MH chap 4,5,6

• Crisis


  Anything that overwhelms an individual's ability to cope/resources
• Categories of Crisis


  • Maturational (developmental: getting married, having a baby, and beginning a career)
  • Situational (unanticipated or sudden: loss of a job, or physical or emotional illness)
  • Adventitious (social crisis: natural disasters, crimes)
• Crisis Intervention


  • Duration of Crisis: usually 4 to 6 weeks
  • Crisis Resolution: Functioning at pre-crisis level, higher level, or lower level
  • Positive outcomes more likely when problem is clearly defined
• Crisis Intervention Techniques


  • Directive Interventions: assess health status, promote problem solving
  • Supportive Interventions: encourage the person to identify and discuss thoughts and feelings to develop empathic understanding
• Crisis intervention includes a variety of techniques based on the assessment of the individual
• In Patient Hospital Treatment - Acute Care

  • Rapid assessment, stabilization of symptoms, discharge planning
  • Client centered, multidisciplinary, approach to brief stay
  • Identify long term issues for out pt therapy

  
• Inpatient Hospital Treatment Clients

  • Short - stay clients
  • Long stay clients (severe, persistent mental illness requiring acute care services)
• Case Management


  An important concept in both inpatient and community settings. Inpatient case managers are usually nurses or social workers who follow the client from admission to discharge and serve as liaisons between the client and community resources, home care, and third-party payer.
• Discharge Planning


  • Environmental supports, such as housing and transportation, and access to community resources and services are crucial to successful discharge planning. Discharge plans that are based on the individual client's needs, including medication management, education, timely outpatient appointments, and telephone follow-up, are more likely to be successful.
• Outpatient Community-Based Services


  • Partial Hospitalization Programs- community setting. Some of these are court mandated and some are voluntary.
  • Day treatment programs

  
• Goals of Partial Hospitalization Programs

  • Eight broad categories of goals

  
• Purpose of In-Patient Hospital Settings

  Rapid assessment, stabilization and discharge back to community

  
• Best case scenario - patient discharged from in-patient hospital in less than two weeks
• Patients can sometimes be "trapped" in the psychiatric ED or on inpatient units for years at a time due to lack of community resources
• Residential Settings


  • Group homes
  • Supervised apartments
  • Board and care homes
  • Adult foster care
  • Respite/crisis housing
  • Transitional housing
• Residential Settings


  • Vary in structure, level of supervision and services provided
  • Expectation to progress to independent living
  • Other programs serve clients for longer periods of time
• Psychiatric Rehabilitation and Recovery Programs


  Services to Promote Recovery: Emphasis on recovery, going beyond symptom control and medication management, includes personal growth. Reintegration into community.
• Psychiatric Rehabilitation Programs


  • Clubhouse Model: provides members with many opportunities, including daytime work activities focused on the care, maintenance, and productivity of the clubhouse; evening, weekend, and holiday leisure activities; transitional and independent employment support and efforts; and housing options. Members are encouraged and assisted to use psychiatric services, which are usually local clinics or private practitioner.
  • Assertive Community Treatment (ACT): One of the most effective approaches, Problem solving orientation- no problem is too small, Direct provision of service rather than referral, Intense services, no time constraints, Meeting people where they are (vs clubhouse they come ) the resources go to the individuals
• People who are homeless and have mental health issues spend more time in jail, are homeless longer, spend more time in shelters, have less family contact, and face greater barriers to employment compared to homeless people who are not mentally ill
• PATH Program


  Projects for Assistance in Transition from Homelessness (PATH) funds community-based outreach, mental health, substance abuse, case management, and other support services through block grants to all 50 states and the U.S. territories. Some limited housing services are available, but PATH works primarily with existing housing services in the given community.
• The rate of mental illness among the incarcerated is estimated to be five times higher than the general population
• Factors for Placement of Mentally Ill in Criminal Justice System

  • Deinstitutionalization
  • More rigid criteria for civil commitment
  • Lack of adequate community support
  • Economizing on treatment for mental illness
  • Attitudes of police and society
• Challenges Faced by Prisoners with Mental Illness

  • Criminalization of mental illness
  • Barriers to successful community reintegration
  • Poverty
  • Homelessness
  • Substance use
  • Violence
  • Victimization, rape, trauma
  • Self harm
• The prevalence of PTSD and major depression is greater among active military and veterans compared to their civilian counterparts
• Other Mental Health Issues Common Among Active Military and Veterans

  • Increased rates of suicide, homicide, injury, physical illness
  • Sleep disorders
  • Substance abuse
  • Marital and family dysfunction
• Patient Centered Care


  • The patient is part of the care team
• Core Skill Areas for the Interdisciplinary Team


  • Interpersonal skills
  • Humanity
  • Knowledge base
  • Communication skills
  • Personal qualities
  • Teamwork skills
  • Risk assessment, risk management skills
• Psychosocial Nursing in Public Health and Home Care

  • Primary Prevention: stress management education
  • Secondary Prevention: early identification of mental health problems
  • Tertiary Prevention: monitoring and coordinating psychiatric rehabilitation services
  • Clinical Practice Issues such as substance abuse, domestic violence, child abuse, grief, depression and others
• Components of the Therapeutic Relationship

  • Trust
  • Congruence
  • Authenticity
  • Unconditional Positive Regard (non judgemental attitude, and acceptance)
  • Empathy
• Empathy


  The ability to perceive a client's meanings and feelings to understand their history and to communicate that understanding. Different from sympathy (feelings of concern or compassion, may project nurse's personal feelings).

  
• Empathy


  The ability to perceive a client's meanings and feelings to understand their history and to communicate that understanding

  
• Sympathy


  Sadness, pity that we have for others
• Pity


  Feeling that someone is below us
• Empathy is a skill that can be developed

  
• Empathy is seeking to understand another person's perspective

  
• Peplau's Phases of Establishing a Therapeutic Relationship

  1. Orientation

  2. Identification and exploration

  3. Resolution (termination)
• Orientation Phase


  • Meeting nurse and client
  • Establishment of roles
  • Discussion of purposes, parameters of future meetings
  • Clarification of expectations

  
• Identification and Exploration Phase

  • Problem identification
  • Client identifies issues or concerns
  • Examination of feelings and responses
  • Development of better coping skills, more positive self image, behavioral change, independence
• Resolution (Termination) Phase


  • Begins when client's problems are resolved
  • Ends when relationship is ended
  • Client may feel termination is impending loss
  • Clients often try to avoid termination
• Possible Transference or Countertransference can erode trust and encourage client dependency