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TRENDS AND ISSUES IN PSYCHIATRIC MENTAL HEALTH NURSING, perhaps the greatest challenge to nursing lies in the future, as we identify and develop clinical provider performance measures that are …

TRENDS AND ISSUES IN PSYCHIATRIC MENTAL HEALTH NURSING, perhaps the greatest challenge to nursing lies in the future, as we identify and develop clinical provider performance measures that are relevant to the care and the people we nurses serve!

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  • 1. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 1 Current Trends and Issues in Psychiatric & Mental Health Nursing Prepared by CHRISTIAN LUTHER FABIA, B.S.N.,R.N. Master of Arts in Nursing Major in Psychiatric and Mental Health Nursing DR. EMILIO ALVAREZ Professor Philippine Colleges of Health Sciences, Inc., Manila School of Graduate Studies Android/ iOS
  • 2. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 2 About the cover: Philippe Pinel, (1745-1826), French physician demanding the removal of chains from the insane at the Bicetre Hospital in Paris. “I cannot here avoid giving my most decided sufferage in favour of the moral qualities of maniacs. I have no where met, excepting in romances, with fonder husbands, more affectionate parents, more impassioned . . . than in the lunatic asylum, during their intervals of calmness and reason.” (A quote by Philippe Pinel on decisions, giving, husbands, parenthood, and reason) ________________________________________ Looking at the past gives a vivid understanding of the present. It is a means of defining and building a future of better, if not the best practices. (THE RATIONALE FOR CHOOSING THE COVER) A painting by Charles Muller; source:
  • 3. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 3 - Rationale for Selection of Topics and Organization of Text – The course title is: Current Trends and Issues in Psychiatric and Mental Health Nursing. My professor at the PCHS- Graduate School, DR. EMILIO ALVAREZ provided me with a course syllabus with the course description written as: “The course deals with the journey of nursing toward its current state of professionalism. It provides a forum for knowledgeable discussion on the logically significant trends and problem that concern all of today’s nurses so that intelligent decision making can occur.” He also advised me that topics in this subject should be specific to psychiatric and mental health nursing in lieu with the major I am pursuing. There were two challenges- first, I am the lone enrollee in this track (Psychiatric and Mental Health Nursing), so that how can a series of fora be possible as the course description suggests? Second, the need to modify the course syllabus parallel to this major. This compilation is the answer to the first challenge. And, for the latter, I made a thorough research on the inclusion of topics utilizing various resources- textbooks, journals, updates from PMH Nurses Association of the Philippines and consultation at Philippine Mental Health Association. I underwent various modification of the final content and, guided by the course syllabus, I came up with the concepts I believe to be essential and consistent with the course title: TRENDS AND ISSUES IN PSYCHIATRIC MENTAL HEALTH NURSING. ________________________________________ The text is organized in four parts. A review of basic concepts progressing to more advanced and updated contents with emphases on the current trends and issues. Literature search were conducted in an attempt to present the most current information available. Part 1, The Development and Evolution of Psychiatric Mental Health Nursing, discusses the benchmarks of psychiatric mental health nursing history from the time of Philippe Pinel who introduced the concept of Asylum to present. It aims to guide appreciation on the journey, evolution and complexes that shaped the current practice of Psychiatric and Mental Health Nursing. Part 2, The Challenges of Psychiatry and Mental Health Today, presents vital issues that confront psychiatric professionals to include nurses in this specialty field. The WHO-AIMS Report on the current situation of psychiatric care delivery in the country present challenges to the government, concerned professionals and to the nation as a whole. Paradigm shift and homelessness are universal issues that are seen to be contributory factors in the increasing number of mentally ill population. Part 3, The Current Bases of Psychiatric Mental Health Nursing, consists of topics that are essential to the practice of the field specialty. The ANA provides both the Standards of Care and Performance of a PMH Nurse which is adapted in most countries to include the Philippines. The NEW approach in the continuum of care is an important guide for a nurse in the classification of clients. It also answers to the problems of role ambiguity and confusion as it directs when to intervene collaboratively or independently. The development of theories and the use of models (which are vital foundations of every profession) are thoroughly discussed and their relation and application to the current practice. Cultural competence has been a dormant issue in the past and is now an emerging discussion in both the practice and the academe. Several researches were done not only in the traditional ethnographic concept but to include ethnopharmacology. The old paradigm of psychiatric care urged nurses to be “caring and more caring” ; the modern paradigm suggests that “caring is most essential but not enough- psychiatric nurses must understand principles, theories and models (eg.: psychoanalysis, psychobiology and psychopharmacology).” Hence, it is a must for a psychiatric nurse to comprehend the vital concepts of theories and models as these are the very bases of his competency. Part 4, Empowerment through Awareness on Legal and Commitment Issues, Advanced Directives and Forensic Nursing (Trends and Issues), explores ethical and legal issues related to psychiatric-mental health nursing. It is through awareness on these issues that nurses in this field become more confident to render their job. Forensic nursing has become one of the fastest growing nursing specialty of today, nurses in this field focus on advocacy for and ministration to offenders and victims of violent crime and the families of both. It is also recognized as a significant resource in the treatment of incarcerated persons. Psychiatric nurses are empowered when they are well informed on vital and current issues and the career path to an expanded role in the arena of psychiatric care. Hence awareness is empowerment. TRENDS AND ISSUES IN PSYCHIATRIC MENTAL HEALTH NURSING, perhaps the greatest challenge to nursing lies in the future, as we identify and develop clinical provider performance measures that are relevant to the care and the people we nurses serve! _______________________________________
  • 4. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 4 - Introduction - Psychiatric-mental health nursing involves the diagnosis and treatment of human responses to actual or potential mental health problems. It is a specialized area of nursing practice that uses theories of human behavior as its scientific framework and requires the purposeful use of self as its art of expression. It is concerned with promoting optimum health for society. Comprehensive services focus on prevention of mental illness, health maintenance, management of and referral for mental and physical health problems, diagnosis and treatment of mental disorders (Haber & Billings, 1993). Psychiatric nurses must be able to make rapid comprehensive assessments; use effective problem-solving skills in making complex, clinical decisions; act autonomously as well as collaboratively with other professionals; be sensitive to issues such as ethical dilemmas, cultural diversity, and access to psychiatric care for undeserved population; be comfortable working in decentralized settings ; and be sophisticated about the costs and benefits of providing care within fiscal constraints (ANA, Statement on Psychiatric-Mental Health Clinical Nursing Practice, 1994,p7). My definition of psychiatric-mental health nursing is based on my personal experience- which is: “A detour from the ordinary; a specialty field for nurses who have discovered that they are by nature empathic. Nurses in this specialty field are professionals who understand the complexes of human behavior that guides them to respect the uniqueness of every individual. Their ability to maintain composure in trying situations is almost infinite!” When I applied at the PCHS Graduate School enrolling in M.A. with Tracks in Psychiatric Mental Health Nursing- I was asked about my option to pursue the major since I was a lone enrollee in this track. I have long contemplated pursuing this major considering that this is my area of interest and is consistent with my professional and academic performances. With the guidance of my chosen institution to pursue my degree- the PCHS Graduate School, ultimately, I envision myself as a Forensic Nurse in the future. The Student About the Compilation This material is a compilation of various information on generally acceptable knowledge, concepts, principles, theories and practices in PSYCHIATRIC AND MENTAL HEALTH NURSING. It adapts contents from various publicly acknowledged publications, authors, theorists, authorities and practitioners whose works are commonly utilized in the academe and practice, and are frequently-tested competencies locally and abroad. The works of these authors, theorists, authorities and practitioners are indispensable in learning PSYCHIATRIC AND MENTAL HEALTH NURSING as they are indispensable in the completeness of this compilation. Care has been taken to confirm accuracy of the information presented and describes generally accepted practices. However the student who prepared this material is not responsible for errors or omissions or for any consequences from application of the information in this compilation. The primary goal of the student is to familiarize concepts in the subject CURRENT TRENDS AND ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING based on the COURSE DESCRIPTION provided by the PCHS-Graduate School with the guidance of his Graduate School Professor DR. EMILIO ALVAREZ. This material is not intended for commercial publication and resources were acquired legally. It is his great pleasure that this compilation be reproduced for reference of other students aiming to thoroughly understand CURRENT TRENDS AND ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING.
  • 5. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 5 - Table of Contents - Part 1: The Development and Evolution of Psychiatric Mental Health Nursing Benchmarks in Psychiatric Nursing History,p.6 Historical Development of Psychiatry in the Philippines, p.9 Development of Psychiatric Education in the Philippines, p.12 Part 2: The Challenges of Psychiatry and Mental Health Today WHO- Assessment Instrument for Mental Health Systems (AIMS): Report on Mental Health System in the Philippines, 2006, p.13 Paradigm Shift and Homelessness: Two Vital Issues in Today’s Psychiatric Care Delivery, p.15 Part 3: The Current Bases of Psychiatric Mental Health Nursing Competencies of a PMHN Nurse, p.16 The Nurses’ Role in the New Continuum of Care, p.17 The Influences of Theories to Current Practice, p.20 Integrating Models in the Current Psychiatric Care, p.21 The Need for Cultural Competence in the Current Practice of Psychiatric Nursing, p.24 Part 4: Empowerment through Awareness on Legal and Commitment Issues, Advanced Directives and Forensic Nursing (Trends and Issues) Legal Issues, p.29 Commitment Issues, p.32 Psychiatric Advance Directives, p.34 General Legislation/ Regulation Pertinent to Mental Health, p.35 Forensic Psychiatry & Forensic Nursing, p.36 Post Script, p.38 SUICIDE: An Alarming Malady Delivered by Christian Luther Fabia, R.N. During the 2010 Scientific Fora, Continuing Education for Health Care Professionals December 10, 2011, Top Plaza Hotel, Dipolog City, Zamboanga del Norte
  • 6. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 6 Part 1: The Development of Psychiatric Mental Health Nursing Benchmarks in Psychiatric Nursing History Benchmark I: Period of Enlightenment The modern age of psychiatric care began with Philippe Pinel in France and another visionary, William Tuke in England. In 1793, Pinel became the superintendent of the institution, Bicerre (for men) and, later, the Salpetririe (for women). Pinel was dismayed by the conditions he found and wrote of the patients, “They were abandoned to the incompetence of a callous director and to the cold brutality of servants…” (Weiner, 1992). Soon after assuming leadership Pinel unchained the shackled, clothed the naked, fed the hungry, and abolished the whips and other tools of abuse. Simultaneously, in England, William Tuke was planning a private facility that would ensure moral treatment for the mentally ill after he witnessed the deplorable condition in public facilities. In 1796, based on Quaker teachings, his York Retreat opened for patients, providing “a place in which the unhappy might obtain refuge- a quiet haven in which the shattered bark might find a means of reparation or safety” (Charland,2007; Gollaher, 1995). Pinel and Tuke crafted this first benchmark of modern psychiatric care. DR. PHILIPPE PINEL FRENCH PHYSICIAN & PSYCHIATRIST BORN APRIL 20, 1745, SAINT-ANDRE, DEPARTEMENT TARN DIED OCTOBER 25, 1826, PARIS He is known to be the instrumental in the development of a more humane psychological approach to the custody and care of psychiatric patients, referred to today as moral therapy. Asylum The first definition of Asylum (sanctuary) had materialized in the form of hospitals built in rural areas. Patients were isolated geographically, socially, and, after release, from follow up care. Patients were also isolated from public scrutiny, which enabled many large institutions to become closed systems. As might be guessed, the beneficence of the reformers was not shared by many of the caretakers who followed. Within a relatively brief period, the meaning of the term asylum changed; it evolved from a place of refuge to a place of torment. Early reformers were driven by a desire to improve the lot of abandoned, mentally-ill persons and to provide asylum for sanctuary. Dorothea Dix (1802 to 1887), one of the first major reformers in the United States, was instrumental in developing the concept of asylum; she played a direct role in opening 32 state hospitals. She visited Tuke’s York Retreat wherein Tuke’s moral treatment influenced her to confront the pain and suffering she had witnessed in her native land. Dix came to believe that the people of the United States had an obligation for their mentally-ill brothers and sisters. She proposed to alleviate suffering with adequate shelter, nutritious food and warm clothing. In Gollaher’s biography of Dix (1995), he quotes from one of her memorials the documents she wrote to expose the terrible plight of the insane. From her Massachusetts memorial, he notes: Concord: A woman from the (Worcester) hospital in a cage in the almshouse. Lincoln: A woman in a cage. Medford: One idiotic subject chained, and one in a close (or narrow) stall for 17 years…
  • 7. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 7 Granville: One often closely confined …now losing the use of his limbs from want of exercise… The period of Enlightenment was short-lived. Within 100 years of the establishment of the first asylum, known as the Eastern Lunatic Asylum, the lunatics were being charged with misuse and abuse of their charges. State hospitals were beset with problems. Today, however, a renewed interest in asylum as a place of rest and restoration exists. This concept can be considered in terms of the four Ps: parents, professionals, patients, and public, each of which has a stake in the discussion of asylum. Benchmark II: Period of Scientific Study The shift in focus from sanctuary to treatment is linked to the second benchmark in psychiatric care, personified by Sigmund Freud (1856-1939). Toward the last third of the nineteenth century, several scientists devoted themselves to understanding the mind and mental illness. Nonetheless, the efforts forever changed the world’s view: mental illness need not be suffered (however humanely patients were treated) but might be alleviated. In a sense, psychiatric care was popularized. Early Scientists Although Freud had the greatest impact on the world’ view of mental illness, He neither thought nor worked in a vacuum. Other men and women had tremendous influence on this newly enthusiastic and optimistic approach to mental illness. Emil Kraeplin (1856-1926) made tremendous contributions to the classification of mental disorders. He was a true scientist whose classic descriptions of schizophrenia are valuable reading. Eugene Bleuler (1857-1939) coined the term schizophrenia and added a note of optimism to its treatment. Still others, many of whom were colleagues or disciples of Freud, made significant contributions to the merging field of psychiatry. Freud’s contributions still influence psychiatric care although, for a number of years, belittling his thinking was popular. Freud described human behavior in psychological terms. He developed a theory of motivation, established the usefulness of talking (catharsis), explained the importance of dreams and proposed to unlock the hidden parts of the mind. He discussed sex openly and remains surprisingly relevant today (Hartmann, 2009). He introduced terms which have become parts of our language- psychoanalysis, id, ego, superego, and free association. He feel free to study human beings as he would with any other animal because of Charles Darwin’s work. The work of others evolved from Freud’s studies. Alfred Adler, Carl Jung, Ernest Jones, Otto Rank, Helen Deutsch, Karen Horney, and Anna Freud (Freud’s youngest child) all made significant, and in most cases, lasting contributions to the field of dynamic psychiatry. Freud’s inspiration, however, reached far beyond those with whom he worked personally. Freud challenged the society to look at human beings objectively and fostered a milieu of thinking about the mind and mental disorders. The nurse-patient relationship is built on this concept and is devoted to the implementation of strategies for working with psychiatric patients.
  • 8. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 8 Benchmark III: Period of Psychotropic Drugs From this milieu of theory and scientific thought came the third benchmark, which began around 1950 with the discovery of scientific drugs. Chlorpromazine (Thorazine), an anti- psychotic drug, and lithium (antimanic agent), were introduced first, and imipramine (Tofranil) an antidepressant, was introduced a few years later. The impact of these drugs have been powerful. Patients who appeared beyond reached became less agitated and experienced a reduction in psychotic thinking. Depressed patients regained normal feelings. Hospital stays were shortened, and hospital environments improved. However,although psychotropic drugs have allowed manypatients to be treated in less restrictive environments, ethical, moral and legal questions have arisen with this treatment modality. Benchmark IV: Period of Community Mental Health In the foregoing suggests the notion that one benchmark period entirely before the next one began, then we will clarify the misunderstanding. Trends tend to overlap as advocates of one view struggle to defend existing strategies while more dynamic forces emerge elsewhere. As the various treatment approaches were being developed in the milieu derived from Freud’s theories, criticism grew and the state hospital system continued its “plunge” into “psychiatric Siberia”. In the U.S., legislations were passed that would change the approach of psychiatric care. In 1946, President Truman signed the National Mental Health Act, enabling the establishment of the National Mental Health Act. In 1947, the Hill-Burton Act legislated funds to build general hospitals that included psychiatric units. This initiative began the effort for early intervention and helped shorten the length of hospitalization for psychiatric patients. In 1961, the Joint Commission on Mental Illness and Health published a report entitled Action for Mental Health. It urged increased support for the state hospital system in recognition for improved treatment of the mentally-ill population. Rather than increasing monetary support for the state hospital system, a convergence of forces set the stage for this hospital benchmark period in psychiatric history: 1. The public’s declining confidence in the state hospital system 2. The failure of various treatment approaches to eradicate mental illness. 3. The legislative climate that had begun in the 1940s, emphasizing the civil rights of the mentally ill. 4. The newfound faith in psychotropic drugs. These factors led to the enactment of the Community Mental Health Centers (CMHC) Act in 1963. The goal was deinstitutionalization of the state hospital system population. The problem of geographic isolation was addressed with the establishment of community treatment centers and community living arrangements (eg.: halfway houses). Keeping the individual closer to the family addressed issues of isolation from family members. Isolation form follow up care was remedied because of various levels of care were available locally. Eventually, community mental health programs were developed to meet the needs of all those living within the boundaries of a designated (eg.: catchment) area. These programs had the following goals:  Emergency Care  24-hour inpatient care  Partial hospitalization care  Outpatient care  Consultation and education for the population served by the center  Screening services Deinstitutionalization Deinstitutionalization refers to the depopulating of state mental hospitals. Nurses and doctors gravitated toward people with whom they can identify. It is much easier to counsel and medicate a woman going through the crisis of divorce than to attempt to understand the babblings of a person with disorganized schizophrenia.
  • 9. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 9 Depopulation of State Hospitals (U.S.A.) The state hospitals reached its peak in 1955, with 558,922 patients. Today, the state hospital population is about 70,000 patients, a decline of over 85%. Almost 1,000,000 people would be in state hospitals today if the same proportion were in effect. Thus over 900,000 individuals who might have been hospitalized years ago are currently living outside institutions. This decline has resulted in the closing of many state hospitals. Patients hospitalized today require a high level of care, have few social relationships, and are psychotic and atypically acutely ill young men. In the Philippines, the following facilities provide treatment for mentally-ill children and adolescents:  Mental Hospital  Out-patient facilities  Day treatment facilities  Community-based in-patient facilities  Community Residential Facilities (WHO-AIMS Report, 2006) Benchmark V: Decade of the Brain The 1990s were declared the Decade of the Brain by Congress. During this decade, a steep increase in brain research occurred that coincided with an increased interest in biologic explanations for mental disorders. The immediate impetus for this benchmark was the significant changes in the diagnostic manual published in 1980. However, in many ways, the emphasis on brain biology represented a completion of the circle started by Kraeplin 100 years before. Kraeplin believed brain pathology was at the root of serious mental disorders. Significant changes in public awareness occurred which enabled clinicians o address relatively complex topics with patients and families. Nursing responded to this challenged with a significant augmentation of psychobiologic content in academic nursing programs and continuing education programs. The Decade of the Brain brought many challenges but the benefits have been tremendous in terms of making psychiatric nursing a more viable specialty. It crystallized the fact that some behaviors are caused by biologic irregularities and not willful contrariness, or worse. It also enabled individuals to move beyond blaming toward a focus on what could be done. This benchmark brought nursing back into the mainstream of psychiatric care. ________________________________________ Historical Development of Psychiatry in the Philippines The history of Philippine psychiatry reflects the convergence of mind, body and spirit in the interpretation of wellness and illness to explain common symptoms of mental illness. Mental health workers to include nurses who have been trained in the Western biomedical model must be able to connect the gap what people believe and what they should be made to know. The approach in which psychiatric nurses deal with their patients and their families and attempts at health promotion and the destigmatization of mental illness is greatly affected by these realities. Thus, redefining the perspective of mental health nursing using vocabulary and experience is necessary. Connecting these to the disease diagnostic criteria as people have learned about them should follow (Casimiro-Querubin and Castro-Rodriguez, 2002). In order to understand the history of treatment of the treatment of mental illness in the Philippines, it is deemed necessary to comprehend the history of psycvhiatry in general, without overlooking the fact that this understanding can never be complete without an appreciation of the system of knowledge or treatment that is essentially Filipino or Asian in character. Reyes and Della (2002) identified the six major periods in the history of mental illness treatment marked by great historical events: 1. Pre-Spanish Regime During this period the Filipinos believed in a world that was equally material and spiritual. The concept of illness was based on the belief in such material and spiritual worlds, thus the treatment of both physical and mental illness depended heavily on the valid and authentic rituals and ceremonies aimed at converting the punishment and at the same time maintaining and protecting the psychological well-being and survival of the people involved. The Filipinos also relied on healers called babaylan (shaman) and
  • 10. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 10 sorcerer healing, through which the spirits communicated with people or healed the sick individual. This cause of healing involved the temporary possession of the medium’s body. 2. Spanish Rule Under the Spanish era, the Filipinos accepted that mental illness was caused by an act of sorcery . As it was written, the mangkukulam (witches) pricked the heads of their magic dolls with their magic pins while the mangaaaway (devil men) solicited satanic powers that can cause individuals to become mentally-ill (Santiago, 1995). Herbolarios (herbsmen) intervene for treatment or “victims” are brought to the church for exorcism or ritual cleaning. Herbolarios are said to have an understanding of the mentally-ill persons. Through their own ability to get rid of the individual’s malady or ailment, they may have been using psychotherapy in a much different and ancient form. Therefore, it goes without saying that the procedures or religious rites have represented the means for the patient’s healing. Early Nineteenth Century The organized care and treatment for individuals with mental illness was established at the Hospicio de San Jose in the early 19th century. This historical event was made possible when the Spanish naval authorities requested for a place of confinement for their mentally-ill sailors. Medical doctors and nuns from the hospicio composed the treatment staff. Carcel de Bilibid served as the place for patients who committed criminal acts and those who are dangerous ones. 3. The American Era In 1904, The Insane Department was opened at San Lazaro Hospital for use by mentally ill patients who were transferred from the Hospicio de San Jose. Dr. Elias Domingo who headed the unit was the first physician to obtain formal training in psychiatry in the U.S. He was assisted by Filipino and American nurses who were also trained in psychiatric nursing care. In 1918, the city sanitarium was constructed to provide a place for treatment solely for patients residing in Manila. Consequently, the insane department in San Lazaro Hospital provided services for patients residing outside Manila. 4. Japanese Occupation The WWII broke out on 8 December 1941 and the Japanese occupation began. Meanwhile the National Psychopathic Hospital continued to operate without regard of the danger and fear that the war was bringing. Many of the patients were fetched by their families while those left in the hospital died due to starvation and lack of medicine. The remaining patients and employees were executed for alleged anti-Japanese activities. The Japanese Imperial Army donated and electroshock apparatus to the hospital. It was a big help to the patients and represented a breakthrough in the treatment of hospital patients. Since then, the electroshock therapy became the principal and famous treatment modality of the time due to the scarcity of medicine. The war was definitely an unprecedented obstacle in the progress of psychiatry and psychiatric treatment. 5. The Liberation Period and the Era of the Republic At the end of WWII and the Japanese Rule, the hospital was liberated by the American Army of Liberation in 1945. With the return of the American to the Philippines, the development and growth in the treatment of mentally-ill patients began. Rehabilitation and expansion of facilities, training of medical staff and improvement in the management of hospitalized patients were immediate. This cooperative effort was in keeping with the general adoption of the concept of “mental health” in the U.S. It was during this period when the National Psychopathic Hospital was renamed National Mental Hospital, with Dr. Jose Fernandez designated as officer-in-charge from October 1946 to April 1961. Additional infirmary buildings for non-paying and paying patients, additional infrastructures and the improvement of basic services were accomplished. Other Psychiatric Services V.Luna General Hospital (AFP Hospital)  In 1946, the hospital established a neuropsychiatric service. The initial modes of treatment were ECT, insulin therapy and narcoanalysis.
  • 11. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 11  In 1947, hypnosis and group therapy were added; First prefrontal lobotomy (destruction of the white matter of the frontal lobe of the brain) was performed by Mjr. Romero Gustillo using an improvised leucotome. It successfully performed to a violent patient who did not respond to ECT and pharmacotherapy.  In 1949, Mjr. Jaime Zaguirre performed the first transorbital lobotomy on another patient with schizophrenia.  In 1953, carbon dioxide and oxygen therapies were initiated.  In 1954, integration hibernation psychotherapy was introduced. University of Sto. Tomas  In 1947, the UST Neuropsychiatry Section was opened with Dr. Leopoldo Pardo as its chief.  In 1986, the section was developed as a separate department from the Medicine Department which was headed by Dr. Gilberto Gimenez. The Philippine Mental Health Association  Was founded by Dr. Eduardo Krapf, Toribio Joson, and Manuel Arguelles in 1949. It is a private organization established purposely to support the mental health services of the government. University of the East Ramon Magsaysay Memorial Medical Center  Established a department of psychiatry in 1956 Philippine General Hospital (UPGH)  Opened its own neuropsychiatric unit headed by Dr. Baltazar Reyes, Jr. in 1958  In 1964, the unit was separated to become a department. In the Philippines, the emphasis of the treatment of mentally-ill patients was psychotherapy and chemotherapy, which were usually based on the development and progress in the U.S. The end of WWII marked the continued interest and expansion of psychoanalysis abroad. Because of its popularity, psychoanalysis was equated often with psychiatry by the general public. However, despite this seeming dominance of the psychoanalytic treatment during this period, the biological orientation as demonstrated by the use of insulin coma in schizophrenia and electric shock in depression were still commonly used. In 1953, this situation was radically changed with the dramatic discoveries in psychopharmacology. Consequently, these developments proved favorable and were largely responsible for the changes in the practice of psychiatry in the country. Soon drugs known to be helpful and beneficial with schizophrenia, depression, and anxiety disorders were being used. In the Philippines the use of chlorpromazine has apparently shortened the hospital stay of psychotic patients. Most importantly, its use facilitated the early discharge of these patients and early reintegration into the community. 6. Present-day Psychiatry In the Philippines, the use of somatic therapies became most popular in this period. In the early 1960s the following drugs were introduced:  Lithium- used specifically for the treatment of mania  Benzodiazepines- usually prescribed for non-psychotic anxiety  Imipramine-like drugs and MAOIs0 commonly prescribed for the treatment of depression and for patients with severe state of anxiety.  Serotonin specific reupateke inhibitors and serotonin-norephineophrine reupatake inhibitors were included in the treatment of depression during the last decades on the 20th century.  Atypical antispsychotics were also introduced in the treatment of mental disorders and they have the advantage of causing few side effects.  Some somatic therapies become obsolete except for ECT.  Collaboration among different professionals- psychologists, social workers, nurses and occupational therapists further enhanced the delivery of care.  Hospitalizations were apparently shortened.  The thrust in the psychiatry movement and attention has now focused on interventions for people who are not necessarily suffering from mental illness.  The growing interest is geared towards assisting individuals who are vulnerable to develop mental health disturbances- these people are who are victims of either domestic or non-domestic violence, victims of disaster, abandoned children, overseas workers, and others. _______________________________________
  • 12. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 12 Development of Psychiatric Education in the Philippines  In 1973, Jesusa Bagan Lara wrote the first textbook entitled An Outline of Psychiatric Nursing.  The Board Examiners for Nurses in 1967 announced that all nursing students must have at least 4 units of Mental Health Psychiatric Nursing to complete the G.N. or B.S.N. programs (Sand and Robles, 1972).  Mental Health Psychiatric Nursing were included as a separate subject in the Nurses Board Exam in 1978 (Lara, 1978).  Nenita Yasay-Davadilla was the first psychiatric nurse to be sent abroad (University of Maryland) to obtain M.S. in Psychiatric Nursing under the WHO scholarship program.  Magda Carolina Go Vera Llamanzares was the first independent nurse practitioner in child psychiatric nursing.  In 1968, the UP College of Nursing offered M.N. program with specialization in psychiatric nursing.  Sotera V. Capellan was the first G.N. to head the psychiatric nursing service at the National Psychopathic Hospitan (now NCMH), 1928-1957.  The National Center for Mental Health with an authorized bed capacity of 4,200 and a daily average of 3,400 in- patients is the only mental hospital in the Philippines and is the main center for clinical practice by nursing students for most colleges in Metro Manila. A good number of students from provincial colleges of nursing also choose to go to NCMH during the summer period for practicum (
  • 13. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 13 Part 2: The Challenges of Psychiatry and Mental Health Today Assessment Instrument for Mental Health Systems (AIMS): Report on Mental Health System in the Philippines, 2006 - Summary of the Report- The Philippines have a National Mental Health Policy since 2001, which addresses the main issues of mental health in the country. There is no mental health legislation, but different stakeholders are currently working towards the passage of a mental health act. A regular budget allocation exists for mental health. In 2005, over 10 million US dollars (five percent of the total health budget) was directed towards mental health. There is a Commission on Human Rights mandated to review/inspect human rights protection of patients. The Philippines has all types of mental health facilities. At present, there are 2 mental hospitals, 46 outpatient facilities, 4 day treatment facilities, 19 community-based psychiatric inpatient facilities and 15 community residential (custodial home-care) facilities. The only mental hospital in the National Capital Region houses 4,200 beds, while almost all mental health facilities are located in major cities. The total number of human resources working in mental health facilities or private practice is 2,900, including 353 psychiatrists, 141 other doctors not specialized in psychiatry, and 769 nurses. Coordinated and sustained efforts are needed to strengthen the mental health system in the Philippines. ____________________________________________________________ Strengths and Weaknesses of the Mental Health System in the Philippines It is apparent that the elements necessary for pursuing an effective mental health program in the Philippines are in place. The major resource in the Philippines is its highly literate population who also values education and professional development. Academic institutions and training centers have in the last 4 decades developed good programs to educate and develop the mental health human resources, specifically psychiatrists, psychologists, social workers, nurses and allied mental health professionals. These have developed a multidisciplinary group of professionals to address the mental health needs in the country, and have broadened the scope of the national mental health program. In some ways these changes have advanced the understanding of mental health disorders so that other agencies have initiated mental health programs relevant to their special needs. The challenge is motivating these professionals to stay in the country and sustain their involvement, especially in the community setting, because the country is continuing to lose this valuable and crucial resource to overseas employment. The Philippines has a constitutionally created Human Rights Commission, but the body should have the authority to oversee regular inspections and provide sanctions. The majority of mental health facilities are still located in the National Capital Region. Hence, access to mental health facilities is uneven across the country, favoring those living near the main cities. In the mid 1990’s, the Mental Health Program made some efforts to strengthen services in the community through trainings of local health professionals. Essential psychotropic medications are available in all the facilities. In terms of support for child and adolescent health, a psychosocial care system in schools has been established through collaboration with the Department of Health and different government agencies and NGOs. However, psychosocial support in schools is mainly delivered by teachers and only a few schools have part-time or full-time mental health professionals. ____________________________________________________________ Organization of Mental Health Services The Department of Health institutionalizes the National Mental Health Program through organization of functional management structures that groups mental health stakeholders into different committees. The national program management committee acts as the main authority and facilitates the overall implementation of priority targets and strategies aligned to health systems goals of improving the health status in the country. They are composed of mental health advocates from
  • 14. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 14 central and regional units of the Department of Health, the Director of the National Center for Mental Health, mental health experts from the medical centers, academe, consumer groups and professional organizations as well as representatives from other government agencies. a. Mental health outpatient facilities There are 46 outpatient mental health facilities available in the country, of which 28% allocate units that are for children and adolescents only. These facilities treat 124.3 users per 100,000 general population. Of all users treated in mental health outpatient facilities 43% are female and 8% of all contacts were children or adolescents. The leading diagnoses of users treated in outpatient facilities are mainly schizophrenia and related disorders (57%) and mood disorders (19%). Information on diagnosis is based on number of users treated. The average number of contacts per user is 1.87. Twenty four percent of outpatient facilities provide follow-up care in the community, while 11% have mental health mobile teams. In terms of available treatments, a majority (51- 80%) of the patients received psychosocial treatments. All (100%) mental health outpatient facilities have at least one psychotropic medicine of each therapeutic class (anti-psychotic, antidepressant, mood stabilizer, anxiolytic, and antiepileptic medicines) available in the facility or a near-by pharmacy all year round. b. Day-treatment facilities There are four day-treatment facilities available in the country, which treat 4.42 users per 100,000 general population. Of all users treated in day-treatment facilities, 44% of them are female and 7% are children or adolescents. There is one day-treatment facility (25%) that devotes a unit for children and adolescents only. On average, users spent 2.59 days per year in day treatment facilities. c. Community-based psychiatric inpatient units There are 19 community-based psychiatric inpatient units available in the country for a total of 1.58 beds per 100,000 general population. Only 1% of beds are reserved solely for children and adolescents. Thirty seven percent of admissions are female, while 6% of admissions are children/adolescents. The diagnoses of admissions to community-based psychiatric inpatient are primarily from the following two diagnostic groups: schizophrenia and related disorders (63%) and mood disorders (24%). On average patients spend 69.65 days per admission. The majority (51-80%) of patients in community- based psychiatric inpatient units received one or more psychosocial interventions in the last year. All of community-based psychiatric inpatient units have at least one psychotropic medicine of each therapeutic class (anti-psychotic, antidepressant, mood stabilizer, anxiolytic, and antiepileptic medicines) available in the facility. d. Community residential facilities There are fifteen community residential facilities, or what is casually referred to in the Philippines as “home-care facility”. They are mostly available in urban areas. They provide for a total of .61 beds/places per 100,000 general population. About 3% of the beds in community residential facilities are reserved for children and adolescents only. Thirty three percent of users treated in community residential facilities are female and only 2% are children and adolescents. The number of users in community residential facilities is 1.09 per 100,000 general population. e. Mental hospitals There are two mental hospitals available in the country for a total of 5.57 beds per 100,000 general population. Two percent of these beds are reserved for children and adolescents only. Thirty eight percent of admissions in mental hospitals are female. The two hospitals are organizationally integrated with mental health outpatient facilities. The patients admitted to mental hospitals belong primarily to the following two diagnostic groups: schizophrenia and related disorders (71%) and mood disorders (18%). The number of patients in mental hospitals is 8.97 per 100,000 general population. The average number of days spent in mental hospitals is 209. Sixty-four percent of patients spend less than one year, 18% of patients spend 1-4 years, 13% of patients spend 5-10 years, and 5% of patients spend more than 10 years in mental hospitals. Some (21-50%) patients in mental hospitals received one or more psychosocial interventions in the last year. One hundred percent of mental hospitals have at least one psychotropic medicine of each therapeutic class (anti-psychotic antidepressant, mood stabilizer, anxiolytic, and antiepileptic medicines) available in the facility. There has been neither an increase nor a decrease of number of beds in the last five years. The occupancy rate is about 92%. f. Forensic and other residential facilities In addition to beds in mental health facilities, there are also 400 beds (0.47 per 100,000 general population) for people committed by courts for confinement in forensic inpatient units. All forensic beds are located at the National Center for Mental Health. Thirty three percent of patients spend less than one year, 38% of patients spend 1-4 years, 25% of patients spend 5-10 years, and 4% of patients spend more than 10 years. There is only one residential facility (with 540 beds) specifically for people (of any age) with mental retardation. This facility is managed by the government social welfare service, which now operates beyond its bed capacity. There are six facilities (250 beds - private and public combined) specifically for people with substance abuse problems. There is one facility that cares for senior citizens aged 60 and above, both male and female, who are abandoned, neglected and mostly suffering from dementia. ________________________________________
  • 15. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 15 Paradigm Shift and Homelessness Two Vital Issues in Today’s Psychiatric Care Delivery Paradigm Shift in Psychiatric Care “Asylum psychiatry, and the Kraeplinian model on which it was based, fell into relative decline” (Wilson 1993) Psychiatry in general lost interest in the severe mental illness (SMI) as a result of the influx of psychoanalysts in the 1930s and 1940s (Miller, 1984). As Freud himself had discovered, his analytic approach was most helpful to persons with less severe problems and was not particularly helpful to psychotic patients. Thus, as Freudian thinking influenced more psychiatrists and psychiatric nurses, a natural withdrawal from the SMI and refocusing on individual’s more amenable to treatment occurred. Public mental hospitals lost prestige, as did the physicians and nurses working in them. Within the psychiatric nursing fraternity, staff nurses were not as highly valued as those who worked in the role of therapist. The devalued inpatient psychiatric nurses were referred to as either lazy or crazy. The mainstream of psychiatry and psychiatric nursing turned from chronically disturbed patients to individuals with lowered self- esteem, those who were striving to reach their potential, and those who were existentially unhappy (Detre, 1987). Psychiatry changed its focus from one extreme of the psychiatric care continuum (the SMI) to the other (the worried well) over a few decades. Psychiatry and psychiatric nursing became interested in issues such as poverty, racism, alternate lifestyle, sexism at the professional level. Some clinicians believe that this process of enlightenment and social relevance further distanced the mainstream of psychiatric care from persons most in need of that care. Psychiatry returned to its roots with the birth of the Diagnostic and Statistic Manual-III in 1980. That edition has been described by Wilson (1993) as the “remedicalization of psychiatry”. Psychiatric nursing was much slower to embtrace research (eg.: evidence- based diagnosis) and the biologic underpinnings of the more severely mentally ill. But as the Decade of the Brain (1990s) progressed, psychiatric nursing and psychiatric nursing textbooks reflected the new understandings. ____________________________________________________________ Homelessness People who are homeless and mentally ill present a challenge to the political systems in the society. These individuals are usually single or separated from loved ones, and have a weak social support system. The homeless SMI are found in parks, transport terminals, jails, and general hospitals among others. They often present a troubling appearance and many of them have become bold in their efforts to survive, assaulting the sensitivities of passersby. From aggressive panhandling to embarrassing public elimination of body wastes, societal standards are being affronted. Homeless people may live exclusively in the streets, or they may live in community shelters. A possible third group includes individuals who are able to stay in cheap hotels, alternating between this and nights in less accommodating surroundings. Still another significant group moves among homeless shelters, rehabilitation programs, jails, and prisons. In the U.S. many psychiatric professionals directly linked to deinstitutionalization of state hospitals. About 800,000 people are homeless each night (SAMSHA, 2005). Homeless population includes people and their families who have been displaced by social policies over which they have no control. Perhaps 25% are children, and another 25% are employed in low-paying jobs. The consensus of opinion is that between 20-25% of the adult homeless population has SMI, and that 50-70% suffer from alcohol or drug abuse (SAMSHA, 2005). Many suffer from both. In the Philippines, The National Statistics Office defines homeless as “households living in parks, along sidewalks and all those without any form of shelter”, it is estimated that 4.5 million Filipinos are in this situation. Seventy five percent of which is believed to be squatters or illegal settlers in the main urban centers.
  • 16. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 16 In Quezon City alone —the largest city in the National Capital Region (NCR) that is greater Manila—200,000 families are described as ‘informal settlers.’ Data gathered from the Quezon City Urban Poor Affairs Office (QC-UPAO) records showed that that 47.6 percent or 95,188 of these poor families occupy private land. More than 84,000 others reside in areas covered by government-owned and controlled corporations. The top five places occupied by the homeless in Quezon City are sidewalks and open spaces (7, 852 families); areas under the Pasig River Rehabilitation Program (4,117); and properties owned by the Metropolitan Waterworks and Sewerage System (2,342). The rest of the urban poor live along creeks and rivers; transmission and old railway lines, bridges and various sites owned by electricity distributor Manila Electric Company (MERALCO) and the National Power Corporation. Others squat in and live off the city’s garbage dumps. People often become homeless when their housing and economic issues collide with other crisis such as domestic violence, physical or mental illness, addiction, transition into adulthood, and relational strains. Up to half of homeless women and children are victims of domestic violence. Just recently, the number of Filipinos with no health insurance has been reported at over 50 million. About 26% of people who experience homelessness nationwide are mentally ill (Department of Housing and Urban Development). This compares to 6% of the country’s general population (Substance Abuse and Mental Health Services Administration). Homelessness is and end product of chronic mental illness and probably exacerbates it as well. Stated another way, many chronically ill persons end up on the streets because of their inability to succeed in a competitive society and, once they are on the streets, the stresses of the homeless life compound their mental health problems; they are in a no-win situation. ________________________________________
  • 17. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 17 Part 3: Part 3: The Current Bases of Psychiatric Mental Health Nursing Competencies of a PMHN Nurse A. Standards of Psychiatric-Mental Health Nursing Practice Standards of practice are authoritative statements used by nursing profession to describe the responsibilities for which nurses are accountable. They provide direction for professional nursing practice and a framework for evaluation of practice. They also define the nursing profession’s accountability to the public and the client’s outcomes for which nurses are accountable. Below is the current revision of Scope and Standards of Psychiatric-Mental Health Nursing Practice (ANA, 2000). Standards of Care Standard I. Assessment (collection of client health data). Standard II. Diagnosis (analysis of collected data in determining diagnosis) Standard III. Outcome Identification (identification of expected outcomes individualized to the client) Standard IV. Planning (develops plan of care that is negotiated among the client, nurse, family and healthcare team and prescribes evidence-based interventions to attain expected outcomes. Standard V. Implementation of interventions identified in the Plan of Care:  Standard Va. Counseling- to improve or regain previous coping abilities, fostering mental health, and preventing mental illness and disability.  Standard Vb. Milieu Therapy- provides structures and maintains a therapeutic environment in collaboration with the client and other healthcare providers.  Standard Vc. Promotion of Self-Care Activities- structuring interventions around the client’s activities of daily living to foster self-care and mental and physical well-being.  Standard Vd. Psychobiologic Interventions- the use of knowledge of psychobiologic interventions and the application of clinical skills to restore the client’s health and prevent future disability.  Standard Ve. Health Teaching- through which, the nurses assists the client in achieving satisfying, productive and healthy patterns of living.  Standard Vf. Case Management- coordination of comprehensive health services and ensure continuity of care.  Standard Vg. Health Promotion and Maintenance- employment of strategies and interventions to promote and maintain mental health and prevent mental illness. Standard of Professional Performance Standard I. Quality of Care Systematic evaluation of the quality of care and the effectiveness of nursing practice Standard II. Performance Appraisal Evaluation of one’s own psychiatric-mental health nursing practice in relation to professional practice standards and relevant regulations. Standard III. Education Acquisition and maintaining current knowledge in nursing practice Standard IV. Collegiality Interaction and contribution to the professional development of peers, healthcare clinicians and others as colleagues. Standard V. Ethics Assessment, actions and recommendations on behalf of clients are determined and implemented in an ethical manner. Standard VI. Collaboration Collaboration with the client, significant others, and healthcare providers in giving care.
  • 18. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 18 Standard VII. Research Contribution to nursing and mental health through the use of research methods and findings. Standard VIII. Resource Utilization Considering factors related to safety, effectiveness, and cost in planning nd delivering client care. ________________________________________ The Nurses’ Role in the New Continuum of Care Continuum of Care The continuum of care provides individuals with a wide range of treatment options. Obviously, not everyone needs admission to the hospital nor our economy can afford this level of care for the large number of people who are said to be suffering from mental health problems. The hope then is to have effective alternatives within a context of a seamless continuum. The role of nurses and other professionals is to assess the individual’s current level of functioning and then direct or escort the person to appropriate resources. Coordination of services for the individual necessitates multidisciplinary collaboration. Without this coordination, the continuum of care will not be seamless and, in fact, may hinder the very thing it purports to help. Multidiscplinary care has been expanded to include not only professional staff, but also noprofessionals, patients, family and various nonpsychiatric resources (nursing homes, medicare representative, medical clinics, etc.). The seamless continuum: SUSPECTED MENTAL HEALTH PROBLEM Leave the system NO Problem Confirmation YES RISK ASSESSMENT:  Dangerous to self and others?  Gravely disabled?  Acutely psychotic?  Suicidal or homicidal? NO YES Treatment options:  Residential services  Outpatient services  Self-help resources  Other Community-based care, consider:  Severity of patient’s illness  Amount of supervision required by the patient Hospital-based care Discharge Planning Examples: 1. An individual with auditory hallucinations telling her to kill her newborn infant needs inpatient hospitalization with 24-hour nursing care and supervision in a safe environment. 2. An individual with thoughts of suicide but without a plan might be managed effectively by attending a day treatment program 5 days a week for 2 weeks.
  • 19. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 19 3. An individual with a history of medication noncompliance who needs a place to live might be appropriately placed in a group home with a 24-hour supervision. 4. An individual with alcoholism who has completed acute detoxification might need referral to outpatient counseling or self- help groups such as Al-Anon. For any individual, additional referrals along the continuum of care can be made if needs change. An individual might be referred to mental health services at any suggestions of family physicians, police officer, family member or nursing staff from the any of the programs within the continuum. Self-referral is also a means whereby individuals can gain entry into the mental health system. Continuum of Care Treatment Options Hospital-Based Care Historically, hospitals were the point of entry into the health care system, whereas the point of entry now can be anywhere along the continuum of care. Patients admitted for psychiatric hospitalization stayed about 4-6 weeks. Today, length of stay (LOS) is typically 3-5 days. Current issues include:  Economic decisions  Decreased reimbursement  Goals, staffing patterns, acuity of patients, and discharge planning of hospitalization have changed as well: - Goals of crisis intervention is safety - Staffing must be cost-effective while maintaining quality of service - Acuity of patients has increased - Discharge planning begins immediately The highest priority for admission to hospital-based care is safety for self and others. Hospitalization provides thorough psychiatric evaluation to identify the underlying cause of their symptoms in addition to safety and protection.  When a patient is deemed a danger to self (suicidal) and others (homicidal), a 24-hour supervision in a secure environment is required.  Individuals who are acutely psychotic or those who are confused and disoriented might not function well enough to meet their basic needs including physical safety.  Individuals with toxic reactions to medications or other substances and who need medical intervention when withdrawal from substances might produce life-threatening conditions.  Some patients are admitted for a medical evaluation or because the medical illness produces or complicates a psychiatric disorder. Types of Hospital-based care include: - Locked units - Open or unlocked units - Psychiatric Intensive Care Units (PICUs) for high-acuity patients - Specialty units (eg: edults, geriatric, child and adolescent, substance abuse) Traditional Outpatient Services (TOS)  Outpatient treatment that are conducted in mental health clinics and private offices.  Psychiatrist, Psychologist, Social Worker of a Psychiatric Nurse Specialist provide counseling  The typical pattern for a patient with chronic mental illness might be a visit with a counselor or case manager, and periodic appointments with a psychiatrist for medication review.  Counseling should determine the need for additional or more intense service/s. TOS Who may benefit? Essential to program Partial Programs and Day Treatment Individuals who need some supervision, structured activities, ongoing treatment and nursing care.  Performed 4-8 hours/ day and 1-5 days/ week  Programming can occur during the day or nighttime  Specific populations or type of problem are considered when group or community treatment is conducted Psychiatric Home Care Patients who are homebound because their illness or disability inhibits their ability to leave home and obtain services.  Home visit occur in conjunction with other community-based services  Home care for patients with severe and persistent mental illness Community Outreach Programs Developed to reach individuals in areas in which lack of traditional medical and social services exists.  Mobile crisis teams reaching out to homeless population, migrant workers and their families  Mobile programs that serve the needs of mentally-ill individuals on the streets, under bridges, in parks, etc.  Physicians and nurse volunteers work hand in hand in operating neighborhood clinics
  • 20. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 20 Residential Services Available to help individuals who need temporary or long term housing needing 24- hour supervision. The LOS might be 3-6 months or longer  Extended care facilities (eg.: nursing homes) are available for people who require 24-hour supervision and medical nursing care; people with severe developmental disabilities such as dementia or acute and chronic medical illnesses benefit most  Group homes may provide temporary or permanent housing for individuals with chronic mental disorders (staff might be present for 24 hours/day or less); group therapies and structured activities are done in some group homes whereas in some, they only provide meals, bed and laundry services.  Halfway houses are commonly for individuals with chemical dependency; residents are expected to seek employment and participate in cooking and cleaning chores; self-help groups (eg.: Al Anon) in which meetings are conducted by members and not professionals and can take place on a weekly basis; Today, halfway houses are also open for individuals with other problems Primary Care Individuals with mental health problems such as anxiety, depression and sleep disturbances sometimes seek help for these problems in primary care offices and clinics. Reasons include:  Stigma of mental health care (no one will know)  Lack of knowledge about who o see and where to get help  Reduced access to care Psychopharmacologic medications are prescribed at times by primary care providers without a comprehensive history and assessment of the patient. The patient’s immediate need might be addressed, but other modes of treatment that could benefit the patient might not be provided. The nurse working in primary care areas provides those interventions (self, drugs, milieu) that benefit individuals with mental health needs. Thus, psychotherapeutic management is relevant in the primary care setting as well. ______________________________________________________________________________ Current Trend: Assertive Community Treatment (ACT), an Evidence-based Practice ACT is a comprehensive community-based service delivery model in which a team of professionals assumes direct responsibility for providing services needed by the client 24 hours a day, 7 days a week. The multidisciplinary team members compose of a nurse, psychiatrist, social worker, and substance abuse counselor work together and share responsibility for providing comprehensive treatment and support for a specified number of clients. It is an evidence-based practice model of community treatment that has reduced hospital admissions and improved social functioning and quality of life for individuals with severe mental illness (Marshall et al, 2005; Marshall and Lockwood, 2005) Treatment and services include:  Assistance with shopping  Laundry  Transportation  Housing  Healthcare and Medication monitoring; Emergency response ______________________________________________________________________________ ________________________________________ The Influences of Theories to Current Practice Prior to 1950s, the medical dominated psychiatric-mental health nursing practice. Physicians and psychiatrists assessed diagnosed and planned care for individuals with psychiatric disorders. Nurse practitioners were supervised mainly by physicians and psychiatrists who incorporated the theories of individuals such as Freud, Sullivan, Skinner, Bowen or Erikson in their practice. However, during this same period, nursing leaders began to emerge to provide impetus for the development of psychiatric nursing as an independent discipline.
  • 21. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 21 Theorist Theory Impact on Nursing Theory Sigmund Freud Psychoanalytic Nurses began to focus on human behavior, early stages of sexual development, and the use of maladaptive defense mechanisms. Harry Stack Sullivan Interpersonal Nurses recognized that humans are social beings who develop personal relationships that could result in stress or anxiety, the use of maladaptive behaviors, or alteration of the development of one’s personality. B.F. Skinner Behavior Nurses recognized that interventions could be used to bring about change in thoughts, feelings, and observed behavior. Murray Bowen Family Systems Nurses developed an understanding of individual and family behaviors and their relationship to each other. Erik Erikson Developmental Nurses recognized that personality development begins at birth and continues across the lifespan until death. Significant Nursing Theories to Psychiatric and Mental Health Nursing a. Peplau’s Interpersonal Theory Hildegard Peplau was responsible in part for the emergence of theory-based psychiatric nursing practice. She believed that the nurse served as therapist, counselor, socializing agent, manager, technical nurse, mother, surrogate and teacher. He also incorporated communication and relationship concepts and identified the four phases during the interactive processes- orientation, identification, exploitation, and resolution (Meleis, 1997). Analysis of this theory (Johnson 1997) reveals that it is effective in long-term care facility which allows for the development of nurse-client relationship. b. Orem’s Behavioral Nursing Theory The theory focuses on self-care deficit- it proposes that recipient of nursing care are persons who are incapable of continuous self- care or independent care because of health-related or health-derived limitations (Johnson, 1997). Because of the individual’s self-care deficit, a nurse, family member or friend may educate or consult with the individual to improve the deficit. This is utilized in psychiatric setting where individuals may neglect needs such as eating, drinking, rest, personal hygiene, and safety because of their underlying disorder. c. Roy’s Theory of Adaptation Human beings are use coping mechanisms to adapt to both internal and external stimuli. Two major internal coping mechanisms are the regulator and cognator. The regulator mechanism refers to an individual’s physiologic responses to stress, whereas the cognator mechanism pertains to perceptual, social and information-processing factors. Coping behaviors occur in four modes- physiologic, self-concept, role function and interdependence. This theory is important in psychiatric setting as the nurse assesses client behavior and stimuli and develops a plan of care to assist the client in adaptation in the four modes- contributing to health, quality of life, and dying with dignity (Johnson, 1997). Application of theories to Practice (Meleis, 1997) a. Needs-Oriented Approach suggests active doing and functioning. Nurses problem-solve, perform physiologic and psychosocial activities for the client, supplement knowledge, and may become temporary self-care agents for clients with self-care deficits. b. Interaction-Oriented Approach is used by nurses who rely on interactions and include themselves as therapeutic tool and evaluate their actions according to the client’s response. They counsel, guide and teach clients, helping them to find meaning in their situations. Nurses appear to be process-oriented. c. Outcome-Oriented Approach is used by nurses who are viewed as goal setters. They are referred to as controllers, conservators, and healers without touch. They focus on maintaining and promoting energy and harmony with the environment. They do not view themselves as therapeutic agents as they focus on enhancing the development of health environments. d. Eclectic Approach is an individualized style that incorporates the client’s own resources as a unique person with the most suitable theoretical model. The therapist realizes that there is no one way to deal with all of life’s stresses or problems of living and is open to new ideas and approaches as the need arises. ________________________________________
  • 22. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 22 Integrating Models in the Current Psychiatric Care Psychoanalytic Model This model is a theory of personality originated by Sigmund Freud that emphasized unconscious processes or psychodynamic factors as the basis for motivation and behavior. The theorist believed that an individual’s drives, instincts, libido, and psychosexual attitude are formed early in life and are crucial to understanding of the personality. Key Concepts a. Personality Processes consists of id, ego and superego- that function as a whole to bring about behavior. When these processes function in harmony, the individual experiences stability; when disharmony occurs, the individual is in conflict.  The individual is all Id at birth wanting to experience only pleasure principle; it involves immediate gratification, enabling the individual to strive for pleasure through the use of fantasies and images; it is compulsive without morals; the ego controls id impulses and mediate between reality and fantasy.  The ego focuses on reality principle and strives to meet the demands of the id while maintaining by maintaining the well-being of the individual by distinguishing fantasy from environmental reality. Secondary process thinking comprises rational, logical thinking and intelligence. It is the part of personality that experiences anxiety and uses defense mechanisms for protection; heredity, environmental factors, and maturation influence the formation of the ego.  The superego is concerned with right and wrong- that is the conscience. It provides the ego with an inner control to help cope with id; it is formed from the internalization of what parents teach their children about right and wrong through rewards and punishment. Self-esteem is affected by the perception of a person’s actions as good or right. The theorist proposed that guilt and inferiority are experienced when the individual cannot live up to parental standards. Inner conflicts result when the id, the ego, and the superego are striving for different goals. b. Consciousness concept of Freud is central to understanding problem of personality and behavior:  Consciousness or material within an individual’s awareness is only a small part of the mind.  Unconscious is a larger area and consists of memories, conflicts, experiences and materials that have been repressed and cannot be recalled at will.  Precocious refers to memories that can be recalled to consciousness with some effort. The theorist believed that uncovering unconscious material generates an understanding of behavior that enables individuals to make choices about behavior and thus improve their mental health. Insight into the meaning of the symptom facilitates change. c. Defense Mechanisms The ego usually copes with anxiety through rational means. But when anxiety is too painful, the individual copes with using defense mechanisms to protect the ego and diminish anxiety. When these mechanisms are used excessively, individuals are unable to face reality and do not solve their problems. Defense mechanisms are primary unconscious behaviors; however, some are within voluntary control. Painful feelings connected with childhood conflict are often repressed. Later in life, as similar conflicts are experienced once again, repression fails, and these feelings emerge, causing anxiety and discomfort. Freud defined three types of anxiety that form the basis of mental disorder:  Reality anxiety stemming from an external real threat  Neurotic anxiety, dealing with the fear that instincts will cause the person to do something to invite punishment, such as being promiscuous  Moral anxiety, such as guilt experienced when an individual acts contrary to his or her conscience Relevance to Current Practice The goals of Freudian psychoanalytic therapy and other psychodynamic therapies are to bring the unconscious into consciousness, enabling the individual to work through the past and understand their past and current behaviors. By overcoming repression and resistance to exploring feelings and thoughts, childhood experiences can be analyzed. Uncovering the causes of current behavior leads to insight (Miller, 2004). Only then individuals decrease their self-defeating behaviors and improve their mental health. In traditional long-term psychoanalysis, the therapist uses free association (allowing the patient to say everything that comes to mind) so that repressed material can be identified and interpreted for patients.
  • 23. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 23 Dream analysis helps patients uncover the meaning of their dreams, which also increases awareness about present behavior. Patient’s inconsistencies and resistance to therapy are confronted. Transference (an unconscious emotional reaction based on past experience) that occurs in the current relationship with the therapist is used to encourage working through feelings that would otherwise remain unconscious. Supportive therapy was developed for ill patients who were unable to tolerate intense probing of intrapsychic conflict, defenses and transference issues. It involves interaction with the patient (not silent listening) and emphasizes focus on the present (not on the past). Questioning is less challenging and critical, and the approach conveys empathy and understanding (Miller, 2004). In brief therapeutic encounters, the nurse must recognize and understand the maladaptive defense mechanisms that patient’s use. The nurse assesses the client’s behaviors and other relevant data gathered to formulate a nursing diagnosis. The nurse carefully shares these observations regarding these mechanisms with patients to increase awareness with these behaviors to increase adaptive behavior. Example: An individual who denies a problem with alcohol must recognize that an arrest for public intoxication, a pending divorce, and three job losses are in fact, related to drinking and that abstinence from alcohol is the major adaptive coping mechanism needed. In long-term relationships, patients can be assisted with learning to think, feel and behave according to their own individual values, beliefs and needs, not according to someone else’s. Example: A college student who is pursuing Fine Arts at the insistence of a domineering parent can be assisted in deciding his career goals, while developing ego strength to withstand parental pressures. Patients might also need assistance with accepting their desires and drives as normal, for which they need not feel guilt or shame, and with choosing acceptable ways of expressing their desires and drives. ______________________________________________ Developmental Model Erik Erikson (1963, 1968) built on Freud’s psychoanalytic model by including psychosocial and environmental influences along with the Freudian psychosexual concepts. This model spans the total life cycle from birth to death. The theorist believed that each of the eight stages of development afforded opportunities for growth, even to the acceptance of the person’s own death. Key Concepts Each Eriksonian stage is comprised of a developmental crisis involving positive and negative experiences. Mastery of critical tasks is the result of having more positive than negative experiences. Nonmastery of tasks inhibits movement to the next stage. Erikson believed that the drive of humans to earlier states and behaviors; therefore, he saw regression as a possibility. Regression often occurs as a result of trauma, prolonged or severe stress, and physiologic or psychiatric illnesses. Implied but not clearly described in Erikson’s model is the concept of partial mastery of critical tasks in development. The degree of mastery of each stage is related to the degree of maturity that the adult attains. Deficits in development carried from one stage to the next progressively interfere with functioning, until the individual is no longer capable of growing without returning emotionally to an earlier stage to resolve the crisis. Examples: A person might develop enough trust in others to engage in superficial relationship but might not be able to develop intimacy with a spouse; A person might have enough initiative to accept job but might have lack the industry to stay with it. An environmental or social tragedy can shake the early foundations of development, such as when divorce from a spouse threatens the individual’s sense of trust in others and results in self-doubt. An individual can skip developmental stage because of life circumstances, but might have to return to that stage later to master those critical tasks: Example: A young teenager mother might skip the stages of identity and intimacy as a result of the responsibilities of caring for a child (genarativity). However, this new mother will probably be drawn back to the issues of identity and intimacy, often before her child enters school. This creates an inherent conflict in roles, feelings, and behaviors.
  • 24. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 24 Mastery of the critical tasks of each stage occurs more easily when it is chronologically appropriate. Overcoming delayed or incomplete development is difficult but possible. Relevance to Current Practice Most patients with psychiatric disorders demonstrate partial mastery of the developmental stages preceding the stage for their chronologic age. The nurse conducts an assessment of the patient’s level of functioning through the interpretation of verbal and nonverbal behaviors and identifies the degree of mastery of each stage up to the patient’s chronologic age. The behavioral manifestations of problems are clues to issues to be addressed in working with the patient. Example: An adolescent is overwhelmed with shame about being sexually abused as a child. Mature relationship will not be achievable until the shame and doubt are solved through dealing more effectively with the memories and emotions related to the abuse. Patients diagnosed with schizophrenia are often struggling with trust issues because of suspiciousness and fear of closeness. The nurse must concentrate on trust-building strategies with these patients. Although Erikson focused on the polarity of each developmental stage (Eg.: trust vs. mistrust) as if the positive pole were the desirable task to be accomplished, it is now recognized that the extremes of either pole produce problems in functioning: Examples: Being overly trusting can result in being repeatedly taken advantage by others; Having too much industry will result in working beyond working hours without any time for recreation. The Need for Cultural Competence in Today’s Psychiatric Nursing Culture is critical component of patient’s lives that affects their health care attitudes and actions as well as their ability to understand and use the interventions that psychiatric nurses develop (Campinha-Bacote, 2005, 2007; Warren, 2000, 2007). Culture is the internal and external manifestation of a person’s group’s, or community’s learned and shared values, beliefs, and norms used to help individuals function in life and understand and interpret life occurrences (Leininger and McFarland, 2006). The cultural perspectives and patterns of both the nurse and patient influence the nurse-patient interaction. These perspectives and patterns also affect a patient’s level of mental health. For example, a patient’s behaviors might be labeled as pathologic if a nurse misinterprets the patient’s normal or culturally relevant beliefs and health care actions (Warren, 2000, 2007). Furthermore, a patient labeled as noncompliant might not be receiving culturally competent care (Purnll, 2009; Purnell and Paulanka, 2003). Culture and Psychiatric Nursing The U.S. Surgeon General’s report on mental health has emphasized the need for culturally competent mental health care (U.S. Surgeon General, 2001). Nurses provide services to a multitude of patients from diverse cultures. The term cultural diversity might encompass areas such as age, gender, socioeconomic status, religion, race, ethnicity, mental illness, and physically challenging conditions (Andrews and Boyle, 2007; Campinha-BAcote, 2005, 2007; Comas-Diaz and Green, 1994; giger and Davidhizar, 2008; Institute of Medicine [IOM], 2003 Leininger and McFarland, 2006;Spector,2004). The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) has incorporated additional information regarding specific cultural features for each diagnostic category and includes an appendix, Outline for Cultural Formulation, and a Glossary of Culture-Bound Syndromes (American Psychiatric Association [APA], 200). Barriers to Culturally Competent Care A growing knowledge and research base has indicated that patient’s adherence to treatment increases when cultural needs are incorporated into health care planning (APA, 2000; U.S. Surgeon General, 2001; Warren, 2001). Because nurses are often the gatekeepers for health care systems, knowledge of cultural factors related to psychiatric care is important.
  • 25. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 25 The most common barrier to the delivery of culturally competent nursing care involves miscommunication between nurses and patients. A nurse might lack knowledge and sensitivity regarding a patient’s cultural beliefs and practices hence, the nurse might not recognize the importance and value of these beliefs to the patient as they relate to health care practices. Similarly, patients might be unaware of the nurse’s cultural perspectives and misinterpret health care recommendations from the nurse (Diala et al., 2001). It is true to the Philippines society that miscommunication between the nurse and the patient might occur. Being an archipelago and acculturated by different races, the Philippines has many local languages and beliefs (Jacano, 1998). Consequently, to facilitate successful relationships with their patients, the nurse must understand his or her own cultural beliefs and values and how these beliefs and values influence patient care. This cultural awareness facilities the psychotherapeutic relationship and the nursing process (Quander, 2001; Warren, 2008a). Cultural Etiology of Illness and Disease Nurse’s and patient’s health care actions and beliefs are generally formulated by three factors: (1) their definition of health; (2) their perception of the way in which illness occurs; and (3) their cultural worldview (Carter, 1995; Chong, 2002; Diala et al.,2001; Herrera et al., 1999). Nurses and patients might define health quite differently. Closely connected to a nurse or patient’s definition of health is his or her belief of how illness and disease occur. The nurse or patient might believe that illness and disease are created by natural, unnatural, or scientific causes. For example, a person who believes in the concept of natural cause of illness or disease believes that everyone and everything in the world is interrelated and that a disruption of this connectedness (e.g. a tornado) causes an illness or disease (Giger and David bizar, 2008; Spector, 2004). Conversely, nurses or patients might believe that unnatural or outside forces create illness and disease. An individual might believe that another person enlists the services of a magician, witch, ghost, or supernatural being to cast a spell or hex on him or her. Finally, nurses or patients might believe in the scientific cause of illness—specific, concrete explanations exist for every illness and disease (i.e, the entrance of pathogens such as viruses, bacteria, and germs into the body) (Campinha-Bacote, 2005, 2007; Warren, 2007). The scientific model is the typical model taught in most Western culture schools of nursing. However, many non-Western culture acknowledge and teach health care providers the importance of the natural and unnatural causes of illness. Patient’s health care beliefs and actions are related not only to the way in which health, illness, and the cause of illness are defined but also to individual worldviews. There are four primary worldviews: (1) analytic, (2) relational, (3) community, and (4) ecologic. This primary worldview is often the one that individuals express or are comfortable with when they are with family or significant others, or during stressful times. Many individuals use a mixture of the four worldviews or adopt another worldview when they are in another environment, such as a work or business setting. The nurse’s failure to understand the patient’s primary worldview might negatively affect the nurse-patient relationship and impede successful interventions and mental health outcomes. THE FOUR WORLDVIEW Analytic A person who experiences the analytic worldview values detail to time, individuality and possessions. A person with this view also prefers to learn through written hands on, and visual resources the relational worldview is grounded in a belief in spiritually and the significance of relationships and interactions between and among individuals. The preferred learning style is through verbal communication. And individual who expresses the community worldview believes that community needs and concerns are more important than individual ones. Quiet, respectful communication, as well as meditation and reading, are valued as a learning style. The ecologic worldview is based on a belief that a form of interconnectedness exists between human beings and the earth, and that individuals have a responsibility to take care of the earth. Learning is accomplished through quiet observation and contemplation, and verbal communication is minimized. Worldviews form a basis for the expression of culturally bound mental health and wellness issues. For example, a patient or nurse using an analytic worldview perspective might espouse specific detail to time, calculations, individuality, and the importance of acquiring material objects. Being on time for appointments, immediately getting to the purpose of a health visit, and using printed pamphlets and books for health education are valued. Nurses and other health care professionals must be extremely accurate and precise when providing care for these patients. The example of individuality and valuing material goods is often embodied in traditional American society’s values, beliefs, and actions. Relational The individual with a relational worldview values the development of interactions and relationships, usually prefers learning through verbal communication, and views spirituality as an important context for living life. These individuals might want to chat for a moment before getting to the heart of the health visit. They might desire the involvement of relatives, friends, or spiritual and religious advisors during the health visit or during the nurse’s development of the
  • 26. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 26 nursing process. The relational worldview might be noted in certain individuals from African-American, Latino (Latina) or Hispanic cultures (Plummer, 1996; Warren, 2007). Community Individuals with a community worldview value the importance and needs of the community over the individual. People with this perspective often use meditation and contemplation techniques. A patient with this view is respectful and polite regarding health care advice and might not want to question a nurse or physician. This reticence might occur even if the patient does not understand the nurse’s recommendation. People from some Asian cultural groups often embody these philosophers (Warren, 2007). Ecologic A patient or nurse with an ecologic worldview values interconnectedness with other people and the universe takes responsibility for others and the world, and feels a need to maintain peace and tranquility. These individuals prefer a quiet, restful approach in interactions with others. Conversation is respectful, concise, and often kept to a minimum. Individuals from some of the indigenous or Native-American cultures might embrace this worldview. EUROPEAN-AMERICAN WORLDVIEW Component Perspective Cultural value Value is placed on the member or object or on the attainment of the object. Knowledge Knowledge is acquired according to proof of the existence of anything- that is, the ability of an individual to see, hear, touch, taste or smell it. Logic Dichotomous mode of reasoning is used. Relationship Relationships are developed based on the perceived need for them. AFRICAN, AFRICAN-AMERICAN, HISPANIC, AND ARABIC WORLDVIEW Component Perspective Cultural value Value is placed on the maintenance and development of interpersonal relationships. Knowledge Knowledge bases are developed through the use of affective or feeling senses. Logic Reasoning ability is based on the union of opposites. Relationship Development of interpersonal relationships is based on the fact that all relationships are interrelated across all continua. ASIAN, ASIAN-AMERICAN AND POLYNESIAN WORLDVIEW Component Perspective Cultural value Value is placed on the balance between member and group interactions Knowledge Knowledge bases are developed in striving for transcendence of the mind and body. Logic Reasoning ability is based on the belief that the mind and body can exist independently of the physical world. Relationship Development of relationships is grounded in the belief that everyone and everything in the physical and physical worlds are related. NATIVE-AMERICAN WORLDVIEW Component Perspective Cultural value Value is placed on the context of a person’s relationship to a Greater or Supreme Being. Knowledge Knowledge bases are developed on the basis of a person’s understanding of an individual’s relationship with the Greater or Supreme Being. Logic Reasoning ability is grounded on the belief that every person is innately good and has no evil within. Relationship Development of relationships with another person, group or community is grounded on the idea that the Greater or Supreme Being is in every person; hence all persons should be valued. Culture-Bound Mental Health Issues Culture-bound syndromes are recurring patterns of behavior that create disturbing experiences for individuals (APA, 2000). These behaviors might or might not be congruent with symptomatology presented in the DSM-IV-TR for various diagnostic categories. However, because these behaviors can be culture-based, nurses must be aware of the symptoms to assess patients who are from racially and ethnically diverse cultures accurately. People from racially and ethnically diverse cultures often use culturally specific language to describe mental distress that they experience (Munoz and Luckmann, 2005; Ross, 2001; Taylor, 2003). One example involves the description of depressive symptoms and the actual symptomatology (Baker, 2001; Delahanty et el., 2001; Pouissaint and Alexander, 2000).  Native Americans might state that they are “having heart pain” or are “heartbroken” when they experience depressive symptomatology (Warren, 2007).
  • 27. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 27  A person of Hispanic descent might say that his or her “soul was lost” (susto) because of another person’s ability to cause a frightening experience or to place an “evil eye” (mal ojo) on them (APA, 2000; Campinh-Bacote, 2005, 2007). Someone who is experiencing a lost soul might be lethargic, have appetite and sleep changes, and have multiple physical complaints. Because good health is contingent on the restoration of a person’s equilibrium, and ill person might initially consult a healer or “root doctor” to help break the spell of the evil eye and return the lost soul (Giger and Davidhizar, 2008). Traditional Western health care might be the last resource that the person contacts. Nurses must be knowledgeable about and sensitive to these beliefs. People from diverse cultural groups often describe psychotic symptomatology differently. Individuals from Malaya and Laos use the term running amok. People from certain Native-American nations might use the term ghost stickness. African-American and Applachian-American individuals might say a spell has been bound syndromes can be found in Appendix I of the DSM-IV-TR (APA,2000). Alternative Therapies People from racially and ethnically diverse groups often use alternative therapies. These treatments might include the use of acupuncture, acupuressure, nutritional therapies, skin scrapping, moxibustion, and cupping.  Acupressure and acupuncture restore balance by stimulating linear and circular lines throughout the body, known as meridians, with the use of needles (acupuncture) or pressure (acupressure) (Giger and Davidhizar, 2008).  Nutritional therapies might include the use of certain foods or herbs.  Skin scrapping or coining, moxibustion, and cupping are used to restore balance by bringing heat to the skin surface, which allows the release of the toxin or evil spirit from the affected body area (Giger and Davidhizar, 2008). - In the case of skin scrapping or coining, a person (generally a healer in the community) uses a coin and briskly rubs or scrapes the skin surface. - In moxibustion, a cotton ball containing a substance known as moxa is ignited with a match in a small glass or cup, which is then placed on the skin above a meridian. The belief is that the illness or evil is released from a person’s body when heat is generated within the meridians. However, skin abrasions and contusions, often occurring on the skin as a result of skin scraping or coining, moxibustion, or crupping, might provide a climate for infection.  Certain cultural groups (e.g., Hispanic, South American) believe that the certain liquids, foods, or medicines must be taken in balance to restore health (Fontaine, 2000; Spence and Jacobs, 1999). A medicine might be labeled as being hot and might need to be taken in conjunction with a cold liquid or food to be effective. The terms hot and cold have nothing to do with temperature but are indicative of how the substance reacts within the body to restore equilibrium. Herbal medicines have been used for hundreds of years in many countries and are now being used in increased frequency:  St. John’s wort is used to treat depression and is 2nd most purchased herbal product in the U.S. (Malaty, 2005).  Kava is used to treat anxiety and can potentiate the effects of alcohol and sedative-hypnotic drugs  Valerian helps produce sleep and is sometimes used to relieve stress and anxiety  Gingko Biloba is primarily used to improve memory but is also taken for fatigue, anxiety, and depression. It is important that the nurse doing an assessment should ask the client if he is taking any herbal preparations as it may lead to unwanted effects when combined with drugs. In the context of Philippine society, despite of its modernized and westernized changes, majority of the locals believe in folk and faith healers. FolK healers are using herbs, oils, and ritual prayers in providing treatment to the patient. Faith healers, on the other hand, perform “mystic surgeries” to drive out the cause of illness (de Torres, 2002). Ethnopharmacology Ethnopharmacology is the study of pharmacogenetic, pharmacodynamics, and pharmacokinetic influences based on different ethnic, racial, and cultural groups (Herrera et al., 1999; Munoz and Hilgenberg, 2006, Warren, 2007, 2008a). Culturally competent care is enhanced when this type of cultural knowledge is incorporated into patient care. Individuals react to pharmacologic interventions based on their normal biologic makeup, environmental influences, and cultural influences (Herrera et al., 1999, Keltner and Folks 2005). Specific ethnic, racial and cultural differences affect a patient’s medication options and close requirements. Variation in metabolism is most often cited as the cause of cross ethnic differences in response to medications. Herrera and associates (1999) have indicated that individuals from certain racial and ethnic groups have a genetically based pharmacokinetic variation, which causes them to be fast or slow metabolizes. Drugs might accumulate in a patient’s body when medications are metabolized too slowly:  People of Asian (about 50%) and Native-American descent are more sensitive to the effects of alcohol than people from other ethnic and racist backgrounds. This sensitivity is based on their relative deficiency of aldehyde dehydrogenase,
  • 28. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 28 resulting in allowed metabolism of the highly toxic intermediate product, acetylaidehyde (Herrera et al., 1999). Symptoms include a reddened flush to the neck and face, tachycardia, and a burning sensation in the stomach.  Studies have shown that African-Americans respond more rapidly to antipsychotic medications and TCAs than do whites; and they have greater risk of developing side effects from both drugs than do whites; they have higher blood levels of lithium than whites when given the same dosage and they experience more side effects requiring them lower dosage than do whites to achieve desired effects (Chen et al, 2002).  Asians metabolize antipsychotics and TCAs more slowly than do whites, therefore they require lower dosages to achieve the same effects; they also respond to lower dosages of lithium than do whites.  Hispanics require lower dosages of antidepressants than do whites to achieve the desired results (Woods et al, 2003).
  • 29. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 29 Part 4: Empowerment through Awareness on Legal and Commitment Issues, Advanced Directives and Forensic Nursing (Trends and Issues) Legal Issues Sources of Law: There are three basic sources of law: Common law which is derived from judicial decisions; Statutory or legislative law which is created by the national, federal and state legislatures and Administrative law which is developed by administrative agencies. When written laws are not completely clear or are contradictory to other laws, the judicial system is responsible for resolving these disputes. The resulting judicial decisions often influence legislative action to create an appropriate statute. 1. Common Law The term common law is applied to the body of legal principles that has evolved and continues to evolve and expand from actual court cases. The judicial system is necessary because having a law that covers every potential event that might occur is impossible. Moreover, the judicial system serves as a mechanism for reviewing legal disputes that arise in the written law; it is an effective review mechanism for those issues in which the written law is silent or confusing, and for situations issues involving both written law and common law decisions occur. Many of these rulings have influenced the current legal view of mental illness: M’Naghten rule (1843) states that individuals who do not understand the nature and implications of murderous actions because of insanity cannot be held legally accountable for murder. This ruling was based on the case of Daniel M’Naghten, a Scotsman who felt persecuted by the ruling party and attempted to kill the Prime Minister. Although he failed to kill the Prime Minsiter, he did shoot the Prime Minister’s secretary. He was ruled not guilty by reason of INSANITY and was committed to an asylum. This case has provided a basis for legal decisions in American courts since 1851. _____________________________________________________________________________ When applied today, the M’Naghten criteria state generally that a person is not criminally responsible at the time of act if, because of mental disease or “defect” , the person did not know the nature and quality of the act. Or if the person did not know it, he or she did not know that the act was wrong. Because this standard focuses on the knowledge of “right and wrong”, it is occasionally referred to as the cognitive standard. It is estimated that this defense in only 1% of cases (Moran, 2002). _____________________________________________________________________________ Clinical Example: Pedro Pandacan dropped building material off overpasses, then began shooting at automobiles on a major highway. He was behind 12 shootings and 200 acts of vandalism in Tondo, Manila area in 2003 and 2004. He has pleaded innocence by reason of insanity to murder and 23 other counts. He said voices called him a “wimp”. Cases: a. “Not guilty by reason of insanity” is a phrase that evokes passion in may people. Jeffrey Dahmer, the cannabilist murderer did not say that he didn’t do it. He said he was not guilty by reason of insanity. b. Wyatt v. Stickney, 344 F Supp 373 (MD Ala 1972), confirmed a right to treatment. In this case, the entire mental health system of Alabama was sued for providing an inadequate treatment program. The court ruled that the Alabama mental health system must do the following at each institution:  Stop using patients for hospital labor needs.  Ensure a humane environment.  Develop and maintain minimal staffing standards.  Establish institutional human rights committees.  Provide the least restrictive environment for each patient.
  • 30. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 30 After nearly 30 years, this case was settled in 2000 under a consent decree that forced the state of Alabama to implement a wide range of mental health services at the local level. c. Rogers v. Okin, 478 F Supp (D Mass 1979), determined the right to refuse treatment. In this case, the ruling prohibited Boston State Hospital from forcing nonviolent patients to take medications against their will. The court based its decision on the constitutional right to privacy. Furthermore, this decision required patients or their guardians to give informed consent before drug treatment could begin. This case has significant implications for nurses who are tempted to “force” patients to take medications for “their own good”.” d. Tarasoff v. The Regens of the University of California (1976) 17 Cal 3rd 425, ruled that mental health professionals have a duty to warn of threats of harm to others. In this case, a patient confided to the therapist that he intended to kill an unnamed but readily indetifiable girl when she returned from spending summer in Brazil. The therapist notified the campus police and requested their assistance in confining the man. The officers took the patient into custody but he relased him because he appeared rational. Shortly after her return from Brazil, the man, Prosenjit Poddar, killed Tatianna Tarasoff on October 26, 1969. Her parents successfully sued the University of California, claiming that the therapist had a duty to warn their daughter of Poddar’s threat. The duty to protect endangered third parties is now a national standard of practice, although some jurisdictions still hold that any disclosure of confidential information is a violation of patient’s rights. ______________________________________________________________________________ 2. Legislative Law Legislative law is a written law developed from legislature body, such as national policy-making body or any local ordinances. A statute can abolish any rule of common law by specifically stating the rule. Statutory law follows a chain of command, with the constitution of the Philippines being the highest in the hierarchy of enacted written law. Article VI of the Constitution declares: The legislative power shall be vested in the Congress of the Philippines which shall consist of a Senate and a House of Representatives, except to the extent reserved for the people by the provision on initiative and referendum. This article means that the Philippine Constitution, takes precedence over the approved legislative laws and local jurisdictions, such as local councils. R.A. 9173 or the Philippine Nursing Act of 2002 was enacted by the Senate and the House of Representatives of the Philippines during the 12th Congress. This law declared the policy of the State to assume the responsibility for the protection and improvement of the nursing profession by instituting measure that will result in relevance to nursing practice, nursing education, humane working conditions, better career prospects, and a dignified existence for our nurses. 3. Administrative Law or Executive Orders Administrative law is a public law issued by administrative agencies authorized by statute to administer the enacted laws of the government. This branch of law controls the administrative operations of government. One example of these agencies is the state board of nursing. The BON have been created to issue guidelines for nursing practice, licensure and compliance monitoring in the interest of public safety. TORTS (Civil Law) 1. Negligence is a personal wrongdoing that is distinguished from a criminal law violation. It is described as the failure to do or not to do what a reasonably careful person would do under the circumstances. It is a form of conduct that is considered careless and is a departure from the standard of conduct generally imposed on reasonable persons. The four elements are: a. Duty to Care  Legal obligation of care, performance, or observance imposed on a person who is in a position to safeguard the rights of others.  Such duty arises from special relationship, such as the nurse-patient.  Duty to care can arise from telephone conversation, out of voluntary act; or assuming the care of the patient.  Duty can also be established by statute or contract between the physician and the patient. b. Reasonable Care (Standard of Care)  Refers to the degree of skill, care and knowledge ordinarily possessed and exercised by nurses in the care and treatment of patients.
  • 31. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 31  A nurse must be reasonable in the exercise of professional judgment as to the care rendered; however , reasonable judgment must not present a departure from the requirements of accepted nursing practice.  “Did the nurse meet the standards of care?” (is the question in court cases where nurses are sued for negligence wherein expert nursing witnesses provide testimony to answer this question). c. Breach of Duty  It is defined as the failure to conform to or departure from a required duty of care owed to a person.  The obligation to perform according to standard of care might encompass either doing or refraining from doing a particular act. Clinical Example: A patient was admitted to a psychiatric facility late at night from a general hospital emergency room 1.5 hours away. The patient was known to have overdosed on a long acting opioid drug. Although pronounced mentally stable by the first hospital, the patient was noted to be semi-conscious and incoherent, with an irregular respiration of rate of 12 breaths/ minute. The patient’s respiratory irregularity did not improve, but neither the physician on call nor the paramedics were called. The patient died before morning of respiratory arrest. The nurses did not carry out the obligation to meet the standards of care. d. Proximate Cause or Causation  This fourth element necessary to establish negligence requires that a reasonable, close, and causal connection or relationship exists between the defendant’s negligent conduct and the resulting damages suffered by the plaintiff.  The defendant’s negligence must be a substantial factor causing the injury- that the mere departure from a proper and recognized procedure is insufficient to enable a patient to recover damages, unless the patient can show that the departure was unreasonable and the proximate cause of the patient’s injuries.  Foreseeability, as an element of negligence, is the reasonable anticipation that harm or injury is likely to result from an act or an omission to act- its test is whether anyone of ordinary prudence and intelligence should have anticipated the danger to another caused by his or her negligence. 2. Malpractice A form of professional negligence is called malpractice which can be brought against various professions including nurses. These claims against nurses are often the result of the nurse’s failure to take measures to prevent harm to patients or a failure to maintain the standard of care of nurses in the community. The psychiatric nurse is responsible for many significant decisions in the care of psychiatric patients. Lapses in attention to specific legal issues related to nursing practice can result in liability and suits against the nurses and his employer. Areas of concern that can lead to suits include:  Inappropriate dissemination of confidential information  Illegal confinement  Failure to obtain consent for medication  Inadequate treatment  Medication errors  Breach of duty to warn of threatened suicide or harm to others Understanding the concept of master-servant rule is vital to both clinical nurses and supervisors. Simply stated, an employer is responsible for the acts of the employee as long as the employee is acting within the scope and authority of employment. A nurse who exceeds clinical boundaries or fails to act reasonable and prudent nurses would, in the same similar circumstance, incurs liability to the employer. Similarly, understanding that unlicensed nursing assistants/ personnel who exceed their clinical boundaries or authority and under the direction of a nurse will cause liability to be incurred on the nurse is critical. _____________________________________________________________________________ With the push to lower health care costs in the U.S., the use of unlicensed assistive personnel (UAPs) has increased significantly. More nurses are finding themselves with job responsibilities that include delegating certain tasks to UAPs. When a nurse delegates, the authority to carry out the act on behalf of the nurse is conveyed to the assistant; however, the nurse remains accountable for the consequences of act and for the adequate supervision of the assistant. When delegating, the nurse at a minimum should:  Know and follow the local hospital procedures in order to stay within his or her scope and authority.  Ensure that UAPs assigned have been fully trained and are qualified to carry out the tasks they are expected to perform. Know the limitations and responsibilities of nursing practice in his country (in the U.S., standards may vary among states). _____________________________________________________________________________
  • 32. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 32 3. Duty to Warn Others Another area of importance to psychiatric nurses is the “duty to warn of threatened suicide or harm”. As noted, this duty is derived from the landmark case of Tarasoff v. The Regents of the University of California. Before the Tarasoff ruling, mental health professionals had no legal duty to warn of threatened suicide or harm to others. In 1976, the California Supreme Court issued the Tarasoff ruling, which states that failure to warn, coupled with subsequent injury to the threatened person, exposes the mental health professional to civil damages for malpractice. Based on this case and other rulings, the mental health professional must balance a duty to protect confidentiality with a responsibility to warn society of possible danger. _____________________________________________________________________________ A nurse who is aware of a patient’s intention to cause harm to self or others must communicate this information top other professionals and take steps to protect the potential recipient of harm. Not all comments or vague threats should be reported. The Tarasoff ruling specifies that a specific to a readily identifiable person or persons must be made. Whenever possible, a decision to communicate confidential patient communication must be discussed with the clinical team before taking an action to ensure that patient’s rights are balanced with those of third parties. Documentation in the patient’s records is crucial for effective communication of this information. The nurse who fails to take prudent action can be held liable. _____________________________________________________________________________ 4. Assault, Battery and False Imprisonment a. Assault  Its distinguished feature from battery is that assault is the apprehension of physical contact or the person’s mental security, whereas battery is the actual physical contact.  It is a deliberate threat coupled with the apparent ability to physical harm to another- no actual contact necessary.  Verbally threatening a patient that you are going to force him to take medication against his will constitutes an assault. b. Battery  It is an intentional touching of another person, in a socially impermissible manner, without the person’s consent.  It is an intentional conduct that violates the physical security of another.  The receiver of the battery does not have to be aware that battery has occurred.  Unlawful detention of a person constitutes battery. c. False Imprisonment  Is defined as the unlawful restraint of an individual’s personal liberty or the unlawful restraint or confinement of an individual.  The only necessity is that an individual who is physically confined to a given area experiences a reasonable fear that force, which may be implied by words, threats, or gestures, will be used to detain or intimidate him or her without legal justification, examples follow: - Excessive force used to restrain a patient (false imprisonment and battery) - Preventing a patient from leaving a health care facility (false imprisonment) - Wrongfully committing a patient to a psychiatric facility (false imprisonment) A psychiatric facility should have a policy that defines the parameters of confinement , and the nurse must follow the policy guidelines. ________________________________________ Commitment Issues The decision to become a patient in a psychiatric facility is important. Patients must admit to themselves and to others that self-management is no longer a viable option for emotional stability. The paradox for individuals who require inpatient care is that the process of becoming a patient can itself cause anxiety and might be depressing. The psychiatric nurse should be aware of this aspect and of the legal status of the patients in his charge. a. Voluntary Patients The vast majority of people with people with mental health problems are voluntary patients- that is, they seek help voluntarily. Although, specific procedures vary from hospital to hospital, the basic procedure is that individuals or their
  • 33. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 33 therapists request admission and patients sign the appropriate documents including consent to treatment. When individuals are ready to leave the treatment setting, they sign themselves out. In the U.S., most states have a grace period of 48-72 hours to allow professional staff time and opportunity to assess patients before they leave voluntarily. Voluntary patients who want to sign themselves out can be placed on an involuntary commitment status by the court when the staff’s assessment indicates a need for further treatment. b. Involuntary Patients (Commitments) Mental illness is not equivalent to incompetence. Competence involves the patient’s ability to comprehend. Involuntary treatment means that an individual who has the legal capacity to consent to mental health treatments refuses to do so. In the U.S., every state allows involuntary treatment of individuals who are considered dangerous to self and others because of a mental disorder. However, the state must produce clear and convincing evidence to prove that a person is both mentally ill and dangerous. Failure to comply with these guidelines can render a commitment illegal. A third criterion- gravely disabled-is also a cause (or required) for involuntary treatment in many states. Involuntary treatment is divided into three common categories:  Emergency care  Short-term observation and treatment  Long-term commitment (3,6 or 12 months)  EMERGENCY CARE Individuals who meet any of these three criteria:  Dangerous to self  Dangerous to others  Gravely disabled An authorized person such as a police officer signs documents to place an individual under involuntary care. In the U.S., the length of involuntary status varies from state to state; typically 48-72 hours is the average. _____________________________________________________________________________ The nursing staff must be absolutely aware of the point at which the emergency treatment period is over and prepare the patient for discharge at that time. Patients must be asked to remain voluntarily in the facility and, if they refuse, they might then be asked to sign out against medical advice. _____________________________________________________________________________  SHORT-TERM OBSERVATION AND TREATMENT A qualified expert must determine whether a person has a treatable mental disorder. In most states in the U.S., a psychiatrist, master’s prepared nurse, psychologist or a social worker is given an authority. For example, a person who is hearing voices telling her to kill herself meets this criterion, whereas someone who is simply angry and threatening to kill someone might not. If during emergency evaluation period, it is suspected that further hospitalization is needed, a certification hearing takes place. A complaint or a probable cause statement is written, indicating that the person is a danger to self and others or is gravely disabled, given that “search and seizure of a person without probable cause” is illegal. In this context, probable cause means that the known facts would lead an ordinary person to believe that the person detained is mentally disordered and is a danger to self or others or is gravely disabled. The probable cause hearing is not held to determine whether the person is mentally-ill, but whether just cause exists to keep the person for treatment against his will. If probable cause exists, individuals can then be detained for observation and treatment. These individuals must be informed on their rights on being certified for this level of involuntary care. In the U.S., the length and treatment varies from state to state. _____________________________________________________________________________ Patients must be released when no legal basis exists for continued confinement in the hospital. The hospital staff might suggest voluntary admission and, if it is refused, might require patients to sign out against medical advice. The staff cannot hold someone simply because they believe that the individual needs to be protected from himself. _____________________________________________________________________________  LONG-TERM COMMITMENT Long term commitment is reserved for persons who need prolonged psychiatric care but refuse to seek help voluntarily. These hospitalizations can last from 90 days to much longer. Such individuals are usually brought before a hearing officer, which is a major part of the system that checks and balances that decreases the possibility of someone being railroaded into a mental hospital.
  • 34. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 34 Commitment of Incapacitated Persons In the U.S., most states follow a procedure which is required for establishing a conservator or guardian for a gravely disabled person (the conservatee) because adults are presumed competent before the law. The legal system in the U.S. maintains that, although a person might be undergoing severe mental and emotional upheaval, that the person is nonetheless recognized as competent. The person who is being judged as gravely disabled, on the other hand is viewed by the legal system as incompetent. Once judged incompetent, the individual loses rights such as the right to marry, vote, drive a car, and enter into contracts. Gravely disabled is defined as the inability to provide food, clothing and shelter for oneself because of a mental illness. This does not mean that all people living on streets are gravely disabled, nor they should be hospitalized for their own good. However, people with money in their pockets who cannot negotiate arrangements for food or shelter are gravely disabled. (In the U.S., some states have a category for “gravely disabled”, whereas other states do not.) Conservators and Guardians The appointment of a conservator or guardian is a serious legal matter, and full legal protection is provided for persons being evaluated for conservatee status. The proposed conservatee is entitled to representation by an attorney challenge conservatorship. An appointed conservator or guardian can be given broad powers, including the right to order the conservatee to receive psychiatric treatment. Technically, although patients might receive treatment against their will, a legal distinction exists between this type of commitment and an involuntary commitment. That distinction is based on the premise that the conservator now speaks for the patient; hence, the treatment is not involuntary. Conservators are legally obligated to act in the best interests of their conservatees. _____________________________________________________________________________ Because conservators speak for conservatees, the nurse must obtain consent from conservators for decisions that are otherwise made by patients. A nurse who forgets to obtain conservator approval might face legal consequences. _____________________________________________________________________________ The Patient’s Rights 1. Right to treatment with the least restrictive environment 2. Right to confidentiality of records 3. Right to freedom from restraints and seclusions 4. Right to give or refuse consent to treatment Suspension of Rights Occasionally, suspending rights for the protection of patients or others and for therapeutic purposes is necessary. For example, the use of telephone privilege is always set on limit, primarily because unlimited use of phone by patients might not be therapeutic. _____________________________________________________________________________ Suspension of rights requires the nurse to document clearly that allowing the patient to continue to exercise the specific right might result in harm to the patient or others. For example, a suicidal patient’s right to access personal belongings might be suspended because it is believed that such a patient might attempt to harm himself with those objects. The nurse must document the concern and suspension of this right in the nurse’s notes. _____________________________________________________________________________ ________________________________________ Psychiatric Advance Directives Advance directives for mental health treatment are similar to medical care advance directives in many ways, but they have a number of additional challenges. The issue of ensuring competency when directives are executed is problematic for patients with fluctuating mental disorders. Nonetheless, in advance of a mental health crisis, individuals can issue directives about treatment in a number of areas, including but not limited to (1) the use of specific medications, including dose and route; (2) the use of specific treatment options, such as ECT; (3) the use of behavior management including
  • 35. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 35 restraint, seclusion and sedation; (4) a list of individuals who are to be notified and allowed to visit; (5) a consent to contact health care providers and obtain treatment records; and (6) a willingness to participate in research studies (Srebnik and LaFond, 1999). _____________________________________________________________________________ Nurses should be aware of the patient’s rights to establish advance directives for both physical and mental health care in the form of written statement of preference, or by legal documentation of a durable power of attorney. Nurses should be familiar with and follow employer procedures and laws that govern how the patient is made aware of this right. The following actions are also important to ensure that the patient’s right to self-determination is exercised:  Documentation in the medical record of either properly executed forms or a statement or signed waiver must be made indicating that the patient chooses not to exercise his right to provide advance directives.  The attorney in fact chosen by the patient is consulted before making decisions regarding the patient in areas specified by the document.  All members of the healthcare team are made aware of advance directives and that they are considered in treatment planning. _____________________________________________________________________________ The Effect of Mental Illness on the Justice System 1. The justice system was not designed to treat mental health problems. Psychiatric services are usually inadequate because of the relative insufficiency of psychiatric professionals and the inadequate budget allotted for. 2. The staff and budget issues are compounded by the large number of inmates who pretend to have mental disorders in order to receive medications or in order to be housed in more comfortable environment. 3. Frequently, the mentally ill who need treatment are fearful of taking medications since some medications have the potential to render them less able to defend themselves from fellow inmates. This reluctance to take medication may make individuals less capable of meeting the demands of prison. 4. When the mentally ill inmate does receive treatment, there is risk that these agents will be abused. Prisoners have been known to abuse the medication themselves, sell the drugs to others, or have the drug taken from them by stronger inmates. _____________________________________________________________________________ General Legislation/ Regulation Pertinent to Mental Health Legislation/ Regulation Year Adoption  Family Code  Child and Youth Welfare Code (PD 603) 1998 1974 Welfare legislation (eg.: benefits and payments for the old, disabled and the ill)  Labor code of the Philippines, as amended  Social Security Act of 1997  Government Service Act of 1997  National Health Insurance Act of 1997  Senior Citizens Act  Retirement Law 1974 1997 1997 1997 1992 1993 Alcohol availability, alcohol/ tobacco advertisements  Special protection of children against child abuse, exploitation and discrimination (RA 7610) 1992 Employment Law  Labor Code of the Philippines, as amended  Technical Education and Skills Development Act of 1994  Solo Parents Welfare Act of 2000 1974 1994 2000 Antidiscrimination on race, creed, disability, age, gender, sexuality  1987 Philippine Constitution  Labor Code of the Philippines, as amended  Special Protection of Children Against Child Abuse, Exploitation, and Discrimination Act (RA 7610) as amended (RA 7658)  Women in Developing and Nation Building Act  Anti-Sexual Harassment Act  Magna Carta of Women (RA 9710)  Magna Carta for Disabled Person (RA 7277)  Anti-Violence against Women and Their Children Act (RA 9262) 1987 1974 1993 1992 1995 2009 2007 2004 Reduction of income inequalities  Labor Code of the Philippines, as amended  Social Reform and Poverty Alleviation Act (RA 8425) 1975 1997 Compulsory education (school-leaving age, availability and access)  Children’s Television Act of 1997  Children not attending school, children in care  Child and Youth Welfare Code 1997 1974 1974 R.A. 6425 (Dangerous Drugs Act); Sale, administration, delivery, distribution and transportation of prohibited drugs are punishable by law with corresponding penalty of imprisonment to death and fine. 1972
  • 36. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 36 Forensic Psychiatry & Forensic Nursing The involvement of mental health professionals in the operations of the legal system has been the subject of debate and discussion. The issue of criminal responsibility involves questions of moral judgments and related legal and public policy issues rather than medical, psychiatric or psychological judgments. However, mental health professionals are called on to provide assistance and consultation about a wide range of civil, criminal and administrative proceedings (Curan,McGarry, & Shah, 1986). For example, a judge may order a client to undergo a psychiatric evaluation before trial or may request appearance of an expert witness to provide data related to a criminal lawsuit. The judicial system has guarded the right of an accused person to receive a fair, impartial criminal trial by determining whether the individual is competent to stand trial. Various please may be introduced:  The plea of diminished capacity is used to assert that because of mental impairment such as mental retardation, the defendant could not form the specific mental state required for a particular offense, such as first degree murder. The defendant is typically found guilty of a lesser offense such as manslaughter.  The plea of not guilty by reason of insanity is entered in the presence of a mental disease, such as delusional disorder, at the time of the commission of the alleged criminal act.  Guilty but mentally ill is a third plea that may be used by individuals who exhibit clinical symptoms of a psychiatric disorder such as substance abuse or sexual offenses. The criminal act occurred because of the client’s illness but the client is responsible for his behavior (eg.: a substance abuser robs a store to obtain money to buy drugs). Evaluation of an individual’s competency and mental condition at the time of an alleged crime constitutes the specialized area of mental health referred to as forensic psychiatry. If a defendant is found mentally incompetent, a judicial decision about treatment must be made. Elements of Mental Competency to Stand Trial The client:  Has mental capabilities to appreciate his presence in relation to time, place and things  Has elementary processes enabling him to comprehend that he is in a court of justice, charged with criminal offense  Comprehends that: - there is a judge on the bench - a prosecutor will try to convict him of his criminal charge - that he has a lawyer who will undertake to defend him against the charge - he will be expected to tell his lawyer the circumstances, to the best of his mental ability and the facts surrounding him at the time and place of the alleged law violation - there is or will be a jury present to pass upon evidence adduced as to his guilt or innocence of such charges has memory sufficient to relate those things in his or her own personal manner. If it is determined that a defendant could benefit from psychiatric treatment, commitment to an appropriate facility is the most common disposition. Court clinics, correctional institutions and mental hospitals provide such services. Reevaluation for mental incompetency occurs periodically, generally every 6 month, so that courts can review an individual’s treatment progress and rule on restoration of competency. A person’s commitment may be extended if it appears that competency can be restored in a foreseeable future, or it may be terminated if pretrial competency does not appear attainable (Curran, McGarry, & Shah, 1986). The Role of the Forensic Nurse The forensic nurse may function as a staff nurse in an emergency room or correctional setting, a nurse scientist, a nurse investigator, an expert witness or an independent consulting nurse specialist. The roles of client advocate, and counselor are also fulfilled. It requires familiarity with the law and legal provisions related to the area in which care is rendered. An ethical dilemma could occur because the duty to the legal system (not the client) could conflict with the issue of confidentiality is similar to Miranda Warning, in which a person who is arrested is informed of his legal rights. In other words, the client is aware, prior to the inset of care, that the nurse may be legally required to repeat anything the client has discussed in a confidential manner.
  • 37. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 37 The forensic nurse must adhere to principles of honesty, strive for objectivity, and maintain professional skills, interest, and empathy. The forensic nurse as an expert witness is to combine empathy with a willingness to translate complex, scientific and psychiatric findings into clear and pertinent meaning. Factors that determine expert witness include level of education, clinical training, licensure, specialty board certification, experience and reputation. Scholarship, or the participation in workshops and the publications of articles in leading journals, adds to one’s reputation as an expert witness (Curran, NcGarry, & Shah, 1986). _____________________________________________________________________________ In today’s medical-legal environment, the expert witness must also be familiar with courtroom procedures and the limitations of his own potential liability. An expert witness may serve as a consultant about the quality of care provide in a malpractice claim, may conduct evaluation of hospital policies and procedures, or may provide a testimony in court. ___________________________________________________________________________
  • 38. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 38 Postscript SUICIDE: An Alarming Malady Delivered by Christian Luther Fabia, R.N. During the 2010 Scientific Fora, Continuing Education for Health Care Professionals December 10, 2011, Top Plaza Hotel, Dipolog City, Zamboanga del Norte The Vice President for Academic Affairs of the Andres Bonifacio College, Dean Nelly Saberon; The dean of the Philippine Advent College School of Nursing, Dean Arlene Berago; Fellow professionals, ladies and gentlemen, a pleasant evening! How Alarming SUICIDE is? According to the World Health Organization, the Philippines has a relatively low suicide rate. Based on a study conducted by the WHO in 1993, an average of 2.5 males and 1.7 females among 100,000 Filipinos commit suicide. In 2009, economic depression was noted in the first world countries that suicide behaviors increased. But it was not as alarming as the 1959 when profound economic depression hit the business world and businessmen jump off from the high floors of Time Square buildings. In 2011, A POLL STUDY completed in Washington D.C. opposed the theory of suicide prevalence IS HIGHLY RELATED with economic wealth. In a studies conducted by Gallup Polls from 2005-2010 it revealed that lower suicide rates is not a matter of national income but religiosity plays a vital role. The polls show that countries that are more religious tend to have lower suicide rates. From the same studies: - Philippines has a religiosity rate of 79% and a suicide of 2.10 - Japan has a religiosity rate of 29% and a suicide of 24.20 - Kuwait has a religiosity rate of 83% and a suicide rate of 1. 95%. THE HIGHER THE RELIGIOSITY, the lower than suicide rate. This has been constant in the 66 countries in which the study was conducted. Although, the Philippines has one of the world’s lowest suicide count, it is very alarming to know that a tribal minority in Palawan has the WORLD’S HIGHEST SUICIDE RATE. An anthropological studies conducted in Palawan from 1972 to year 2002 by Charles Mc Donald revealed that the Tamlang Tribe, a minority in the highlands of the province of Palawan have the WORLD’S HIGHEST suicidal rate. The established statistics is as high as 173 per 100,000 population, compared to 24.20 of Japan and 36.15% of Russia. In October 2011, the ABS CBN late night documentary, CHECHE LAZARO PRESENTS (popularly called CLP) featured stories of suicide that did highlight the TAMLANG tribe of Palawan. People have constant references to self-inflicted death to the effect that “one would just take a length of rattan, tie it to the roof-beam and . . . that’s it!” A number of recent occurrences of suicide were pointed out during taped interviews. Suicide seemed to be an ever-present topic of conversation. People were threatening to commit suicide and they said it with no apparent levity. They could name victims and share stories with cheerfulness, no traces of tragedy! They believed that committing suicide is bravery so that victims are given honors, they have no concept of eternity or “life after death”. According to the investigative report, Christianity, Muslim or any formal religion has been consistently rejected by the tribesmen since their first attempt in the 1970s. In 2003 studies in the US, two of every 3 suicide victims are white males, however, the suicide rate among African-Americans is rising. In 2010 Studies, suicide rates among immigrants in the America is higher than those among native-born population. This can be alarming for Filipinos since US is the destination of choice for most Filipino immigrants.
  • 39. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 39 In this discussion, we will focus on different dimensions of SUICIDE as an alarming malady. 1: The Transcultural Aspect of Suicide How SUICIDE is viewed differently in varied cultural settings? Minimal information is available pertaining to cultural beliefs about suicide, nurses should be aware of possible cultural influences. Suicide is forbidden under Islamic law and is considered SHAMEFUL in the Filipino Culture. In other parts of the world, the suicide of elderly Eskimos who could no longer participate as productive members of a tribe was expected. Culturally sanctioned suicide has been practiced by the Japanese (hara-kiri) and Hindu widows (sutee). Members of militant groups in the Middle East (eg. Palestine, Iraq) still place culturally sanctioned suicide, such as by attaching explosives themselves and detonotating them when approaching specific targets. The suicide patterns around the world vary widely among cultural backgrounds and important factors would include- the physical environment, the process of imitation, social environment (group integration, cohesion and regulation), poverty and economic change. In general, 16.9% of youth around the globe who are emotionally distressed attempt suicides. And, Native American adolescents, among the documented phenomena in civilized settings have the highest incidence of nearly 50%. #2: Etiology of Suicide 1. Biologic a. Genetic Studies In 2000, the Muller studies revealed through DNA analysis the presence of 102T/C polypmorphism in 5-HT2a receptor gene that is significantly associated with major depression. The neurotransmitter SEROTONIN receptor levels did not normalize after depression was treated successfully. The genetic analysis suggests that an individual with such genetic characteristics may be biologically predisposed to depression and recurrent, profound depression may lead to suicide. Perhaps if clients knew that their suicidal urges had a genetic component, they might seek help more readily. b. Twin Studies: In 2003 Saddock studies focused on suicidal behavior among twins and adoptees. According to the studies of twins, suicide among identical twins was significantly higher (11.3%) than suicide among fraternal twins (1.8%). The studies also revealed that adoptee suicide victims experiencing a situational crisis or impulsive suicide attempt or both had more biologic relatives who had committed suicide than members of the control group. 2. Sociologic Suicide can be divided into three categories based on the degree of an individual’s socialization: a. Egoistic suicide- suicide by an individuals who are not strongly integrated into any social group (eg. an elderly male whose wife died and had no children). b. Altruistic suicide- suicide by persons who believe sacrificing their lives will benefit society (eg. A suicide bomber believes that killing himself will benefit the overall condition of the society). c. Anomic suicide- suicide that occurs when an individual has difficulty relating to others, adapting to a world of overwhelming stressors, or adjusting to expected normal social behavior (eg. a college student who is popular in highschool in his province has difficulty adjusting to college life, feels socially unaccepted on campus and commits suicide) 3. Psychologic Theories Sigmund Freud Suicide Theory He believed that suicide was a result of anger turned inward. According to him, suicide represented aggression against an introjected love object. He also doubted that suicide would occur without an earlier repressed desire to kill someone else. That is, he postulated that suicide is an inverted homicide act because of anger towards another person. Freud, the father of psychoanalysis concluded that an individual has a self-directed death instinct composed of the wish to kill, the wish to be killed and the wish to die. Theory of Parasuicidal Behavior The term parasuicide describes individuals who engage in self-injury (eg. self-inflicted wounds) but usually DO NOT WISH to die. Self-injury is often a coping method used to deal with disturbing thoughts and emotions to relieve tension. Clients who self-injure themselves generally claim to experience no pain and state they are angry at themselves or others. The incidence of self-injury in the psychiatric setting has been estimated to be more than 50 times that of general population. It also occurs in 30% of oral substance abusers and 10% on intravenous drug abusers. The most common form of self-injury is TRICHOTOLIMANIA (compulsive hair pulling). Individuals who exhibit this behavior claim that they experience an increasing sense of tension immediately before pulling out the hair, followed by pleasure,
  • 40. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 40 gratification or relief. Pulling of hair may continue until external events or soreness intervenes or an elusive “just right” feeling is achieved. The social consequences to self-esteem due to hair loss may precipitate depression, use and abuse of substance to cope with feelings or place the client at risk for suicidal behavior. Other Psychological Factors: a. A reunion wish or fantasy- Common phenomenon is the suicide of an elderly widow or widower whose husband or wife just died. b. A way to end one’s feelings of hopelessness and helplessness- persons who are helpless and hopeless feel insecure, believing there are no solutions to problems. They experience the SENSE OF THE IMPOSSIBLE. c. A cry for help- some people attempt suicide to draw attention to themselves. d. An attempt to “save face”- These people viewed themselves as competent, successful and respected before suicidal ideations invaded their thoughts. With sudden failure, an effort to save face to relieve them from the responsibility from that failure precipitates the suicidal event. e. Success depression is an overwhelming experience in which the person cannot contain the thought of future responsibilities, suicidal ideations and attempts usually succeed. #3: Individuals at Risk for SELF-DESTRUCTIVE BEHAVIOR a. Clients with Psychiatric Disorders- Clinical cases such as major depression, BPDO, schizophrenia, schizoaffective DO, personality DOs, Eating and alcoholism or drug abuse are considered the most serious of risk factors. At some point of hospitalization, 50% of these patients attempt suicide. Studies also show that male depressed clients successfully commit suicide approximately five times more often than females who are depressed. Approximately 4,000 clients with the diagnosis of schizophrenia commit suicide per year; approximately 5% of clients diagnosed with antisocial PD commit suicide per year; and approximately 10-15% of individuals who abuse alcohol commit suicide per year. Although 20% of client with the diagnosis of anxiety attempt suicide, they are usually unsuccessful. Precipitating events to suicide would include command hallucinations, delusions of grandeur, lack of impulse control and manipulative behavior. It is important that nurses learn to recognize and communicate these signs in patients with psychotic disorders. Overwhelming grief, severe anxiety, panic attacks, agitation or a chemical imbalance are linked to suicide risk in clients with depression. Individuals with severe depression have been known to commit suicide following treatment and during the recovery process, a time during the client experiences an increased in energy level as the effect of anti-depressant drugs. Patients with anorexia or bulimia nervosa exhibit a passive form of suicide that could become active due to feelings of frustration, guilt, anger or manipulation and loss of control. Alcohol and certain drugs are known to cause central nervous system depression. The mixing of drugs and alcohol may cause a drug-alcohol interaction that could lead result in death. Death as a result of self-destructive behavior is more associated with drug- drug interaction rather than drug-alcohol interaction. This is because more drugs can cause dependency creating emotional and psychological problems as well as physiologic deterioration. b. Clients with Alexithymia The term is NOT a psychiatric diagnosis, but a construct introduced in 1972 derived from the Greek Language, it literally means, “having no word for emotions”. This construct is useful for characterizing clients who seem not to understand the feelings they experience and seem to LACK THE WORDS to describe their feelings to others. It is simply A DEFICIT OF SELF. It is an experience that have been found to be at risk for self-mutilation and suicidal behavior. c. Clients with Medical Illnesses The suicide rate among NON-PSYCHIATRIC general hospital clients after discharge has been reported to be three times higher than it is among the general population. Pain, suffering and decreased quality of life are among of the various verbalized reasons for suicide attempt and executions. The presence of neurologic alterations is the leading cause of suicide associated with medical illnesses: - Suicide post traumatic brain injury is two to three times higher than in the general population.
  • 41. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 41 - In clients with SCI, the period of immediately after the injury is one particular vulnerability. Approximately 83% of the suicides occur within 6 months of the injury and 90% occur within years. - Epilepsy raises the expected death rate due to suicide fivefold in men and twofold in women. - Suicide risk is as much as 13 times higher in patients with Huntington’s Disease compared to the general population. d. Adolescent Clients According to the statistics in Adolescent clients done in 2003, the rate of suicide has quadrupled since 1950 from 2.5 suicides to 11.2 suicides per 100,000 population in the year 2000. According to the Philippine Center for Mental Health in 2006, Filipinos do not take seriously the suicidal threats or behavior in adolescent population making it difficult to document or obtain population for research studies. In the United States, the studies done in 2003 reveals that 12,000 children and adolescents are hospitalized for suicidal attempts. Suicidal ideations, gestures and attempts are associated with adolescent depression and have become a growing mental health problem. Suicidal behaviors are often linked to school performance, making potential high school dropouts a high risk group. e. Identity Crises: It has been constantly identified that PUBERTY is a stage of extreme crisis in which the psychosocial task is to resolve conflict of IDENTITY- sexually, behaviorally, emotionally and the need to satisfy the sense of belongingness. Acceptance and idealism are the preoccupations of teenagers. f. High-risk Population Groups In my review class, we adopt the DSM IV TR’s ellipsis: SAD PERSONS, but in a scientific forum such as this, I would like to discuss methodically WHO ARE THE HIGH RISK groups for suicide. It’s alarming to know that link between certain occupations and suicide behavior has been proven. Individuals whose occupations require selfless public service and dedication and who work under pressure are at highest risk. For example, a police officer or a soldier who work long hours and often experience disruptions of family and social life may develop major depressive DO or substance-related DO due to ineffective coping. Thus, suicide may be a means for them to escape feelings of hopelessness or helplessness. Several studies have indicated that occupations with the highest risk of suicide include anesthesiologists, psychiatrists and dentists (Crisis Intervention Network, 2002). In popular Hollywood TV shows, some personas have become popular by engaging in masochistic sexual acts by using devices to enhance autoerotic feelings, and “daredevils” such as David Blane who attempt death-defying acts. Such acts are considered to be passive suicidal behavior. Now, let me recapitulate the ellipsis SAD PERSONS: Sex: Men commit suicide more frequently than women do; however, women make more suicide attempts. Age: Those at greater risk for suicide are younger than 19 and older than 45 Depression: The risk of suicide increases with depression Previous Attempts: The rate of suicide increases among people with a history of suicide attempts Ethanol or alcohol abuse: The rate of suicide is higher among alcoholics than among the general population Rational Thinking: Individuals who experience impaired judgment (eg, psychosis, substance abuse, neurologic DO) are at greater risk Social Support: individuals who lack support systems are at greatest risk Organized Plan: The more organized the plan for committing suicide, the greatest risk No spouse: Single, divorced, widowed or separated individuals are at greatest risk for suicide than whose are married Sickness: Individuals who experience a chronic or debilitating illness are at greatest risk #4: How Nurses Intervene? Forensic Psychiatry: The involvement of mental health professionals in the operations of a legal system has been the subject of debate and discussion for several years in the judicial system. The issue of criminal responsibility involves questions of moral judgments and related legal and public policy issues rather than medical, psychiatric or psychological judgments. (Eg.: A patient who is highly at risk for self-mutilation and suicide is put to restraint- the argument of the patient’s freedom from restraint arises. Illegal Detention which is a legal issue rather than the patient’s safety from harm may be the focus of debate). For suicide victims whose family or significant others suspect that it was homicide rather than the victim killed himself, should file a case against the suspected murderer, the court may invite an EXPERT WITNESS to investigate for the presence of suicidal cues
  • 42. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 42 that may have been exhibited by the victim before the suspected suicide actually did happen. That is, to either support or disprove the suspected suicide. Do Nurses have Role in Forensic Psychiatry? Nurses may play role in forensic psychiatry. The role of the forensic nurse varies according to legal status of the client. Forensic nurses function as staff nurses in an emergency room, correctional settings, social work department and most commonly, an EXPERT WITNESS (“Friends of the Court”). The role of forensic nurse encompasses various aspects of care- CLIENT ADVOCACY, EDUCATION AND COUNSELING. Particularly for suicidal individuals, the nurse acts as CRISIS FORENSIC by assessing the dangerousness of a client’s behaviour toward self or others. A FORENSIC NURSE plays a vital role in the assessment of suicidal ideations and implementing measures to prevent executions of such. ASSESSMENT Assessing the Degree of Suicide Risk Although suicide is an alarming phenomenon, it is also considered as the MOST PREVENTABLE CAUSE OF DEATH among other fatal human experiences (eg.: Cancer, Accident, Physical Trauma). This statement is based on the assumption that all suicidal persons are AMBIVALENT about life and therefore are never 100% suicidal (the theory of self-preservation/ basic human instinct). Putting psychotics are at higher risk of committing suicide than those of neurotics. The decision to provide care for a suicidal client requires the use of excellent assessment skills and crisis intervention techniques. In crisis forensic, the terminology commonly used to describe the range of suicidal thoughts and behavior, often referred to as “the suicide lexicon”, it includes: A. Suicidal ideation (the vague, fleeting thoughts about wanting to die) B. Suicidal intent (thoughts about concrete plan to commit suicide) C. Suicidal threat (the expression of a person’s desire to end his life) D. Suicidal gesture (intentional self-destructive behavior that is clearly not life-threatening but does resemble an attempted suicide) E. Suicidal attempt (self-destructive behavior by which an individual responds to ambivalent feelings about living) In most cases, the client’s degree of suicidality is not a static quality, possibly fluctuating quickly and unpredictably. Therefore, a nurse should assess risk in an ongoing process, NOT A SINGLE EVENT. But, assessment requires an in-depth knowledge about the client and information is obtained primarily from the client. If this could not be possible, significant others are involved in the risk assessment. Indicators of suicide may include: a. The statement that he wish to die. b. In the hospital, the patient inquires about the routines of night shift duty personnel, the height of the window from the ground, how many pills would it take to kill a person, and so forth. c. Fears being unable to sleep and fears the night d. Appears to be depressed and cries frequently e. Self-imposed isolation, hopeless, helpless attitude and guilt feelings are common f. Imagines some serious illness such as cancer (the person may want to end the suffering or decrease the imagined burden to the family. g. Talks or thinks about punishment. Torture and being persecuted h. Auditory hallucination (telling the patient to take his life) i. Suddenly seems very happy, without any apparent reason after being depressed for some time (for he finally figured out a methof of committing suicide). j. Collects and hoards strings, pieces of galss, knofe or anything sharp that might be used for self-harm k. Aggressive, impulsive, acts suddenly and unexpectedly l. Shows an unusual amount of interest in geeting his or her affairs in order m. Gives away personal belongings n. Has a history of suicide attempts Tools in Suicide Assessment In 1977, Bailey and Dreyer developed the SUICIDE INTENTION RATING SCALE (SIRS) for Hospitalized Clients s a guide in implementing nursing measures. The severity increases with the score. 0: No evidence of past, present suicidal ideation 1+ : Suicidal ideation but no attempt or threat 2+ : Actively thinking suicide (or history)
  • 43. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 43 3+ : Suicidal threat verbalized 4+ : Actively attempted suicide or hospitalized to prevent self-destructive behavior Planning and Implementing Interventions A. SUICIDE PREVENTION 1. PRIMARY PREVENTION Identify and eliminate factors that cause or contribute to the development of an illness or disorder that could lead to suicide. Example: A hospitalized teenager due to an injury faces the possibility of being confined to wheelchair. Recognizing that teens with disabilities are at risk for depression and suicide, primary prevention focuses on providing a support system, promoting positive coping skills, and educating the teenager about his hospitalization. 2. SECONDARY PREVENTION Involves attempts to identify and treat physical or emotional disorders in the early stages before they become disturbing to an individual. Example: A woman experiences feelings of increased anxiety when told by her husband that he files legal separation. Secondary prevention such as individual therapy may alleviate the symptoms and prevent onset of self-destructive behavior. 3. TERTIARY PREVENTION Used to reduce residual disability after an illness. Example: Home visits, continuous follow ups or encouraging involvement in civic activities for a post-alcoholic patient who previously attempted suicide and is recovering from severe depression. Supervision and social support are important since relapse could still be possible. B. SUICIDE PRECAUTIONS Clients at risk for suicide need either constant (one-to-one visual supervision) or close (visual check every 15 minutes) observation is a safe, secure environment. C. NO-SUICIDE CONTRACT Since 1973, nurses, social workers, psychologists and psychiatrists have endorsed the use of no harm or no suicide contract, believing them beneficial in treating suicidal clients. In such a contract, the client is asked to agree to control suicidal impulses or to contact a nurse or therapist before attempting suicide. However, NO-SUICIDE contracts must be used with caution because they may give false sense of security to the HC team, who may overlook the impact of depression on a client’s mental functions, cognitive and perceptual processes, and capacity to exercise, self-control, judgment and discretion. Contracts are often made with clients whose suicidal risks are underestimated. D. SECLUSION AND RESTRAINT The hospitalized client may require confinement to a secure room to allow staff to observe the client’s behavior more readily. Upon admission, BODY SEARCH is done to remove all dangerous objects the client may carry with him to the hospital. The clothing of the patient upon admission is removed and changed with seclusion gown. Clothing and bed linens are removed from the room because these items have been used to attempt suicide by hanging oneself. The use of restraint, full or belt is considered to be the last resort to immobilize an agitated, self-destructive clients. The door to the seclusion room is locked whenever the client is left alone, and frequent periodic checks are made according to established protocol. Basic human needs must be met since clients at risk for suicide often neglect physiologic needs. Medical care is provided as needed. In most cases, visitation by family members and significant others are restricted. Visitors may accidentally left behind items that the client may use for executing his plans or the visitor may innocently alter the patient’s emotional and psychological conditions. Chemical restraint is the term used when psychotrophic drugs are use to manage behavior. Antidepressant drugs have been the mainstay of treatment for suicidal patients precipitated by extreme depression. Continuum care must be addressed after the acute situation has stabilized. Social services referrals regarding assistance with basic needs and the discussion of a 24-hour suicide hotline are vital. In Manila, various NGOs offer over-the-phone counseling for clients in extremely difficult situations. Caritas Manila and the 700 Club Asia to name two. It is also important that the CRISIS FORENSIC educate the family on the signs of depression and recurrence of suicidal attempts. Clinical Example: MRS. AGUILAR, a 35 year-old teacher and mother of three children has been admitted to the neuropsychiatric unit of Philippine Center for Mental Health with a diagnosis of depression. During the interview, she exhibited symptoms of suicidal ideation because
  • 44. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 44 he made statements such as “I’d better off dead”, “My family would be better off without me”, and “yes I have thought of killing myself”. With these, she was placed in strict suicide precautions and antidepressant medication began attending therapy sessions on the unit. Within 3 weeks, the suicidal precautions were lifted, and Siyanse was granted garden privileges but was to be supervised by one of the unit employees. She appeared to be improving and was granted a day pass to visit her family 4 weeks after her admission. At approximately 3:00 PM tha day aftyer visited her family, she asked for garden priveleges to play badminton. Although, MRS. AGUILAR was supervised by a hospital employee, he was able to run away and leave the facility’s grounds. Later that evening, her family notified the facility that she had secured a handgun and committed suicide. If you were the nurse who is beginning to develop a therapeutic relationship with the patient, how do you respond emotionally, psychologically and mentally? Nurses who are not used to handle a case like this would be shocked, experience guilt and wonder whether something was to upset him. Hence, victims of a suicidal event may not only include the dead person but also includes the health care provider, the family and other patients. The nurse needs to instrospect about his personal views of the event, whether or not he must feel guilty for missing an assessment or an intervention that led to the success of the suicide. With this, the expertise of a crisis forensic nurse is of particular importance. In April 2009, the death of Trina Etong (wife of the famous broadcaster Ted Failon) became a nationwide headline. It was initially believed that a foul play did happen and Ted Failon was the initial suspect for the crime HOMICIDE. Forensic examination of Etong's skull showed the contusion collar on the entry wound is uniformly level. The contusion collar is the wound caused by the bullet trajectory to the human body. The contusion collar is very significant because it is the bruise made by the entry of the bullet. This is very significant because her contusion collar was very uniform. What this means is that the gun used was directly perpendicular to Etong' s head. This shows that it is most likely a suicide. Psychological Autopsy supplemented the forensic examination revealing Trina Etong’s significant suicidal behaviors which were shared by her friends and family members. It was consistent “she wanted to die after the graduation of her daughter”. The investigation concluded that it was a SUICIDE rather than homicide. Failon was back on the national television months after the incident. Psychological Autopsy is the review of the client’s behavior and suicidal act done through an interaction with staff members, the family and friends of the patient. It is a process used to examine what clues, if any, were missed so that staff members can learn from evaluation of a particular situation. This process also provides staff with an opportunity to self-assess their behavior and responses and discuss their concern with peers. As mentioned earlier, survivors of successful suicide attempt are also victims, commonly experiencing feelings of confusion, shock and disbelief initially. When they recover from the psychological impact of a loved one’s death, feelings of anger, ambivalence, guilt, grief and possible rejection emerge. The Crisis Forensic Nurse intervenes with Postvention for Bereaved Survivors. 1. In the first phase (within the first 24 hours) the goal is to allow ventilation of feelings of shock and grief. 2. During the second phase, survivors are given the opportunity to develop new coping methods to help prevent the development of maladaptive or destructive behaviors. The survivor learns to cope with feelings of lowered self-esteem, depression and fear of developing a close interpersonal relationship. 3. The third phase, the focus is on helping the survivor view the grief experience (it lasts on the first anniversary of death/ normal grief) And to end this discussion, I shall answer the foundation of this discussion: WHY SUICIDE AN ALARMING MALADY? A malady we say because it is an integrative dilemma of both the human body and the human soul. Somatic therapies may intervene with the treatment of physical symptoms of depressions that may lead to suicide but it is alarming to know that there cans BE NO medication to cure the human soul. Thus, suicide may still persist even with the effect of an anti-depressant. It is the very evidence that soul do exist. I will leave you the question: HOW DO YOU INTERVENE AS A COMPETENT AND ETHICAL REGISTERED PROFESSIONAL? The first step in the acquisition of wisdom is silence, the second listening, the third memory, the fourth practice, the fifth teaching others. - Solomon Ibn Gabriol Daghang Salamat!
  • 45. CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 45 References: Textbooks: Basic Concepts of Psychiatric- Mental Health Nursing; Author- Louise Rebraca Shives, 6th Edition Keltner’s Psychiatric Nursing; Authors- Norman L. Keltner, Carol E. Bostrom, Teena M. McGuines Psychiatric-Mental Health Nursing, 4th Ed.; Author- Sheila L. Videbeck Journals: WHO-AIMS/ DOH report on mental health system in the Philippines (2006), Manila, Department of Health APA (2000); DSM-TR (4TH ED.); Washington DC, APA Internet Resources