Chapter 1:

Foundations of PsychiatricMental Health Nursing

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Mental Health
Difficult to define
No single, universal definition
Many components influenced by factors
Dynamic, ever-changing state
Influencing factors:
Individual (personal)
Interpersonal (relationship)
Social/cultural (environmental)

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Mental Illness
Mental disorder: behavioral or psychological
syndrome or pattern (clinically significant)
Association with present distress or disability or
increased risk of death, pain, disability or
important loss of freedom

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Mental Illness (contd)

General criteria for diagnosis
Dissatisfaction with characteristics, abilities,
accomplishments
Ineffective or unsatisfying relationships
Dissatisfaction with ones place in the world
Ineffective coping with life events
Lack of personal growth
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Mental Illness (contd)

A persons behavior must not be culturally
expected or sanctioned.
Deviant behavior does not necessarily indicate a
mental disorder.

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Mental Illness (contd)

Factors contributing to mental illness can
also be viewed within:
Individual
Interpersonal
Social/cultural

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Mental Illness (contd)

Individual
Factors include:
Biologic make up
Intolerable or unrealistic worries or fears
Inability to distinguish reality from fantasy
Intolerance of lifes uncertainties
Sense of disharmony in life
Loss of meaning in ones life.

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Mental Illness (contd)

Interpersonal
Factors include:
Ineffective communication
Excessive dependency on or withdrawal from
relationships
No sense of belonging
Inadequate social support
Loss of emotional control.

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Mental Illness (contd)

Social/cultural
Factors include:
Lack of resources
Violence
Homelessness
Poverty
Unwarranted negative view of the world
Discrimination such as stigma, racism, classism, ageism and
sexism.

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Diagnostic and Statistical Manual of

Mental Disorders
DSM-IV-TR: taxonomy of American
Psychiatric Association
Purposes:
Standardize nomenclature, language
Identify defining characteristics or symptoms
Assist in identifying underlying causes

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

DSM-IV-TR Classification
Axis I: major psychiatric disorders except
mental retardation, personality disorders
Axis II: mental retardation, personality
disorders
Axis III: current medical conditions
potentially relevant
Axis IV: psychosocial, environmental
problems
Axis V: Global Assessment of Functioning
Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question
Tell whether the following statement is true
or false:
The definition of mental health is
standardized and universally accepted.

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer
False
There is no single universal definition of
mental health, which has many components
and is influenced by myriad factors.

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Historical Perspectives
Ancient times
Sickness as displeasure of gods; punishment for
sins; view as demonic or divine
Aristotle and imbalances of the four humors
(blood, water, yellow and black bile); balance
restoration via bloodletting, starving, purging
Early Christians view as possession by demons

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Historical Perspectives (contd)

Period of Enlightenment (1790s)
Creation of asylums; moral treatment
Dorothea Dix

Sigmund Freud: scientific study, treatment of

mental illness

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Historical Perspectives (contd)

Psychopharmacology (1950s): development
of psychotropic drugs
Community mental health movement
Deinstitutionalization
Legislation for disability income
Changes in commitment laws

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Mental Illness and the 21st Century

Current state
More than 26% of Americans 18 and older have
diagnosable mental disorder (NIMH, 2008)
15 million adults, 4 million children and
adolescents with impaired daily activities
Economic burden exceeds that by all types of
cancer

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Mental Illness and the 21st Century

(contd)
Current state
Leading cause of disability in United States
Canada for those 15-44 years of age
1 in 4 adults and 1 in 5 children and adolescents
getting care needed

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Mental Illness and the 21st Century

(contd)
Issues and concerns:
Revolving-door effect due to
deinstitutionalization
Shorter hospital stays, decompensation,
rehospitalization, dual diagnoses

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Mental Illness and the 21st Century

(contd)
Issues and concerns:
Homelessness ( estimated to have serious
mental illness; over with substance abuse
problems)
Lack of adequate community resources

ACCESS to address needs of full- or parttime homeless persons with mental illness

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question
Which statement best reflects the current
state of mental health and mental illness?
A. Mental health care costs exceed the costs for
cancer care.
B. Most adults and children receive adequate
mental health care.
C. Community resources for the homeless with
mental illness are adequate.
D. Deinstitutionalization has reduced the
revolving door effect.
Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer
A. Mental health care costs exceed the costs
for cancer care.
The economic burden of mental illness
exceeds that for all types of cancer care.
Only 1 in 4 adults and 1 in 5 children received the
necessary mental health care. Community
resources for homeless clients with mental illness
are inadequate. Deinstitutionalization has led to
the revolving-door effect.
Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Objectives for the Future

Healthy People 2010 objectives
Increase number of people identified, diagnosed,
treated, helped to live healthier lives
Decrease rates of suicide, homelessness
Increase employment for those with serious
mental illness
Provide more services for incarcerated persons
with mental health problems
Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Community-Based Care
Lack of appropriate number of community
mental health centers to provide services
Development of community support
programs
Availability, quality of services highly variable
Inaccurate anticipation of extent of peoples
needs
Despite flaws, positive aspects making them
preferable for treatment
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Cost Containment and Managed Care

Managed care movement (early 1970s)
Development of utilization review
firms/managed care organizations (1990s);
case management
Separation of mental health care from
physical care for insurance coverage

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Cost Containment and Managed Care

(contd)
Mental health care management through
privately owned behavioral health care firms
If no private insurance, reliance on counties of
residence for payment

HCFA: Medicare, Medicaid

Mental health parity, insurance coverage

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Cultural Considerations
Culturally diverse population
Cultural differences influencing mental
health, treatment of mental illness
Changes in family structure

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Question
Tell whether the following statement is true
or false:
Community-based programs are preferable
for treating many people with mental illness.

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer
True
Although there are flaws in the system,
community-based programs have positive
aspects that make them preferable for
treating many people with mental illness.

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Psychiatric Nursing Practice

Linda Richards: first American psychiatric
nurse
McLean Hospital, Belmont MA: site of first
training for nurses to work with persons with
mental illness
Expansion of role with development of
somatic therapies

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Psychiatric Nursing Practice (contd)

First psychiatric nursing textbook (Nursing
Mental Diseases) published in 1920
Johns Hopkins: first school of nursing to
include psychiatric nursing course (1913)
National League for Nursing (1950) requiring
schools to include psychiatric nursing
experience

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Psychiatric Nursing Practice (contd)

H. Peplau: therapeutic nurse-client
relationship; interpersonal dimension
(foundation for current practice)
J. Mellow: focus on clients psychosocial
needs, strengths
American Nurses Association and Standards
of Care (see Box 1.3)
Psychiatric-Mental Health Nursing
Phenomena of Concern (see Box 1.2)
Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Psychiatric Nursing Practice (contd)

Basic-level functions
Counseling

Advanced-level
functions

Milieu therapy

Psychotherapy

Self-care activities

Prescriptive authority
for drugs

Psychobiologic
interventions
Health teaching

Consultation, liaison
Evaluation

Case management
Health promotion,
maintenance
Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Student Concerns and Psychiatric-Mental

Health Clinical Experience
Saying the wrong thing
Knowing what to do
Being rejected or not talking to student
Asking personal questions
Handling bizarre, inappropriate, or sexually
aggressive behavior
Handling feeling unsafe
Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Student Concerns and Psychiatric-Mental

Health Clinical Experience
Seeing someone known on the unit
Dealing with similar problems or
backgrounds

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Question
Tell whether the following statement is true
or false:
The National League for Nursing required
schools to include a psychiatric nursing
experience before the first nursing school
included a psychiatric nursing course in its
curriculum.

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer
False
Johns Hopkins was the first school of nursing
to include a course in psychiatric nursing in
its curriculum; this was done in 1913. It was
not until 1950 that the National League for
Nursing required schools to include an
experience in psychiatric nursing.

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Self-Awareness Issues
Everyone with unique or different values,
ideas, beliefs
Possible conflict between personal
values/beliefs, those of client
Need to accept differences, view each client
as worthwhile regardless of opinions or
lifestyle
Self-awareness through reflection
Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins