Nursing Assignment
hsingbeh@20
Chapter32SeriousMentalIllness1.pptxChapter 32
Serious Mental Illness
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Objectives
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Discuss the effects of serious mental illness (SMI) on daily functioning, interpersonal relationships, and quality of life.
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Describe three common problems associated with serious mental illness.
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Define anosognosia and its impact on accessing treatment and maintaining treatment adherence.
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Discuss five evidence-based practices for the care of individuals with SMI.
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Serious Mental Illness
Defined: Group of psychiatric conditions, most of which are primarily biological in origin, that can significantly affect functioning and one's quality of life, especially if they go untreated
U.S. organizations use the abbreviation SMI
4.6% of all adults in United States have SMI
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Examples of SMI
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Mood disorders
Personality disorders
Psychotic disorders
Subtypes of schizophrenia
Case Study
Marcus, 23, has been stigmatized all his young adult life ever since, at the age of 16, he began displaying early schizoid symptoms. Teased and bullied in high school and one (disastrous) semester at college, he has tried a long string of fast-food jobs, only to be fired because of a crippling social anxiety in such a fast-paced setting. He is currently homeless after becoming physically aggressive and frightening his aging parents.
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Older Adults with SMI
Before deinstitutionalization, psychiatric hospitals were long-term residences
Patients became dependent on services and structure and were unable to function independently
Now, current challenges are inadequate housing, diet, and more physical toll and medication-induced medical conditions
This Photo by Unknown author is licensed under CC BY.
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Younger Adults with SMI
Limited experience with formal treatment
Experience series of disjointed short-term hospitalizations
Cycles of quick treatment, brief recovery, nonadherence, and relapse
Hospitals often fail to recognize need for treatment
Additional problems, such as increased frequency of relapse, legal difficulties, homelessness, substance use, unemployment, and poorer long-term prognosis
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Development of Serious Mental Illness
Similarity to Chronic Physical Illness
Original problem develops
Original problem increases
Coping erodes
New problems develop (e.g., loss of social skills)
Social interactions provoke more anxiety
Withdrawal leads to isolation & lack of support
Coping and functioning continue to deteriorate
This Photo by Unknown author is licensed under CC BY-SA-NC.
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Rehabilitation versus Recovery
Rehabilitation—focuses on
Managing patients’ deficits
Helping them learn to live with their illness
Recovery—focuses on
Client empowerment and strengths
Achieving goals of clients’ choosing
Leading increasingly productive and meaningful lives
Supported by NAMI
This Photo by Unknown author is licensed under CC BY-SA.
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The recovery model: Is patient/client-centered.
Is hopeful and empowering.
Emphasizes the person and the future rather than the illness and the present.
Involves an active partnership between patient and care providers.
Focuses on strengths and abilities rather than dysfunction and disability.
Encourages independence and self-determination.
Focuses on achieving goals of the patient s choosing (not the staff s).
Emphasizes staff working collaboratively with clients, building on strengths to help consumers achieve the highest possible quality of life.
Aims for increasingly productive and meaningful lives for those with SMI.
Case Study
After an anxious outburst outside a popular restaurant, Marcus is taken by police for a mandatory 3-day psych hospitalization for the third time in 6 weeks.
Fortunately for Marcus, due to a rise in the tourist industry in his city, the city council has developed a “three-strikes” program for its mentally ill homeless population. After three mandatory hospitalizations, patients are given a case worker who works to help patients find more long-term rehabilitation options to help keep them off the streets.
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Issues Confronting Those with SMI
Establishing a meaningful life
Comorbid conditions
Physical disorders
Suicide
Substance use
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Issues Confronting Those with SMI (Cont.)
Social problems
Stigma
Isolation and loneliness
Victimization
Economic challenges
Unemployment and poverty
Housing instability
Caregiver burden
This Photo by Unknown author is licensed under CC BY-SA-NC.
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Issues Confronting Those with SMI (Cont.)
Treatment issues
Anosognosia: inability to recognize one’s own illness
Nonadherence
Medication side effects
Treatment inadequacy
Residual symptoms
Relapse, chronicity, and loss
This Photo by Unknown author is licensed under CC BY-SA-NC.
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Case Study
Marcus’s case worker finds him a bed in a halfway house for men with SMI. During intake, the admissions nurse learns from Marcus that he initially did well on his medications when he was first diagnosed.
“But then,” Marcus says, “I started doing good and I figured out that I was cured. I didn’t need those drugs and their side effects anymore. I don’t need them now either. I’m not ill. I’m just pissed off. People are just out to get me, like in high school. This society never changes.”
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Quick Quiz
Part of Marcus’s illness, then, is an inability to recognize that he is ill. This is called
relapse.
anosognosia.
nonadherence.
residual symptom.
ANS: B
Anosognosia is a symptomatic inability to recognize the illness as an illness. Relapse is the cycle of getting better only to fall into the cycle of severe SMI symptoms and behaviors again. Sometimes this is due in part to nonadherence: noncooperation with one’s treatment regimen. While this is certainly true of Marcus, the nonbelief in his own illness is in itself called anosognosia.
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SMI Resources
Research & educational support
Comprehensive community treatment
Community services and programs
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Community Services and Programs
Case management
Day programs
Group and individual psychotherapy
Family therapy
Psychoeducation
Support groups
Crisis intervention services
This Photo by Unknown author is licensed under CC BY-NC-ND.
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Community Services and Programs (Cont.)
Emergency psychiatric services
Housing services
Partial hospitalization programs (PHPs)
Intensive outpatient programs (IOPs)
Community outreach programs
Multiservice centers
Substance use treatment
This Photo by Unknown author is licensed under CC BY-ND.
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Evidence-Based Treatment Approaches
Assertive community treatment (ACT)
Consumer works with multidisciplinary team to receive range of services as opposed to going to multiple agencies
Cognitive-behavioral therapy (CBT)
Focus on patterns of thinking and “self-talk”
Cognitive enhancement therapy (CET)
Computer-based drills and exercises to strengthen brain function
This Photo by Unknown author is licensed under CC BY-SA-NC.
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Evidence-Based Treatment Approaches (Cont.)
Family support and partnership
Includes NAMI’s Family-to-Family program
Social skills training
Vocational rehabilitation and related services
This Photo by Unknown author is licensed under CC BY-NC-ND.
NAMI’s Family-to-Family program focuses on understanding SMI, coping skills, and the recovery process.
NAMI meetings and support groups are specific to various SMIs, for example, the Depression and Bipolar Support Alliance, serve as excellent sources of support and practical guidance for primary consumers (patients) and secondary consumers (their significant others).
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Evidence-Based Treatment Approaches (Cont.)
Vocational rehabilitation and related services
Clubhouse model
Consumers run programming
Supported employment model
Financial incentives to employers
Rapid placement in job preferred by the patient
Continuing individualized support on the job
Integration of mental health and employment services
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Other Treatment Approaches
Court-Involved Intervention
Psychiatric advance directives
Guardianship
Consumer-Run Programs
Peer Support
Technology
Exercise
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Quick Quiz
Marcus’s new therapist helps him learn to focus on identifying his own distorted thinking and using “self-talk” to get control of a situation and turn his thinking around. This treatment is popularly referred to as
ACT.
CET.
CBT.
NAMI.
ANS: C
CBT (cognitive behavioral therapy) involves helping the patient focus on (a) identifying distorted thinking and (b) using “self-talk” to come to a more realistic frame of mind. In ACT (assertive community treatment), the consumer works with multidisciplinary team to receive range of services as opposed to going to multiple agencies. CET (cognitive enhancement therapy) uses computer-based drills and exercises to strengthen brain function. Finally, NAMI (National Alliance on Mental Illness) is not a treatment so much as it is a family and caregivers’ support agency. It is the leading mental health consumer support and advocacy organization in the United States.
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Objectives
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Explain the role of the nurse in the care of people with serious mental illness.
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Develop a nursing care plan for an individual with serious mental illness.
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Discuss the causes of treatment nonadherence and plan interventions to promote treatment adherence.
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Identify current issues affecting individuals with serious mental illness such as outpatient commitment and incarceration.
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Nursing Care of Patients with SMI
Assessment strategies
Intentional risk
Unintentional risk
Depression or hopelessness
Anxiety
Signs of impending relapse
Physical health problems
Comorbid illnesses
Treatment nonadherence
This Photo by Unknown author is licensed under CC BY-SA.
Table 32.1 lists selected signs and symptoms of problems associated with SMI, potential nursing diagnoses that apply to the patient with SMI, and examples of specific nursing outcomes.
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Nursing Care (Cont.)
Nursing Diagnoses
Impaired verbal communication
Impaired socialization
Social isolation
Nonadherence
Chronic low self-esteem
Caregiver stress
Table 32.1 lists selected signs and symptoms of problems associated with SMI, potential nursing diagnoses that apply to the patient with SMI, and examples of specific nursing outcomes.
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Nursing Care (Cont.)
Intervention Strategies
Involve patient in goal-setting and treatment plan
Emphasize quality of life over symptoms
Sustain therapeutic relationships
Focus on coping with current issues over past
Encourage reality testing
Teach how to respond to stigma
Promote social skills & support groups
Educate patients on illness and recovery
Care for the whole person
Help with access to substance use disorder services
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Current Issues Affecting Individuals with SMI
The practice of outpatient commitment is controversial. On the one hand, individuals who do not recognize having a mental illness are provided with healthcare and, potentially, a better quality of life. They are allowed maximum freedom and are able to live in the community and avoid institutionalization. On the other hand, this approach is paternalistic and at odds with the recovery model of mental healthcare.
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Outpatient commitment
Criminal offenses and incarceration
Deinstitutionalization and transinstitutionalization
Inadequate access to care
Quick Quiz
James Holmes was the shooter at the Batman premiere in Aurora, Colorado, in 2012. Do you think this incident contributes to the stigma of mental illness in our society?
Yes
No
Not sure
ANS: Answers will vary.
Define stigma as it relates to mental illness. Does our society view all people with mental illness as violent and unpredictable?
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Quick Quiz
Marcus responds to CBT and is recommended for a day program that incorporates the clubhouse model. The focus of the clubhouse model of treatment is:
stabilizing through peer-to-peer counseling.
conducting research studies in the community.
providing an opportunity to build job skills.
intensive treatment of SPMI.
ANS: C
Day programs may use a clubhouse model in which clients run the programing for peers. Client-run businesses, such as a coffee shop or housekeeping service, teach all members to perform a job in the business, as well as different aspects of running a business. Such programs have led to the supported employment model, which has been shown to be more effective in helping individuals with SMI achieve employment .
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