct contact = personal interestDirect contact = personal interest

• Vocal CuesVocal Cues– How a message is verbalizedHow a message is verbalized– Pitch, tone, loudness, rate of speakingPitch, tone, loudness, rate of speaking

Communication Communication TechniquesTechniques• AcceptanceAcceptance

– Non-judgmental attitudeNon-judgmental attitude– Convey respectConvey respect

• Offering SelfOffering Self– Sense of presenceSense of presence– Being availableBeing available

• Open-ended QuestionsOpen-ended Questions– Broad openings allow Pt to select the topicsBroad openings allow Pt to select the topics

• ValidationValidation– Confirming what the patient has saidConfirming what the patient has said

Communication TechniquesCommunication Techniques

• ReflectionReflection– Content & feeling is referred back to PtContent & feeling is referred back to Pt– Pt recognition & acceptancePt recognition & acceptance

• RestatementRestatement– Paraphrase main content or emotionParaphrase main content or emotion

• FocusFocus– Direct conversation to a single conceptDirect conversation to a single concept

• ClarificationClarification– Enhance understanding vague or Enhance understanding vague or

confused messageconfused message

Communication TechniquesCommunication Techniques

• Convey InformationConvey Information– Supply data via statementSupply data via statement

• Provide FeedbackProvide Feedback– Specific constructive informationSpecific constructive information

• State ObservationsState Observations– Verbalize what is witnessed or perceivedVerbalize what is witnessed or perceived

• Connect InformationConnect Information– Identify relationships, similarities or Identify relationships, similarities or

differences to clarify behavior/ thoughtsdifferences to clarify behavior/ thoughts

Communication TechniquesCommunication Techniques

• ConfrontationConfrontation– Identify discrepancies between Identify discrepancies between

what the Pt says & doeswhat the Pt says & does

• SummarizeSummarize– Highlight the main themes of Highlight the main themes of

content & feelings discussedcontent & feelings discussed

• Present RealityPresent Reality– Orient to the presentOrient to the present– Clarify misperceptionsClarify misperceptions

• SilenceSilence– Interaction without wordsInteraction without words

Blocks to CommunicationBlocks to Communication• False ReassuranceFalse Reassurance

– May discourage Pt from disclosing feelingsMay discourage Pt from disclosing feelings

• RejectingRejecting– Refusing to consider the Pt’s ideas or Refusing to consider the Pt’s ideas or

behaviorsbehaviors

• Giving ApprovalGiving Approval– Passing judgment or Pt “right or wrong”Passing judgment or Pt “right or wrong”

• Giving AdviceGiving Advice– Implies RN knows what is best for the Pt.Implies RN knows what is best for the Pt.

• ProbeProbe– Pushing for answers the Pt does not want Pushing for answers the Pt does not want

to discussto discuss

Blocks to CommunicationBlocks to Communication

• DefendDefend– Implies Pt has no right to express his own Implies Pt has no right to express his own

ideasideas

• BelittleBelittle– Minimizing Pt. distress Minimizing Pt. distress → Pt. unimportant→ Pt. unimportant

• Change the SubjectChange the Subject– RN takes over the direction of the RN takes over the direction of the

conversationconversation

• DenialDenial– Blocks further discussionBlocks further discussion

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